Philadelphia College of Osteopathic Medicine

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PCOM Psychology Dissertations Student Dissertations, Theses and Papers

2016

Therapeutic Effectiveness, Stress, and Burnout in

Mental Health Professionals
Christina Pimble
Philadelphia College of Osteopathic Medicine, christinapi@[Link]

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 Philadelphia College of Osteopathic Medicine

Department of Psychology

THERAPEUTIC EFFECTIVENESS, STRESS, AND BURNOUT IN MENTAL

HEALTH PROFESSIONALS

By Christina Pimble

Submitted in Partial Fulfillment of the Requirements for the Degree of

Doctor of Psychology

June 2016
 PHILADELPHIA COLLEGE OF OSTEOPATIDC MEDICINE
DEPARTMENT OF PSYCHOLOGY

Dissertation Approval

This is to certify that the thesis presented to us by Christina Pimble

on the 301h day of March, 2016, in partial fulfillment of the requirements for the degree of

Doctor of Psychology, has been examined and is acceptable in both scholarship and

literary quality.

Committee Members' Signatures:

Barbara A Golden, PsyD, ABPP, Chairperson

Robert A DiTomasso, PhD, ABPP

Anna Zacharcenko, PsyD

Robert A DiTomasso, PhD, ABPP, Chair, Department of Psychology

 iii

Acknowledgements

I would like to acknowledge Dr. Barbara Golden and Dr. Robert DiTomasso,

thank you for your unending guidance and dedication on this endeavor, and thank you for

constantly challenging and supporting me. To the Psychology faculty at PCOM, you

forever have my gratitude. I am appreciative of your mentorship, support, and

supervision, as it has allowed me to thrive as a student, a researcher, and a clinician.

To my big brother, Tom Pimble, thank you for always challenging me, fighting

for me, and supporting me. Thank you for setting the bar so high and always creating a

healthy sense of competition; I would not be where I am today without having your

footsteps to follow in. Finally, to my parents, Tom and Linda Pimble, thank you for

always believing in me, pushing me to achieve my best, and never doubting me or my

capabilities. You have encouraged and backed me in every endeavor I have taken on, and

cheered me every step of the way. Thank you for loving and supporting me throughout

this incredible journey. I love you and I couldn’t have done it without you.
 iv

Abstract

Therapists face a great deal of stress in their day-to-day work, which arises from issues

regarding psychotherapy effectiveness, therapist gender, client population, and job

dissatisfaction. These stressors make therapists susceptible to personal mental health

issues, which can lead to burnout. The purpose of this study is to investigate the

relationship between therapist perception of therapeutic effectiveness, perceived stress,

and burnout experienced by the therapist as influenced by, but not limited to, therapist

gender, client population, the type of setting in which the therapist works, and length of

time in the field. Findings from this study may provide insight into stressors experienced

by therapists at present, as well as the relationship between perceived therapeutic

effectiveness and therapist demographics. A review of current literature, including an

overview of stress, is presented. Possible explanations, limitations of the study, and

implications of the findings are also discussed.

Keywords: Stress, Burnout, Therapeutic Effectiveness, Therapists

 v

Table of Contents

Acknowledgements………………………………………………………………………iii

Abstract………………………………………………………………………………...…iv

Table of Contents…………………………………………………………………...……..v

List of Tables………………………………………………………………………....…..ix

Chapter 1: Introduction……………………………………………………………………1

Statement of the problem………………………………………………………….1

Purpose of the study……………………………………………………………….3

Chapter 2: Literature Review……………………………………………………………...4

Stress literature………………………………………………………….…………4

Theory of stress: Conservation of resources………………………………………5

Stress and decision making………………………………………………………..6

Stressors therapists face………………………………………………………..….7

Stress and Burnout……………………………………………………………...……..….8

Therapeutic Effectiveness/Outcome Related to Stress………………………..…10

Factors contributing to effective therapy………………………………...10

Factors contribution to ineffective therapy………………………………11

Self-Care and Burnout: Conservation of Resources Model, Burnout, & Work-Family

Conflict………………………………………… ………………………………...……..12

Demographics and Stress……………………………………………………………...…13

Client population and secondary traumatic stress………………………………..13

Adolescent sex offenders…………………………………………………….…..15

Suicidal clients………………………………………………………….………..15
 vi

Clients with serious mental illness……………………………………….………16

Students…………………………………………………………………………..16

Graduate programs with self-care emphasis…………………………………..…18

Professionals………………………………………………………………….….18

Professionals seeking therapy……………………………………………………19

Barriers to professionals seeking therapy……………………………………..…19

Gender………………………………………………………………...………….20

Therapy Setting/Type of Therapist………………………………………………………21

Clinical military psychologists…………………………………………….…….22

Correctional psychologists and therapists……………………………………..…22

Substance abuse counselors……………………………………………………...23

College campus mental health counselors…………………………………….....23

Mental health nurses………………………………………………………..…....24

Mental health social workers…………………………………………………….24

Chapter 3: Hypotheses…………………………………………………………………...26

Chapter 4: Method……………………………………………………………………….28

Design…………………………………………………………….……………...28

Participants…………………………………………………………..…………..28

Measures…………………………………………………………..……………..28

Demographic Questionnaire………………………………………..……28

Perceived Stress Scale……………………………………………………28

Maslach Burnout Inventory………………………………………...……29

Therapeutic Effectiveness Scale…………………………………………30

 vii

Procedure…………………………………………………………………….…..30

Chapter 5: Results………………………………………………………………..………34

Demographics……………………………………………………………………34

Hypothesis I……………………………………………………………………...35

Hypothesis II…………………………………………………………….……….36

Hypothesis III………………………………………………………………….…37

Hypothesis IV……………………………………………………………………38

Hypothesis V………………………………………………..……………………38

Hypothesis VI………………………………………………………………...….39

Hypothesis VII……………………………………………………………...……40

Hypothesis VIII………………………………………………………………..…41

Additional Analyses………………………………………………...……………49

Chapter 6: Discussion………………………………………………………………...….52

Implication of findings…………………………………………………….……..52

Therapeutic effectiveness and burnout……………………………..……52

Gender and burnout…………………………………………………..…..53

Length of time in the field and burnout……………………………….…54

Hours spent conducting therapy and burnout ……………………………55

Hours of self-care and burnout………………………………………......56

Perceived stress and burnout……………………………………………..56

Predictors of emotional exhaustion, depersonalization, and personal

accomplishment…………………………………………………….……57
 viii

Additional analyses………………………………………………………………58

Limitations………………………………………………………………...……..59

Future Directions…………………………………………………………..…….60

Summary and Conclusions…………………………………………………..…..61

References………………………………………………………………………..………62

Appendix A…………………………………………………………………………...….69

Appendix B………………………………………………………………………………71
 ix

List of Tables

Table 1: Participant Descriptive Statistics……………………………………………….35

Table 2: Regression model summary for dependent variable of emotional exhaustion....41

Table 3: ANOVA for dependent variable of emotional exhaustion……………………..42

Table 4: Multiple regression analysis summary for the dependent variable emotional

exhaustion………………………………………………………………………………..43

Table 5: Regression model summary for dependent variable of depersonalization……..44

Table 6: ANOVA for dependent variable of depersonalization……………………...….44

Table 7: Multiple regression analysis summary for the dependent variable

depersonalization………………………………………………………………………...46

Table 8: Regression model summary for dependent variable of personal

accomplishment………………………………………………………………………….47

Table 9: ANOVA for dependent variable of personal accomplishment…………………47

Table 10: Multiple regression analysis summary for the dependent variable personal

accomplishment……………………………………………………………………….…49
 Chapter 1: Introduction

Statement of the Problem

People working in the field of mental health, specifically therapists, face unique

challenges, pressures, and susceptibilities (Cushway & Tyler, 1996). Stress is one of the

major challenges that therapists face on a regular basis, making them more vulnerable to

substance use issues, mental health problems, and suicide (Cushway & Tyler, 1996;

Shapiro, Brown, & Biegel, 2007). Stress results from a lack of balance between the

resources and the coping strategies that an individual possesses and his or her perception

of environmental demands (Kinman & Jones, 2005). Stress may impact therapist

effectiveness overall because it can have an adverse effect on a person’s concentration,

attention, and ability to make decisions (Shapiro et al., 2007). Therapists experiencing the

greatest stress tend to be new to the field of psychology, and are often trainees or students

who have not yet learned to manage the stress of their work (Rodolfa, Kraft, & Reilley,

1988). Clinical psychology trainees, in particular, are susceptible to high levels of stress,

which can have a negative influence both on their professional and on their personal lives

(Pakenham & Stafford-Brown, 2006). Students in graduate clinical psychology programs

have reported stress related to job and school-life balance, as well as to difficulty

balancing the obligation of practicum clinical activities with clients (El-Ghoroury,

Galper, Sawaqdeh, & Bufka, 2012). Psychology students and trainees have also reported

more stress than professionals (El- Ghoroury et al., 2012), suggesting that the length of

time in the field may be related to stress. Clinical psychology students have fewer coping

strategies and support systems than do their professional counterparts, leaving students

more susceptible to mental health issues and burnout (El-Ghoroury et al., 2012).
THERAPEUTIC EFFECTIVENESS AND STRESS 2

Additionally, certain demographic characteristics tend to be associated with

higher levels of stress for students and for professional psychologists (Cushway & Tyler,

1996), including therapist gender, client population, and work setting. For instance,

female therapists report greater stress than do their male counterparts, which may result

from the pressure of playing multiple roles, including therapist, wife, and mother

(Cushway & Tyler, 1996). Those therapists working with clients who have personality

disorders or clients who have suffered from abuse or trauma also report more stress

(Shapiro et al., 2007). Further, therapists who are actively engaging in psychotherapy

with clients report being more stressed than those who are not providing psychotherapy

(Rodolfa et al., 1988). Rodolfa et al. (1988) suggests that factors involved in counseling,

such as reacting to client behavior and maintaining a strong therapeutic alliance are

related to higher levels of stress. The effectiveness of psychotherapy serves as an

additional stressor affecting therapists; research indicates that psychotherapists often put

themselves under a great deal of stress because they feel the need to appear highly

competent at all times (Deutsch, 1984; Thériault & Gazzola, 2006). Therapists have also

stated that conducting therapy that is not successful is a major source of stress for them

(Deutsch, 1984; Thériault & Gazzola, 2006). Uncertainty regarding effectiveness in

therapy is one of the most commonly reported difficulties when working in the field of

psychology, regardless of therapist experience (Thériault & Gazzola, 2010).

Therapists who were not satisfied with their jobs also reported greater stress

(Cushway & Tyler, 1996), and stated additional issues, including feeling unable to help

clients, clients making suicidal remarks, and clients lacking motivation in therapy

(Deutsch, 1984). The culmination of these stressors over a period of time can lead to a
THERAPEUTIC EFFECTIVENESS AND STRESS 3

therapist experiencing burnout, which is a type of emotional fatigue and pessimism

(Rupert & Morgan, 2005) affecting approximately one third of psychologists (El-

Ghoroury et al., 2012).

Purpose of the study

Therapists face a great deal of stress in their day-to-day work that arises from

issues regarding psychotherapy effectiveness, therapist gender, client population, and job

dissatisfaction. These stressors may make therapists susceptible to personal mental health

issues, which can lead to burnout, if not addressed. Although previous studies have

investigated stressors affecting psychotherapists, there is a dearth of literature

investigating stress resulting from perceived lack of therapeutic effectiveness and its

relationship with therapist demographics. The purpose of this study is to investigate the

relationship between therapist perception of therapeutic effectiveness, perceived stress,

and burnout experienced by the therapist as influenced by, but not limited to, therapist

gender, client population, the type of setting in which the therapist works, and length of

time in the field. Findings from this study may provide insight into stressors experienced

by therapists at present, as well as the relationship between perceived therapeutic

effectiveness and therapist demographics. Because prolonged stress can lead to mental

health issues, substance use issues, and burnout in therapists if not addressed, this is an

important field of study.

THERAPEUTIC EFFECTIVENESS AND STRESS 4

Chapter 2: Literature Review

Current stress literature, including occupational stress and the conservation of

resources theory will be discussed. The relationship between stress and burnout will then

be presented, followed by stressors that mental health therapists face and the stress

associated with degree of therapeutic effectiveness. Stress in relation to therapist

demographic variables, including client population, length of time in the field, gender,

and type of therapist also will be discussed. Finally, a gap in the current literature will be

discussed, followed by the results of the current study intended to fill this gap.

Stress Literature

Stress results from a lack of balance between the resources and the coping

strategies that an individual possesses and his or her perception of environmental

demands (Kinman & Jones, 2005). Occupational stress can lead not only to physical

health problems, but also to a variety of mental and emotional health issues (Wirtz et al.,

2013). For example, stress in the workplace can increase depression and anxiety,

particularly in younger people (Melchior et al., 2007). People who experience higher

demands from their jobs, such as time pressures and greater workloads are at greater risk

for depression and anxiety compared with those who have fewer demands from their jobs

(Melchior et al., 2007).

A variety of studies have investigated the stressor-strain relationship in regard to

occupational stress and its effect on one’s health (Mazzola, Schonfeld, & Spector, 2011).

The stressor in this theory is the condition in the environment that causes an emotional

reaction; the strain refers to a person’s response to the stressor, which may be behavioral,

physical, or psychological (Mazzola et al., 2011). If specific stressors in the workplace

THERAPEUTIC EFFECTIVENESS AND STRESS 5

can be identified, policies can be formed to lessen or defend against resulting strains

(Mazzola et al., 2011). Numerous theories have been studied in order to explain stress

and its functioning in different work places and environments.

Theory of Stress: Conservation of Resources

Stress, particularly stress occurring in the workplace, has been conceptualized in a

number of ways (Dewe, O’Driscoll, & Cooper, 2012). One conceptualization of stress

that focuses on resources and relates to stress in the workplace and burnout is the

“conservation of resources” theory (Dewe et al., 2012, p. 31). Hobfoll (1989) introduced

the conservation of resources theory to conceptualize stress and connect views of stress in

regard to environment and cognitions. According to the idea that supports this theory,

people attempt to create, keep, and protect resources and then feel threatened when they

are at risk of losing those resources (Dewe et al., 2012; Hobfoll, 1989). This theory is

based on the model suggesting that people achieve goals by attempting to create positive

personal characteristics and social situations, known as resources, in order to insure

reinforcement and to prevent losing these positive characteristics and social situations

(Dewe et al., 2012; Hobfoll, 1989). Resources may include socioeconomic status,

mastery, self-esteem, social support, and employment (Dewe et al., 2012; Hobfoll, 1989).

The conservation of resources theory also views stress in relation to both

perceived and actual loss of resources, stating that stress can be produced in either

circumstance (Hobfoll, 1989). Regardless of whether or not a person’s resources are

actually at risk, simply the assumption alone that he or she is at risk can produce a great

amount of stress (Hobfoll, 1989). Resources can be threatened based on situations in

one’s environment. For example, giving a poor work performance can put one at risk of
THERAPEUTIC EFFECTIVENESS AND STRESS 6

losing one’s job, further threatening loss of resources, such as status at work and

socioeconomic status (Hobfoll, 1989).

The conservation of resources theory states that when people are facing stress,

they attempt to minimize their total loss of resources (Dewe et al., 2012; Hobfoll, 1989).

When people are not dealing with stress, they attempt to develop as many resources as

possible for future circumstances that may result in resource loss (Dewe et al., 2012;

Hobfoll, 1989). In order to prepare for future resource loss, people often invest in such

commodities as love, time, and energy (Hobfoll, 1989). Four different types of resource

categories exist: object resources, conditions, personal characteristics, and energies

(Hobfoll, 1989). Object resources are material possessions, such as houses, that provide

not only shelter, but may also provide status. Conditions include such commodities such

as marriage or work status, and are related to one’s resistance to stress; for example,

people who are married have the support of their spouses (Hobfoll, 1989). Personal

characteristics also aid in stress resistance; for example, people who have high self-

esteem may have more psychological strength to deal with stressful situations. Finally,

energies include resources such as time and money, which aid people in acquiring other

resources (Hobfoll, 1989). Social support is found among all of these categories of

resources, and is important in preserving additional resources that a person has at any

given time (Hobfoll, 1989). Mental health professionals provide support for their clients,

but may also be in need of support themselves.

Stress and Decision Making

Often people make decisions while engaging in numerous activities, causing these

decisions to be made under stress (Pabst, Schoofs, Pawlikowski, Brand, & Wolf, 2013).
THERAPEUTIC EFFECTIVENESS AND STRESS 7

People experiencing acute stress may have an impaired ability to make decisions,

especially when they are also engaging in executive processing tasks (Pabst et al., 2013).

The Yerkes-Dodson law states that a person’s performance on moderately difficult or

complex tasks tends to increase with mental arousal, but only to a certain point (Hanoch

& Vitouch, 2004). If arousal is too high, performance will then decrease (Hanoch &

Vitouch, 2004). Therapists are often required to make quick decisions, especially when

working with seriously mentally ill or suicidal clients, and stress may impair the

decisions they are required to make. Emotions can also influence decision making, and

people under stress may experience negative emotions (Pabst et al., 2013). These

negative emotions can, in turn, affect important decisions.

Stressors Therapists Face

Those in the helping professions, including counselors/therapists and

psychologists, face unique pressures and stressors in their line of work; this can lead to

mental health issues, substance use issues, and eventually, to burnout (Shapiro, Brown, &

Biegel, 2007). These stressors include worrying about therapeutic effectiveness and

outcome and working with seriously mentally ill clients. Additionally, therapists are

exposed to clients dealing with traumatic events, and client suicidal behavior (Shapiro et

al., 2007). Certain demographic characteristics, such as being a student in training, being

a woman, and working in community agencies, also may add to the stress that a therapist

experiences (Shapiro et al., 2007). Aside from the mental and physical health issues that

stress can cause for people working in the mental health profession, other problems

include being absent from work, high work turnover, and reduced worker efficiency

(Hannigan, Edwards, & Burnard, 2004).

THERAPEUTIC EFFECTIVENESS AND STRESS 8

Stress and Burnout

The culmination of stressors over periods of time can lead to burnout, which is a

type of emotional fatigue and pessimism (Rupert & Morgan, 2005). Burnout, viewed as a

“stress-related illness”, has been studied in great depth over the last few decades

(Glasberg, Eriksson, & Norberg, 2006, p.393). Based on a metaphor, burnout literally

refers to the extinguishing of a flame, which is likened to a worker no longer being able

to shine brightly at his or her job (Schaufeli, Leiter, & Maslach, 2009). Originally,

burnout was regarded as a work stressor affecting people who were naïve and cynical,

but this assumption is no longer valid (Schaufeli et al., 2009). Current training programs

and even the media leave little of the working world to the imagination, and few workers

enter their fields in a naïve state, yet they are still vulnerable to burnout (Schaufeli et al.,

2009).

The cause of burnout is generally attributed to stressors in the workplace, work

attitude, and a combination of one’s personality characteristics (Glasberg et al., 2006). It

typically occurs in people who have jobs that involve working closely with other people

(Glasberg et al., 2006). Burnout encompasses an experience of emotional exhaustion,

depersonalization, and a poor view of one’s self-competence, particularly in relation to

one’s job abilities (Glasberg et al., 2006). A long-standing imbalance of work demands

overtaking available resources contributes to a person experiencing burnout (Schaufeli et

al., 2009). Additionally, employees who work for organizations that have views and

motives different from their own views and motives are at risk for developing burnout

(Schaufeli et al., 2009).

THERAPEUTIC EFFECTIVENESS AND STRESS 9

Christina Maslach has had a large role in the theory of burnout and its three

dimensions, including developing a scale to assess burnout in health care personnel

(Maslach, Schaufeli, & Leiter, 2001). She initially interviewed employees in the field of

human service about stress on the job, and found that those with coping strategies tended

to report less stress (Maslach et al., 2001). Burnout is especially prevalent in those

working in the field of health care, including nurses, physicians, and therapists (Glasberg

et al., 2006). She discovered that burnout is more common in younger people as

compared with their older counterparts, and is also more common in female workers than

in male workers, although these age and gender differences may be the result of differing

occupational choices (Glasberg et al., 2006).

Studies investigating social support and its link to burnout have yielded

inconsistent findings, which may suggest that social support serves as a moderator of the

relationship between burnout and stress experienced in the workplace (Glasberg et al.,

2006). Additionally, burnout is associated with specific personality traits, such as

resilience and self-esteem; those lacking these traits are most likely to experience burnout

(Glasberg et al., 2006).

Burnout has become a large area of interest and study, especially since the change

from industrial-based societies to service-based economies (Schaufeli et al., 2009). A

number of European countries have even established burnout as a medical diagnosis,

illustrating the necessity of recognizing this condition (Schaufeli et al., 2009). Those in

the helping professions, especially, are at greater risk of experiencing burnout (Glasberg

et al., 2006; Schaufeli et al., 2009). Consequently, those who experience burnout are
THERAPEUTIC EFFECTIVENESS AND STRESS 10

unable to provide the professional services that they typically might, thus harming both

the service provider and the person receiving services (Schaufeli et al., 2009).

Therapeutic Effectiveness/Outcome Related to Stress

One of the many stressors that therapists face is stress related to therapeutic

effectiveness or outcome (Cushway & Tyler, 1996; Deutsch, 1984; Theriault & Gazzola,

2006). However, there is a dearth of literature exploring the amount of stress that this

worry causes for therapists. This worry and concern about the paucity of research on

these topics of therapeutic effectiveness and outcome may lead to a therapist’s feeling

more stressed and incompetent (Deutsch, 1984; Theriault & Gazzola, 2006). Uncertainty

and doubt over one’s capabilities and skills in therapy have also been identified as factors

creating stress in therapists and students in training (Cushway & Tyler, 1996).

An investigation of stressors that affect a psychologist’s ability to function

effectively found that burnout was reported most frequently (Bearse, McMinn, Seegobin,

& Free, 2013). Professional psychologists were asked to rate on a Likert scale, the degree

to which burnout, personal trauma, depression, vicarious traumatization, and

countertransference affected their professional ability. After burnout, countertransference

was the second most frequently reported stressor impacting therapeutic efficacy, followed

by vicarious traumatization, depression, and the experience of personal trauma (Bearse et

al., 2013). However, one must note that none of the five stressors was reported as

affecting therapeutic efficacy “often”, suggesting that these factors serve as stressors, but

may not significantly affect therapeutic effectiveness.

Factors contributing to effective therapy. Apart from client variables, a number

of specific therapist factors contribute to whether or not therapy is successful (Lambert &
THERAPEUTIC EFFECTIVENESS AND STRESS 11

Barley, 2001). Factors within the therapist that contribute to successful therapy are most

often referred to as common factors (Lambert & Barley, 2001). As much as 30% of

improvement in clients can be accounted for by common factors of the therapist, twice

the 15% of improvement that is the result of the specific therapeutic technique used in

session (Lambert & Barley, 2001). Some common factors include showing empathy,

engaging the client, focusing on client’s problems, and affirming the client’s thoughts

(Lambert & Barley, 2001). Common factors have also been compared with the three

components of person-centered therapy: empathy, unconditional positive regard, and

congruence (Lambert & Barley, 2001).

Factors contributing to ineffective therapy. In order to discuss

unsuccessful/ineffective therapy, one must be able to recognize unsuccessful therapy.

Unsuccessful therapy can be defined in a number of ways, such as clients not improving

or not responding to treatment, or clients becoming worse throughout their time in

therapy, the latter being more rare (Lambert, 2011). Others view treatment as

unsuccessful even if the client had an overall good outcome but had a difficult time

throughout the time in therapy, and if therapy procedures needed to be modified often

throughout sessions (Lambert, 2011).

A variety of therapist characteristics related to unsuccessful therapy have been

identified; these include lack of empathy, disinterest, hostility, and rejection towards the

client (Lambert, 2011). Additionally, therapy may be considered unsuccessful if a

therapist does not respond when he or she feels that the therapy is not going well, but

instead continues with treatment (Lambert, 2011). Therapists also tend to be optimistic

about client progress in therapy, and sometimes think clients are making progress when
THERAPEUTIC EFFECTIVENESS AND STRESS 12

they are not (Lambert, 2013). Unfortunately, therapists also overlook negative changes

made by clients, and are poor at predicting whether or not clients will improve with

therapy (Lambert, 2013).

Self-Care and Burnout: Conservation of Resources Model, Burnout, & Work-

Family Conflict

Based on the conservation of resources model, and in order to prevent burnout,

therapists must have resources available to overcome work stressors, including support

outside of the workplace (Rupert, Stevanovic, & Hunley, 2009). Resources may be lost,

however, when there is a work-family conflict or when factors associated with work,

such as time obligations and work distress, affect home life (Rupert et al., 2009). Family-

work conflict, on the other hand, may occur when factors associated with family, also

including time obligations or distress, affect work life (Rupert et al., 2009). Work-family

conflict is related to less satisfaction with one’s job, less satisfaction in life overall and

burnout (Rupert et al., 2009).

As previously mentioned, maladaptive coping responses to stress can lead to

therapist impairment and eventually to burnout (Barnett, Baker, Elman, & Schoener,

2007). Although self-care is considered an ethical standard that psychologists strive to

uphold, many psychologists do not place an emphasis on self-care, often putting their

clients ahead of themselves (Wise, Hersh, & Gibson, 2012). Stressors and challenges that

therapists and psychologists in training face may be managed with self-care, and

neglecting to engage in self-care can lead to harming one’s clients and oneself (Barnett et

al., 2007). Additionally, compassion is an integral part of conducting psychotherapy, and

THERAPEUTIC EFFECTIVENESS AND STRESS 13

research indicates that people who engage in self-care are able to be more compassionate

both to themselves and to others (Boellinghaus, Jones, & Hutton, 2013).

Psychologists experience just as much day-to-day stress as anyone else, and often

have vulnerabilities that put them at heightened risk for impairment (Barnett et al., 2007).

Some mental health professionals chose their field because they have had experiences

similar to those of their clients, such as trauma or abuse, and want to take on the role of

care-giver (Barnett et al., 2007). However, having had these histories puts one at greater

risk of experiencing stress and burnout, making self-care imperative. Although self-care

can be different for each person, it is essentially any activity in which one engages to

focus on health and well-being, such as spiritual or religious activities, mindfulness-based

practices, yoga, exercise, personal therapy, or exercise (Wise et al., 2012). Practicing

self-care involves the ability of the therapist to balance one’s own needs with the needs of

others, the ability to have control over oneself, and to experience self-awareness

(Boellinghaus et al., 2013).

Demographics and Stress

Client Population and Secondary Traumatic Stress

Aside from dealing with the day-to-day stressors of working with people who

have mental illness, therapists also face a unique stressor, known as “secondary traumatic

stress” (Arvay, 2002, p. 283). Secondary traumatic stress symptoms are similar to those

of posttraumatic stress disorder (PTSD), even though a sufferer never actually

experiences the trauma first-hand, but instead experiences it via their client (Arvay, 2002;

O’Halloran & Linton, 2000). A stressor that directly threatens a person is considered a

primary stressor, whereas the person having directly experienced a trauma, in this case
THERAPEUTIC EFFECTIVENESS AND STRESS 14

the client, serves as the secondary stressor to the therapist (Buchanan, Anderson,

Uhlemann, & Horwitz, 2006). Therapists treating clients with PTSD repeatedly hear the

traumatic stories of their clients, providing them with a place to release feelings of fear

and anger (O’Halloran & Linton, 2000). Over a period of time, this repetition can lead the

therapist to experiencing secondary traumatic stress (O’Halloran & Linton, 2000).

Therapists working with people who have experienced trauma are more highly

prone to developing secondary traumatic stress than are their counterparts working with

non-trauma populations (Arvay, 2002). Female counselors who worked with survivors of

sexual violence had increased symptoms of PTSD and more overall emotional distress

than those who did not work with survivors of sexual violence (Arvay, 2002).

Additionally, mental health workers in Canada who had personal histories of trauma were

even more likely to experience secondary traumatic stress when working with clients who

had experienced trauma (Buchanan et al., 2006).

Crisis intervention therapists also face a greater risk of experiencing secondary

traumatic stress than therapists working with clients with less severe mental illness

(Miller, 1998). These therapists provide brief, intense interventions to clients facing acute

crises. This work may be considered more stressful to therapists because it is intense,

because they have little control over the situation, and also because they have no time to

prepare for the intervention (Miller, 1998). Those therapists who work with victims of

crimes or tragedies face a great deal of stress; this is also true about those therapists who

work with perpetrators, such as sex offenders.

THERAPEUTIC EFFECTIVENESS AND STRESS 15

Adolescent Sex Offenders

Therapists working with adolescent sex offenders are also at greater risk for

increased compassion fatigue and early burnout (Kraus, 2005). These therapists listen to

stories of violence from the sex offenders, often in graphic detail, which can lead to

secondary traumatic stress; however, listening to a client who is a victim can also lead to

secondary traumatic stress (Kraus, 2005). Furthermore, studies have demonstrated that

therapists working with this population experience increased worry about their loved

ones, as well as heightened hypervigilance, and suspiciousness. Interestingly, it was also

found that engaging in self-care was not related to decreased compassion fatigue or

decreased burnout in these therapists (Kraus, 2005). However, therapists working with

this population did feel more compassion satisfaction when they engaged in self-care

(Kraus, 2005). Experiencing compassion satisfaction allows one to continue working

with a difficult population, even when he or she is facing distress (Krauss, 2005).

Findings of this study suggest that working with adolescent sex offenders may be more

stressful and more difficult than working with other populations.

Suicidal Clients

Therapists working with clients who have exhibited suicidal behavior, or clients

who have committed suicide, also face additional stress compared with that experienced

by therapists who do not work with this population (Ting, Jacobsen, & Sanders, 2011).

Therapists in this situation are often called “clinician-survivors”; i.e., those who have

reactions to their client’s suicide similar to the reactions experienced by the client’s

family (Ting et al., 2011, p. 327). Clinician-survivors also experience feelings of failure,

low self-competence, and guilt (Ting et al., 2011). Unfortunately, this guilt sometimes
THERAPEUTIC EFFECTIVENESS AND STRESS 16

leads to therapists isolating themselves from colleagues and friends when they are most

seriously in need of support (Ting et al., 2011).

Clients with Serious Mental Illness

Mental health professionals work with many different populations, including

clients with serious mental illness. Clients with serious mental illness are often difficult to

work with because they can have more chronic conditions and complicated problems

(Acker, 1999). Often, clients with serious mental illness have trouble contributing to the

therapeutic relationship and are difficult to engage in therapy. In these cases, therapy is

typically of longer duration, and it may take a long time to see improvement (Acker,

1999). Mental health professionals working with this population may experience feelings

of inadequacy or feel as though they are failing because they are not seeing significant

changes in their clients’ maladaptive behaviors (Acker, 1999).

An investigation of mental health social workers who have dealt with seriously

mentally ill clients found that the time spent with these clients was positively correlated

with emotional exhaustion and depersonalization (Acker, 1999). Additionally, those

working specifically with clients with schizophrenia reported higher emotional

exhaustion, more depersonalization, and less personal accomplishment. However, those

who reported that they had high levels of support were more satisfied with their jobs and

reported less emotional exhaustion (Acker, 1999).

Students

The length of time that a therapist has spent working in his or her field also exerts

an influence on the amount of stress the therapist experiences. Students have obviously

been in the field far less time than their professional counterparts. Although there is a
THERAPEUTIC EFFECTIVENESS AND STRESS 17

dearth of literature investigating students’ stress, available research suggests that students

in clinical psychology training programs tend to report more stress and deal with more

stressors than their professional counterparts (El-Ghoroury, Galper, Sawaqdeh, & Bufka,

2012; Pakenham & Stafford-Brown, 2012). Students have fewer coping strategies

available to them in dealing with stress than do professional therapists (El-Ghoroury et

al., 2012). Students also have more difficulty in balancing responsibilities such as

academic work, practicum and internship work with clients, time management, and

finance, as well as personal anxiety (El-Ghoroury et al., 2012). Research also found that

poor sleep and poor exercise habits were associated with higher rates of stress in students

(El-Ghoroury et al., 2012). Additionally, racial minority students are more likely than

their white counterparts to experience discrimination as an additional stressor (El-

Ghoroury et al., 2012).

Although many graduate psychology programs recommend that their students

engage in self-care on their own, self-care typically is not embedded into the school

curriculum, and therefore does not always occur (Pakenham & Stafford-Brown, 2012).

Programs may also recommend that students attend personal therapy, but this is generally

a recommendation, not a requirement (Pakenham & Stafford-Brown, 2012). Previously

mentioned time constraints and financial burdens may be part of the reason that students

do not engage in self-care practices or personal therapy (El-Ghoroury et al., 2012).

Although “wellness” itself is typically an idea that therapists focus on for their clients,

they often overlook this practice for themselves (O’Halloran & Linton, 2000, p. 354).

From this literature, one can glean that students clearly face more stress than their
THERAPEUTIC EFFECTIVENESS AND STRESS 18

professional counterparts, suggesting that the length of time spent in the field has an

effect on the amount of stress.

Graduate programs with self-care emphasis. Students in graduate schools that

emphasize self-care tend to have a perceived quality of life that is higher than that of

other graduate school students (Goncher, Sherman, Barnett & Haskins, 2013). More than

200 students in clinical psychology doctoral programs were surveyed and asked about the

emphasis of self-care in their programs and also about their overall quality of life

(Goncher et al., 2013). Students who indicated that their programs had a strong self-care

emphasis reported higher quality of life, and students who actually engaged in self-care

also reported having a higher quality of life (Goncher et al., 2013). Although this study

utilized only a small number of participants, it illustrates well the importance not only of

emphasizing self-care in doctoral programs, but also the importance of actually practicing

appropriate self-care.

Professionals

Professional therapists also experience a great deal of stress, although typically

less than that reported by their student counterparts (Rodolfa, Kraft, & Reilley, 1988).

Years of experience dealing with time-management and learning coping strategies may

be a reason that those who are in the field longer experience somewhat less stress than

those with less experience. There is a dearth of literature regarding stress in students,

compared with the same type of literature regarding stress in professional therapists; thus,

this area needs to be studied further (El-Ghoroury et al., 2012). However, almost one

third of professional psychologists may be experiencing burnout symptoms at any time

THERAPEUTIC EFFECTIVENESS AND STRESS 19

(El-Ghoroury et al., 2012). Additionally, as many as one half of psychologists may report

significant symptoms of depression at any time (El-Ghoroury et al., 2012).

Professionals may also experience stress as a result of the number of roles they

play (O’Connor, 2001). Professional psychologists often assume the roles of researchers,

administrators, therapists, and teachers, in addition to the roles they take on in their home

lives (O’Connor, 2001). These roles are also constantly shifting because one may have

individual therapy with a client, followed by supervision with a supervisee, and then

perhaps an afternoon class to teach.

Professionals seeking therapy. In one study, professional therapists who had

sought therapy reported doing so for various reasons, with depression being the most

common (Pope & Tabachnick, 1994). In addition to depression, marital issues, self-

esteem and self-confidence issues, anxiety, and career or work issues were also common

reasons for seeking therapy (Pope & Tabachnick, 1994). The majority of those who

sought therapy found it to be extremely helpful, and 70% of the 476 therapists surveyed

felt that psychology students in graduate training programs should be required to attend

therapy (Pope & Tabachnick, 1994). Additionally, 4% of the therapists admitted to

having attempted suicide, and 29% reported they had suicidal thoughts (Pope &

Tabachnick, 1994).

Barriers to professionals seeking therapy. Although those who have sought

therapy generally found it beneficial, a number of unique barriers keep professionals

from seeking help (Bearse et al., 2013). A stigma regarding mental health treatment exists

for most people, but psychologists face the fear of stigma from their clients, colleagues,

and employers who may think therapists are not able to perform their professional duties
THERAPEUTIC EFFECTIVENESS AND STRESS 20

fully if they are seeking treatment themselves (Bearse et al., 2013). Insurance is also a

factor because certain psychological diagnoses affect the insurance coverage available for

an individual (Bearse et al., 2013). Some psychologists have individual health care plans

as opposed to group health care plans because they have fewer federal regulations.

However, these individual plans are more exclusive regarding preexisting conditions,

which may prevent psychologists from receiving appropriate coverage (Bearse et al.,

2013). Since the adoption of the Affordable Care Act, however, the laws regarding

preexisting conditions have changed (U.S. Department of Health and Human Services,

2014). Another issue is confidentiality. Privacy policies are always in place, but

professionals may fear that a client or someone else will observe them in the waiting

room of a therapist’s office and pass this information to others (Bearse et al., 2013).

Finally, selecting a therapist may be difficult for a professional, simply because one may

already have a relationship with the majority of therapists in his or her immediate area

(Bearse et al., 2013).

Gender

Gender also plays a role in the amount of stress that a therapist experiences, and

for many years female therapists have typically reported more stress than that reported by

their male counterparts (Cushway & Tyler, 1996; Deutsch, 1983; Rupert & Morgan,

2005). However, the amount of stress experienced by each gender was different when

related to a therapist’s work setting (Rupert & Morgan, 2005). Female therapists working

in agencies, such as community mental health centers and outpatient clinics, experienced

greater stress than male therapists working in agencies, but male therapists working in

independent group practice settings experienced greater stress than their female
THERAPEUTIC EFFECTIVENESS AND STRESS 21

counterparts in the same type of setting (Rupert & Morgan, 2005). Additionally, female

therapists working in independent practices reported less emotional exhaustion than

female therapists working within agencies (Rupert & Kent, 2007).

Gender differences can also be found when looking at the utilization of career-

sustaining behaviors that may decrease emotional exhaustion and burnout (Rupert &

Kent, 2007). Female therapists, in comparison with their male counterparts, found that

continuing education and case consultation to be great importance. Additionally, female

therapists are more likely to discuss their concerns with colleagues, maintain a balance

between their work and personal lives, and spend time with their friends than do their

male counterparts (Rupert & Kent, 2007). Aside from gender, the stress that a therapist

experiences is also influenced by the setting in which one works and also the type of

therapist one is.

Therapy Setting/Type of Therapist

The type of setting in which a therapist works also seems to have an impact on the

amount of stress he or she experiences (Rupert & Morgan, 2005). Overall, independently

practicing therapists experience less stress than their counterparts working within

agencies such as hospitals, community mental health centers, or outpatient clinics,

perhaps because independent therapists not only have more control over their practices

but also because their clients may not be as seriously mentally ill as clients seen in

agencies (Rupert & Morgan, 2005).

One should note, however, that hours of therapy that are conducted differ in

different settings, as do amounts of time spent doing paperwork, and numbers of clients

seen (Rupert & Morgan, 2005). Independent therapists typically saw fewer clients,
THERAPEUTIC EFFECTIVENESS AND STRESS 22

totally, but spent more time conducting therapy, whereas those working in agencies had

more clients, but spent less time conducting therapy and more time doing paperwork,

suggesting that these factors may contribute to differences in stress levels (Rupert &

Morgan, 2005).

Clinical military psychologists. Clinical military psychologists face even more

unique challenges in their specific profession than do others who work in the field of

mental health (Linnerooth, Mrdjenovich, & Moore, 2011). Since 2001, hundreds of

psychologists have been deployed to hostile situations, facing a number of emotional, as

well as physical, stressors (Linnerooth et al., 2011). Military psychologists often work

with clients dealing with trauma, and often take on a large burden when working with

other veterans (Linnerooth et al., 2011).

Correctional psychologists and therapists. Psychologists working in

correctional facilities also face a great deal of stress (Senter, Morgan, Serna-McDonald,

& Bewley, 2010). Correctional therapists working specifically with sex offenders

reported feelings of depression, as well as stress and burnout (Senter et al., 2010). Female

therapists also reported feeling more vulnerable when working with male sex offenders

than did their male counterparts (Senter et al., 2010). Overall, correctional psychologists

experience more burnout than their professional counterparts working at Veteran’s

Affairs and in university counseling centers (Senter et al., 2010). However, correctional

psychologists who experienced a high level of professional identity, that is, one’s

attitudes, beliefs, and feelings about their profession and experiences, were less likely to

experience burnout, suggesting that professional identity may be a protective factor

(Senter et al., 2010).

THERAPEUTIC EFFECTIVENESS AND STRESS 23

Substance abuse counselors. Mental health professionals often encounter clients

with substance abuse problems, sometimes via dual diagnosis clients, and other times at

substance abuse treatment agencies. Unfortunately, substance abuse treatment agencies

face a high rate of turnover for mental health professionals (Knudsen, Ducharme, &

Roman, 2006). The most common reason that mental health professionals leave

substance abuse settings is due to high rates of emotional exhaustion, suggesting that

these professionals face increased stress in their line of work. This emotional exhaustion

in turn leads to voluntary turnover in this setting (Knudsen et al., 2006). Specific stressors

faced by mental health professionals in this setting include pressure from the organization

to provide quality services with few resources, working with managed care, and working

with clients who are mandated to enter treatment (Knudsen et al., 2006).

College campus mental health counselors. Although there is a dearth of

literature investigating mental health counselors working on college campuses, research

has investigated college students with serious mental illnesses and the stressors that they

face. Far more students now face mental illnesses, and more young adults are now

pursuing college, yet they are not prepared for the stressors and pressures that come with

attending college (Mowbray et al., 2006). Additionally, more minority students, including

racial minorities and students with disabilities, are attending college, and these students

may experience more stressors because they are dealing with unique problems (Mowbray

et al., 2006). As previously mentioned, mental health professionals working with serious

mental illnesses face a great deal of stress when working with this population, and one

can assume that these stressors are exaggerated when working with college students who

also deal with school, social, and financial stressors in addition to their mental illness.
THERAPEUTIC EFFECTIVENESS AND STRESS 24

Mental health nurses. Along with mental health social workers, therapists, and

psychologists, mental health nurses also face unique challenges when working with their

patients (Mann & Cowburn, 2005). Mental health nurses face the challenge of “emotional

labor,” which occurs when a nurse must pretend to feel a specific emotion, or when he or

she actually tries to feel an emotion (Mann & Cowburn, 2005, p.154). Mental health

nurses may engage in emotional labor with their patients because doing so is expected by

the organizations for which they work (Mann & Cowburn, 2005). However, because the

emotion that the nurse is exhibiting is not necessarily the emotion the nurse is feeling,

stress may result (Mann & Cowburn, 2005). It has been widely documented that those in

the nursing profession, in general, experience a great deal of stress; however, nurses

working specifically with mentally ill patients experience increased stress as a result of

their intense work with patients (Edwards, Burnard, Coyle, Fothergill, & Hannigan,

2000). Additional factors contributing to stress in mental health nurses include constant

changes within organizations, shift changes, and training (Mann & Cowburn, 2005).

Mental health social workers. Along with the previously mentioned

professionals, mental health social workers are also subject to an increased amount of

stress in the workplace (Coyle, Edwards, Hannigan, Fothergill, & Burnard, 2005; Pottage

& Huxley, 1996). Social workers interact with clients on a variety of levels, and are often

included in direct care, as well as in case management (Coyle et al., 2005). As with other

professionals who work in the field of mental health, female social workers are more

likely than their male counterparts to experience increased levels of stress (Coyle et al.,

2005). Additional factors leading to stress in mental health social workers include not

feeling a sense of accomplishment in the workplace, not feeling appreciated; it also

THERAPEUTIC EFFECTIVENESS AND STRESS 25

includes the amount of work they are expected to do (Coyle et al., 2005). Additional

sources of stress reported by social workers included overall distress in the workplace

stemming from lack of organization and poor management (Coyle et al., 2005). Poor

supervision and lack of support from colleagues and lack of personal support were also

stated as reasons that people were experiencing stress (Pottage & Huxley, 1996). Social

workers also struggled with feeling that they were incompetent and feeling as though

they did not have enough time and resources to help their clients (Coyle et al., 2005).

Those working with adults also reported more stress than those working primarily with

children (Coyle et al., 2005).

Stress has long been a major issue affecting people in a variety of occupations,

but mental health professionals are a population facing their own unique challenges and

vulnerabilities. Mental health professionals have great responsibility to help and serve

their clients; therefore, it is necessary to establish what specifically causes stress and

burnout in order to help prevent it in the future.

THERAPEUTIC EFFECTIVENESS AND STRESS 26

Chapter 3: Hypotheses

The present study will examine the relationship between the therapist’s perception

of therapeutic effectiveness and the therapist’s perceived stress; it will also examine

demographic variables, such as therapist gender, clinical setting, and length of time in the

field. Eight hypotheses have been created to investigate these relationships. First, there

will be a significant negative relationship between the therapist’s perception of

therapeutic effectiveness as measured by the therapeutic effectiveness measure, and

burnout as measured by the Maslach Burnout Inventory. Second, a female therapist will

typically be associated with higher scores on the Maslach Burnout Inventory than will a

male therapist. Third, there will be a significant, positive relationship between years of

experience in the field and burnout, as measured by the Maslach Burnout Inventory.

Fourth, therapists working in community mental health centers will report significantly

higher levels of burnout than therapists working in other settings, as measured by the

Maslach Burnout Inventory. Fifth, there will be a significant, positive relationship

between the numbers of hours seeing clients each week and burnout, as measured by the

Maslach Burnout Inventory. Sixth, there will be a significant, negative relationship

between the number of reported weekly hours spent in self-care activities and burnout, as

measured by the Maslach Burnout Inventory. Seventh, therapist scores on perceived

stress, as measured by the Perceived Stress Scale, will be positively correlated with

therapist scores on burnout, as measured by the Maslach Burnout Inventory. Eighth, the

combination of level of perceived therapeutic effectiveness, female gender, years of

experience, setting, number of hours seeing clients each week, number of reported
THERAPEUTIC EFFECTIVENESS AND STRESS 27

weekly hours spent in self-care activities and scores on the Perceived Stress Scale will

predict scores on the Maslach Burnout Inventory.

THERAPEUTIC EFFECTIVENESS AND STRESS 28

Chapter 4: Method

The study design was based on a regression model investigating the association

between therapist perception of therapeutic effectiveness, therapist gender, setting in

which the therapist works, length of time in the field, and other demographic variables on

perceived therapist stress and burnout.

Participants

Participants in this study included a sample of convenience recruited online via survey

monkey. Participants included 109 licensed psychologists who see patients at least twenty

hours a week.

Measures

Demographic Questionnaire

Participants completed a self-report questionnaire, created by the investigator,

which included eighteen multiple choice and yes/no questions. Questions included basic

demographic questions such as gender, marital status, and education, as well as personal

health questions applying to each participant. The questionnaire can be found in

Appendix A.

Perceived Stress Scale

The “Perceived Stress Scale” (PSS) is a 14-item scale intended to measure the

amount of perceived stress one is currently experiencing based on different situations

(Cohen, Kamarck, & Mermelstein, 1983, p.385). The scale was developed by Cohen in

1983, and is designed for use with community samples that have at least a junior high

education (Cohen et al., 1983). The coefficient alpha reliability in the initial 3 PSS

validations of 2 college student samples and one smoking-cessation sample was “.84, .85,
THERAPEUTIC EFFECTIVENESS AND STRESS 29

and .86”, respectively (Cohen et al., 1983, p.390). The higher one scores on the PSS, the

more stress he or she experiences.

Maslach Burnout Inventory

The Maslach Burnout Inventory is a 22 item measure assessing burnout in people

working in the human service field (Maslach & Jackson, 1986). The measure consists of

three subscales, measuring emotional exhaustion, depersonalization, and personal

accomplishment. The questions on the measure are based on a Likert scale; responders

answer how often they feel a certain way about their jobs (Maslach & Jackson, 1986).

Convergent validity of the initial validation of the measure was illustrated by comparing

independent observations of behavior ratings made by a friend or family member of the

participant completing the burnout scale (Maslach & Jackson, 1981). Additionally, scores

were correlated with other scales that were expected to have a relationship with burnout

(Maslach & Jackson, 1981). “Research that has been conducted has found each of the

MBI-HSS subscales to be stable over time with correlations in the .50 to .82 range”

(Maslach, Jackson, & Leiter, p.34, 1996). Coefficient alpha reliability analyses of the

three subscales of the Maslach Burnout Inventory, including emotional exhaustion,

depersonalization, and personal accomplishment, demonstrated strong internal

consistency with Cronbach’s Alphas of .89, .77, and .74, respectively (Maslach et al.,

1996). The higher one scores on the Emotional Exhaustion subscale, the greater is the

emotional exhaustion that he or she experiences. The higher one scores on the

Depersonalization subscale, the greater is the depersonalization that he or she

experiences. The higher one scores on the Personal Accomplishment subscale, the greater

is the personal accomplishment that he or she experiences.

THERAPEUTIC EFFECTIVENESS AND STRESS 30

Therapeutic Effectiveness Scale

Participants were given a therapeutic effectiveness instrument measuring their

perceived levels of effectiveness when performing therapy overall. The specific measure

was created by the responsible investigator, and consisted of 25 Likert-type questions

asking the therapists a variety of questions regarding their perceptions of effectiveness in

therapy. Coefficient alpha reliability analyses of the Therapeutic Effectiveness Scale

revealed a Cronbach’s Alpha of .90, indicating that this measure has high internal

consistency and measures a homogeneous construct, supporting the practice of using the

overall total score for this measure. The higher individuals score on the Therapeutic

Effectiveness Scale, the less effective they perceive themselves to be. The lower

individuals score, the more effective they perceive themselves to be. The Therapeutic

Effectiveness Scale can be found in Appendix B.

Procedure

Data were collected on demographic characteristics including age, gender,

occupation, theoretical orientation, number of years in the field, number of patients seen

on a weekly basis, number of hours per week spent in direct client contact, and number of

hours per week spent engaging in self-care. Data were collected via an online survey on

survey [Link]; links to the survey were distributed via listserv and facebook, a

social networking website. The online survey included a total of four instruments,

including a demographic questionnaire, the perceived stress scale, the Maslach Burnout

Inventory, and the therapeutic effectiveness measure created by the examiner. The survey

took approximately 15-20 minutes to complete.

THERAPEUTIC EFFECTIVENESS AND STRESS 31

Inclusion criteria included the following: participants had to be18 years of age or

older, and had to be English speaking, licensed psychologists. Exclusion criteria included

the following: those who are not licensed; those who are working less than 20 hours per

week with clients in the field, and those who are not working in relevant fields.

The participants in this study took part in the study via an online link available

through email listserv and Facebook. A brief description with the link explained that a

student who was researching a dissertation topic was seeking psychologists to participate

in a brief (15-20 minute) survey. Participants clicked on a link that directed them to a

survey monkey questionnaire. On screen instructions directed the participants to fill out

the previously mentioned demographic questionnaire, followed by the perceived stress

scale, the Maslach Burnout Inventory, and the therapeutic effectiveness measure.

Statistical Plan

Nine statistical tests were conducted to analyze the eight hypotheses. Six

correlations and three linear multiple regressions were conducted. An a priori power

analysis was completed using G Power with 7 predictor variables, indicating that at

α=0.05 and a power of 0.80; 103 participants were necessary for a moderate approximate

effect size of 0.15.

Hypothesis I

Hypothesis I: There will be a significant, positive relationship between therapist’s

perception of therapeutic effectiveness, as measured by the therapeutic effectiveness

measure and burnout, as measured by the Maslach Burnout Inventory. To test this

hypothesis, a simple correlation was conducted.

Hypothesis II
THERAPEUTIC EFFECTIVENESS AND STRESS 32

Hypothesis II: Being a female therapist will be more positively correlated with

scores on the Maslach Burnout Inventory. To test this hypothesis, a simple correlation

was conducted.

Hypothesis III

Hypothesis III: There will be a significant, positive relationship between years of

experience in the field and burnout, as measured by the Maslach Burnout Inventory. To

test this hypothesis, a simple correlation was conducted.

Hypothesis IV

Hypothesis IV: Therapists working in community mental health centers will

report significantly higher levels of burnout than therapists working in other settings, as

measured by the Maslach Burnout Inventory. To test this hypothesis, an ANOVA was

conducted.

Hypothesis V

Hypothesis V: There will be a significant, positive relationship between the

number of hours seeing clients each week and burnout, as measured by the Maslach

Burnout Inventory. To test this hypothesis, a simple correlation was conducted.

Hypothesis VI

Hypothesis VI: There will be a significant, negative relationship between number

of reported weekly hours spent in self-care activities and burnout, at measured by the

Maslach Burnout Inventory. To test this hypothesis, a simple correlation was conducted.

Hypothesis VII

Hypothesis VII: Therapist scores on perceived stress, as measured by the

Perceived Stress Scale will be positively correlated with therapist scores on burnout, as
THERAPEUTIC EFFECTIVENESS AND STRESS 33

measured by the Maslach Burnout Inventory. To test this hypothesis, a simple correlation

was conducted.

Hypothesis VIII

Hypothesis VIII: The combination of level of perceived therapeutic effectiveness,

female gender, years of experience, setting, number of hours seeing clients each week,

number of reported weekly hours spent in self-care activities and scores on the Perceived

Stress Scale will predict scores on the Maslach Burnout Inventory. To test this

hypothesis, three linear multiple regressions were conducted.

THERAPEUTIC EFFECTIVENESS AND STRESS 34

Chapter 5: Results

Demographic characteristics of the participants will be presented, followed by

results of the statistical analyses. A discussion of whether or not the examiner’s

hypotheses were supported will follow.

Demographics

Participants included 109 licensed psychologists who work directly with clients at

least 20 hours a week. Participants included 75 females and 34 males. The average age of

the participants was 51.5 years. Participants were working in the field an average of 14.3

years, and conducted an average of 27.4 hours of therapy per week. Participants engaged

in an average of 8.7 hours of self-care activities per week, and reported getting an

average of 5.5 hours of sleep per night. Fifty-four participants (49.5%) identified their

theoretical orientation as Cognitive-Behavioral; eleven (10.1%) identified as

Psychodynamic; two (1.8%) identified as Humanistic; thirty-two (29.4%) identified as

Eclectic, and ten (9.2%) identified as “other”. Forty-five participants (41.3%) evaluated

their physical health as very good; sixty-one (56%) evaluated their physical health as

good, and three (2.8%) evaluated their physical health as poor. Ninety-six participants

(88.6%) reported drinking caffeine, with an average of 1.8 cups per day. One participant

(0.9%) reported using nicotine. Participants reported drinking an average of 2.0 alcoholic

drinks per week. Seventy-five participants (68.8%) reported being married; eight (7.3%)

were divorced; one (.9%) was widowed; seven (6.4%) were living with their significant

other, and seventeen (15.6%) were single. Thirty participants (27.5%) reported having a

child or children under the age of eighteen for whom they are the primary care takers.

Twenty-four participants (22%) reported living in the Eastern region of the United States,
THERAPEUTIC EFFECTIVENESS AND STRESS 35

twenty (18.3%) in the Western region, four (3.7%) in the Southern region, eleven

(10.1%) in the Central region, one (.9%) in the Northern region, thirty-nine (35.8%) in

the Northeast region, five (4.6%) in the Southeast region, and four (3.7%) in the

Southwest region. Demographic information with means and standard deviations is

presented in Table 1.

Table 1
Participant Descriptive Statistics
Characteristic N Mean Std. Deviation
Years in field 109 14.3 10.6

Hours of therapy per 106 27.4 8.2

week
Age 108 51.5 55.4

Hours of sleep per night 96 5.6 3.1

Hours of self-care per 106 8.8 6.8

week
Cups of caffeine per day 84 1.8 1.7

# of alcoholic drinks per 95 2.0 3.2

week

Hypothesis I

A Pearson correlation analysis was conducted to determine if Hypothesis 1 was

supported. Hypothesis 1 predicted that there would be a significant, positive relationship

between therapist’s perception of therapeutic effectiveness as measured by the

therapeutic effectiveness measure and burnout, as measured by the Maslach Burnout

Inventory. Specifically, it was hypothesized that the less effective a psychologist felt, the

higher his or her scores would be on the Emotional Exhaustion and Depersonalization

subscales of the Maslach Burnout Inventory, and the lower his or her scores would be on

the Personal Accomplishment subscale of the Maslach Burnout Inventory. Pearson

THERAPEUTIC EFFECTIVENESS AND STRESS 36

correlational analysis revealed that higher scores on the Therapeutic Effectiveness

Measure (which indicates psychologists feeling less effective) were associated with

higher scores on the Emotional Exhaustion subscale of the Maslach Burnout Inventory,

r(109)=.520, p<.01. The coefficient of determination revealed that 27.04% of the

variability in emotional exhaustion is attributable to differences in Therapeutic

Effectiveness. Pearson correlational analysis showed that higher scores on the

Therapeutic Effectiveness measure were associated with higher scores on the

Depersonalization subscale of the Maslach Burnout Inventory, r(109)=.570, p<.01. The

coefficient of determination revealed that 32.5% of the variability in Depersonalization is

attributable to differences in Therapeutic Effectiveness. Pearson correlational analysis

also showed that higher scores on the Therapeutic Effectiveness measure were associated

with lower scores on the Personal Accomplishment subscale of the Maslach Burnout

Inventory, r(109)=-.604, p<.01. The coefficient of determination revealed that 36.5% of

the variability in Personal Accomplishment is attributable to differences in Therapeutic

Effectiveness.

Hypothesis II

Hypothesis II predicted that being a female therapist would be positively

correlated with scores on the Maslach Burnout Inventory. Specifically, it was

hypothesized that being a female would be associated with higher scores on the

Emotional Exhaustion and Depersonalization subscales of the Maslach Burnout

Inventory, and lower scores on the Personal Accomplishment subscale of the Maslach

Burnout Inventory. Pearson correlational analysis revealed that being a female therapist

was associated with lower scores on the Emotional Exhaustion subscale of the Maslach
THERAPEUTIC EFFECTIVENESS AND STRESS 37

Burnout Inventory, r(109)=-.312, p<.01. About 9.7% of the variability in Emotional

Exhaustion is attributable to gender. However, the Pearson correlation between female

gender and scores on the Depersonalization subscale of the Maslach Burnout Inventory

was not significant, r(109)=-.114, p=.119. Likewise, the Pearson correlation between

female gender and scores on the Personal Accomplishment subscale of the Maslach

Burnout Inventory was also not significant, r(109)=.111, p=.126.

Hypothesis III

Hypothesis III predicted there would be a significant, positive relationship

between years of experience in the field and burnout as measured by the Maslach

Burnout Inventory. Specifically, it was hypothesized that the greater number of years of

experience in the field that a psychologist had, the higher his or her scores would be on

the Emotional Exhaustion and Depersonalization subscales of the Maslach Burnout

Inventory, and the lower his or her scores would be on the Personal Accomplishment

subscale of the Maslach Burnout Inventory. Contrary to the prediction, Pearson

correlational analysis revealed that the number of years spent in the field was associated

with lower scores on the Emotional Exhaustion subscale of the Maslach Burnout

Inventory, r(109)=-.188, p<.05. About 3.5% of the variability in Emotional Exhaustion is

attributable to the number of years in the field. The Pearson correlation analysis revealed

that the number of years spent in the field was associated with lower scores on the

Depersonalization subscale of the Maslach Burnout Inventory, r(109)=-.228, p<.01.

About 5.2% of the differences in Depersonalization are attributable to differences in

number of years spent in the field. The Pearson correlation also revealed that the number

of years spent in the field was associated with higher scores on the Personal
THERAPEUTIC EFFECTIVENESS AND STRESS 38

Accomplishment subscale of the Maslach Burnout Inventory, r(109)=.171, p<.05. About

3% of the differences in Personal Accomplishment are attributable to differences in

number of years spent in the field.

Hypothesis IV

Hypothesis IV predicted that therapists working in community mental health

centers would report significantly higher levels of burnout than therapists working in

other settings, as measured by the Maslach Burnout Inventory. Hypothesis IV could not

be analyzed because only four participants in the study reported working in community

mental health.

Hypothesis V

Hypothesis V predicted that there would be a significant, positive relationship

between the number of hours seeing clients each week and burnout, as measured by the

Maslach Burnout Inventory. Specifically, it was hypothesized that the greater number of

hours a psychologist spent seeing clients each week, the higher his or her scores would be

on the Emotional Exhaustion and Depersonalization subscales of the Maslach Burnout

Inventory, and the lower his or her scores would be on the Personal Accomplishment

subscale of the Maslach Burnout Inventory. Pearson correlational analysis between the

number of hours seeing clients each week and scores on the Emotional Exhaustion

subscale of the Maslach Burnout Inventory was not significant, r(109)=.037, p=.352.

Likewise, the Pearson correlation between the number of hours seeing clients each week

and scores on the Depersonalization subscale of the Maslach Burnout Inventory was not

significant, r(109)=.116, p=.118. Additionally, the Pearson correlation between the

THERAPEUTIC EFFECTIVENESS AND STRESS 39

number of hours seeing clients each week and scores on the Personal Accomplishment

subscale of the Maslach Burnout Inventory was not significant, r(109)=.121, p=.108.

Hypothesis VI

Hypothesis VI predicted there would be a significant, negative relationship

between number of reported weekly hours spent in self-care activities and burnout, as

measured by the Maslach Burnout Inventory. Specifically, it was hypothesized that the

greater number of hours a psychologist spent engaging in self-care activities per week,

the lower his or her scores would be on the Emotional Exhaustion and Depersonalization

subscales of the Maslach Burnout Inventory, and the higher his or her scores would be

on the Personal Accomplishment subscale of the Maslach Burnout Inventory. Pearson

correlational analysis revealed that the number of reported weekly hours spent in self-

care activities was associated with lower scores on the Emotional Exhaustion subscale of

the Maslach Burnout Inventory, r(109)=-.289, p<.01. About 8.4% of the differences in

Emotional Exhaustion are attributable to differences in number of reported weekly hours

spent in self-care activities. Likewise, the Pearson correlation analysis revealed that the

number of reported weekly hours spent in self-care activities was associated with lower

scores on the Depersonalization subscale of the Maslach Burnout Inventory, r(109)=-

.168, p<.05. About 2.8% of the differences in Depersonalization are attributable to

differences in number of reported weekly hours spent in self-care activities .Additionally,

the Pearson correlation analysis revealed that the number of reported weekly hours spent

in self-care activities was associate with higher scores on the Personal Accomplishment

subscale of the Maslach Burnout Inventory, r(109)=.215, p<.05. About 4.6% of the
THERAPEUTIC EFFECTIVENESS AND STRESS 40

differences in Personal Accomplishment are attributable to differences in number of

reported weekly hours spent in self-care activities.

Hypothesis VII

Hypothesis VII predicted that therapist scores on perceived stress, as measured by

the Perceived Stress Scale would be positively correlated with therapist scores on

burnout, as measured by the Maslach Burnout Inventory. Specifically, it was

hypothesized that higher scores on the Perceived Stress Scale would be associated with

higher scores on the Emotional Exhaustion and Depersonalization subscales of the

Maslach Burnout Inventory, and lower scores on the Personal Accomplishment subscale

of the Maslach Burnout Inventory. Pearson correlational analysis revealed that higher

scores on the Perceived Stress Scale were associated with higher scores on the Emotional

Exhaustion subscale of the Maslach Burnout Inventory, r(109)=.580, p<.01. About

33.6% of the differences in Perceived Stress are attributable to differences in Emotional

Exhaustion. Likewise, the Pearson correlation analysis revealed that higher scores on the

Perceived Stress Scale were associated with higher scores on the Depersonalization

subscale of the Maslach Burnout Inventory, r(109)=.546, p<.01. About 29.8% of the

differences in Perceived Stress are attributable to differences in Depersonalization.

Additionally, the Pearson correlation analysis revealed that higher scores on the

Perceived Stress Scale were associated with lower scores on the Personal

Accomplishment subscale of the Maslach Burnout Inventory, r(109)=-.604, p<.01. About

36.5% of the differences in Perceived Stress are attributable to differences in Personal

Accomplishment.
THERAPEUTIC EFFECTIVENESS AND STRESS 41

Hypothesis VIII

Hypothesis VIII predicted that the combination of level of perceived therapeutic

effectiveness, female gender, years of experience, number of hours seeing clients each

week, number of reported weekly hours spent in self-care activities and scores on the

Perceived Stress Scale will predict scores on the subscales of the Maslach Burnout

Inventory. Three linear multiple regression analyses were used to develop a model for

predicting therapists’ scores on the Maslach Burnout Inventory.

Linear multiple regression analysis 1

First, A linear multiple regression analysis using SPSS 23 employing the ENTER

method was conducted. The predictor variables included scores on the Perceived Stress

Scale, years in the field, number of hours of therapy conducted per week, gender, number

of reported weekly hours spent in self-care activities, and scores on the therapeutic

effectiveness scale. The criterion variable was the Emotional Exhaustion subscale of the

Maslach burnout inventory. The overall regression as shown in Table 2 was significant,

indicating that the regression equation was better than using the mean, according to Field

(2009), in predicting Emotional Exhaustion. Table 3 shows the ANOVA for the

dependent variable of emotional exhaustion.

Table 2
Regression model summary for dependent variable of emotional exhaustion
Model R R Adjusted Standard R Square Durbin-
Square R Error of the change Watson
Square Estimate
1 .657 .432 .397 .92694 .432 1.808
THERAPEUTIC EFFECTIVENESS AND STRESS 42

Table 3
ANOVA for dependent variable of emotional exhaustion
Model Sum of df Mean Square F Sig.
Squares
Regression 64.578 6 10.763 12.527 .000
Residual 85.062 99 .859
Total 149.640 105

The assumptions of regression were met. The Durbin-Watson statistic, according to Field

is a measure of “tests for serial correlation between errors in the regression models.

Specifically, it tests whether adjacent residuals are correlated, which is useful in assessing

the assumption of independent errors” (Field, 2009, p.785). Field recommends, as a

conservative approach, that values less than 1 or greater than 3 are cause for concern. A

Durbin-Watson statistic of 1.8 suggests that serial correlation between the errors is not a

problem. To test for collinearity, tolerance statistics and variable inflation factors were

calculated. Tolerance statistics measure multicollinearity and are the reciprocal of the

variance inflation factor. None of the values is below .1, which is cause for concern about

serious problems. The variance inflation factor is also a measure of collinearity and

indicates whether or not a predictor has a strong relationship with other predictors. A

value of 10 is a good value. It is a value at which to begin being concerned about

collinearity and there is no indication of collinearity problems. The regression

standardized residual on the dependent variable emotional exhaustion are distributed

normally. The pp (probability-probability) plot is “a graph plotting the cumulative

probability of a variable against the cumulative probability of a particular distribution

(often a normal distribution). Deviations from the diagonal show deviations from the

distribution of interest” (Field 2009 p.792). “If values fall on the diagonal of the plot then

the value shares the same distribution as the one specified” (Field 2009, p.792). These
THERAPEUTIC EFFECTIVENESS AND STRESS 43

values fall close to the line, suggesting that not only is the relationship linear, but also

that there is homoscedasticity. A scatterplot of the regression standardized residual on the

x axis and a regression standardized predictor value on the y axis suggests that the

relationship is linear. Consequently, all of the assumptions of regression were met. In

Table 4, the outcomes suggest that therapeutic effectiveness and perceived stress are

significant predictors of emotional exhaustion. Additionally, in Table 4 unstandardized

and standardized beta coefficients, t values, and significant levels are reported.

Table 4
Multiple regression analysis summary for the dependent variable emotional exhaustion
Variable B SEB β t p

Constant -.470 .810 -.580 .563

Therapeutic Effectiveness .939 .330 .274 2.847 .005*

Gender -.359 .210 -.137 -1.710 .090

Years in the field -.004 .009 -.038 -.488 .627

Hours of therapy conducted per week .018 .011 .124 1.580 .117

Hours of self-care per week -.018 .014 -.101 -1.262 .210

Perceived Stress .856 .237 .359 3.604 .000*

*p<.05
These data reveal that the positive beta coefficient suggests that the higher one’s scores

on therapeutic effectiveness (the less effectively does one perceive him or herself) the

more emotional exhaustion one has. Likewise the perceived stress scale indicates that the

higher one’s perceived stress, the higher is the level of emotional exhaustion.

Linear multiple regression analysis 2

A second linear multiple regression analysis using SPSS 23 employing the

ENTER method was conducted. The predictor variables included scores on the Perceived
THERAPEUTIC EFFECTIVENESS AND STRESS 44

Stress Scale, years in the field, number of hours of therapy conducted per week, gender,

number of reported weekly hours spent in self-care activities, and scores on the

Therapeutic Effectiveness Scale. The criterion variable was the Depersonalization

subscale of the Maslach Burnout Inventory. The overall regression as shown in Table 5

was significant, indicating that the regression equation was better than using the mean,

according to Field 2009, in predicting depersonalization. Table 6 shows the ANOVA for

the dependent variable depersonalization.

Table 5
Regression model summary for dependent variable of depersonalization
Model R R Adjusted Standard R Square Durbin-
Square R Error of the change Watson
Square Estimate
1 .676 .456 .423 .64833 .456 2.260

In Table 6 the overall regression equation is significant, as shown by a significant F (6,

99) = 13.854, p < .001.

Table 6
ANOVA for dependent variable of depersonalization
Model Sum of Squares df Mean Square F Sig.
Regression 34.940 6 5.823 13.854 .000
Residual 41.613 99 .420
Total 76.553 105

The assumptions of regression were met. The Durbin-Watson statistic, according to Field,

is a measure of “tests for serial correlation between errors in the regression models.

Specifically, it tests whether adjacent residuals are correlated, which is useful in assessing

the assumption of independent errors” (Field, 2009, p.785). Field recommends, as a

conservative approach, that values less than 1 or greater than 3 are cause for concern. A

Durbin-Watson statistic of 1.8 suggests that serial correlation between the errors is not a
THERAPEUTIC EFFECTIVENESS AND STRESS 45

problem. To test for collinearity, tolerance statistics and variable inflation factors were

calculated. Tolerance statistics measure multicollinearity and are the reciprocal of the

variance inflation factor. None of the values is below .1, which is cause for concern about

serious problems. The variance inflation factor is also a measure of collinearity and

indicates whether or not a predictor has a strong relationship with other predictors. A

value of 10 is a good value. It is a value at which to begin being concerned about

collinearity and there is no indication of collinearity problems. The regression

standardized residual on the dependent variable emotional exhaustion are normally

distributed. The pp (probability-probability) plot is “a graph plotting the cumulative

probability of a variable against the cumulative probability of a particular distribution

(often a normal distribution). Deviations from the diagonal show deviations from the

distribution of interest” (Field 2009 p. 792). “If values fall on the diagonal of the plot

then the value shares the same distribution as the one specified” (Field 2009, p.792).

These values fall close to the line, suggesting that not only is the relationship linear but

also that there is homoscedasticity. A scatterplot of the regression standardized residual

on the x axis and a regression standardized predictor value on the y axis suggests that the

relationship is linear. Consequently, all of the assumptions of regression were met. In

Table 7, the outcomes suggest that therapeutic effectiveness, hours of therapy conducted

per week, and perceived stress are significant predictors of depersonalization, with

therapeutic effectiveness and perceived stress contributing relatively more predictive

power to the model than hours of therapy weekly Additionally, in Table 7 unstandardized

and standardized beta coefficients, t values and significant levels are reported.
THERAPEUTIC EFFECTIVENESS AND STRESS 46

Table 7
Multiple regression analysis summary for the dependent variable depersonalization
Variable B SEB β t p

Constant -2.600 .567 -4.587 .000*

Therapeutic Effectiveness .957 .231 .391 4.146 .000*

Gender .182 .147 .098 1.241 .217

Years in the field -.006 .006 -.070 -.905 .367

Hours of therapy conducted per week .027 .008 .257 3.339 .001*

Hours of self-care per week .003 .010 .022 .286 .776

Perceived Stress .643 .166 .377 3.873 .000*

*p<.05

These data reveal that the positive beta coefficient suggests that the higher one’s scores

are on therapeutic effectiveness (the less effective does one perceives oneself), the greater

amount depersonalization one experiences. Additionally, the greater number of hours of

therapy that one conducts per week, the higher the level of depersonalization one

experiences. Likewise, the perceived stress scale indicates that the higher one’s perceived

stress is, the higher is the level of depersonalization.

Linear multiple regression analysis 3

A third linear multiple regression analysis using SPSS 23 employing the ENTER

method was conducted. The predictor variables included scores on the perceived stress

scale, years in the field, number of hours of therapy conducted per week, gender, number

of reported weekly hours spent in self-care activities, and scores on the therapeutic

effectiveness scale. The criterion variable was the Personal Accomplishment subscale of

the Maslach Burnout Inventory. The overall regression as shown in Table 8 was
THERAPEUTIC EFFECTIVENESS AND STRESS 47

significant, indicating that the regression equation was better than using the mean,

according to Field (2009), in predicting personal accomplishment. Table 9 shows the

ANOVA for the dependent variable personal accomplishment.

Table 8
Regression model summary for dependent variable of personal accomplishment
Model R R Adjusted Standard R Square Durbin-
Square R Error of the change Watson
Square Estimate
1 .668 .447 .413 .46566 .447 1.732

Table 9
ANOVA for dependent variable of personal accomplishment
Model Sum of Squares df Mean Square F Sig.
Regression 17.323 6 2.887 13.315 .000
Residual 21.467 99 .217
Total 38.790 105

The assumptions of regression were met. The Durbin-Watson statistic, according to Field

is a measure of “tests for serial correlation between errors in the regression models.

Specifically, it tests whether adjacent residuals are correlated, which is useful in assessing

the assumption of independent errors” (Field, 2009, p.785). Field recommends, as a

conservative approach, that values less than 1 or greater than 3 are cause for concern. A

Durbin-Watson statistic of 1.8 suggests that serial correlation between the errors is not a

problem. To test for collinearity, tolerance statistics and variable inflation factors were

calculated. Tolerance statistics measure multicollinearity and are the reciprocal of the

variance inflation factor. None of the values is below .1, which is cause for concern about

serious problems. The variance inflation factor is also a measure of collinearity and

indicates whether or not a predictor has a strong relationship with other predictors. A
THERAPEUTIC EFFECTIVENESS AND STRESS 48

value of 10 is a good value. It is a value at which to begin being concerned about

collinearity and there is no indication of collinearity problems. The regression

standardized residual on the dependent variable emotional exhaustion are distributed

normally. The pp (probability-probability) plot is “a graph plotting the cumulative

probability of a variable against the cumulative probability of a particular distribution

(often a normal distribution). Deviations from the diagonal show deviations from the

distribution of interest” (Field 2009 p.792). “If values fall on the diagonal of the plot then

the value shares the same distribution as the one specified” (Field 2009, p.792). These

values fall close to the line, suggesting that not only is the relationship linear but also that

there is homoscedasticity. A scatterplot of the regression standardized residual on the x

axis and a regression standardized predictor value on the y axis suggests that the

relationship is linear. Consequently, all of the assumptions of regression were met. In

Table 10 the outcomes suggest that therapeutic effectiveness and perceived stress are

significant predictors of personal accomplishment, and that they contribute approximately

equally to the prediction model. Additionally, in Table 10 unstandardized and

standardized beta coefficients, t values and significant levels are reported.

THERAPEUTIC EFFECTIVENESS AND STRESS 49

Table 10
Multiple regression analysis summary for the dependent variable personal accomplishment
Variable B SEB β t p

Constant 7.236 .407 17.776 .000*

Therapeutic Effectiveness -.684 .166 -.392 -4.125 .000*

Gender -.084 .105 -.063 -.799 .426

Years in the field .000 .004 .008 .104 .917

Hours of therapy conducted per week -.001 .006 -.012 -.153 .879

Hours of self-care per week .003 .007 .031 .387 .700

Perceived Stress -.441 .119 -.363 -3.693 .000*

*p<.05

These data reveal that the negative beta coefficient suggests the lower one’s scores are on

therapeutic effectiveness (more effective one perceives oneself to be) the more personal

accomplishment one has. Likewise the perceived stress scale indicates the higher one’s

perceived stress, the lower the level of personal accomplishment.

Additional Analyses

Although not originally hypothesized, additional analyses were conducted to mine

the data. Pearson correlational analysis revealed that the number of years that a therapist

has spent in the field, was associated with lower scores on the Therapeutic Effectiveness

measure, r(109)=-.266, p<.01. About 7% of the differences in Therapeutic Effectiveness

are attributable to differences in number of years a therapist has spent in the field.

Likewise, the Pearson correlation revealed that the number of years a therapist has spent

in the field was associated with lower scores on the Perceived Stress Scale, r(109)=-.177,
THERAPEUTIC EFFECTIVENESS AND STRESS 50

p<.05. About 3% of the differences in Perceived Stress are attributable to differences in

number of years that a therapist has spent in the field.

Pearson correlational analysis revealed that the number of hours seeing clients

each week was associated with lower scores on the Perceived Stress Scale, r(106)=-.162,

p<.05. About 2.6% of the differences in Perceived Stress are attributable to differences in

number of hours seeing clients each week. Likewise, the Pearson correlational analysis

revealed that the number of hours seeing clients each week was associated with lower

scores on the Therapeutic Effectiveness measure (indicating that a therapist feels more

effective), r(106)=-.170, p<.05. About 3% of the differences in Therapeutic Effectiveness

are attributable to differences in number of hours seeing clients each week.

Pearson correlational analysis revealed that the number of reported weekly hours

spent in self-care activities was associated with lower scores on the Therapeutic

Effectiveness measure(indicating that a therapist felt more effective), r(109)=-.197,

p<.05. About 3.8 % of the differences in Therapeutic Effectiveness are attributable to

differences in the number of reported weekly hours spent in self-care activities. Likewise,

the Pearson correlational analysis revealed that the number of reported weekly hours

spent in self-care activities was associated with lowers cores on the Perceived Stress

Scale, r(109)=-.309, p<.01. About 9.5 % of the differences in Perceived Stress are

attributable to differences in the number of reported weekly hours spent in self-care

activities.

Pearson correlational analysis between scores on the Perceived Stress Scale was

associated with higher scores on the Therapeutic Effectiveness measure (indicating

THERAPEUTIC EFFECTIVENESS AND STRESS 51

feeling less effective), r(109)=.583, p<.01. About 33.9 % of the differences in

Therapeutic Effectiveness are attributable to differences in Perceived Stress.

THERAPEUTIC EFFECTIVENESS AND STRESS 52

Chapter 6: Discussion

Results of this study will add further knowledge to the field of psychology by

providing information on the relationship between perceived therapist stress, therapeutic

effectiveness, and burnout. Significant findings will be discussed, followed by a

discussion of study limitations and future directions.

Interestingly, of the 109 participants who completed the survey, only one

indicated that he/she used nicotine, and a majority reported that they engaged in self-care

activities, on average, for eight hours per week. Additionally, for those that reported

drinking alcohol, the average amount was two drinks over the course of the week.

Overall, it seems as though the population that participated in the study was relatively

healthy, with the majority of the participants rating themselves in “good” health (61

participants, 56%). Moreover, the majority of the participants (67 participants, 61.5%)

reported that they work in a private practice setting, and the majority was female (75

participants, 68.8%). The literature explains that female therapists working in

independent practices typically reported less emotional exhaustion than female therapists

working within agencies, so the current sample may have been less stressed than those

working in other settings (Rupert & Kent, 2007). Additionally, it is possible that the

current sample utilized more effective coping strategies to help deal with the stressors

that they experience.

Therapeutic Effectiveness and Burnout

Therapeutic effectiveness and its relationship with burnout was analyzed, with

results suggesting that the less effective a psychologist feels, the more emotional

exhaustion and depersonalization he or she feels, and also the more decreased sense of
THERAPEUTIC EFFECTIVENESS AND STRESS 53

personal accomplishment he or she experiences. Overall, findings suggested that

psychologists experience greater feelings of burnout when they feel they are not being

effective with their clients. As the literature suggests, worrying about the outcome of

therapy can cause a great deal of stress and worry for therapists, so if a therapist feels less

effective, this stress and worry may lead to burnout (Deutsch, 1984; Theriault & Gazzola,

2006). Generally, therapists feel effective when they are engaging in common factors,

which include showing empathy, engaging the client, focusing on client’s problems, and

affirming the client’s thoughts (Lambert & Barley, 2001). As stated previously, a variety

of therapist characteristics related to unsuccessful therapy have been identified, including

lack of empathy, disinterest, hostility, and rejection towards the client (Lambert, 2011).

Those feeling less effective with their clients may also be experiencing these negative

characteristics, which may be causing additional stress for the therapist and influence his

or her level of burnout.

Gender and Burnout

Contrary to what was expected, and to what the literature suggests, the analysis of

gender and burnout has suggested that female psychologists experienced less emotional

exhaustion; also no relationship was found between gender and depersonalization or

personal accomplishment. This may be due to females coping with stress differently or to

the type of setting where they work. Although the literature suggests that female

therapists report more stress in general than their male counterparts, females may deal

with this stress differently, or may utilize other coping mechanisms such as support from

friends and family to prevent burnout (Rupert & Kent, 2007). Females may also engage

in more self-care, which may help them to deal with the stress and burnout that they
THERAPEUTIC EFFECTIVENESS AND STRESS 54

might experience. Additionally, females working in private practice tended to report less

stress than females working within agencies, and the fact that the majority of the sample

worked in private practice may have influenced the findings of the current study. The

literature has also shown that female therapists, to a greater degree than their male

counterparts, found that continuing education and case consultation were very important;

therefore, females may be dealing with stressful clients by consulting with other

therapists or colleagues in the field (Rupert & Kent, 2007). Friendly contact and

conversation with one’s supervisor was also found to be associated with lower levels of

burnout, so females may also be engaging in pleasantries in the workplace that are

alleviating some of their stress (Maslach et al., 2001). Additionally, Rupert and Kent

(2007) found that females tended to receive more supervision than men, so this support

may also alleviate feelings of stress and burnout. Females also engaged in more “career-

sustaining behaviors”, such as “engaging in hobbies, spending time with friends,

engaging in spiritual activities, and maintaining a sense of control and self-awareness”

(Rupert & Kent, 2007, p.93).

Length of Time in the Field and Burnout

Contrary to what was expected, analysis of the length of time in the field and its

effect on burnout suggests that the longer a psychologist is in the field, the less emotional

exhaustion and burnout he or she experiences. Additionally, the longer a psychologist is

in the field, the greater sense of personal accomplishment he or she experiences.

Psychologists who have been in the field for many years may have learned more effective

coping strategies and may be better equipped to deal with daily stressors, which may in

turn lead to decreased rates of burnout (El-Ghoroury et al., 2012). The average age of the
THERAPEUTIC EFFECTIVENESS AND STRESS 55

sample was fifty-two years, so participants may have had many years to learn effective

ways to deal with stress. Additionally, the sample engaged in an average of eight hours of

self-care per week, which may have alleviated some of the stress they were experiencing.

The literature has shown that those who utilize coping strategies tended to report less

stress than those who did not, so it is possible that therapists who make time for self-care

have more effective coping strategies at hand (Maslach et al., 2001). Additionally, the

majority of the current sample was married, and those who are married typically have the

support of their spouses to help them cope with life stressors (Hobfoll, 1989).

Hours Spent Conducting Therapy and Burnout

Hours spent conducting therapy was not related to the amount of burnout a

psychologist experienced. It was predicted that psychologists who spend more hours

providing direct therapy to clients would experience a greater amount of burnout, but

results suggested that there was not a relationship between the two factors. However,

interestingly, a relationship was found between hours spent conducting therapy each

week and perceived stress and therapeutic effectiveness. The more hours spent with

clients a week, the less stressed psychologists felt, and the more effective they reported

feeling. The effectiveness of psychotherapy can serve as a stressor for therapists;

therefore it is possible that this population of psychologists rated themselves as more

effective overall (Deutsch, 1984; Thériault & Gazzola, 2006). Additionally, research has

shown that those who are able to make their own decisions regarding their work have a

greater sense of autonomy, which has been associated with lower feelings of burnout

(Maslach et al., 2001). It is possible that the population studied was able to choose the
THERAPEUTIC EFFECTIVENESS AND STRESS 56

number of hours they spent with clients per week, thus increasing their sense of

autonomy.

Hours of Self-Care and Burnout

The number of hours one spends in self-care activities and the relationship of this

factor with burnout were analyzed; results suggested that the more a person engages in

self-care, the less emotional exhaustion and depersonalization he or she feels, and the

greater sense of personal accomplishment he or she experiences. These findings suggest

that the more self-care a psychologist engages in, the less burnout he or she experiences.

Those engaging in self-care may have more resources available to them than others,

which can help alleviate the amount of overall stress they experience (Rupert et al.,

2009). Self-care is also beneficial for one’s overall physical health and well-being, as

well as the well-being of one’s clients. If a therapist is not taking care of himself or

herself this may influence the care of the clients as well (Barnett et al., 2007).

Perceived Stress and Burnout

Psychologists’ perceptions of their stress and its relationship with burnout was

analyzed, with results suggesting that the more stress that psychologists felt, the more

emotional exhaustion and depersonalization they experienced. Additionally, the more

stress they experienced, the less sense of personal accomplishment they felt. These

findings suggest that the more highly stressed, overall that a psychologist feels, the more

likely he or she is to experience burnout. Consistent with the literature, it appears that the

culmination of stressors over periods of time can lead to burnout (Rupert & Morgan,

2005). When one is experiencing stress, his or her decision-making skills can be

impacted. This is serious for mental health professionals, who often need to make quick
THERAPEUTIC EFFECTIVENESS AND STRESS 57

decisions when working with their clients (Pabst et al., 2013). In a situation with an at-

risk client, a therapist may already be experiencing increased stress, so poor decision-

making skills and negative thoughts could greatly influence their reactions. If a client is

experiencing suicidal or homicidal ideations, and a therapist is having difficulty making

decisions, both the client and others may potentially be at harm. Poor decision making

skills and burnout may lead to professionals becoming impaired, which can affect both

their personal and professional lives (Pabst et al., 2013). Therapists may turn to other

coping methods to deal with their stress, such as alcohol, which could further impair their

decision making abilities.

Predictors of Emotional Exhaustion, Depersonalization, and Personal

Accomplishment

Findings suggest that both perception of therapeutic effectiveness and perceived

stress were predictors of emotional exhaustion in psychologists. More specifically, these

findings suggest that a psychologist feeling diminished therapeutic effectiveness and

increased stress was likely to feel more emotionally exhausted. Findings also suggest

that therapeutic effectiveness, number of hours conducting therapy per week, and

perceived stress were predictors of depersonalization in psychologists. Specifically,

findings suggest that feeling diminished therapeutic effectiveness, spending more hours

per week conducting therapy, and experiencing higher levels of perceived stress predicted

a psychologist feeling increased depersonalization. Finally, therapeutic effectiveness and

perceived stress were predictors of personal accomplishment in psychologists.

Specifically, experiencing higher levels of therapeutic effectiveness predicted higher

levels of personal accomplishment in psychologists. Additionally, experiencing increased

THERAPEUTIC EFFECTIVENESS AND STRESS 58

levels of perceived stress predicted lower levels of personal accomplishment. As the

conservation of resources theory suggests, when a person has fewer resources, he or she

may experience an increased amount of stress (Dewe et al., 2012; Hobfoll, 1989). The

fewer resources a person has at any given time, the harder he or she works to hold on to

the current resource he or she has, creating more stress for that person (Dewe et al., 2012;

Hobfoll, 1989). If a psychologist feels that he or she is not accomplishing much

professionally such as not achieving goals and not earning rewards, he or she may feel an

increased sense of stress and the need to hold on to the current available resources. Stress

can also increase when one fears that he or she is at risk of losing resources, even if none

has actually been lost (Hobfoll, 1989).

Additional Analyses

A relationship was found between the length of time spent in the field and

therapeutic effectiveness and perceived stress. The longer a psychologist has spent in the

field, the more effective he or she felt, and the less stress he or she experienced. A

relationship was also discovered between hours spent conducting therapy and perceived

stress and therapeutic effectiveness. The more hours a psychologist spent conducting

therapy with clients, the less stressed he or she felt, and the more effective he or she felt.

Additionally, a relationship was found between hours of self-care activities and

therapeutic effectiveness and stress. The more hours spent involved in self-care, the more

effective a psychologist felt, and the less stress he or she experienced. A relationship

between perceived stress and effectiveness was also discovered, suggesting that the

greater stress a psychologist felt, the less effective he or she perceived him or herself to

be. Because the literature shows that uncertainty and doubt over one’s capabilities in
THERAPEUTIC EFFECTIVENESS AND STRESS 59

therapy has been identified as a factor creating stress in therapists, if one feels that he or

she is not being effective with clients, he or she may be experiencing an increased

amount of stress (Cushway & Tyler, 1996).

Limitations

A few limitations to the study should be noted. The link to the survey was

available online only, so those who do not frequent the internet may not have been

included in the sample. The study was time-limited, so more participants may have

responded if the study had been available online longer. Additionally, this was a self-

report study, so people may not have been forthcoming on the therapeutic effectiveness

or on the other measures. Inclusion criteria required participants to speak English and to

be providing therapy to clients for at least twenty hours a week, which may have also

limited those included in the sample. The sample may have also been biased because

those who are less stressed and thus experiencing less burnout may have had the extra

time to participate in the study.

Future Directions

Because significant differences were found when psychologists reported engaging

in self-care, one could study the effect that self-care has on decreasing burnout and stress

in this population, and even investigate if self-care could reverse the effects of burnout.

Different types of self-care activities could also be studied in order to determine those

types of activities that seem to be associated with less stress and burnout.

Additionally, because a relationship was found between stress and therapeutic

effectiveness, further studies should investigate what may be involved in this

relationship, and also whether or not this relationship continues to be found. Identifying
THERAPEUTIC EFFECTIVENESS AND STRESS 60

factors involved both in therapeutic effectiveness and in stress would allow programs to

be created and implemented in order to reduce the incidence of these occurring in the

mental health profession.

Further, future directions may include studying perceived stress, therapeutic

effectiveness, and burnout in more specific populations of therapists, students, or social

workers. Moreover, studies investigating the relationship of stress and burnout with

gender and investigating the length of time in the field are also necessary because

findings in this area have been inconsistent. Additionally, adding a social desirability

scale to a similar study in the future would allow one to predict whether or not therapists

were forthcoming in their responses to the questionnaires.

One could also view therapeutic effectiveness from the client’s perspective, and

investigate that relationship to perceived stress and burnout. Because all of the measures

involved self-reporting in this study, in the future, stress could be measured in more

objective ways. Additionally, one could use a similar study in order to develop an official

measure to assess therapeutic effectiveness. Future studies could also focus on

developing programs and trainings for graduate students so that they might learn to cope

with and prevent stress early in their training. For example, mindfulness based stress

reduction or stress-inoculation programs could be implemented and analyzed to

determine if these programs reduce the amount of stress that graduate students are

experiencing. Studies could also follow these students over time in their careers in order

to determine if a self-care program helps to prevent stress and burnout throughout an

individual’s career.
THERAPEUTIC EFFECTIVENESS AND STRESS 61

Other future studies may be used to develop a more specific model for predicting

burnout in mental health professionals. Because therapeutic effectiveness, perceived

stress, and number of hours spent in therapy with clients per week were found to be

predictors of the different subscales of burnout, one could further develop this model to

identify how many hours of client contact per week a therapist should engage in to avoid

experiencing higher levels of burnout.

Summary and Conclusions

Overall, findings of this study suggest that there is certainly a relationship

between therapeutic effectiveness, perceived stress, and burnout. This relationship seems

to be influenced by many factors, including the number of hours spent conducting

therapy with clients per week, the number of hours per week one engages in self-care, the

length of time a therapist has been in the field, and gender of the therapist. Results of the

current study provided a brief glimpse into this complex relationship, and hopefully

future studies will provide a greater in-depth look at the relationship between and among

these factors and perhaps develop a model determining how therapists can prevent

burnout.
THERAPEUTIC EFFECTIVENESS AND STRESS 62

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Appendix A

Demographics Questionnaire

1. What type of setting do you work in?

a. Community Mental Health
b. Private Practice
c. Inpatient Psych Clinic
d. Hospital/Medical Center
e. Inpatient Rehabilitation
f. Substance Abuse Rehabilitation
g. College Counseling Center
h. Forensic
i. Other

2. How long have you been in the field?

3. What is your therapeutic orientation?

a. Cognitive-Behavioral Therapy
b. Psychodynamic
c. Humanistic
d. Eclectic
e. Other

4. How many hours of therapy do you conduct per week?

5. What population do you work with? (Check all that apply)

a. Children
b. Adolescents
c. Adults
d. Serious Mental Illness
e. Substance Abuse
f. Medical Patients
g. Rehab Patients (Traumatic Brain Injury, Etc.)
h. Other

6. What is your gender?

a. Female
b. Male

7. What is your age?

8. What is your education level?

a. Master’s Degree
b. Post Graduate Degree
THERAPEUTIC EFFECTIVENESS AND STRESS 70

9. How many hours of sleep do you get per night?

10. How many hours per week do you engage in self-care activities (spiritual
activities, hobbies, exercise)?

11. Evaluate your personal physical health.

a. Poor health
b. Good health
c. Very good health

12. Do you drink caffeine?

a. Yes
b. No

13. If yes, please specify number of cups per day.

14. Do you use nicotine?

a. Yes
b. No

15. If yes, please specify number of cigarettes smoked per day.

16. How many alcoholic drinks do you consume per week?

17. What is your marital status?

a. Married
b. Divorced
c. Widowed
d. Living with significant other
e. Single

18. Do you have children under the age of 18 for whom you are the primary
caregiver?
a. Yes
b. No

19. What geographical region do you live in?

a. East
b. West
c. South
d. Central
e. North
f. Northeast
g. Southeast
h. Southwest
THERAPEUTIC EFFECTIVENESS AND STRESS 71

Appendix B

Therapeutic Effectiveness Scale

Instructions: Please read each question carefully and rate each question as honestly and

objectively as possible. Please use the scale below where 1= never, 2= rarely, 3=

sometimes, 4= often, 5= almost always and rate the extent to which you have experienced

the listed feelings and behaviors over the course of the last year.

1. I have had difficulty feeling empathy toward my clients.

2. I have lost interest in what my clients are telling me.

3. I have difficulty attending and focusing on what my clients are telling me.

4. I have had some feelings of hostility toward my clients.

5. I have continued offering therapy to clients, even when they are not improving.

6. I have been quite interested in what my clients are telling me.

7. I have had difficulty giving my clients the respect they deserve.

8. I feel that I have understood the needs of my clients.

9. I feel I have been able to develop a good working alliance with my clients.

10. I have shown unconditional positive regard (prizing) to my clients.

11. I have had difficulty working collaboratively with my clients.

THERAPEUTIC EFFECTIVENESS AND STRESS 72

12. I have had difficulty being genuine and real in the moment with my clients.

13. I have had difficulty expressing warmth towards my clients.

14. I have been distant with my clients.

15. I have had difficulty being open with my clients.

16. I have felt irritable toward my clients.

17. I have had difficulty developing a mutual trust with my clients.

18. I have had difficulty being honest with my clients.

19. I have found myself being rigid with my clients.

20. I have been cold towards my clients.

21. I have been able to see the world through the eyes of my clients.

22. I have been able to express true empathic understanding by putting myself in the
shies of my clients.

23. I am able to reflect feelings back to my clients.

24. I am able to paraphrase or reflect statements what my clients are telling me.

25. I have been able to keep an objective stance with my clients.

THERAPEUTIC EFFECTIVENESS AND STRESS 73

Lambert, M. J. (2011). What have we learned about treatment failure in empirically

supported treatments? Some suggestions for practice. Cognitive and Behavioral

Practice, 18, 413-420.

Lambert, M. J. (2013). Outcome in psychotherapy: The past and important advances.

Psychotherapy, 50, 42-51. doi:10.1037/a0030682