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TRANSCRIPT – Case Studies

Overview of the Organization

Berkshire Community Health (BCH) is a comprehensive healthcare facility serving western Massachusetts. BCH’s central campus consists of emergency services; specialty medical units, including a leading oncology department; a behavioral health therapy unit; and a social work team. Social workers are integrated throughout the facility to support behavioral health and interdisciplinary care. The social work team is supervised by Janell Morris, who is empathetic and supportive. Janell communicates effectively and encourages team-building through regular check-in meetings. The team is close and compassionate with one another. However, social workers often experience conflict with other collegial relationships beyond the team. As they are embedded within various units in the facility, they must work in interprofessional collaboration with other disciplines. Overall, social workers are devalued outside of the social work team. Recently, BCH rolled out a public relations campaign in which they declared the organization to be “trauma-informed.” However, no organization-wide policies or procedures have been implemented that reflect trauma-informed principles, nor were social workers consulted in the development of the campaign. To support the health and wellness of staff, the organization has an employee assistance program that is available 24 hours a day, 7 days a week. The organization also offers premier health insurance for full-time employees. Full-time constitutes working at least 36 hours a week.

Social Worker 1: Tyrone Tyrone is a 41-year-old male social worker who identifies as heterosexual, Black, and Latino. He is a divorced dad to a teenage daughter and shares custody with his ex-wife. Tyrone conducts individual therapy with clients at BCH to address mental health and substance use. In his therapeutic role, Tyrone sees individuals with complex trauma who have high therapeutic needs, compounded by high case-management needs. The expectation for this role is to see seven or eight clients per day, a standard that Tyrone has kept up with throughout his employment over the past 4 years. Substance Use and Work Tyrone, who has no recent history of substance use, has started drinking one to three glasses of wine at night and “nips” of alcohol during the workday. Tyrone explains that he “feels emotionally numb” and has difficulty concentrating and completing tasks at home and at work. He has begun to avoid people, places, and things that remind him of

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work with his clients, and he has also canceled sessions with clients who have higher levels of trauma to “stop my heart from pounding.” Tyrone complains of decreased sleep due to nightmares, difficulty falling asleep, and experiencing anxiety, but reports that he can “handle it on my own” by “doing what I need to do.” He has also expressed that he doesn’t know why he continues to meet with clients because “I’m not going to help them in the end anyway.” Social Support and Self-Care Tyrone describes limited social support. He declined invitations to social events for months, and, when he did attend, he’d just frustrate his friends by talking mostly about work. He also started expressing the belief that something bad is going to happen and that there is little hope for anything to change in the future. When friends attempted to confront Tyrone about their concerns, Tyrone became angry and irritable. Tyrone stopped attending church 3 months ago because he was “too tired” to go. He had previously identified church as a primary support. Tyrone reports a positive relationship with his ex-wife. He also reports a good relationship with his parents, who live a couple hours away. For self-care, Tyrone attempts to journal 3 or 4 days a week and takes short walks with his dog in the morning and evening. Anxiety Tyrone describes a recent event in which his 16-year-old daughter came home several minutes late from a social event. He began thinking of a client he was working with whose child had been murdered. Tyrone was pacing, looking out the window, and texting his daughter repeatedly because he became extremely anxious about her whereabouts.

Social Worker 2: Mei Mei is a 25-year-old female social worker who identifies as heterosexual and Asian American. She lives with her mother 1 hour away from BHC but is planning to move into her own apartment in an area more convenient to work. In her role at BHC, Mei is an emergency room social worker who performs psychological assessments and manages crises. Mei recently had an annual physical with her primary care physician, during which she complained of gastrointestinal (GI) upset. The primary care physician confirmed GI upset as well as high blood pressure and weight gain due to binge eating. The physician has referred Mei to you for therapy. Work Mei explains that work has become difficult for her, especially the unpredictability of the days in the ER. She is expected to work four 10-hour shifts a week and is also expected to take additional shifts as needed, due to a high rate of staffing turnover. Mei finds it

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difficult to separate personal and professional life as a helper, often thinking about her cases on the commute to and from work. On one morning’s commute, a car veered into her lane, and she was slow to react. She regretted that it did not result in an accident because then she “wouldn’t have had to go to work.” Mei reports feeling trapped by her job and that the work no longer satisfies her. She had thought she was doing what she wanted, but is now feeling like she made a mistake in choosing this line of work. Despite feelings of avoidance, Mei has difficulty setting boundaries with work and often stays for 12–14 hours. She feels as though the job is never finished. Her behavior is reinforced by colleagues in the ER telling the team to be “like Mei.” Physical Health Mei’s physical health has declined over the past year. She has gained 50 pounds because she often eats fast food, as it is “easier and more satisfying.” When Mei returns home after work, she eats several snacks and watches dramas on a streaming video service and “zones out.” She does not feel that she has the energy to exercise. Social Support and Self-Care In this same timeframe, Mei has felt herself losing a sense of connectedness to others, both personally and professionally. She has two childhood best friends who hold her accountable and are expressing concerns. However, she has reduced her time engaging socially with her friends and with her younger cousins, who are like siblings to her. In the early mornings at work, Mei feels particularly bad in her stomach and has been avoiding completing assessments in the ER at that time. Mei continues to engage in faith-based practices and has a good relationship with her mother, even though her mother is often already asleep when Mei returns home from work.

Social Worker 3: Destiny Destiny is a 52-year-old female social worker who identifies as queer and White. She lives with her partner, Candace. At BHC, Destiny serves as a case manager on the specialized oncology interdisciplinary team. Destiny and Candace have been fighting, with Candace reporting that Destiny’s mood is unpredictable and that she gets upset “over the littlest things all the time.” In a recent argument that became particularly hostile, Candace broached the subject. “Hey, I’ve noticed that you are more irritable lately…. What can we do differently?” Destiny denied being irritable. She yelled and threw her phone, and then said, “All you ever do is point out what I do wrong! What about what you’re doing?” Following the argument, Candace urged Destiny to see a therapist.

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Mood Destiny and Candace have been fighting, with Candace reporting that Destiny’s mood is unpredictable and that she gets upset “over the littlest things all the time.” In a recent argument that became particularly hostile, Candace broached the subject. “Hey, I’ve noticed that you are more irritable lately…. What can we do differently?” Destiny denied being irritable. She yelled and threw her phone, and then said, “All you ever do is point out what I do wrong! What about what you’re doing?” Following the argument, Candace urged Destiny to see a therapist. Work Destiny reports that she has been calling out from work on a regular basis. She is enraged by the policies of the organization that require taking on additional shifts due to staffing turnover. Additionally, Destiny had a recent conflict with colleagues in oncology regarding how they treat her and “talk down to her” as the social worker on the team. She made an initial angry comment, but now feels it is “pointless” to try and find a resolution because “it won’t make a difference.” Destiny states that day after day, she sees suffering and pain, and for the past 10 years she’s seen more people die than in all the previous years of her life. Social Media Use Destiny’s partner, friends, and colleagues have all commented on the excessive use of social media. Candace states that Destiny feels the phone is more important and only wants to connect with people who “are social media friends.” Coinciding with the increased use of social media, Destiny has started to withdraw from her partner. When she does communicate with Candace, the communication is filled with anger, yelling, and frustration. Destiny displays limited insight into why she might be irritable or avoidant. Social Support and Self-Care Destiny draws on the supportive relationships with her parents and in-laws and the bond she has with her supervisor, Janell, as they have worked together for 10 years. In the past, Destiny has enjoyed hiking and reading mystery novels. She also loves playing with her cat.

(Illustration by iStock/ALAA ASHRAF)

Health

Burnout From an Organizational Perspective Instead of pressuring already-stressed individuals to fix themselves, true wellness requires organization-level interventions.

By Leah Weiss Oct. 20, 2020

The term “burnout” �rst came into use in the early 1970s

in the context of air tra�c control, after an increase in

human error-precipitated collisions was linked to

frustrations with increased tra�c, poor human-machine

interfaces, and the general monotony of the work.

Described by the WHO as “resulting from chronic

workplace stress that has not been successfully managed,”

burnout is characterized by “feelings of energy depletion

or exhaustion, increased mental distance from one’s job, or feelings of negativism or cynicism related to

one's job; and reduced professional e�cacy.” But just as the early research on burnout showed it to be a

fundamentally systemic problem—since the air tra�c controllers being studied were extremely well-

trained in coping with stress (many were military veterans)—more recent researchers also describe the

causes of burnout as collective, and impossible for an individual to �x without a systems perspective.

Factors like overwork or insu�cient resources play a role in burnout, but according to Christina

Maslach, of University of California, Berkeley, and Michael Leiter, at Saint Mary’s University, it’s at least

as important to focus on fairness, transparency, and purpose in the workplace. Comparing workers to

cucumbers in vinegar, Maslach said: “We should be trying to identify and analyze the critical

components of ‘bad’ situations in which many good people function. Imagine investigating the

personality of cucumbers to discover why they had turned into sour pickles without analyzing the

vinegar barrels in which they had been submerged.”

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Burnout is undeniably costly. While individuals with full-blown cases can lose months and years of

wages and carry the burden of expensive mental health interventions, more than half of all professionals

fall somewhere on the burnout continuum. Burnout increases risk of coronary disease and type II

diabetes, is associated with lower heart rate variability—generally understood to be indicative of reduced

worse health and aging—and there have been studies of telomeres (protective caps at the end of

chromosomes) that indicate telomere shortening usually associated with biological aging. Burnout has

neurological implications, associated with thinning in the prefrontal cortex, larger amygdala, and

smaller caudate, giving people less capacity for decision-making and implicating memory, attention, and

emotion regulation. And beyond the physical implications of burnout, there are signi�cant economic

and social costs: Beyond the cost of treating burnout, research indicates severe consequences for

burnout on relationships, especially our closest relationships. A partner of someone who burns out is at

higher risk for burnout themselves, especially given compassion fatigue. Burnout costs organizations

$120-190 billion a year, a rate comparable to cancer, at $172.8 billion in losses a year.

How can we stop blaming cucumbers for becoming pickles? How to mitigate the acidity in the

environment? Individuals can’t yoga or meditate their way out of burnout. Indeed, heightening pressure

on already-stressed individuals to “�x themselves” only perpetuates the cycles of stress. Organization-

level interventions are needed.

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The Causes of Burnout

If we can better understand what causes burnout, we can detect it before it unfolds into complete

mental and physical collapse. This means learning how to recognize an early phase symptom like

“workaholism” for what it is, before it blossoms into a crisis.

Causes of burnout can appear at all three levels of an organization:

Individual Causes

Personal predispositions and character, such as perfectionism, and positive a�ect

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Personal situations, such as the stress we experience, the support networks we have created for

ourselves, or the type of job we are in

Personal coping and regulation mechanisms, such as how well we are able to self-regulate our

emotions and process them

Team-Level Causes

Underlying team structures, such as the size of the team, how they collaborate, and how they get

things done

Atmosphere created within the team, such as the degree to which people communicate openly

and are able to take risks

Organizational Causes

Level of transparency in the organization, such as how readily leadership shares salient

information with employees

Organizational structures, such as vacation time and other bene�ts and role clarity

Wellness Is Not the Answer

Wellness in the workplace is an $8 billion industry in the United States, and forward-thinking

workplaces may think they are doing a great service by o�ering yoga, meditation classes, and other

wellness services. But the research reveals that those e�orts are not working. A 2019 Harvard Medical

School study published in the Journal of the American Medical Association (JAMA) shows that

workplace wellness programs had no impact on overall health, sleep quality, nutrition choices, health

markers, or health care usage, failing to move the needle on the very issues that they claimed to redress.

The programs also failed to improve basic workplace metrics such as absenteeism, performance quality,

and retention of key employees.

The current spend on wellness is not �xing the problems it targets. So what can? First, we must broaden

our de�nition of the term and better understand that burnout is not a yes or no (you have it or you

don’t) condition.

Burnout Is a Spectrum That Can Be Measured

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With a broader view of what burnout is—less like an o�/on switch and more like temperature-taking—

we can begin to measure burnout. As the saying goes: “If you can’t measure it, you can’t improve it.”

New de�nitions of burnout have allowed us to recognize that:

Burnout is not binary. Most believe that one has the condition or does not have it. Yet it is actually

a spectrum and one that starts with seemingly harmless symptoms.

Burnout is distinct from depression and anxiety. Although it has some overlapping symptoms, it

de�nitely manifests di�erently and is often caused by a broader set of environmental factors.

Burnout should not be con�ated with compassion fatigue. Compassion fatigue is a speci�c

subset of burnout—associated with medical professionals, teachers, and social workers—which

relates to the diminishment of empathic response over time. But it’s a misnomer in the sense

that compassion does not become depleted whereas empathy does. Compassion activates the

reward response in the brain, but empathy �res the pain response, mirroring the pain of the

person being supported. Burnout is primarily a response to job demands, fairness, transparency,

and other issues beyond responding to pain over time.

There are various measures of burnout: the MBI (Maslach Burnout Inventory), the CBI (Copenhagen

Burnout Inventory), and Freudenberger’s 12 stages of Burnout. But current measurement tools here are

limited in three main ways:

�. They often confuse symptoms of burnout with risk factors of burnout, which is like equating

someone having genetic predispositions to a condition with having it.

�. They are designed to be measured at an individual level only, despite the fact that most causes of

burnout are either outside an individual’s control or informed by their environment.

�. They do not segue easily into action-taking, which is particularly problematic for a condition

whose de�nition includes a lack of personal e�cacy. Providing results without providing

immediate assistance in action-taking is at best careless, and at worst irresponsible.

Organizational Awareness

Early intervention o�ers the possibility to mitigate damage. While it takes an average of 14 months to

two years to recover from full-blown burnout, catching burnout upstream in an earlier phase can reduce

cost and length of interventions. To do this requires organizational awareness from leadership and

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managers, and requires regular collection of data at the individual, team, and aggregate levels of

burnout.

I argue for the imperative to create action-oriented, team-based diagnostics, since it is easy to miss

burnout at the individual level. It’s hard, if not impossible, to self-assess because early stages of burnout

masquerade as workaholism and believing you aren’t at risk is a risk factor. The causes of burnout are

social, and its measurement should re�ect that. It is critical to understand how clusters of people are

faring with burnout in order to lead to interventions that work. Individual-level action-taking is hard

because it’s hard to stay accountable and often stigmatizing. But change can be harnessed at the team

level. By going to the team-level, you spread the responsibility out and make it easier to stay accountable.

Team action-taking is also more nimble and can happen more quickly versus trying to change an entire

organizational culture at once, which can be quite complicated.

A better diagnostic approach would ask questions at all three levels—individual, team, and organization

—to understand both the cucumber and the vinegar it �nds itself in:

“Do you see the world as a place full of opportunity?”

“Do you feel a sense of autonomy and voice in your team?”

“Do you feel that reward systems in your organization are fair and transparent?”

In case studies we’ve done with medium and large organizations, diagnostic tools have helped

organizations determine where they are on a burnout spectrum and take e�ective actions: what gets

measured can be improved.

With Entrepreneurs Organization we worked with a team of 150 people that completed full burnout and

resilience diagnostics, which included 33 risk factors that contribute to burnout risk. We were able to

extract the three major themes for the organization to focus on, and to sequence action-taking based on

their scores and organizational needs. This burnout work will be embedded in their strategic planning

at the highest levels for cultural change, bene�t change decisions, and training budget decisions. In

addition, each of their 11 teams received customized action-planning support based on their results

which included: team coaching with highly quali�ed and trained coaches, and nudges that are

customized to each team’s chosen course of action. 

At Space Center Houston, we worked with a team of 50 who completed diagnostics to assess their

burnout risk factors. In 2020, Houston has been speci�cally hit hard by both the COVID-19 pandemic

and natural disaster damage caused by Hurricane Laura, so organizations in the area have been

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incredibly sensitive to burnout within their teams. The data from our diagnostic outlined patterns of

risk factors that recurred across individual, team, and organizational level. The results of those will

allow for more thoughtful decision-making around bene�t, training and culture change decisions for

the organization today and in the future.

There are also lighter lift entry points for getting started. For example, Stanford Hospital sta� members

were given a two-minute quiz (link here) to better understand their resilience typologies as a group,

helping them understand what might make them more or less at risk of burnout as an individual and as

a team. They also got a snapshot of their motivational styles and coping strategies that set them up for

conversations on how they could support one another more e�ectively.

How to Create a Burnout Shield

While it may be frustrating to know that more meditation won’t necessarily save individuals from

burnout, there are organization-level strategies that companies can take up to safeguard their greatest

resources, their people. Programs that are directed at individuals can have an impact, but only for about

six months or so. But when the intervention targets the organization (e.g. task restructuring, evaluation

changes, supervision shifts impacting job demand, and ability to in�uence decision-making) the impact

lasted up to a year. When the personal and organizational are combined the impact is longer and

stronger. But it is critical to realize that burnout work can’t be done as a one-o�; it needs to be a constant

e�ort over time.

Examining Managerial Behavior. Research shows that bad relationships with direct managers account

for 75 percent of turnover. Too often, managers are incentivized to focus on short-term productivity

metrics and are not trained to understand what is needed for sustainable individual and team

performance. Extensive research by the military on sustainable performance in stressful conditions

teaches that leaders should become champions of health, rather than taskmasters that drive teams and

organizations to burnout.

Upholding Fairness and Transparency. There are some interesting pieces of research on the fact that

even monkeys value fairness. We are wired this way. As a result, when promotions are distributed

unfairly, it contributes to burnout. This is especially true for groups that experience bias and

microaggressions daily, who see themselves, and people who look like them, sidelined from

advancement in the organization. People need coherence, purpose, and fairness to be healthy. Managers

must understand that the behavior they model and the way they distribute work steers their team

toward health or dysfunction and determines the ensuing human and organizational cost.

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