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Health Horizons : New Stresses Spark More Burnout for Counselors : Experts say managed care is adding to an already significant professional hazard. For some, it's time to change jobs.


"I felt like an emotional sponge, wrung out, with nothing left but still being squeezed."

That's how psychologist Gary Kaplan describes the way he felt back when he was treating patients, before he switched a decade ago to teaching at San Francisco State University.

It's called burnout, the debilitating physical and emotional overload that stems from stress on the job.

And although the syndrome strikes many occupations, it has long been common among mental health workers, report psychiatrists, psychologists and other counselors.

Worse, the problem promises to take an even greater toll as new pressures, including managed-care directives that limit autonomy and threaten livelihoods, take hold, practitioners say.

"It's a significant problem," says Anna Beth Benningfield of Dallas, a past president of the American Assn. for Marriage and Family Therapy. "Our [burnout] rates are up there along with those in lawyers, folks at the high end of the computer industry and those who work in medicine--anything where there are huge demands on people for production or service delivery, as well as uncertainty about the climate they're working in."

Burnout "is overwhelming," agrees Dr. Harold Berson, who is on an American Psychiatric Assn. committee that studies the issue. Clinicians "had problems to begin with, getting too involved with their work and their patients," he said. "Now, there's an intensification of the problems as the managed-care system takes away private practices. They're losing their identity."

To help its members with problems associated specifically with the pressures of managed care, the APA set up a toll-free hot line about three years ago, says John Blamphin, director of public affairs.

The problem with managed care, Blamphin says, is that it too often wrongly denies or limits psychotherapy, reduces provider choice and second-guesses decisions mental health professionals make.

"Some psychiatrists report a 30% to 40% reduction of business," he says. "They're being frozen out of the market."

But it's more than a loss of money that is upsetting mental health providers, Blamphin says.

"It's that loss of a sense of dignity that occurs when one is not respected as a highly trained professional," he says. "And it's the worry that patients aren't getting medically necessary care."

San Francisco State's Kaplan first got involved with burnout as a theoretical idea in 1980 while he was at Jefferson Medical College in Philadelphia.

He and his colleagues held a daylong workshop on the subject. Kaplan's job: to review published literature, which then consisted of only three articles, he says. At the workshop, practitioners shared feelings of helplessness and exhaustion, and of never being able to keep up with the job's demands.

"Some thought burnout was terminal, the end of the line--you burn out and there's nothing left," Kaplan said. "Others thought it was reversible, curable, temporary."

So which is it?

"It's some of each," Kaplan says. "For some people, it's an end point. For some, it can be dealt with. Folks in this kind of work really have to know themselves pretty well."

Leaving the profession is sometimes the wisest choice, says Benningfield, who's been in private practice in Dallas for two decades.

"I've seen people leave and be very pleased with that decision," she says. "Change should always be an option, and what's important is that people be assisted in leaving feeling good about that choice."

Kaplan knew himself well enough to get out after things got too rough. He cites the day he spent four hours in an emergency room--with a psychiatrist--trying to talk a disturbed woman into committing herself to the hospital.

"She wouldn't go in," he says. "She walked out the door, and a half-hour later came back dead on a stretcher. She'd gone to a tall building and jumped."

Today, Kaplan conducts burnout seminars for mental health workers and those other helping professions, such as nursing.

He recommends being in a peer support group, getting regular exercise--the "safety valve for the body"--and taking regular vacations--the "safety valve for the head."

Susan Brace, a former acute-care nurse who's now a psychologist with a private practice in Los Angeles, concurs with Kaplan's prescription.

She says she has been able to deal with her occupational stress but that she has to pace herself.

"I need a two-week vacation every three months," she says, "or I can't sit and listen to what people are telling me and contain it. Sometimes at the end of a day, I can't even listen to the radio or hear another word. So I'll numb for a bit and then I resume."

Brace worries about patients who might commit suicide, something she calls the "major stress for mental health professionals."

"It hasn't happened yet, but I've had some very close misses," she says. "But I learned as a nurse that you don't save lives, nor do you lose them. You simply provide care."

She says most mental health professionals she knows are in treatment themselves.

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