The burning issue of how to approach burnout

In January a new yearly assessment of national burnout was published by the charitable organisation Mental Health UK. It reported that 20 per cent of the population had time off work for work-related stress in the last 12 months, and 9 in 10 adults reported experiencing extreme stress in the last year.

Psychologists know how widespread this is, because our waiting lists are overflowing. It needs to be tackled systemically, with interventions at every level of society. Change is needed within organisations and communities, and we need changes to policies and approaches that promote unhealthy ways of working. In the meantime, how can we respond to burnout sufferers seeking support? 

When speaking to fellow applied psychologists about offering therapy to those who identify with burnout, a recurring theme is lack of confidence. Are we the right people to do this?  This makes sense with respect to the systemic issues. They are so widespread and entrenched it can feel hard to know where to start. As a psychologist, you can feel like a fish swimming upstream. But when it comes to individual therapy, we are absolutely equipped to work with burnt out clients. I hope to offer some practical advice for anyone considering how to approach this.

Is burnout an official diagnosis?

The concept of burnout has been around since the 1970s, but today's conceptualisation and measures of burnout stem from the work of Christina Maslach, a social psychologist who became interested in the 'detached concern' she was seeing in care-giving professionals. She identified three dimensions of burnout:

1. Physical and emotional exhaustion
2. Feeling detached from work
3. Reduced efficacy or personal accomplishment

The ICD-11 currently classifies burnout as a syndrome – a set of physical, emotional or behavioural signs and complaints that appear alongside each other, creating a state that is out of the norm. It's considered a syndrome of the three dimensions caused by 'chronic workplace stress that has not been successfully managed'. There is no reference to burnout in the DSM-5.  The WHO definition of burnout is based on the ICD-11 and is clear that it is an 'occupational phenomenon' rather than a medical condition.

There are countries where burnout does have a formal status in clinical settings – the Netherlands, Denmark, Sweden for example – whereas in the UK, burnout is not routinely being recorded in patient notes. British GPs are more likely to code a patient presenting with burnout complaints as 'stress at work', or label them with an anxiety or depression disorder.

The inclusion of  'occupational phenomenon' in the official definition has led to the term burnout being reserved for formal workplace settings only. But this restrictive understanding of work invalidates the experiences of billions of unpaid people such as informal carers, parents, students and so on, which in itself has a negative impact on mental health. Burnout must no longer be left in the realm of occupational health where it first began, and clinical and counselling psychologists shouldn't shy away from offering to work with burnout simply because it isn't a mental health diagnosis and we haven't perhaps learnt about it on our doctoral training.

How to recognise burnout

Clinical burnout

Clinical burnout is when the body has forced a stop in some way so is relatively easy to spot for a clinician, although it's not uncommon for the sufferer to be unaware of the important role that chronic stress has had in this. I think of this as an elastic band, where the stress has caused a stretch for so long that one day it has snapped and the individual finds that they can't get out of bed or has started having non-epileptic stress-induced seizures, or a physical health reaction like a cardiovascular response, or something similar.

High functioning burnout

It is also possible for someone to have higher functioning burnout for quite some time before reaching this breaking point. Often people only realise after recovery just how much they had been masking their level of distress from others and even themselves. If someone comes to therapy in this state then it is a good opportunity to compassionately call it out.

Start by checking in with the typical signs of stress such as irritability, disturbed sleep and appetite, unhealthy coping mechanisms like increased drinking or doom scrolling and so on. We know that a certain amount of stress is manageable, but when it's never-ending then the learned helplessness response can kick in; we stop feeling motivated or energised by the stress and we may get escapism thoughts, like wishing we could get ill to avoid the demands or even suicidal. 

Listen out for this learned helplessness, typically expressed as feeling like they are running on empty; lethargic; unable to imagine life any different. Are they exhibiting low self-belief, and a disconnection from friends, family or activities that used to light them up? 

Differentiating from other mental health diagnoses

Recent research (Tavella et al., 2020) tells us that the top five signs of burnout are exhaustion, anxiety, indifference, depression and irritability. Clearly this list of symptoms overlaps with other mental health diagnoses, so you'd be looking for differentiating features. For example in the anxiety disorders this would be the nature of anxious thoughts, intrusions and safety behaviours. In depression it would be the history of adversity and lack of control beyond their work context. 

It is also helpful to consider the six common external stressors shown to lead to burnout (Maslach & Leiter, 2016):

1. Work overload – having too much to do and not enough time to do it.
2. Lack of control – having little or no agency over decisions that affect how you spend your  time.
3. Insufficient rewards – any of the ways in which your efforts leave you feeling unvalued, such as lack of appreciation, monotonous work, or work where there is a long delay before seeing the outcome.
4. Break down in community – being in isolation or in an unsupportive environment means we have no psychological safety and not only does this make us feel unhappy but also means there is less chance of seeking support.
5. Lack of fairness – when others are being treated differently to us and it makes us feel cynical or angry.
6. Conflict in values – when we are asked to do things we don't agree with.

When exploring these, be careful not to focus solely on their paid work. Take into consideration all areas of their life and how they interact with others in these arenas, for example when studying, doing housework, volunteering and caring for dependents both young and old.

How I approach treatment planning

We all have different training in evidence-based models to draw on for individual therapy, but whatever models you prefer working with, here are some extra thoughts I tend to consider where burnout appears to be prime reason for coming.  

Deciding where to start depends on an individual's level of functioning and main presenting complaints. As with all cases, if someone's basic needs aren't being adequately met or they have unhealthy coping behaviours that are making things worse, then these need to be tended to first. Beyond this, they could benefit from spending time with you to identify people or organisations in a position to support them practically (e.g. HR, bosses, unions, partner, family) and could use therapy to practise asking for this support and dealing with any pushback or unhelpful responses.  

I find those coming to therapy for burnout feel relieved to hear what this term really means, and that there isn't something 'wrong' with them because this is how all humans react to chronic stress. Often there can be frustration where attempts at self-care haven't worked, feeling that mindfulness or journaling are extra item on an already bulging to-do list. I always explain that this isn't their fault, it's a sign of where their nervous system is at and that they need something before they can engage in those types of cognitive tools, such as somatic tools to discharge adrenaline or thaw out. Personally I draw on tools from EMDR and Polyvagal informed approaches for this (I share these in chapter five of my book Burnout: How to Manage Your Nervous System Before It Manages You.)

My psychoeducation of the human stress responses goes beyond the parasympathetic and sympathetic nervous system explanation. In my book I draw parallels between trauma and burnout and for this reason go on to explain dorsal shutdown in the way we do in trauma therapy – I find this helps people to understand the de-energised, lost and empty experiences which can't be explained by the sympathetic nervous system alone. 

I give space to explore the culture of productivity we live in and how this, alongside modern technology, keeps us in a state of being overstimulated and 'always on'; as well as the types of cultural narratives they may have internalised, some examples 'men as providers', 'women as nurturers' and there are other examples in my book. These cultural narratives create expectations  of us that we use to measure our self-worth.  These then show up as negative or self-attacking thoughts entangling us in a cycle that exacerbates burnout.

Whilst work like this with clients helps validate their distress, it also highlights areas of choice.  This can be enhanced further by using the 'sphere of control and influence' model (Covey, 1989). For example, consider the areas of life that someone has some agency in and help them to make small, consistent changes that have the potential to influence the level of stress they are under.

When someone is able to do deeper work, a longitudinal formulation can help them to understand their stress responses in context i.e. where their patterns of responding to demands come from. Do these still serve them and what are the unintended consequences? Typically areas that show up in burnout are insecure-striving in the form of Perfectionism and/or People-pleasing; or experiential avoidance through overworking. These behavioural patterns make it hard to tune in to one's own stress levels with compassion. Instead, the focus is drawn to protecting oneself from rejection or criticism in a way that can perpetuate the stress, such as believing you don't deserve self-care unless you have worked hard enough; putting others needs before their own, or feeling unable to set boundaries and so on.

Next steps

Burnout is a huge topic. Searching online for models, measures and approaches can be overwhelming, and there are many books available, by authors with various core professions. However, when I started researching this topic, I couldn't find one written by a clinical or counselling psychologist. I felt that this lens could contribute so much to this topic, such as the bio-psycho-social model, formulation and evidence-based therapy techniques that we are trained in.

This is why I wrote Burnout: How to Manage Your Nervous System Before It Manages You. It outlines concepts that my clients find helpful, such as the three subtypes of burnout and the 5-stage model. It also gives accessible psychoeducational material then formulation from a Compassion Focused Lens before offering a platter of psychological interventions from boundaries to values work. I hope all of this will be helpful to psychologists and those trying to understand and wrestle with this modern-day epidemic that has become an issue not only for those personally affected but also for their employers, co-workers and partners.

Dr Claire Plumbly is an HCPC-registered Clinical Psychologist, Chartered Member of the British Psychological Society, and Director of Good Therapy Limited, a centre for psychological therapy based in Somerset and online. She is also author of a debut book Burnout: How to Manage Your Nervous System Before It Manages You, out in the UK now and in the US in January 2025 as The Trauma of Burnout.

References

Covey, S.R. (1989). The 7 Habits of Highly Effective People. Simon & Shuster, London.

Maslach, C. & Leiter, M. P. (2016). Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry: official journal of the World Psychiatric Association (WPA).

Tavella, G., Hadzi-Pavlovic, D. & Parker, G. (2020) Burnout: re-examining its key constructs. Psychiatry Research, 287.