Soc Psychiatry Psychiatr Epidemiol (2004) 39 : 752–757 DOI 10.1007/s00127-004-0808-7

■ Abstract Background This study investigated the ex-tent to which occupational therapists and social workersemployed in Australian mental health settings are af-fected by burnout. Method Questionnaires were sent tooccupational therapists and social workers who had in-dicated that they were interested in participating in thestudy. An overall response rate of 76.6 % (n = 304) wasachieved. The outcome measure was the MaslachBurnout Inventory (comprising emotional exhaustion,depersonalisation and personal accomplishmentscales). Results There were no significant differences,with respect to any of the three burnout scales, betweenoccupational therapists and social workers. Both groupsexperienced high emotional exhaustion, moderate de-personalisation, and high personal accomplishment.Levels of burnout were not significantly different be-tween inpatient and community staff.Conclusions Theseresults suggested that,while occupational therapists andsocial workers reported emotional exhaustion, therewas less evidence of depersonalisation and they re-ported very high personal accomplishment in theirwork. Results are congruent with those of previousstudies and it is argued that the focus of future researchshould be on identifying characteristics of mentalhealth work that contribute to emotional exhaustion.

■ Key words occupational therapists – social workers –mental health – burnout

ORIGINAL PAPER

Chris Lloyd · Robert King

A survey of burnout among Australian mental health occupational therapists and social workers

Accepted: 17 March 2004

SPPE

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Introduction

As a result of mental health reform, there have beenwidespread changes in mental health services and ex-tensive initiatives to improve service delivery are cur-rently taking place (Australian Health Ministers 1998).For new service developments to be successful, skilledand dedicated health professionals need to be retainedwithin them. Literature from the United Kingdom hasindicated that the long-term sustainability of intensivecommunity services may be threatened by diminishingmorale and increasing burnout among mental healthstaff (Prosser et al. 1996, 1999; Onyett et al. 1997; Reidet al. 1999). The extent to which burnout may be an issuefor mental health staff working in Australian settings islargely unknown.

According to Maslach et al. (1996), burnout differsfrom occupational stress in that it is specific to work thatrequires intense involvement.The defining feature of oc-cupational stress is an imbalance between occupationaldemands and available coping resources (Maslach et al.1996). The burnout concept integrates feelings of ex-haustion with staff members’ involvement in their work,especially the people with whom they work, and theirsense of efficacy or accomplishment. Burnout is usuallythought of as the outcome of chronic stress (Cushwayet al. 1996).

Burnout is a complex phenomenon which consists ofemotional exhaustion, depersonalisation, and reducedpersonal accomplishment (Maslach et al. 1996). Staff feelthat they are unable to give of themselves at a psycho-logical level, develop a negative attitude about theirclients, evaluate themselves negatively and feel dissatis-fied with their accomplishments on the job (Maslachet al. 1996). This has serious implications for the staffthemselves, the clients they interact with, and the organ-isation. A number of recent studies investigating levelsof stress and burnout in mental health staff have ac-knowledged the need to consider staff as well as clientoutcomes in assessing the long-term effectiveness ofservice models (Reid et al. 1999).

C. Lloyd, PhD (�)Dept. of Occupational TherapyUniversity of QueenslandSt Lucia (QLD) 4072, AustraliaE-Mail: c.lloyd@shrs.uq.edu.au

R. King, PhDDept. of Psychiatry,University of QueenslandHerston (QLD), Australia

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The person who burns out is unable to successfullydeal with the chronic emotional stress of the job, andthis failure to cope can be manifested in a number ofways, including low morale, impaired performance, ab-senteeism, and high turnover (Maslach et al. 1996;Soderfeldt et al. 1995).A common response to burnout isto change jobs, move into administrative work, or evenleave the profession entirely (Brown and Pranger 1992;Soderfeldt et al. 1995). Additionally, burnout is corre-lated with various indices of personal dysfunction.Emo-tional exhaustion is often accompanied by physical ex-haustion, illness, psychosomatic symptoms, increaseduse of alcohol and drugs, and increased marital andfamily conflict (Maslach et al. 1996). As a result of thesefactors, a deterioration in the quality of care that servicerecipients receive may occur (Maslach et al. 1996).

■ Literature review

Community mental health teams have become the mainvehicle for a shift towards co-ordinated community-based health and social care. This has required staff torefocus their practice and ideology to prioritise peoplewith the most complex health and social care needs(Onyett et al. 1997). In a review by Edwards et al. (2000),the evidence indicated that those health professionalsworking as part of community teams are experiencingworkloads, increasing administration and lack of re-sources.A study of 445 team members in 57 communitymental health teams in Britain found that emotional ex-haustion was high among some of the key disciplines,notably social workers, nurses, consultant psychiatrists,and clinical psychologists (Onyett et al. 1997).

Prosser et al. (1996), in their study, compared stressand job satisfaction between community and hospital-based staff, including nurses, psychiatrists, occupationaltherapists, social workers, and psychologists. Commu-nity staff scored significantly higher on the GeneralHealth Questionnaire (GHQ) and experienced higherlevels of emotional exhaustion when compared to hos-pital-based staff. The researchers suggested that the re-sults reflect widespread recent changes in communityservices, inadequate resources, working in a deprivedarea, and lack of training and supervision. This findingmay be explained by the possibility that staff who choseto remain hospital-based were protected against changeper se, whereas developing community services areevolving and changing work-context, quite apart fromresource deprivation and training levels.

In a further study, Prosser et al. (1999) examinedwhether the adoption of a more community-basedmodel in an inner-city psychiatry service was accompa-nied by increasing burnout, poor psychological well-be-ing, and decreasing job satisfaction amongst staff. Thefindings revealed that staff were not becoming increas-ingly burnt out over time, but being based in the com-munity was associated with poorer psychological well-being. The researchers highlighted the importance of

further research to establish why community staff mayhave worse mental health than inpatient staff so thattheir work environment can be improved.

The Prosser et al. (1999) findings were investigatedfurther by Reid et al. (1999) who conducted a qualitativeinterview study. They explored 30 mental health profes-sionals’ views of their work and its effects on them. Theyfound that contact with colleagues was one of the majorrewards of the job and acted as a buffer against stress.Contact with clients was found to be highly rewarding,but staff also felt burdened by a sense of responsibilityfor their clients’ well-being and actions.With limited op-portunities for staff to develop specialist skills in work-ing with particular client groups, they felt ill-equippedto deal with difficult client groups. In the inpatient set-ting, health professionals identified difficulties associ-ated with lack of job autonomy, responsibility, and scopefor developing a therapeutic relationship. Reid et al.(1999) concluded that the reasons why staff in commu-nity services had higher burnout than staff in inpatientsettings had to do with the burdensome nature of thework. Specifically, taking considerable responsibility forclients’ welfare, particularly where there are risks thatclients may harm themselves or others, insufficientstaffing and other resources available to meet the exten-sive responsibilities conferred on them by recent legisla-tion was causing problems.

Harper and Minghella (1997) conducted a quantita-tive study to identify the pressures and rewards of work-ing in community mental health teams. Staff reportedgenerally low levels of burnout on the Maslach BurnoutInventory (MBI). A heavy workload (e.g. caseload sizeand number of referrals) was the most commonly citedpressure followed by bureaucratic structures and prac-tices (specifically too much paperwork), relationshipswith other agencies, poor management, and lack of re-sources. Achieving positive outcomes with clients wasthe most rewarding aspect of working in teams. A limi-tation of this study was the small sample size.

Early studies examining burnout among occupa-tional therapists working in mental health reported lowlevels of burnout on the three MBI subscales (Rogersand Dodson 1988; Sturgess and Poulsen 1983). In con-trast, later work on burnout found levels of emotionalexhaustion to be significantly higher than the normativegroup (Brown and Pranger 1992; Pranger and Brown1992). Studies of burnout among social workers haveconsistently reported moderate to high levels of burnout(Collings and Murray 1996; Martin and Schinke 1998;Prosser et al. 1999; Rabin and Zelner 1992), resulting inthe conclusion that social workers are more vulnerableto burnout than other allied health professionals, espe-cially in respect of low personal accomplishment(Onyett et al. 1997; Prosser et al. 1996).

Australian mental health services have undergonesignificant changes over the last few years. With the ma-jor restructuring of mental health services have comechanges in service development, organisational struc-tures and work practices (National Mental Health Strat-

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egy Evaluation Steering Committee 1997). The reformprocess in Australia has been co-ordinated and compre-hensive. The National Mental Health Plan (1992) identi-fied the steps that the State, Territory, and Common-wealth Government were to undertake in the areas ofstructural and system reform, standards, consumerrights, data, legislation and resource priorities (White-ford et al. 1993). It is important to determine to what ex-tent the current work environment is imposing signifi-cant stresses on the workforce, and in particularwhether burnout is a major factor.

Occupational therapists, as with other health profes-sionals, have been required to assume new roles andresponsibilities. There has been an emphasis on devel-oping a generic skill base in order to assume broad-spectrum mental health professional roles and to pro-vide community-based care (Deakin Human ServicesAustralia 1999; Greaves et al. 2002). It is not known towhat extent mental health reform has impacted onoccupational therapists. There has been limited re-search concerning how occupational therapists haveadjusted to working in restructured mental healthservices, especially in the Australian context, with pre-vious research in this area being conducted more thantwo decades ago.

How occupational therapists have adjusted in com-parison with other mental health professionals such associal workers is also not known. Because occupationaltherapy and social work are cognate professions, socialwork was selected as a comparative group for this study.Occupational therapists and social workers are both fe-male-dominated professions.They also have similaritiesin their undergraduate education. Their education isgeneric with the aim of producing graduates with abroad range of skills in a considerable range of practicesettings. Social workers and occupational therapists arerequired to develop their expertise in mental health onthe job, as well as by undertaking in-service training,and self-initiated postgraduate studies (Deakin HumanServices Australia 1999; Greaves et al. 2002).

■ Aim of the study

This study focused on practitioners in mental healthand aimed to identify the extent of burnout experiencedby occupational therapists and social workers. In thelight of previous findings, it was hypothesised that socialworkers would report higher levels of burnout than oc-cupational therapists and that practitioners working incommunity settings would report higher levels ofburnout than practitioners working in inpatient set-tings.

Subjects and methods

■ Design and instrumentation

The study design was a cross-sectional survey, incorporating a stan-dardised measure of burnout, of 304 Australian mental health occu-pational therapists and social workers.

■ Outcome variable

The Maslach Burnout Inventory, which is a widely used human ser-vices burnout measure, was used in this study. It comprises three sub-scales – emotional exhaustion, depersonalisation, and personal ac-complishment (Maslach et al. 1996).

■ Explanatory variables

The potential variables measured were: a) Work activity; b) Level ofexperience; c) Time in current position; d) Profession (occupationaltherapist, social worker); e) Demographic variables (age, gender);f) Client group; g) Type of service or team.

■ Sample

Questionnaires were sent to staff working in Australian public men-tal health services who had expressed an interest in participating inthe study. Contact had previously been established with senior staffoutlining the purpose of the study and soliciting staff who would bewilling to participate.An overall response rate of 76.6 % (n = 304) wasachieved based on the total possible responses (n = 397). The returnsample consisted of 196 (64.4 % of the sample) occupational thera-pists and 108 (35.6 % of the sample) social workers. The return sam-ple consisted of 196 (64.4 % of the sample) occupational therapists ofwhom 178 (91 %) were female and 108 (35.6 % of the sample) socialworkers of whom 69 (64 %) were female.

Pearson’s chi square test of independence [χ2 (1) = 33.14, p = 0.00]indicated that there were significant gender differences between oc-cupational therapists and social workers. The occupational therapysample had a significantly greater proportion of females than did thesocial work sample.

Most participants were in the 20 to 30 year age bracket. WhenPearson’s chi square test of independence was applied, there were sig-nificant differences [χ2 (5) = 58.10, p = 0.00] between social workersand occupational therapists with the occupational therapists beingyounger. Specifically, there were 117 (59.7 %) occupational therapistsaged 20–30 compared to 18 (16.7 %) social workers.

One hundred and forty-one (46.4 %) respondents held a base-grade discipline-specific position, 82 (27 %) held a discipline-specificsenior position, 14 (4.6 %) held a head or director position, and 67(22 %) held a generic position. The length of time in the position cur-rently held by the respondents ranged from 1 month to 26 years. Twohundred and forty-three (79.9 %) respondents had worked in theircurrent position for up to 5 years.

■ Data analysis strategy

The study aimed to address two questions, each of which implied aspecific approach to data analysis. The first question concerned thelevels of burnout in two allied health professions. Data analysis in re-spect of this question required only calculation of mean scores oneach of the subscales of the MBI and comparison of these scores forthe two professional groups. The second question concerned sourcesof burnout and in particular the relationship between the nature ofthe work environment and burnout. This required a more complexapproach to analysis as it might be expected that a range of factors in-cluding age, gender and experience of the practitioner, client group,work location (rural or urban) and professional duty profile impact

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on burnout. To manage this complexity, a multivariate analysis ofvariance (MANOVA) was used with the three MBI subscales as de-pendent variables, gender, profession and work location as fixed fac-tors and age, experience, and duty profile variables as covariates. Thenumber of variables included in the analysis resulted in increased riskof Type I error and, to reduce this risk, the level of significance was setat p < 0.01 rather than the conventional p < 0.05.

Results

■ Burnout

The MBI mean scores for the sample as a whole were22.7 (SD = 9.9, range = 2–52) for emotional exhaustion,6.1 (SD = 4.9, range = 0–26) for depersonalisation, and36.4 (SD = 5.9, range = 19–48) for personal accomplish-ment. The MBI mean scores for the occupational ther-apy and social work participants are displayed inTable 1. When these means were compared using t-testfor independent samples, they were not found to be sta-tistically significant.

Maslach et al. (1996) suggested that based on a nor-mative sample of 730 mental health workers, burnout inmental health professionals is indicated by scores of 21or more for emotional exhaustion, 8 or more for deper-sonalisation, and 28 or less for reduced personal accom-plishment. Using these cut-off points, 173 (57 %) of thesample were positive for emotional exhaustion, 98(32.7 %) were positive for depersonalisation and 26(8.9 %) were positive for low personal accomplishment.Chi-square tests were used to investigate differences be-tween social workers and occupational therapists withrespect to positive burnout scores. No significant differ-ences were found.

■ Multivariate analysis

Multivariate analysis confirmed that profession is notassociated with burnout, even when gender, work loca-tion and setting, age, experience and duty profile aretaken into account. There was no evidence of effect foreither of the other fixed factors (gender and service lo-cation). Among covariates, three met the criteria ofp < 0.01 and were investigated further. There was evi-dence that greater amount of activity in general clinicalwork was associated with higher personal accomplish-ment (F = 16.0, df = 1, p < 0.001). Pearson correlation wasused to investigate the strength of relationship between

these variables and yielded a coefficient of r = 0.26.There was also evidence that younger age (F = 7.8, df = 1,p = 0.006) and a higher proportion of time spent under-taking case management (F = 7.6, df = 1, p = 0.006) wasassociated with higher depersonalisation scores. Fur-ther investigation of the relationship between thesethree variables using partial correlation revealed thatage (partial r = –0.16, n = 297, p = 0.006), but not casemanagement, met the probability criteria of p < 0.01.

Discussion

The findings reported in this study reveal that the par-ticipants had high rates of burnout in the area of emo-tional exhaustion, average rates in the area of deperson-alisation, and low rates in the area of personalaccomplishment.

The findings from this study share similarities withother studies examining burnout among mental healthprofessionals. For example, Prosser et al. (1996) foundhigh scores for emotional exhaustion (mean 22.9), aver-age scores for depersonalisation (mean 7.5) and highscores for personal accomplishment (mean 33.5) amongmental health staff working in inpatient and commu-nity-based services. They found that levels of burnoutwere especially high among social workers. When theMBI was readministered 3 years later, Prosser et al.(1999) found that there had been no significant changesover time for emotional exhaustion, depersonalisation,and personal accomplishment.

Onyett et al. (1997), in a study of community mentalhealth teams, found burnout on the emotional exhaus-tion scale was significantly higher than the scale norms(mean 20.0), significantly lower on the depersonalisa-tion scale (mean 4.7),but significantly higher on the per-sonal accomplishment scale (mean 35.7). Forty-five percent of their sample fell into the high emotional exhaus-tion category. Unlike this study, social workers experi-enced high levels of emotional exhaustion in compari-son with occupational therapists and most othergroups.Contrasted to this, the findings from the study ofcommunity mental health staff by Harper andMinghella (1997) found that mental health staff experi-enced low levels of burnout. There were no significantdifferences between staff groups.

In considering studies examining burnout in occu-pational therapists, the mean scores on the MBI in earlystudies were lower than test norms (Rogers and Dodson1988; Sturgess and Poulsen 1983). The exception to thiswas in the area of personal accomplishment which wasslightly higher than the norm. In contrast, later work onburnout found levels of emotional exhaustion to be sig-nificantly higher than the normative group (Brown andPranger 1992; Pranger and Brown 1992). In this study,higher levels of burnout on emotional exhaustion anddepersonalisation were found compared to earlier stud-ies. Similar to other studies, high levels of personal ac-complishment were evident.

Table 1 MBI mean scores for occupational therapists and social workers

OT SW

Mean SD N Mean SD N

EE 22.5 9.9 193 22.9 10.4 108

DP 5.9 4.5 192 6.3 5.4 108

PA 36.2 6.1 189 36.8 5.8 104

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In previous research, social workers have been foundto experience moderate to high levels of burnout (Mar-tin and Schinke 1998; Prosser et al. 1999; Rabin and Zel-ner 1992). It has been suggested that they may experi-ence higher levels of burnout compared to otherprofessional groups, particularly on feelings of personalaccomplishment. In this study, social workers show sim-ilar levels of emotional exhaustion and depersonalisa-tion to those reported in other studies (Onyett et al.1997; Prosser et al.1996). In this study,unlike in previousstudies, the social work participants experienced highlevels of personal accomplishment.

Previous research had found that people in commu-nity settings reported higher levels of burnout than in-patient practitioners (Prosser et al. 1996, 1999; Reid et al.1999). Interestingly in this study, inpatient staff were nodifferent from community staff in the levels of reportedburnout. This may be in part due to the nature of Aus-tralian mental health services where integrated modelsof practice are followed with staff participating in arange of roles and functions. Greaves et al. (2002) foundthat mental health professional groups such as occupa-tional therapists had adapted well to the demands ofmultidisciplinary service delivery approaches that char-acterise contemporary mental health practice. They alsofound that occupational therapists had a high capacityto learn new skills on the job.

Despite measurement of a broad range of variablesthought likely to affect burnout, only two variables (ageand level of general clinical activity) survived the strin-gent analysis strategy and probability settings to emergeas predictors of burnout. Older occupational therapistsand social workers were less vulnerable to depersonali-sation than younger practitioners and high levels of ac-tivity in general clinical work was associated with higherlevels of personal accomplishment.

According to Maslach et al. (1996), emotional exhaus-tion is the scale that is most responsive to the organisa-tional environment and social interactions that charac-terise human service work. Emotional exhaustion isseen as mediating the environment’s relationships withdepersonalisation. In contrast, personal accomplish-ment is less closely related to emotional exhaustion instructural models and may develop in parallel withemotional exhaustion (Maslach et al.1996).This appearsto be the case in this study. A sense of achievement orcompetence operates as distinct from emotional ex-haustion and serves as a protective factor.

Previous research has provided some indication thatburnout can be offset by the benefits of experience andadaptation at both an individual and organisationallevel (Prosser et al. 1999). However, in this study, agerather than duration of employment in mental healthwas the protective factor and it is possible that personalmaturity rather than experience is decisive in manage-ment of depersonalisation.The finding that general clin-ical activity, but not specialist clinical activity, is associ-ated with high personal accomplishment suggests that itis everyday interaction with clients rather than deploy-

ment of highly specialised expertise that is most satisfy-ing and protective for occupational therapists and socialworkers.

■ Limitations of the present study and future research

There are a number of limitations to this study, whichneed to be considered when reviewing the findings. Asin any questionnaire survey, there is always a percentageof non-responding participants. The sample of non-re-sponding participants was not checked for possible re-sponse bias. It is, therefore, not known whether the non-respondents experienced more pressure at work andwere more burnt out. The sample that responded may bemore highly motivated and possibly less burnt out thanthe broader population of occupational therapists andsocial workers in mental health. The rate of return, whilehigh, overestimated the underlying response rate to thesurvey as return rate is based on participating sites andit is not possible to calculate the number of potential re-spondents in non-participating sites. The absence of in-formation in relation to the non-responders means thatthe generalisability of the results obtained from theachieved sample to the broader population cannot beaccurately determined.

Another limitation of the study was that it was re-stricted to two allied health professions rather than allallied health professions or all mental health profession-als. This limits the findings and subsequent implicationsto these two professions and does not shed any light onhow other mental health professionals have adjusted towork practices brought about by mental health reform.The sample did not include private mental health ser-vices and was restricted to public mental health teams.In addition, no comparison with burnout results forgeneral health, welfare or other work teams is possible.

Methodological weaknesses notwithstanding, a sub-stantial empirical study such as this yields important in-formation about the burnout profile of specific groupsof health professionals, and adds to an internationalbody of evidence that is showing substantially conver-gent trends. It is clear that emotional exhaustion is a ma-jor contributor to burnout among occupational thera-pists and social workers and it is a matter of concern thatthis study failed to identify any clear workplace factorsassociated with emotional exhaustion, despite measure-ment of a broad range of workplace variables. Burnoutis a complex phenomenon that is usually conceptualisedas developing over time rather than as a response to spe-cific events or working conditions. A cross-sectionalsurvey is clearly limited in its capacity to detect changesover time. In this study, we found that duration of workexperience in mental health is not a predictor ofburnout, but this may be because people succumbing toburnout leave this area of work and burnout effects are,therefore, not detected cross-sectionally. An improvedstudy design would use a repeated measures model.Maintaining data integrity would present practical

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problems as high levels of attrition might be expected ina study that spanned the period relevant for investiga-tion of burnout. However, such a study has potentialbenefits and subject to feasibility should in our view beconsidered.

There may be a role for qualitative research in identi-fying characteristics of mental health work that con-tribute to emotional exhaustion prior to much neededintervention studies. It would be of value to identifymental health professionals that do not suffer from emo-tional exhaustion. Further study of this group with aview in the first instance to confirming previous studiesand, subject to this confirmation determining charac-teristics of their work activity that are protective in rela-tion to emotional exhaustion may be a priority.

Conclusion

The findings from this study indicate that occupationaltherapists and social workers are experiencing high lev-els of burnout in the areas of emotional exhaustion andmoderate levels of depersonalisation, but that this is off-set by high personal accomplishment.There were no sig-nificant differences between the two groups in the threeaspects of the burnout syndrome.Whether practitionerswere based in inpatient or community-based settingswas not associated with higher levels of burnout. Thefindings share many similarities with studies of mentalhealth professionals conducted in the UK. Younger agewas found to be associated with greater risk of deper-sonalisation and greater general clinical activity wasfound to be associated with higher levels of personal ac-complishment. Given that staff are the most valuable re-source in the delivery of an effective mental health ser-vice, it is time to take a closer look at factors thatcontribute to emotional exhaustion, specifically with aview to the development of workplace strategies withpotential to reduce burnout for occupational therapistsand social workers.

■ Acknowledgements We would like to thank the staff who gavetheir time to complete the questionnaires and Chris Foley for his ad-ministrative assistance. This article is based on a presentation at theMental Health Services Conference of Australia and New Zealand,Sydney, August 2002.

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