Personal and Contextual Predictors of Mental Health

58 Journal of Mental Health Counseling

Volume 36/Number 1/January 2014/Pages 58–77

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Personal and Contextual Predictors of Mental Health Counselors’ Compassion Fatigue and Burnout

Isabel A. Thompson Ellen S. Amatea

Eric S. Thompson

This study applied transactional stress and coping theory to explore the contributions of coun-selor gender, years of experience, perceived working conditions, personal resources of mindful-ness, use of coping strategy, and compassion satisfaction to predict compassion fatigue and burnout in a national sample of 213 mental health counselors. Multiple regression analyses revealed that in this sample while perceived working conditions, mindfulness, use of coping strategy, and compassion satisfaction accounted for only 31.1% of the variance in compassion fatigue, these factors explained 66.9% of the variance in burnout. Counselors who reported less maladaptive coping, higher mindfulness attitudes and compassion satisfaction, and more posi-tive perceptions of their work environment reported less burnout. The utility of these findings in understanding the development of counselor burnout and compassion fatigue are discussed, as are directions for future research.

It has long been observed that qualities that make counselors effective with their clients—such as empathy, compassion, and caring—may also leave them vulnerable to such negative outcomes as compassion fatigue and burn-out (Figley, 1995; Lawson, Venart, Hazler, & Kottler, 2007; Pines & Maslach, 1978). Burnout was first recognized as a psychological problem among health-care and social service professionals in the 1970s (Pines & Maslach, 1978). Extensive research led to burnout being defined as a psychological syndrome that develops in response to chronic emotional and interpersonal stress and is characterized by three features: emotional exhaustion; depersonalization (a defense mechanism for caregivers and service providers to gain emotional distance from clients); and feelings of ineffectiveness or lack of personal accomplishment (Maslach, 2003; Maslach, Schaufeli, & Leiter, 2001). While burnout was originally conceptualized as a response to job stress produced by

Isabel A. Thompson and Eric S. Thompson are associated with Nova Southeastern University and Ellen S. Amatea with the University of Florida. Correspondence about this article should be addressed to Isabel A. Thompson, Nova Southeastern University, Center for Psychological Studies, 3301 College Avenue, Fort Lauderdale, FL 33714 Email: [email protected].

RESEARCH

Predictors of Compassion Fatigue and Burnout

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the demands of helping clients, it was quickly recognized that organizational factors also contribute to burnout (Maslach, 2003).

Research on compassion fatigue emerged from observations of psycho-logical problems among caregivers in the human service sector (Figley, 1995, 2002). Like burnout, compassion fatigue was primarily conceptualized as a response to the stress of interpersonal interactions. However, unlike burnout, compassion fatigue was viewed as a response to working with traumatized clients. Figley (1995) was the first to formulate the concept after noticing the unique work conditions and experiences of those working with traumatized individuals in the mental health profession and others who assume caregiving roles (e.g., families, medical personnel). Figley (1998, 2002) also described compassion fatigue as manifesting with exposure to persons who have been traumatized. Hence, the term compassion fatigue has often been used to describe secondary traumatic stress (Bride, Radey, & Figley, 2007). While some of these components are also elements of burnout, the core symptoms of compassion fatigue and secondary traumatic stress are similar and consist of flashbacks, nightmares, and intrusive thoughts (Galek, Flannelly, Greene, & Kudler, 2011). Compassion fatigue is thought to be a unique occupational haz-ard for those working with trauma victims (Devilly, Wright, & Varker, 2009). Moreover, due to the prevalence of traumatic experiences, many mental health counselors may provide clinical services to clients who have experienced trauma (Williams, Helm, & Clemens, 2012).

Understanding how contextual factors may contribute to compassion fatigue and burnout can help address a continuing challenge for counselors: protecting their own well-being while providing excellent client care. Because the stakes are high, researchers have sought to clarify how negative outcomes occur by examining specific aspects of the work. A number of researchers have examined the relationship between compassion fatigue or burnout and the institutional or organizational contexts in which mental health professionals work (Demerouti, Bakker, Nachreiner, & Schaufeli, 2001; Lent & Schwartz, 2012). For example, Dupree and Day (1995) reported that psychotherapists in private practice exhibited less burnout than those working in the public sector. Similarly, Lent and Schwartz (2012) found that community mental health out-patient counselors reported significantly more burnout than either private prac-tice or inpatient counselors. Mental health counselors working in outpatient community settings “scored significantly lower on personal accomplishment … and higher on depersonalization than professionals in private practice” (Lent & Schwartz, 2012, p. 363). They also “scored significantly higher on emotional exhaustion” than counselors working in inpatient settings (Lent & Schwartz, 2012, p. 363). These findings suggest that private practitioners may have less risk of burnout than counselors working in community settings, perhaps due to greater autonomy and fewer contextual or systemic stressors. However, Sorgaard, Riley, Hill, and Dawson (2007) found no significant differences in burnout between community and inpatient counselors.

Researchers have also examined how the volume, nature, and severity of client problems may affect counselor burnout or compassion fatigue (Collins

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& Long, 2003; Craig & Sprang, 2010; Figley, 2002). For example, Kassam-Adams (1999) and Flannelly, Roberts, and Weaver (2005) found that com-passion fatigue was directly related to the number of hours spent counseling trauma victims. yet Baird and Jenkins (2003) found no correlation of hours per week of trauma counseling and number of trauma clients with the degree of compassion fatigue in staff working in sexual assault and domestic violence agencies.

Researchers have also examined which workplace characteristics might buffer counselors against job stress, such as coworker support (Ducharme, Knudsen, & Roman, 2008). Some have found that psychotherapists relied on social support from supervisors and colleagues to prevent burnout, and that lack of supervisor support heightened burnout (Maslach et al., 2001). However the results of these and other studies (e.g., Linley & Joseph, 2007) suggest that work-setting factors alone do not fully explain these negative outcomes for mental health professionals.

As a result, a second research strategy has been to explore the influence of certain demographic characteristics, such as gender, age, or length of time working in the field, on these occupational outcomes (Galek et al., 2011). Naisberg-Fennig, Fennig, Keinan, and Elizur (1991) found that neither gen-der nor years of experience was associated with burnout among psychiatrists. Later, however, Dupree and Day (1995) and Van Morkhoven (1998) reported that male psychotherapists had more burnout than females. It has also been reported that number of years in the same position is positively correlated with burnout among psychotherapists (Vredenburg, Carlozzi, & Stein, 1999). However, some studies have demonstrated that the total number of years of professional experience is inversely related to burnout among counselors and therapists (e.g., Ackerley, Burnell, Holder, & Kurdek, 1988; Boscarino, Figley, & Adams, 2004). For example, Craig and Sprang (2010) reported that younger professionals reported higher levels of burnout than more experienced professionals who had provided trauma treatment longer. A literature review by Lerias and Byrne (2003) revealed that, based on limited data, female and younger trauma workers are somewhat more likely to exhibit signs of compas-sion fatigue. However, the participant samples for these studies did not consist of mental health counselors.

Because certain demographic characteristics may correlate with partic-ular styles of coping with work stressors, researchers have begun to examine specific personal resources counselors may call on to reduce the harmful effects of stressful working conditions, such as self-care practices (Kraus, 2005; Venart, Vassos, & Pritcher-Heft, 2007); mindfulness attitudes and practices (Valenta & Marotta, 2005; Vilardaga et al., 2011); active problem-focused or emotion-focused coping (Collins & Long, 2003; Skovholt, 2001); or appraisal of personal benefits from working with clients, such as compassion satisfaction (Kraus, 2005; Sprang, Clark, & Whitt-Woolsey, 2007).

Among personal resources, mindfulness attitudes and practices have gained increased attention (Goodman & Calderon, 2012; Stauffer & Pehrsson, 2012). Mindfulness has been defined in contemporary Western literature as


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moment-to-moment nonjudgmental awareness, characterized by an open and receptive approach to living in the present moment (Kabat-Zinn, 1994). Mindfulness can also be examined as a dispositional trait or a situational response or state. In the current study the Mindfulness Attention Awareness Scale (MAAS) trait version was used to assess dispositional mindfulness (Brown & Ryan, 2003). In the healthcare field, mindfulness practices have shown promise in reducing stress outcomes, particularly the Kabat-Zinn (1990) mind-fulness-based stress reduction program (MBSR). Mindfulness has become more prominent in counseling, with applications in trauma counseling (Goodman & Calderon, 2012) and proposed mindfulness competencies for mental health counselors (Stauffer & Pehrsson, 2012). Counselor mindfulness attitudes may also mediate between self-care and counselor well-being outcomes (Richards, Campenni, & Muse-Burke, 2010). In the current study, dispositional mindful-ness attitudes were examined as a personal resource because of their possible impact on the stress appraisal process.

Compassion satisfaction was also examined as a personal resource because of its potential to impact the stress appraisal process and buffer a coun-selor’s stress experience. In a series of studies, Collins and Long (2003) reported that a positive appraisal of the benefits of counseling clients, conceptualized as compassion satisfaction, was negatively correlated with compassion fatigue and burnout. Participants reported satisfaction from being part of a multidis-ciplinary team with great camaraderie, seeing clients recover, being part of a community recovery, and receiving supervisor and staff support. Collins and Long speculated that compassion satisfaction may fuel people’s will to work and protect against compassion fatigue and burnout.

Counselors who take more time to sustain relationships and practice self-care tend to be less at risk for the negative effects of helping (Stamm, 2002). Further, active problem-focused and emotion-focused coping strategies are more effective in reducing compassion fatigue and burnout in mental health professionals than such maladaptive strategies as substance abuse (Kramen-Kahn & Hansen, 1998; Kraus, 2005; Wallace, Lee, & Lee, 2010). Collins and Long (2003) reported that the most common strategies counselors used to cope with work-related stress were such active strategies as seeking emotional support, seeking instrumental social support, planning, and using humor. All of these were associated with fewer unpleasant psychological symptoms, fewer PTSD symptoms, less vicarious trauma, and less burnout. Other coping strategies associated with lower work stress and burnout were activities that promoted physical health, such as exercising and eating healthy foods; spiritu-ally-oriented activities, such as meditation or being in nature; leisure activities, such as reading, gardening, and listening to music; and seeking both emotional and instrumental support by, e.g., talking with friends and family and seeking advice from coworkers and supervisors (Wallace, Lee, & Lee., 2010). Thus, certain personal resources appear to be closely related to avoidance of burnout and compassion fatigue.

The transactional model of stress (Lazarus & Folkman, 1984) provides a theoretical basis for studying the stress experiences of mental health counselors

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from a systemic perspective. This model conceptualizes a dynamic relationship between individuals and their environment; work stress and its potential results of compassion fatigue and burnout occur when individuals see the environ-ment as taxing or exceeding their personal coping resources. Consequently, individuals may appraise work demands as exceeding (leading to stress, fatigue, and burnout) or not exceeding their own coping resources. The perception depends not only on the strength of the demands but also on the individual’s cognitive appraisal of the situation and of the coping resources available. We hypothesized that the levels of compassion fatigue or burnout that mental health counselors report can be explained more fully by examining both coun-selor appraisal of the work setting and their personal coping resources (com-passion satisfaction, mindfulness, and use of certain types of coping strategies) than by examining only counselor appraisal of the work setting, gender, and length of time in the field.

Although researchers examining counselor compassion fatigue and burn-out have not typically employed this model, the transactional model (Lazarus & Folkman, 1984) best represents current understandings of the stress process. Of particular importance may be the impact of appraisal on the levels of compassion fatigue and burnout. Although optimistic appraisal of a stressful situation and personal resources for coping have been found to mediate the level of reported strain by persons in other professions (Amatea & Fong, 1991), the model has not been used to predict degrees of counselor strain, compassion fatigue, or burnout

The purpose of this study was to use the transactional stress and coping perspective to explore the impact of counselor gender, length of time in the field, appraisal of working conditions, and five personal resources on the levels of burnout and compassion fatigue reported by a national sample of mental health counselors. The five personal resources examined were (a) level of com-passion satisfaction, (b) extent of general mindfulness attitudes, and use of (c) problem-focused coping strategy, (d) emotion-focused coping strategy, and (e) maladaptive coping strategy. This study examined four questions:

1. Are counselor compassion fatigue and burnout significantly associated with their perceptions of their working conditions?

2. In addition to counselor perception of their working conditions, does counselor gender predict the level of counselor compassion fatigue or counselor burnout?

3. In addition to counselor perception of their working conditions, does length of time working in the field predict the level of counselor com-passion fatigue or burnout?

4. In addition to counselor gender, length of time working in the field, and perception of their working conditions, does the use of personal resources, such as emotion-focused and problem-focused coping, mal-adaptive coping, mindfulness attitudes, and compassion satisfaction pre-dict the degree of compassion satisfaction or burnout counselors report?


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meThod

SampleThe study sample was composed of 213 mental health counselors who

completed an online survey and met four selection criteria: (a) self-identified as a mental health or licensed professional counselor, (b) reported completion of a master’s degree in counseling, (c) currently worked as a counselor at least 20 hours per week, and (d) had worked in their current work setting for at least six months. Post-master’s degree counselors who reported working toward state licensure were included. Convenience sampling was used to recruit a national sample of counselors working in a variety of settings. Participants were recruited by email from the membership roster of the American Mental Health Counselors Association (AMHCA) and by announcements posted by professional associations and other counseling interest listservs (Association for Spiritual, Ethical, and Religious Values in Counseling; the Alabama Counseling Association; the Ohio Counseling Association; the Counselor Education and Supervision Network Listserv; and the University of Florida Counselor Education Listserv). Study invitations were also posted on the AMHCA Facebook page. Because of these convenience sampling procedures, the exact response rate is not known. In the current study, there were 361 responses to the survey invitation; however, only the data in the 213 responses that were found to be usable were analyzed. The rest were excluded due to incomplete or missing data or lack of conformity to the selection criteria.

The 213 participants in the sample ranged in age from 24 to 78, with 4% reporting age as 25 and younger, 28% as 26 to 35, 17% as 36 to 45, 19% as 46 to 55, 25% as 56 to 65, and 7% as 66 or older; 14% (n = 51) were male and 76% (n = 162) female. Eighty-four percent of the participants reported themselves as White/Caucasian (n = 179), 9% Black/African American (n = 19), 4% Latino/a (n = 9), 0.5% Asian (n = 1), and 2% multiethnic (n = 4). Sixty-two percent (n = 131) stated they were married, 13% (n = 27) single, 15% (n = 30) in relation-ships, 8% (n = 18) divorced, and 2% (n = 5) widowed.

Institutional review board approval was obtained before the study began. All participants consented to engage in the study after receiving an informed consent document with detailed information about participant rights. They reported an average of 12.58 years (SD = 10.38) of experience in the field, with the least experienced reporting half a year of experience and the most experienced 53 years. As for work settings, 32% were in private practice, 31% in community mental health agencies, 6% in college counseling centers, 5% in substance abuse treatment centers, 3% in hospital settings, 1% in crisis stabilization units, and 1% in career counseling centers; 21% percent reported “other” as their work setting. About 41% (n = 87) of the sample reported work-ing 36–40 hours per week, 12% (n = 25) 20–25 hours, 9% (n = 20) 26–30 hours, and 9% (n = 20) 31–35 hours. In contrast, 14% (n = 30) reported work-ing 41–45 hours per week, 7% (n = 15) 46–50 hours, 4% (n = 8) 51–55 hours, 2% (n = 4) 56–60 hours, 0.5% (n = 1) 61–65 hours, 0.5% (n = 1) 66–70 hours, and 1% (n = 2) 80–85 hours.

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Participants came from 43 states and Puerto Rico. The largest percentages were from Florida (21%), Alabama (13%), and Ohio (9%). Fifty-six percent (n = 119) reported that they were members of the American Counseling Association (ACA) and 38% (n = 80) were members of the AMHCA.

MeasuresEach participant was asked to complete an online questionnaire asking

about their educational background, employment history, work environment, coping strategies, mindfulness attitudes, and levels of compassion satisfaction, compassion fatigue, and burnout. The questionnaire also included measures to assess each of the variables of interest.

Perceptions of work environment. Counselor perceptions of their work-ing conditions were measured by an instrument created for use in this study titled the Perceived Working Conditions Scale. This instrument measures the frequency with which counselors report experiencing the following working conditions: (a) fairness in administrative decision-making, (b) adequate finan-cial compensation, (c) flexibility of hours worked, (d) quality of supervision, (e) quality of coworker relationships, (f) clinical preparedness to serve the types of clients on their caseload, (g) nature of job tasks, and (h) overall organiza-tional climate (e.g., a competitive work atmosphere). Respondents were asked to indicate on a five-point Likert-type scale the frequency with which they experienced specific positive or negative working conditions. Items depicting negative working conditions were reverse-scored, so that the higher the total score, the more often the respondent reported positive rather than negative working conditions.

In developing this instrument, existing instruments and research were first examined to identify an initial pool of items related to specific aspects of counselor work life. Content validity was established through review by a panel of three mental health counselors and counselor educators who had research expertise in occupational stress and burnout prevention. This panel evaluated whether the items were representative, suggested additional items, and edited the items. The final instrument, based on panel feedback, consisted of 50 items. A confirmatory factor analysis (N = 213) was then conducted on study participant responses, resulting in identification of one underlying factor; of the original 50 items in the instrument, 46 loaded on this factor with correla-tions of .40 or greater. The .40 cut-off point for factor loadings is considered a robust measure in instrument development (Costello & Osborne, 2005). On this factor, perceptions of positive working conditions loaded positively and negative working conditions negatively. The 46 items were then summed to form one overall score for counselor perceptions of the work environment, with a Cronbach’s alpha coefficient of .94. Each participant’s total score on the 46-item instrument was used in all further data analysis.

coping strategies. The extent to which problem-focused, emotion-fo-cused, or maladaptive coping strategies were used was measured using the brief COPE Inventory developed by Carver (1997) to measure a respondent’s


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situational or dispositional coping. The brief COPE was used to assess the frequency of use of 28 specific strategies organized into the three categories of problem-focused, emotion-focused, and maladaptive coping based on the conceptualization by Meyer (2001). Using a four-point Likert-type scale, respondents indicated the frequency with which they used each strategy in a particular stressful work situation. Problem-focused strategies included use of instrumental support and planning. Emotion-focused strategies included use of emotional support, humor, and religious beliefs. Maladaptive strategies involved activities such as self-distraction, denial, substance use, and self-blame. Cooper, Katona, and Livingston (2008) calculated validity and reli-ability for the brief COPE using composite subscales: a Cronbach’s alpha of 0.72 for the emotion-focused subscale, 0.84 for the problem-focused subscale, and 0.75 for the dysfunctional subscale. These composite subscales have also been reported to have good convergent and concurrent validity (Cooper et al., 2008). For this study, the Cronbach’s alpha coefficients were .75 for the 10-item emotion-focused coping subscale, .83 for the 6-item problem-focused coping subscale, and .75 for the 12-item maladaptive coping subscale.

extent of mindfulness attitudes. This was measured by the 15-item Mindful Attention Awareness Scale, Trait Version (MAAS; Brown & Ryan, 2003). Respondents rated the frequency with which they experienced each condition described using a six-point Likert-type scale from “almost always” to “almost never.” Cronbach’s alphas ranging from .80 to .90 have been reported for this measure (Brown & Ryan, 2003); for this study sample the Cronbach’s alpha was .92.

compassion satisfaction. The Professional Quality of Life Scale 5 (ProQOL; Stamm, 2010) has separate subscales to assess compassion satis-faction, burnout, and compassion fatigue/secondary traumatic stress among helping professionals (Stamm, 2010). Each subscale is scored separately and no composite score is calculated, which allowed the researchers to use each subscale independently. The compassion satisfaction subscale has 10 items to assess work-related fulfillment, for example: “I feel invigorated after working with those I counsel.” Respondents rate the frequency with which they have experienced each statement in the last 30 days on a five-point Likert-type scale ranging from “never” to “very often.” Hooper, Craig, Janvrin, Wetsel, and Reimels (2010) reported a Cronbach’s alpha of .87 for the compassion satisfac-tion subscale; for this study, the Cronbach’s alpha was .91.

compassion fatigue. The ProQOL secondary traumatic stress subscale (Stamm, 2010) was used to assess compassion fatigue. The secondary traumatic stress subscale (formerly called the compassion fatigue scale) has 10 items, such as “I am preoccupied with more than one person I counsel.” A five-point Likert-type scale with responses ranging from “never” to “very often” is used. These items capture the sense of fear and preoccupation related to exposure to traumatic client material that is characteristic of the secondary traumatic stress associated with compassion fatigue. For a sample of emergency room nurses the compassion fatigue subscale had a Cronbach’s alpha of .87 (Hooper et al., 2010); for this study it was .83.

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Burnout. The burnout subscale of the ProQOL (Stamm, 2010) has 10 items, such as “I feel worn out because of my work as a counselor.” Respondents rate how often they have experienced each statement in the past 30 days on a five-point Likert-type scale. The subscale assesses the overall sense of fatigue and exhaustion with the work context that is characteristic of burn-out. The examples provide a window into the differences between compassion fatigue and burnout, with more global exhaustion evident in the burnout items. For their sample of emergency room nurses, Hooper and colleagues (2010) reported a Cronbach’s alpha of .90 for the burnout subscale (2010). For this study sample, the Cronbach’s alpha was .79.

length of time in field. Participants were asked to report how long they had worked as counselors, not including clinical experiences during graduate studies. Descriptive statistics for the study sample for this index and the mea-sures described earlier are summarized in Table 1.

Table 1. Means and Standard Deviation for the Measures (N = 213)

Variable/Measure Mean SD Possible Range

Maladaptive 1.72 .41 1-4

Emotion-focused 2.57 .54 1-4

Problem-focused 2.75 .71 1-4

Mindfulness 4.58 .84 1-6

CS score 49.95 10.02 18.04-63.90

Burnout score 49.92 10.01 32.62-81.95

CF score 50.04 10.06 36.97-85.25

PWC 172.29 24.83 46-230

Length of time in field 12.58 10.38 .5-53

Note. CS=compassion satisfaction, CF=compassion fatigue, PWC=counselor perceived working conditions.

Gender. Participants reported their gender in the demographic section of the online questionnaire. Gender was coded numerically for subsequent analysis. Descriptive statistics were computed for this index.

resulTs

To examine relationships between variables, correlations were computed for all possible pairs of variables (Table 2). These correlations revealed a signif-icant inverse relationship between counselor perceptions of positive working conditions and their level of compassion fatigue (r = -.361, p < .001). That is, the more positively the counselor rated the work environment, the less the compassion fatigue reported. An even stronger inverse relationship was demonstrated between counselor perceptions of positive working conditions and burnout (r = –.643, p < .001): The more positively the counselor rated


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the work environment, the less the burnout reported. Moreover, while females were more likely to report compassion fatigue than males, there was not a sig-nificant association by gender with the reported level of burnout. Interestingly, length of time working in the field was inversely related to both compassion fatigue and burnout; i.e., the longer the counselor had worked in the field, the less compassion fatigue and burnout was reported.

Research questions about the influence on counselor compassion fatigue and burnout of gender and length of time working in the field in addition to perceptions of the work context were estimated using hierarchical regression analyses. The results, which appear as Model 1 in Tables 3 and 4, revealed that when compassion fatigue was regressed on perceptions of work conditions and gender, gender was not a significant predictor of compassion fatigue. This model explained only 29% of the variance in compassion fatigue scores (Table 3). When burnout was regressed on perceptions of working conditions and gender, the latter was not found to be a significant predictor of burnout (Table 4). Similarly, as can be seen in Model 2 in Table 3, when compassion fatigue was regressed on perceptions of working conditions and length of time working in the field, the latter was not found to be a significant predictor of compassion fatigue. Similarly (see Table 4), when burnout was regressed on perceptions of working conditions and length of time working in the field, the latter was not found to be a significant predictor of compassion fatigue.

Table 2. Correlation Matrix: Working Conditions, Personal Resources, Compassion Fatigue, and Burnout (N = 213)

1 2 3 4 5 6 7 8 9 10

1 PWC _

2 GDR -.099 _

3 YIF .283** -.319** _

4 MD .343** -.202** .243** _

5 CS .542** -.044 .183** .423** _

6 EF .023 .000 -.034 -.131 .092 _

7 PF -.019 .047 -.068 -.050 .037 .565** _

8 MC -.413** .041 -.097 -.418** -.210** .300** .212** _

9 BO -.643** .076 -.219** -.546** -.679** -.037 .087 .466** _

10 CF -.361** .223** -.186** -.448** -.205** .097 .110 .411** .499** _

Note. PWC=counselor perceived working conditions, GDR=counselor gender, YIF=counselor years in field, MD=mindfulness, CS=compassion satisfaction, EF=emotion-focused coping, PF=problem-focused coping, MC=maladaptive coping, BO=burnout, CF=compassion fatigue**p ≤ .001

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Table 3. Regression Model Predicting Counselor Compassion Fatigue Level (N = 213)

Variable Unstandardized B

Std. Error Standardized β

t Significance

Model 1

Counselor perception of working conditions .219 .024 .543 9.319 .000

Gender .236 1.366 .010 .172 .863

R2 = .294F∆ (2, 210) = 43.702p < .0001

Model 2

Counselor perception of working conditions -.136 .027 -.335 -5.022 <.001

Years as a counselor in field -.088 .065 -.091 -1.358 .176

R2 = .138F∆ (2, 210) = 16.803p <.001

Model 3

(Constant)Counselor perception of working conditions

64.195-.079

7.615.031 -.196

8.430-2.561

<.001.011

Years as counselor in field 3.139 1.464 .134 2.145 .033

Gender -.006 .062 -.006 -.095 .925

Mindfulness -3.576 .855 -.299 -4.185 <.001

Compassion satisfaction .082 .074 .082 1.113 .267

Emotion-focused coping -.857 1.369 -.046 -.626 .532

Problem-focused coping .871 1.000 .062 .871 .385

Maladaptive coping 5.386 1.778 .217 3.030 .003

R2 = .311F∆ (8, 204) = 11.50p < .001

In the third step of the analysis (Model 3), the five personal resource vari-ables were introduced into the perceived working conditions, gender, length of time in the field, and compassion fatigue equations. This model (see Table 3) explains 31% of the variance in counselor compassion fatigue scores (R = .558, R2 = .311, p <.001). However, only three of the eight variables in Model 3 (perceived working conditions, extent of reported mindfulness, and maladap-tive coping) significantly predicted counselor compassion fatigue. In addition to perception of working conditions (B = -.196, t = -2.56, p <.001), mindfulness was a significant predictor of compassion fatigue, having an inverse relation-


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ship to it (B = -3.576, t = -4.185, p <.001). In contrast, maladaptive coping was positively associated with compassion fatigue at the .003 level (B = 5.386, t = 3.030, p = .003).

Table 4. Regression Model Predicting Counselor Burnout Level (N = 213)

Variable Unstandardized B

Std. Error Standardized β

t Significance

Model 1


Gender .293 1.242 .013 .236 .814

R2 = .017F∆ (2, 210) = 74.227p < .001

Model 2


Years as a counselor in field -.039 .053 -.041 -.739 .461

R2 = .416F∆ (2, 210) = 74.645p < .0001

Model 3

(Constant)Counselor perception of working conditions

94.814-.109

5.250.021 -.270

18.060-5.084

<.001<.001

Years as counselor in field -.004 .043 -.004 -.082 .935

Gender -.682 1.009 -.029 -.676 .500

Mindfulness -2.698 .589 -.227 -4.580 <.001

Compassion satisfaction -.386 .051 -.386 -7.550 <.001

Emotion-focused coping -2.998 .944 -.162 -3.176 .002

Problem-focused coping 1.913 .690 .136 2.775 .006

Maladaptive coping 4.907 1.226 .199 4.004 <.001

R2 = .669F∆ (8, 204) = 51.58p < .001

What was the contribution of the five personal resources to the prediction of counselor burnout? When these were introduced into the perceived work-ing conditions, gender, length of time in the field, burnout equation (see Table 4), they explained 67% of the variance in burnout score levels in this sample of mental health counselors (R2 = .656, p < .001). The unstandardized beta

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coefficients, also presented in Table 4, indicate the extent to which each of the variables contributed to predicting levels of counselor burnout. As can be seen in Model 3 in Table 4, while perceived working conditions significantly predicted burnout (the higher the positive perceptions of the work environ-ment, the lower the burnout level), gender and length of time working in the field did not significantly contribute to predicting burnout. However, four of the five personal resources significantly contributed to prediction of burnout: Mindfulness was a significant inverse predictor of burnout (B = -2.698, t = -4.580, p <.001), as was compassion satisfaction (B = -.386, t = -7.550, p <.001). Maladaptive coping was a significant predictor, being positively related to burn-out (B = 4.907, t = 4.004, p <.001), as was emotion-focused coping (B = -2.998, t = -3.176, p = .002).

discussion

This study explored the prediction of counselor compassion fatigue and burnout from knowledge of perceived working conditions, personal resources, and demographic characteristics. While perception of working conditions was positively associated with both compassion fatigue and burnout at a significant level, working conditions were much more strongly associated with burnout than with compassion fatigue, which supports the distinction between burn-out and compassion fatigue. Burnout has been more closely associated with systemic stressors in the work environment (Maslach, 2003), and compassion fatigue has been associated with the demands of interacting with traumatized clients (Figley, 1995) and with the number of hours spent providing them with therapeutic services (Kassam-Adams, 1999; Flannelly et al., 2005). Interestingly, neither gender nor length of time working in the field was signifi-cantly associated with either outcome. However, the personal resources of the counselor, specifically mindfulness attitudes and use of certain types of coping strategies, were significantly associated with compassion fatigue and burnout.

Aspects of the counselor work environment have been studied in previous research. For example, Linley and Joseph (2007) reported that being clinically supervised was associated with greater personal growth in therapists surveyed. Ducharme and colleagues (2008) found that perception of coworker support was associated with less emotional exhaustion among substance abuse coun-selors. Maslach et al. (2001) also reported that supervisor and coworker social support was instrumental for burnout prevention. Researchers (i.e., Lent & Schwartz, 2012) have also reported that mental health counselor burnout may be impacted by work setting. Our research findings support the major contribution of workplace factors to counselor burnout. However, the rela-tionship of workplace factors with compassion fatigue, though significant, was not as strong. It may be that the contextual factors associated with counselor compassion fatigue and with counselor burnout differ. For example, Flannelly and colleagues (2005) suggested that hours spent working with traumatized clients is a key factor in development of compassion fatigue, while more gen-eral work-setting factors are implicated in development of burnout (Lent &


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Schwartz, 2012). The measure of perceived working conditions used in this study assessed such factors as coworker support and perceptions of fairness and support in the work organization— contextual factors that may be more related to burnout than compassion fatigue.

Although females in this sample were more likely to experience compas-sion fatigue, gender was not found to contribute significantly to prediction of compassion fatigue when added to perception of working conditions. Gender was neither significantly associated with burnout nor contributed to prediction of burnout when it was added to perception of working conditions. These results are inconsistent with those reported by Sprang and colleagues (2007) of gender associations with both burnout and compassion fatigue; they found that females were at higher risk for both. Although additional research is needed, these results suggest that an individual’s perception of working conditions may be a much better predictor of compassion fatigue than gender alone.

There was a significant inverse relationship between length of time as a counselor and burnout (r = -.219, p < .001) with more years working in the field associated with less reported burnout. However, length of time in field did not significantly predict burnout when it was added to perception of working conditions; it may be that experienced counselors have moved up in the orga-nization to positions where working conditions are more positive. For example, although participants were required to be counseling clients at least 20 hours a week, more experienced counselors with longer tenure in an organization may also have been engaged in supervisory or administrative activities while newer hires primarily provide direct services.

There was also a significant inverse relationship in this study sample between length of time as a counselor and compassion fatigue (r = -.186, p < .001). However, length of time in the field did not significantly predict compas-sion fatigue when added to perception of working conditions. While it has been reported that the length of time a counselor remains in the same position is positively correlated with burnout (Vredenburg et al., 1999), other studies have found an inverse relationship between years of professional experience and burnout (Ackerly et al., 1988; Boscarino et al., 2004). The results of the current study contrast with the Linley and Joseph (2007) study of British psychologists, in which more years of clinical experience was associated with more negative psychological changes and compassion fatigue. Examining only counselor length of time in the field may be a more imprecise method than examining the type of work responsibilities and specific types of contact that professionals engage in with their clients.

A major objective of this study was to examine the combined contribution of appraisal of working conditions and personal resources in predicting the level of burnout counselors reported. Perception of working conditions, compassion satisfaction, mindfulness, emotion-focused coping, and maladaptive coping explained a significant amount of the variance in burnout scores. Perception of working conditions (e.g., coworker support, work atmosphere) was a significant predictor of burnout. This outcome provides evidence that working conditions matter and should be addressed in efforts to ameliorate burnout.

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However, certain personal resources were even stronger predictors of burnout. Compassion satisfaction, the strongest predictor in this model, was inversely related to reported burnout. Experiencing a lack of personal accom-plishment is an essential component of burnout. Perhaps counselors who report compassion satisfaction in their helping roles are buffered from burnout due to a sense of personal accomplishment. Compassion satisfaction, which has been linked to reduced risk of burnout (Kraus, 2005), may buffer counsel-ors from the negative effects of exposure to traumatic client material (Collins & Long, 2003). The results of this study are thus aligned with previous research and suggest that compassion satisfaction may be a powerful resource to help counselors deal with perceived stress.

This study also found that mindfulness attitudes were also a powerful and significant predictor of burnout, with higher levels of mindfulness associated with lower levels of burnout. Previous studies have reported associations of mindfulness and self-care with well-being (Richards et al., 2010) and associ-ations between mindfulness and counselor burnout (Vilardaga et al., 2011). Mindfulness attitudes may mitigate the depersonalization associated with burnout by helping counselors focus on the client’s uniqueness in the present moment; mindfulness may reduce the likelihood of feeling a sense of reduced personal accomplishment, since mindfulness attitudes are characterized by nonjudgmental awareness. Further, mindfulness attitudes may ease emotional exhaustion by helping mental health counselors accept their current emotions and then let go of them.

Finally, certain styles of coping were strongly associated with burnout. For example, maladaptive coping was a significant predictor of burnout, indicating that respondents endorsing substance use, denial, distraction, and self-blame coping strategies were more vulnerable to burnout. In addition, the more counselors endorsed the use of emotion-focused techniques, the lower the lev-els of burnout reported. Perhaps counselors who used emotion-focused coping strategies avoided the emotional exhaustion characteristic of burnout. Because adaptive strategies like self-care and career-sustaining behaviors have been the main constructs examined in the literature (Lawson & Myers, 2011; Richards et al., 2010), exploration of the use of both adaptive and maladaptive coping strategies may provide a richer picture of the ways that counselors respond to the stresses they encounter, not just the positive or beneficial ways.

In contrast, with regard to the compassion fatigue scores, much less of the variance was explained by the variables of perception of working conditions, gender, length of time in field, extent of reported mindfulness, compassion satisfaction, and problem-focused, emotion-focused, and maladaptive coping strategy. These factors explained only 31% of the variance in compassion fatigue scores, compared to 67% of the variance in burnout scores. Mindfulness and maladaptive coping were significant predictors of compassion fatigue, mindfulness attitudes with an inverse and maladaptive a direct relationship. Other factors, such as therapist personal trauma history, might better explain counselor compassion fatigue. Although Leonard (2008) reported no signif-icant associations between compassion fatigue and personal trauma history,


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significant associations between therapist personal trauma history and com-passion satisfaction have been reported. Linley and Joseph (2007) also found that therapists who reported a personal trauma history showed greater personal growth. Since the relationship between compassion fatigue and compassion satisfaction is still being studied (Stamm, 2010), including personal trauma history as a predictive variable could be useful in future models for predicting compassion fatigue.

A number of limitations inherent in the study design limit the appli-cability of the findings. Conceptualizing coping strategy use into three cat-egories—problem-focused, emotion-focused, and maladaptive—that were decontextualized from specific situations may have been problematic. Future researchers may want to elicit a fuller description of the context as well as delineate coping strategies more finely.

A second limitation was the exclusive use of self-reporting, which is vulnerable to social desirability bias: Participants may try to present themselves in the best possible light, rather than answering honestly. Further, participants were self-selected volunteers. Counselors who were most stressed might not have taken the time to complete the survey due to their own stress or to the nature of the topic, which limits the generalizability of the results. The conve-nience sampling procedure also limited the generalizability of the study find-ings, since the researcher was unable to describe the percentage of respondents compared to nonrespondents.

imPlicATions

Despite the limitations of the study, the findings suggest that counselor working conditions and perceptions of personal resources are predictive of counselor burnout and compassion fatigue. That has implications for coun-seling practitioners, supervisors, and educators. Although counselor well-being has often been conceptualized in ways that highlight each individual’s respon-sibility to maintain well-being, a counselor’s perceived personal resources and work context may well impact the experience of compassion fatigue and burn-out. Counselors working in less supportive environments may benefit from enhancing personal resources and practicing positive coping strategies to offset perceived stressors. They can also advocate for improvements in work settings and strive to build closer relationships with colleagues to address contextual stressors. Further, supervisors can help trainees understand the systemic nature of counselor stress experiences and develop effective coping strategies to man-age work demands.

Further, the counselors in this study who reported greater compassion satisfaction also reported less burnout and compassion fatigue—findings con-sistent with previous research (Collins & Long, 2003). Counselors who report more compassion satisfaction may experience benefits from their clinical work that may reduce the negative effects of job-related stressors. Those who notice an ebbing of compassion satisfaction may want to seek support so that they can regain a sense of joy and satisfaction in their helping role.

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In this study, dispositional mindfulness attitudes were inversely related to both burnout and compassion fatigue. Other researchers have suggested that mindfulness may mediate the relationship between counselor self-care and well-being (Richards et al., 2010). Perhaps mental health counselors who approach their work with a nonjudgmental present-centered approach that characterizes dispositional mindfulness may be buffered from potential stress-ors. They may perceive their environment differently, be less likely to appraise a situation as a stressor or threat, and be more likely to approach perceived stressors and threats in a nonjudgmental way that allows for greater resilience in the face of stress.

In this sample counselors who reported using maladaptive coping strat-egies, such as denial, distraction, self-blame, and substance use, also reported greater burnout. This suggests that counselors who realize that they are coping with job stress using maladaptive strategies may want to seek support. Self-care is often discussed in the counseling literature (e.g., Richards et al., 2010; Skovholt, 2001). Exploring coping practices allows for examination of both positive and negative strategies that counselors use to mitigate the effects of job stress.

Mental health counselors are mandated to engage in reflective self-mon-itoring to assess their own state of well-being (ACA, 2005; AMHCA, 2010). They are also urged to seek support when a lack of well-being may be affecting their professional functioning. Counselors may also want to monitor their level of compassion satisfaction. Supervisors can help supervisees assess their well-being, current perceived work stressors, and personal resources for manag-ing job-related stressors.

These findings reinforce the results of studies of other professional groups that appraisal of personal resources has an impact on the work stress, compas-sion fatigue, and burnout experienced by mental health professionals (Amatea & Fong, 1991; Demerouti et al., 2000). A unique contribution of this study lies in the use of the transactional stress model to frame the study of counselor compassion fatigue and burnout as a dynamic relationship of individuals with their environment. The responses of this sample of counselors suggest that both appraisal of the work environment and particular personal resources contribute to prediction of burnout and, to a lesser extent, compassion fatigue. It is hoped that these results underscore the viability of using a transactional model of work stress in future research on mental health counselor well-being.

references

Ackerley, G., Burnell, J., Holder, D., & Kurdek, L. (1988). Burnout among licensed psychologists. Professional Psychology: Research and Practice, 19, 624–631.

Amatea, E., & Fong, M. (1991). The impact of role stressors and personal resources on the stress experience of professional women. Psychology of Women Quarterly, 15, 419–430.

American Counseling Association. (2005). Code of Ethics. Alexandria, VA: Author.American Mental Health Counselors Association (2010). AMHCA Code of Ethics. Alexandria, VA:

Author.


75

Baird, S., & Jenkins, S. (2003).Vicarious traumatization, secondary traumatic stress and burnout in sexual assault and domestic violence agency staff. Violence and Victims, 18, 71–86.

Boscarino, J. A., Figley, C. R., & Adams, R. E. (2004). Compassion fatigue following the September 11 terrorist attacks: A study of trauma among New york City social workers. International Journal of Emergency Mental Health, 6, 57–66.

Bride, B., Radey, M., & Figley, C. R. (2007). Measuring compassion fatigue. Clinical Social Work Journal, 35, 155–163.

Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848.

Carver, C. S. (1997). you want to measure coping but your protocol is too long. International Journal of Behavioral Medicine, 4, 92–100.

Collins, S., & Long, A. (2003). Working with the psychological effects of trauma: Consequences for mental health-care workers: A literature review. Journal of Psychiatric and Mental Health Nursing, 10, 417–424.

Cooper, C., Katona, C., & Livingston, G. (2008). Validity and reliability of the brief COPE in carers of people with dementia. Journal of Nervous and Mental Disease, 196, 838–843.

Costello, A. B., & Osborne, J. (2005). Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis. Practical Assessment, Research & Evaluation, 10, 1–9.

Craig, C., & Sprang, G. (2010). Compassion satisfaction, compassion fatigue, and burnout in a national sample of trauma treatment therapists. Anxiety, Stress & Coping, 23, 319–339.

Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2000). The job demands-resources model of burnout. Journal of Applied Psychology, 86, 499–512.

Devilly, G., Wright, R., & Varker, T. (2009). Vicarious trauma, secondary traumatic stress is simply burnout? Effect of trauma therapy on mental health professionals. Australian and New Zealand Journal of Psychiatry, 43, 373–385.

Ducharme, L. J., Knudsen, H. K., & Roman, P. M. (2008). Emotional exhaustion and turnover intention in human service occupations: The protective role of coworker support. Sociological Spectrum, 28, 81–104.

Dupree, P., & Day, H. (1995). Psychotherapists job satisfaction and job burnout as a function of work setting and percentage of managed care clients. Psychotherapy in Private Practice, 14, 77–93.

Figley C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 1–20). New york, Ny: Brunner/Mazel.

Figley, C. R. (l998). Burnout in families: The systemic cost of caring. Clermont, FL: CRC Press.Figley, C.R. (2002). Treating compassion fatigue. New york, Ny: Brunner/Mazel.Flannelly, K., Roberts, S., & Weaver, A. (2005). Correlates of compassion fatigue and burnout in

chaplains and other clergy who responded to September 11th attacks in New york City. Journal of Pastoral Care and Counseling, 58, 231–234.

Galek, K., Flannelly, K., Greene, P., & Kudler, T. (2011). Burnout, secondary traumatic stress and social support. Pastoral Psychology, 60, 633–649.

Goodman, R. D., & Calderon, A. M. (2012). The use of mindfulness in trauma counseling. Journal of Mental Health Counseling, 34, 254–268.

Hooper, C., Craig, J., Janvrin, D. R., Wetsel, M. A., & Reimels, E., (2010). Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. Journal of Emergency Nursing, 36, 420–427. doi:10.1016/j.jen.2009.11.027

Kabat-Zinn, J. (1990). Full catastrophe living. New york, Ny: Delta.

76

Kabat-Zinn, J. (1994). Wherever you go there you are: Mindfulness meditation in everyday life. New york, Ny: Hyperion.

Kassam-Adams, N. (1999). The risk of treating sexual trauma: Sex and secondary trauma in psychotherapists. In H.B. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers and educators (2nd ed., pp. 37–48). Lutherville, MD: Sidran Press.

Kramen-Kahn, B., & Hansen, D. (l998). Rafting the rapids: Occupational hazards, rewards, and coping strategies of psychotherapists. Professional Psychology: Research and Practice, 29, 130–134.

Kraus, V. I. (2005). Relationship between self-care and compassion satisfaction, compassion fatigue, and burnout among mental health professionals working with adolescent sex offenders. Counseling and Clinical Psychology Journal, 2, 81–88.

Lawson, G., & Myers, J. E. (2011). Wellness, professional quality of life, and career-sustaining behaviors: What keeps us well? Journal of Counseling & Development, 89, 163–171.

Lawson, G., Venart, E., Hazler, R., & Kottler, J. (2007). Toward a culture of counselor wellness. The Journal of Humanistic Counseling, Education and Development, 46, 5–19.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New york, Ny: Springer.Lent, J., & Schwartz, R. (2012). The impact of work setting, demographic characteristics, and

personality factors related to burnout among professional counselors. Journal of Mental Health Counseling, 34, 355–372.

Leonard, L. (2008). Trauma therapists’ quality of life: The impact of individual and workplace factors on compassion fatigue and compassion satisfaction (Doctoral dissertation). Retrieved from http://etd.fcla.edu.lp.hscl.ufl.edu/UF/UFE0021907/leonard_l.pdf

Lerias, D., & Byrne, M. (2003). Vicarious traumatization: Symptoms and predictors. Stress and Health, 19, 129–138.

Linley, P. A., & Joseph, S. (2007). Therapy work and therapists’ positive and negative well-being. Journal of Social and Clinical Psychology, 26,385–403.

Maslach, C. (2003). Job burnout: New directions in research and intervention. Current Directions in Psychological Science, 12, 189–192.

Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annual Review of Psychology, 52, 397–422.

Meyer, B. (2001). Coping with severe mental illness: Relations of the brief COPE with symptoms, functioning, and well-being. Journal of Psychopathology and Behavioral Assessment, 23,265–276.

Naibserg-Fennig, S., Fennig, S., Keinan, G., & Elizur, A. (1991). Personality characteristics and proneness to burnout: A study among psychiatrists. Stress Medicine, 7, 201–205.

Pines, A., & Maslach, C. (1978). Characteristics of staff burnout in mental health settings. Hospital and Community Psychiatry, 29, 233–237.

Richards, K. C., Campenni, C. E., & Muse-Burke, J. L. (2010). Self-care and well-being of mental health professionals: The mediating role of self-awareness and mindfulness. Journal of Mental Health Counseling, 32, 247–264.

Skovholt, T. (2001). The resilient practitioner: Burnout prevention and self-care strategies for counselors, therapists, teachers, and health care professionals. Boston, MA: Allyn & Bacon.

Sorgaard, K., Ryan, P., Hill, R., & Dawson, I. (2007). Sources of stress and burnout in acute psychiatric care: Inpatient vs. community staff. Social Psychiatry and Psychiatric Epidemiology, 42, 794–802.

Sprang, G., Clark, J. J., & Whitt-Woosley, A. (2007). Compassion fatigue, compassion satisfaction, and burnout: Factors impacting professionals quality of life. Journal of Loss and Trauma, 12, 259–280.

Stamm, B.H. (2010). The concise ProQOL manual (2nd ed.). Pocatello, ID: ProQOL.org.Stauffer, M. D., & Pehrsson, D. (2012). Mindfulness competencies for counselors and

psychotherapists. Journal of Mental Health Counseling, 34, 227–239.


77

Valenta, V., & Marotta, A. (2005). The impact of yoga on the professional and personal life of the psychotherapist. Contemporary Family Therapy, 16, 99–111.

Van Morkhoven, N. (1998). The prevalence of burnout among psychologists and psychological associates in the state of Texas (Unpublished doctoral dissertation). Houston School of Public Health, Houston, TX.

Venart, E., Vassos, S., & Pritcher-Heft, H. (2007). What individual counselors can do to sustain wellness. The Journal of Humanistic Counseling, Education and Development, 46, 50–65.

Vilardaga, R., Luoma, J. B., Hayes, S. C., Pistorello, J., Levin, M. E., Hildebrandt, M. J., & Bond, F. (2011). Burnout among the addiction counseling workforce: The differential roles of mindfulness and values-based processes and work-site factors. Journal of Substance Abuse Treatment, 40, 323–335.

Vredenburg, L., Carlozzi, A., & Stein, L. (1999). Burnout in counseling psychologists: Type of practice setting and pertinent demographics. Counseling Psychology Quarterly, 12, 293–302.

Wallace, S., Lee, J., & Lee, S. M. (2010). Job stress, coping strategies, and burnout among abuse-specific counselors. Journal of Employment Counseling, 47, 111–122.

Williams, A. M., Helm, H. M., & Clemens, E. V. (2012). The effect of childhood trauma, personal wellness, supervisory working alliance, and organizational factors on vicarious traumatization. Journal of Mental Health Counseling, 34, 133–153.

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