What is our relationship with work? How much of our lives do we spend at work? How does occupation influence other aspects of our lives? What does it mean to have a “good job” and when we tell someone to “get a job?”
For my Occupational & Environmental Health class last semester, I explored the unique occupational hazard of chronic job strain (or stress) and burnout in social work and caring professions. In public health, we are taught to conceptualize the causes of health outcomes on multiple levels: Individual (attitudes, beliefs), interpersonal (social pressures and norms), environmental (community or organizational dynamics), and societal (values held by the larger society). By mapping out elements on each level, we can comprehensively assess the problem—usually, an illness or disease—and develop appropriate interventions.
Job strain, like many other illnesses, is primarily caused by factors at the environmental and societal level. Employers generally determine job functions, workload, required skills, and performance expectations. Depending on the job, schedule and staffing patterns are often set by the employer as well. Karasek’s demand-control model helps to illustrate when organizational conditions put employees at risk of job strain, or chronic job stress: High Demand + Low Control = heightened risk. In other words, workers are more prone to exhibit a chronic stress response when they perceive not only that their job is demanding, but also that they can exercise little autonomy over activities during time spent at work.
Importantly, individual and interpersonal factors mediate the effect of work conditions; social science researchers have long sought to understand the protective mechanisms of social supports, and what one could call “personal resiliency.” Having close family and friends, and personality traits that allow an individual to react more adaptively to stressors, appear to shield some people from the serious consequences of chronic job stress and burning out.
Yet from an occupational health perspective, it doesn’t matter why people react differentially to the same stressors. If any subset of the working population is affected by an adverse outcome of a work environment, that job should be restructured to engineer out the hazard. Just as we would write policies to require personal protective equipment for employees who handle hazardous chemicals, we should implement preventive measures to reduce the prevalence of psychosocial hazards in the workplace. But economic recessions force public and private-sector human service agencies to tighten their belts and do more with less, and the burden often falls to front-line workers to pick up the slack. Instead of trying to figure out better ways of preventing psychosocial stress at work, employees are blamed for being “soft,” and told that they should find another profession. In this way, the ultimate determinant of occupational stress is societal–determined by the macro-economic policies of neoliberalism and cultural attitudes that place the blame for stress squarely on the individual’s “inability to cope.”
That’s both an oversimplification and a disservice to the people who go into social service work and everyone they serve. The way that social workers and other “people professionals” experience chronic job stress is unique. Most people who end up in these occupations (teachers, nurses, first responders) are motivated by some degree of altruism or social justice and, at the least, a desire to help people and do some good in the world. Very few would refer to what they do as “just a job.” So when you, as a caring professional, end up in an organization or community facing expectations that far exceed your capacity for reasons that are beyond your control, the resulting sense of failure resonates to your core. It can provoke serious anguish about your abilities and your role and even your “mission,” if you believe in that sort of thing, and over time, this emotional state of doubt and disappointment becomes a debilitating and paralyzing force. Once you reach the final stages of burnout, your productivity and job satisfaction have suffered immensely, and you’re probably too desensitized to your clients to be any use to them or your co-workers.
Though this reaction doesn’t occur in everyone who enters social service professions, it is a predictable and logical one. Like individuals whose work involves handling toxic chemicals, some people are more sensitive or susceptible to illness than others—but that doesn’t eliminate the need to warn employees of the risk and take steps to prevent them from falling ill or being injured. And yet, very little emphasis is placed on adequately training social workers and other service professionals on self-care, secondary trauma, or healthy work-life balance. It gets nominal treatment in professional journals of clinical psychology, but training of front-line workers is almost exclusively client-centered, focusing on meeting the needs of the population being served. While important, what this strategy misses is the centrality of worker health in providing effective services to clients.
I don’t know how to solve this problem. I’m not optimistic that an overhaul of American economic policy or cultural stigma is a realistic or achievable goal. What I do know is that policies implicating the individual worker’s responsibility in avoiding social work burnout are inadequate, and that social service organizations owe their workforce a responsibility to honestly address the risk of chronic job stress—a predictable effect of the work they are asked to perform.
I chose to research job-related burnout because it is an issue with which I am intimately familiar. I burned out after a year and a half working as a social services case manager at an understaffed and chaotic community health center in the South Bronx. In addition to interviewing and registering all new patients, my daily responsibilities included screening all adults for depression; calling in prescription prior authorizations; requesting medical records; ordering home care and durable medical equipment; assisting patients experiencing insurance problems; setting up mental health care appointments; and managing a telephone follow-up caseload of about 200-300 patients with clinical depression. I carried out all of these duties in both English and Spanish. I was also called on to manage any crises that occurred at the clinic—reports of domestic violence or homicidal and suicidal ideations. I had no training other than a bachelor’s degree in psychology, and my “supervisor” was located at another site, where she was overburdened by involvement in more than 10 different quality control initiatives.
No one had ever told me that burnout was a possibility—despite the fact that mine was a textbook case. I had a history of depression, and did not believe my condition—which was gradually worsening—to be job-related. I began to miss days of work and arrive late frequently, feeling unable to face my patients and co-workers. The quality of my work was seriously suffering, as my screening rates were falling rapidly and I began to avoid non-essential interactions with patients. Finally, I reached out to a case manager who had trained me, and she tried to convince Human Resources to transfer me to a position that did not involve depression screening. My psychiatrist attempted to help with a recommendation for reasonable accommodation, but all of my experiences with the Human Resources department were confrontational. The director treated me as if I had personally and morally failed—slacked off, shirked responsibility, and become lazy. There was no understanding of the systemic and organizational factors that caused me to burn out. In the end, I took a medical leave and applied for disability, my own mental health having deteriorated severely.
Aside from my personal recovery, which took several months, my burnout led to disruption of services for many clients and the organization. I played a critical role in making sure that patients’ visits ran smoothly, and when I was well, I was extremely efficient. I do not know when they found a replacement, but I know that the clinic lost time to that person’s training and adjustment to the position. The patients with whom I had built trusting relationships—many of whom were very vulnerable and ill—had to start from scratch with someone new. Worst of all, other staff was overburdened by the need to take over for duties I’d previously assumed. In keeping with the general attitude that burnout is an individual, and not an organizational phenomenon, I was blamed for what happened, and none of the organizational policies were changed to offer more support for case managers. Until human services organizations, and especially their human resources personnel, begin to realize the drastic consequences of ignoring burnout potential, staff and clients alike will continue to cope with the fallout, and both productivity and quality of service will continue to suffer.