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Key Factors of Internship Burnout and Possible Solutions

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Burg, C., Burg, J., Long, S., Melowsky, J., Pasternak, T., Rascon, C., ... Walters, C. (2017) . Key factors of internship burnout and possible solutions. Psychotherapy Bulletin, 52(3), 16-20.

Psychology Interns

Psychology predoctoral interns face many challenges, as difficult roles and competing expectations may lead to burnout. Edelwich (1980) defined burnout as “a progressive loss of idealism, energy, and purpose by people in the helping professions as a result of the conditions of their work” (p. 14). Common factors contributing to burnout include difficult cases, feeling overworked, not feeling supported when in a “middle” role, and feeling that a particular training experience did not prepare a trainee for the professional postdoctoral world. The experience of burnout is felt across training sites and could negatively impact trainees’ ability to meet the American Psychological Association (APA) training core competencies (APA, 2017). The current paper will consider two particularly salient and potentially harmful areas of burnout: (1) the structure of training sites and general experiences which may result in an unpleasant training year; and (2) difficulties in supervision during the training year. The paper will also make recommendations for changes to training programs, from a feminist theory perspective.

Burnout on Internship

According to Suran and Sheridan (1985), burnout among psychologists may be best understood within the context of developmental theory. The authors proposed a developmental model of burnout that includes the following stages: (a) Stage 1: identity versus role confusion, (b) Stage 2: competence versus inadequacy, (c) Stage 3: productivity versus stagnation, and (d) Stage 4: rededication versus disillusionment. The first stage of burnout, identity versus role confusion, manifests during graduate school training and the internship year. More specifically, a psychology intern is faced with a personal and professional identity crisis that requires a great deal of emotional energy. Professional identity demands include securing a post-doctoral position, developing a specialty, and completing the doctoral paper. The parallel social or personal developmental tasks include forming friendships and romantic relationships, achieving financial stability, deciding whether to have children, building a sense of community, securing employment, and establishing one’s political identity (Suran & Sheridan, 1985). Supervisors and training directors may contribute to intern burnout by failing to balance realistic training needs with the intern’s personal identity development needs. By neglecting to acknowledge or address both of these crucial needs during this stage of development, the intern is prevented from successfully integrating personal and professional identities, leaving the intern more vulnerable to losing a sense of purpose in future employment.

Factors contributing to burnout. Pillay and Johnston (2011) found that 34.9% of 150 clinical psychology interns felt adequately prepared for internship with 53% feeling only partly prepared. Of those surveyed, 53% felt their training was relevant to their internship and 31.3% felt their training was only partly relevant. These statistics concerning preparation and relevant training may speak to the elevated rates found by Kaeding et al. (2017) that 75% of interns reported moderate to high levels of stress during training and 41% reported depression, anxiety, low self-esteem, or professional adjustment stressors. Kaeding et al. (2017) also found that 49% of 1,172 trainees reported high levels of burnout. This statistic directly correlates with Pillay and Johnston’s (2011) findings that approximately 50% of trainees feel prepared or relevantly trained.

Testa and Sangganjanavanich (2016) found that among counseling interns, who are expected to function independently as professional counselors, feelings of uncertainty, insecurity, and stress can increase and make it more difficult for them to attend to their own needs. Collaborative supervision that focuses on infusing wellness can help interns increase awareness of personal emotions and create a greater sense of control, proactively addressing burnout symptoms. One way to help the interns refocus attention toward recognizing when they are feeling emotionally exhausted or detached from their clients is to incorporate mindfulness interventions into the supervision process.

Kim and Lee (2009) examined how supervisory communication impacts burnout and turnover intention among social workers in health care settings. They used Maslach and Jackson’s (1986) conceptualization of burnout defined as having three components: emotional exhaustion (feelings of being overextended and depleted of emotional and physical resources), depersonalization/cynicism (negative or excessively detached responses to various aspects of the job), and diminished personal accomplishment (feelings of incompetence and a lack of achievement at work) (Kim & Lee, 2009; Maslach & Jackson, 1986). Results showed that job-relevant communication and positive relationship communication have a negative correlation with burnout resulting from perceived role stress in health social workers.

Watkins (2013) states that the “developmental literature has well-accented the painful struggle of the therapist identity formation process” (p. 526). These developing therapists often experience a mixture of anxiety, confusion, and other painful states as they undergo the task of acquiring the competencies needed to be effective psychologists (Watkins, 2013). These already difficult developmental growing pains are then often exacerbated during the pre-doctoral internship year when intern-supervisors are placed in the “uniquely triadic and sometimes confusing” roles that occur between the graduate level supervisee, the pre-doctoral intern, and the supervising staff psychologist (Smith-Acuña et al., 2010, p. 50). Role confusion and unclear power dynamics can potentially become major factors in the development of pre-doctoral intern burnout during the final training year. Furthermore, to the level that this triadic hierarchy is both present and inconsistent, both pre-doctoral interns and their graduate level supervisees often experience a lack of effective training, which then tends to foster experiences of burnout and resentment. As will be detailed in the recommendations, the integration of feminist theory practices to the internship training model can serve to both increase role consistency via transparency and reduce the negative experiences of this triadic hierarchy, therefore decreasing the likelihood of its contributions to burnout.

Using Feminist Theory to Combat Burnout

Implementation of the following training and supervision recommendations may alleviate intern burnout. Feminist theory is the umbrella framework under which these recommendations will be most effective. Feminist supervision, which emerged from feminist theory, aims to reduce the power differential inherent in the supervisory relationship to empower the supervisee (Degges-White et al., 2013). According to Degges-White et al. (2013), “it is often the quality of the supervision relationship that is defined as feminist rather than a group of specific supervision techniques” (p. 93). The feminist relationship is one characterized by mutuality and collaboration, mutual trust, transparency, and a focus on strengths (Degges-White et al., 2013). Feminist supervision empowers supervisees through practices such as transparency, acknowledging and addressing power differentials, and providing a safe environment in which trainees can share their mistakes.

Recommendations for training. With regard to specific training recommendations, designated training times should be intentionally prepared for and organized, focusing on topics relevant to each unique intern cohort. Interns should influence the percentage of time dedicated to didactic versus experiential training activities in order to ensure that their individual training needs are realized. The training director’s job description should detail these responsibilities and the individual’s time should be budgeted and managed accordingly in order to ensure that high quality training is offered to each intern group.

An additional recommendation is for the training experience to emphasize finding balance between the intern’s identities of trainee and psychologist as the internship year is both a critical training opportunity as well as a crucial time of transition into independence as a psychologist. With this in mind, the training experience should accomplish four main objectives. First, the training site should offer a supportive atmosphere in which interns feel safe to identify weaknesses, to make mistakes, to seek support, and to learn from those with more experience. Second, the training director should recognize that because interns are still in training, they have outside commitments such as doctoral research papers. Third, training staff should avoid treating interns unfairly by placing unrealistic expectations with regard to work content and hours. Fourth, the training program should outwardly acknowledge each intern’s role and value as a contributing team member within the organization.

A final recommendation for training programs is for the training director and relevant supervisors to create space for interns to feel safe discussing burnout and to intervene early and appropriately. Those in positions of power should be open about all possible strategies for addressing burnout ranging from adjusting the intern’s schedule or work content to taking a medical leave of absence when necessary.

Recommendations for supervision. In order to address burnout related to supervision, the following recommendations are offered. In the beginning of the supervision relationship, it will be important to emphasize that:

Actively listening from “within” [the supervisee’s subjective perspective] increases the likelihood that that (1) the supervisee’s self-experience at this particular time of vulnerability will be heard, accordingly granted center stage, and validated; (2) supervisor and supervisee will be able to openly recognize and collaboratively discuss matters of relationship rupture and initiate reparative measures; and (c) the bond between supervisor and supervisee will be further forged and fortified against future assaults. (Watkins, 2013, pp. 526-527)

It is suggested that internship sites minimize the number of individuals involved in a supervisory relationship; this can be accomplished, for example, by limiting supervision to a triadic system including the supervisee, intern-supervisor, and licensed supervisor. It is also important that the intern-supervisor and licensed supervisor have clear communication about their roles and responsibilities in working with the supervisee. These roles and responsibilities should be structured such that the intern-supervisor’s autonomy is encouraged and authority is not undermined. Additionally, preventing burnout within supervision involves discussing the dynamics and potential pitfalls of a three-tiered system from the outset of the supervisory relationship. In doing so, it is important to address how communication will occur within the system to minimize confusion or splitting.

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References

American Psychological Association. (2016). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code/ethics-code-2017.pdf

Degges-White, S. E., Colon, B. R., & Borzumato-Gainey, C. (2013). Counseling supervision within a feminist framework: Guidelines for intervention. Journal of Humanistic Counseling, 52(1), 92-105. doi: 10.1002/j.2161-1939.2013.00035.x

Edelwich, J. (1980). Burnout: Stages of disillusionment in the helping professions. New York, NY: Human Sciences Press.

Kaeding, A., Sougleris, C., Reid, C., van Vreeswijk, M. F., Hayes, C., Dorrian, J., Simpson, S. (2017). Professional burnout, early maladaptive schemas, and physical health in clinical and counseling psychology trainees. Journal of Clinical Psychology, 1-15. doi: 10.1002/ jclp.22485

Kim, H., & Lee, S. Y. (2009). Supervisory communication, burnout, and turnover intention among social workers in health care settings. Social Work in Health Care, 48(4), 364-385. doi:10.1080/00981380802598499

Maslach, C., & Jackson, S.E. (1986). The Maslach Burnout Inventory. Palo Alto, CA: Consulting Psychologists Press.

Pillay, A. L., & Johnston, E. R. (2011). Intern clinical psychologists’ experiences of their training and internship placements. South African Journal of Psychology, 41(1) 74-82. doi:10.1177/008124631104100108

Smith-Acuña, S., Hergenrother, C., Cassler, C., Doty, T., Fuchs, L., Ging, K., . . . Wartenberg (2010). Training in supervision during the pre-doctoral internship year: Experiences and recommendations. Psychotherapy Bulletin, 45(1), 49-53.

Suran, Bernard G., & Sheridan, Edward P. (1985). Management of burnout: Training psychologists in professional life span perspectives. Professional Psychology: Research and Practice, 16(6), 741-752. doi: 10.1037/0735-7028.16.6.741

Testa, D., & Sangganjanavanich, V. F. (2016). Contribution of mindfulness and emotional intelligence to burnout among counseling interns. Counselor Education and Supervision, 55(2), 95-108. doi:10.1002/ceas.12035

Watkins, C. E., Jr., (2013). Why subject-centered listening is so crucial in the supervision of beginning psychoanalytic supervisees. International Journal of Psychoanalytic Self Psychology, 8(4), 525-527. doi: 10.1080/15551024.2013.825955

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