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A Preliminary Test of a Social Connectedness Burnout Intervention for Mexican Mental Health Professionals.

Job burnout consists of emotional exhaustion, depersonalization, and reduced personal accomplishment, and occurs cross-culturally and in multiple contexts (Maslach, Schaufeli, & Leiter, 2001). With 21-67% reporting high levels of burnout, mental health professionals (MHPs) are at high risk (Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012). MHP burnout decreases work quality, motivation, communication, empathy, creativity, and results in avoidance, poor relationships, and impaired client care and satisfaction (Morse et al., 2012; Salyers, Flanahan, Firmin, & Rollins, 2015). Interventions to reduce burnout produce small, significant effects on emotional exhaustion, but nonsignificant effects on depersonalization and personal accomplishment (Maricutoiu, Sava, & Butta, 2016). Morse et al.'s (2012) review notes only a small number of studies of MHPs, which are primarily conducted in Europe and with inpatient psychiatry units.

The current bumout intervention study is novel in three ways. First, it is the first evaluation of burnout prevention with outpatient MHPs in Latin America (Juarez-Garcia, Idrovo, Camacho-Avila, & Placencia-Reyes, 2014). Second, to enhance sustainability and dissemination efforts (Khanna & Kendall, 2015), the intervention was conducted online. Third, the intervention content was novel. Capitalizing on findings that close work-related attachments and social relationships predict less burnout and improved organizational climates (e.g., Leiter, Day, & Price, 2015; Leiter, Nicholson, Patterson, & Laschinger, 2012), the intervention was designed to improve closeness and connection between coworkers by applying the principles of Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai, Kohlenberg, Kanter, Kohlenberg, Follette, & Callaghan, 2009) as per a behavioral analysis of social psychological models of intimate social relationships. FAP is a contextual-behavioral therapy approach in which the therapist creates an idiographic case conceptualization of the client's in-session clinically relevant behaviors (CRBs) as functional classes, defined in terms of problematic CRBs (CRBls) and improvements in these repertoires (CRB2s). The FAP therapist then applies behavioral principles--taught to therapists as five rules--to notice (Rule 1), evoke (Rule 2), and reinforce (Rule 3) in-session CRB2s, check that the shaping process was reinforcing (Rule 4), and then generalize these improvements to the client's daily life (Rule 5). Evidence has accumulated in support of FAP processes as an effective method of shaping client behavior, particularly behavior related to intimacy and interpersonal relationships (Kanter et al., 2017).

As per Maitland, Kanter, Manbeck, and Kuczynski (2017), the current intervention defined CRBs in terms of behavioral variables identified as important to the intimacy process from the Interpersonal Process Model (IPM; Reis & Shaver, 1988), a well-established social psychological model of intimacy. In particular, the IPM provides a formulation of intimate relationships that applies across relationship types (e.g., romantic partners, friends, family members, coworkers) and emphasizes a turn-by-turn behavioral process, which has been studied experimentally as a "fast-friends" procedure (Aron, Melinat, Aron, Vallone, & Bator, 1997). In particular, the key IPM turn-by-turn process is that Person A of a relational dyad initiates the process by engaging in a vulnerable selfdisclosure, and Person B responds to this disclosure with understanding, validation, and caring. Much research has established that when two members of a relational dyad engage in this process reciprocally and over time, feelings of closeness and intimacy develop (e.g., Laurenceau, Barrett, & Pietromonaco, 1998; Laurenceau, Barrett, & Rovine, 2005; Manne, Ostroff, Rini, Fox, Goldstein, & Grana, 2004).

Although much relationship research has prioritized attachment theory or psychodynamic formulations, the IPM essentially is a behavioral theory and has lent itself to both behavioral analyses of intimacy (Cordova & Scott, 2001) and behavioral experimentation on these processes (Haworth et al., 2015). Cordova and Scott clarified the theory of the IPM process as a behavioral phenomenon in which Person A engages in vulnerable behavior (i.e., vulnerable to, or perceived as at high risk for, interpersonal punishment) and Person B's response is naturally reinforcing rather than punishing, increasing the frequency of the speaker's vulnerable behavior. Haworth et al. demonstrated that experimental participants' vulnerable self-disclosures may be successfully evoked by a series of question prompts, that other individuals may be trained to provide contingent responses to these disclosures that are experienced by participants as providing understanding, validation, and caring, and that these responses are functionally reinforcing, increasing the depth of vulnerable self-disclosure over time, and producing increased feelings of closeness and intimacy. The increased feelings of closeness and intimacy resulting from this process are seen as respondent by-products of this operant process.

Consistent with previous approaches to experiential FAP training that have been shown to successfully improve FAP therapists' repertoires related to intimacy (Kanter, Tsai, Holman, & Koerner, 2013; Keng et al., 2017; Maitland et al., 2016), the current intervention was designed to help participants notice (Rule 1), evoke (Rule 2), and reinforce (Rule 3) each other's behaviors related to vulnerable self-disclosure and responsiveness as per a behavioral understanding of the IPM (Haworth et al., 2015; Maitland et al., 2017). Participants first were introduced to a behavioral understanding of the IPM and how FAP's rules may be applied to evoke and reinforce relevant behavior within that process. Then, guided and modeled by the intervention cofacilitators over six weeks of online meetings, a series of experiential exercises evoked participant behaviors related to sharing vulnerable details about their personal lives and work-related stressors with each other. Participants were coached to respond to each other's disclosures in hopefully reinforcing ways. Participants then checked on the reinforcing qualities of their responses with each other (Rule 4) and then planned engaging in similar behaviors with targeted significant others as between-session homework assignments (Rule 5). The intervention, called the Helping the Helper Program (HTHP), was implemented in a small, uncontrolled pilot trial with MHPs in a public mental health setting in Mexico City. We hypothesized that the HTHP would facilitate increased closeness and emotional support among MHP participants and with others in their lives, and this would lead to decreased burnout, an improved organizational climate, and increases in quality of life.

Method

Participants and Procedure

The intervention setting was the Borderline Personality Disorder Clinic of the National Psychiatric Institute in Mexico City, which was under the codirection of the first author. The first author approached the third author with a request for a FAP-related burnout intervention for his therapists, based on observations that burnout was a significant problem in the clinic (these observations were confirmed by baseline data provided by participants, below). All eight clinic therapists were invited to participate by the first author. Two declined participation. Of the six enrolled therapists, half (n = 3) were male and the other half (n - 3) were female. Five were licensed psychologists and one a licensed psychiatrist, with ages ranging from 26 to 44 years (M = 36.00, SD = 7.59). All therapists provided signed informed consent and completed measures 5, 3, and 1 week(s) before the first session (Phase A), the week of the third session, and 1,4, and 7 week(s) after the final session (Phase B).

The Helping the Helper Program (HTHP)

The Helping the Helper Program (HTHP) was based on an FAP online training protocol developed by Dr. Mavis Tsai and evaluated in Kanter et al. (2013), modified by the current authors with additional exercises, a rationale linking the exercises to the specific behaviors identified as important to intimacy by the IPM, and a clarified focus on engaging in these behaviors in the service of increasing connection between participants. It was hypothesized that the HTHP exercises would: (a) evoke and reinforce the relevant behaviors, making them more likely to occur; (b) produce immediate benefits in terms of enhanced closeness and intimacy between participants; and (c) establish the work setting as an appropriate context to engage in additional intimacy-enhancing interpersonal exchanges, such that additional exchanges would occur and be reinforced outside of the training sessions.

The current program included six weekly online sessions, 2 hours each, with six participants and two group leaders. The full HTHP program is available from the third author upon request.

Preprogram preparation To prepare for the sessions, one of the leaders sent an email to the participants approximately two weeks prior to the beginning of the program to orient them to the program. This email contained the program "vision" and a "Life History" writing assignment that was preparation for the in-session "Life History" autobiography described below. It also asked participants to reflect on how satisfied they were with their work experiences, and how willing they felt to take emotional risks during the program sessions.

Program format and delivery The program was delivered using a commercially available web-conferencing interface that blended instant messaging, audio and video web-conferencing. Some technical problems occurred during the program sessions due to a poor internet connection, but this did not interfere substantially with the delivery of the program sessions. The primary trainer was a monolingual English speaker, whereas the cotrainer and all participants were bilingual in Spanish and English. In general, participants spoke in English but some personal exchanges between some participants occurred in Spanish, which they felt facilitated emotional availability and connection. When participants spoke in Spanish, another participant or the cotrainer simultaneously translated for the primary trainer. Language issues were not perceived as disruptive to the training in any way.

In-session program activities A variety of in-session experiential exercises were conducted during the program, with the overall function of these exercises to evoke exchanges of vulnerable self-disclosure and reinforcing responsiveness between participants. For the participants, as per the language recommended by Tsai et al. (2009), and consistent with the model of FAP CRB targets related to intimacy presented by Maitland et al. (2017), the exercises were described to participants as exchanges of courage (participant) and love (responders) and were intended to both evoke and reinforce the behaviors and build intimate connections between the participants. For example, a Life History exercise occurred during the first two program sessions. In this exercise, each participant provided a 6-8-minute autobiography to the group and was encouraged to take risks related to emotional expression and honesty. At the end of each participant's autobiographical presentation, the group members (and subsequently the trainers) took turns responding to the presenter. Group members were encouraged to respond by genuinely telling the participant how they felt in response to the participant's disclosure, and to express understanding and emotional validation, but otherwise group members were not provided specific instructions in how to respond. After these responses, a brief round of feedback occurred, providing the responders feedback on what was perceived as helpful about their response.

Additional exercises, all functioning to practice the key intimacy behaviors and provide multiple reinforcing exchanges of vulnerable self-disclosure and responsiveness, included feedback on "courage and love logs" (described below), sharing of personal mission and passion statements with the group, discussion of "pure love memories," an "inner voices" exercise that prompted participants to explore multiple aspects of themselves that they typically hide by giving different traits different voices (e.g., the romantic poet, the rejected teenager, the impostor), and "appreciations" in which participants expressed specific appreciations to one another and the trainers.

As the training proceeded, the trainers developed individualized case conceptualizations of the participants. All the exercises were predetermined and not modified to target specific skills deficits of participants, but the case conceptualizations were used to tailor feedback to participants and tailor homework assignments. For example, a female participant who was particularly avoidant of vulnerable self-disclosure would laugh while disclosing, and feedback was provided about how powerful and connecting her disclosures were when she would not laugh, and a male participant who was somewhat authoritative in his responsiveness was encouraged to be softer when responding to his family members during the week.

Between-session homework assignments Each week the participants were encouraged to try similar disclosures and responsiveness with others, including friends, family, and their clients, and to report on these behaviors at the beginning of the next training session in the form of "courage and love logs." Participants were encouraged to tailor this work to their own CRB2s. For example, one participant might have focused on sharing details of her life with friends and family, whereas another participant might have focused more on providing safety and love in response to family members' expressions of needs. The night before the next group meeting, participants emailed their logs to the group. Participants were randomly assigned to different partners each week to give 1-min feedback/reflections on the behaviors engaged in during the week. After each session, participants sent responses to a series of "Session Bridging Questions" (e.g., What was helpful about this session? What would have made it a better experience? What questions do you have? What is hard for you to say?) to the trainers to provide feedback about the quality of the experience and as an opportunity to engage in more targeted behavior.

Session structure The sessions were highly structured and followed a session-by-session protocol. The first session began with a review of the expectations for the group, group guidelines, concerns and fears, and issues of confidentiality and safety related to the personal nature of the group. The trainers then provided a brief overview of their behavioral model of intimacy (as per Maitland et al., 2017), conducted the Life History exercise, and assigned homework (including Session Bridging Questions and Courage and Love Logs). In general, subsequent sessions began with a brief meditation to increase awareness, defined, as per Maitland et al. (2017), as discriminating relevant private events and other antecedents to maximize successful vulnerable self-disclosure and responsiveness. This was followed by feedback/reflections on participants' courage and love logs. The body of each session focused on exercises described above. Each session ended with description of specific homework assignments for the following week.

Program leaders The HTHP was implemented by the first and third authors. The third author is regarded as a FAP expert, with over 15 years of training, treatment development, and research experience with FAP, and served as primary group leader. At the time of the intervention, the first author had 7 years of clinical experience, had attended several previous FAP workshops, and was under clinical supervision of a FAP expert. Because the intervention was highly structured, with clearly defined exercises and time limits, the coleaders monitored treatment integrity themselves, meeting weekly for 1 half-hour before and after sessions to review intervention integrity and discuss participant case conceptualizations and improvements. No deviations from protocol were observed.

Measures

Maslach Burnout Inventory (MBI; Maslach, Jackson, & Leiter, 1996) A validated Mexican version of the MBI was used (Hernandez, Llorens, & Rodriguez, 2011). The MBI is a 21item self-report measure consisting of three factors: (a) Emotional Exhaustion (EE; 9 items), (b) Depersonalization (DP; 4 items), and (c) Personal Accomplishment (PA; 8 items). Example items include "I feel exhausted from my job," "I see some of my clients as if they were impersonal objects," and "I feel refreshed when I have been close to my patients/clients at work" for the EE, DP, and PA subscales, respectively. Respondents rate each item on a 7-point Likert scale ranging from 0 (Never) to 6 (Always). A score for each subscale is computed by taking the sum across all relevant items such that higher scores reflect greater burnout, emotional exhaustion, depersonalization, and feelings of personal accomplishment. Possible subscale scores thus range from 0 to 63, 28, and 56 for the EE, DP, and PA subscales. The MBI instructions were modified to reference a 2-week response window consistent with the study's measurement strategy.

World Health Organization Quality of Life-BREF (WHOQOL; WHOQOL Group, 1998) The WHOQOL is a 26-item self-report measure of perceived quality of life as they relate to four domains and two general questions: (a) physical health (7 items); (b) psychological health (6 items); (c) social relationships (3 items); and (d) environment (8 items). Given the current study's focus on bumout and social relationships, only the psychological health and social relationships subscales were analyzed. Example items for each subscale include "How much do you enjoy your life" and "How satisfied are you with your personal relationships," respectively. Respondents rate each item on a 5-point Likert scale ranging from 1 (Not at all) to 5 (Completely). A score for each subscale is computed by first taking the mean across all relevant items and converting to a transformed score (range 0-20) by multiplying each raw subscale score by 4. Higher scores thus reflect greater psychological health and social relationships. The WHOQOL instructions referenced a 2-week response window consistent with the study's measurement strategy.

Multidimensional Scale of Organizational Climate (MSOC; Patlan Perez & Flores Herrera, 2013) Organizational climate refers to contextual factors in mental health organizations that influence worker satisfaction and effectiveness. Organizational climate is predictive of therapist turnover (Aarons & Sawitzky, 2006), provider rated therapeutic alliance (Aarons, Woodbridge, & Carmazzi, 2003), and outcomes (Glisson & Hemmelgarn, 1998; Schoenwald, Sheidow, Letourneau, & Liao, 2003). The MSOC comprises eight factors organized into three levels of analysis: (a) Individual systems (Worker Satisfaction, Job Autonomy); (b) Interpersonal Systems (Social Relationships, Closeness and Support Among Team Members); and (c) Organizational Systems (Managerial Regard, Benefits and Rewards, Motivation and Effort, Managerial Leadership). Respondents rate each item on a 5-point Likert scale ranging from 1 (Never) to 5 (Always). We analyzed the two interpersonal systems subscales and the total score in the current study, which are computed by taking the mean across all items such that higher scores reflect greater social relationships, closeness and support among team members, and overall organizational climate. Possible total scale scores thus range from 1 to 5. The MSOC instructions were modified to reference a 2-week response window consistent with the study's measurement strategy.

Data Analytic Plan

Given the small sample size employed in the present study, parameter estimation based on ANOVA and other general linear models was not possible. Therefore, we computed a robust improvement rate difference score (R-IRD; Parker, Vannest, & Davis, 2011) and associated 95% confidence interval for each subject in order to test for the effects of the HTHP. Robust IRD scores are computed by taking the difference between proportion of improvements to total observations observed in Phase A (control) and B (treatment). An improvement in Phase B is defined as an observation that does not overlap with any observations in Phase A. Conversely, an improvement in Phase A is defined as an observation that overlaps with observations in Phase B. Possible values lie within 0.00 and 1.00, with 1.00 representing a situation in which all observations in Phase B are improvements with respect to Phase A. A R-IRD value of 0.50 occurs when half of the Phase B scores are improvements (a chance-level finding). Parker, Vannest, and Brown (2009) suggested the following criteria for interpreting IRD values: 0.50 = small/ questionable effect; 0.50 to 0.70 = moderate effect; and 0.70-1.00 = large effect.

Due to the small sample size used in this study, we did not have sufficient variance to accurately estimate Cronbach's a for the measures used (Charter, 1999; Nunnally & Bernstein, 1994; Yurdugul, 2008).

Results

Means and standard deviations for each measure are reported in Table 1 and scores for each of the measures across all seven times points and all six therapists are presented in Figure 1. All R-IRD values and associated 95% confidence intervals can be found in Table 2. For MBI (EE) scores, R-IRD values ranged from 0.42 to 1.00, with one participant evidencing a small/ questionable change and the other five evidencing large changes from preintervention (Phase A) to postintervention (Phase B). The mean preintervention MBI (EE) score across all therapists was 29.00 (SD = 9.60), with decreases found both at mid-intervention (M = 24.17, SD = 6.46) and postintervention (M = 15.89, SD = 5.03). Findings for MBI (DP) were similar, with R-IRD values ranging from 0.42 to 1.00 (M = 0.76), with one participant evidencing a small/questionable change and the other five evidencing large changes from preintervention (Phase A) to postintervention (Phase B). The mean preintervention MBI (DP) score across all therapists was 10.28 (SD = 4.32), with decreases found at mid-intervention (M = 7.33, SD = 2.07) and postintervention (M = 6.33, SD = 1.94/ For MBI (PA) scores, R-IRD values similarly ranged from 0.42 to 1.00, again with one participant evidencing a small/questionable change and the other five evidencing large changes from preintervention (Phase A) to postintervention (Phase B). The mean preintervention MBI (PA) score across all therapists was 39.83 (SD = 3.96), with increases found at mid-intervention (M= 44.83, SD = 4.54) and postintervention (M= 49.89, SD = 5.21). Given the small number of data points per participant, the 95% confidence intervals for this collection of scores, however, were relatively large. Only perfect RIRDs of 1.00 (9 of 18 scores) achieved confidence intervals that did not cross .50, suggesting that although 15 of 18 scores were large by R-IRD standards, we have strong confidence in only half of them.

Results showed a similar pattern of improvement for quality of life. R-IRD values for psychological health ranged from 0.42 to 1.00, with one participant evidencing a small/ questionable change and the other five evidencing large changes from preintervention (Phase A) to postintervention (Phase B). The mean preintervention psychological health score across all therapists was 14.63 (SD = 1.49), with increases found at mid-intervention (M = 15.67, SD = 1.73) and postintervention (M = 17.07, SD = 1.45). Likewise, RIRD values for social relationships ranged from 0.42 to 1.00, with one participant evidencing a small/questionable change and the other five evidencing large changes from preintervention (Phase A) to postintervention (Phase B). The mean preintervention social relationships score across all therapists was 13.63 (SD = 1.92), with increases found at midintervention (M- 16.22, SD = 3.31) and postintervention (M= 18.22, SD - 2.63). Confidence intervals likewise suggested that we only have strong confidence in perfect R-IRD scores of 1.00 (half of the scores).

Results for organizational climate (the social relationships subscale, the closeness and support among team members subscale, and the total score) were stronger, with R-IRD values ranging from 0.71 to 1.00 for all three scales, and all participants evidencing large changes from preintervention (Phase A) to postintervention (Phase B). For total organizational climate, the mean preintervention rating was 3.89 (SD = 0.63), with a large increase found at midintervention (M = 4.69, SD = 0.24) and a slight increase at postintervention (M = 4.69, SD = 0.24). All confidence intervals for these R-IRD values were higher than 0.50, suggesting that we have stronger confidence in these values.

Discussion

Results provide preliminary support for the possibility that a FAP training protocol, defining targeted CRBs in terms of key variables identified as important by the IPM, and adapted as a "Helping the Helper" program, can improve social relationships, reduce burnout, increase quality of life, and improve perceptions of organizational climate among colleagues in a high-stress, public mental health setting in Mexico. As per a behavioral understanding of the IPM (Reis & Shaver, 1988), the training protocol essentially created a series of exercises that evoked and reinforced, in small groups and dyadic exchanges, key repertoires necessary for the development of intimacy and closeness among coworkers. In particular, the intervention facilitated participants engaging in dyadic exchanges of vulnerable self-disclosure and responsiveness with each other, encouraging them to vulnerably share not only work stress and burnout, but other vulnerable details of their lives and histories, and then to engage in similar behaviors with targeted significant others and with each other during the week. We hypothesized that such efforts would improve intimacy and social support in participants' work and personal lives, and this would have downstream effects on burnout and quality of life (Holt-Lunstad, Smith, & Layton, 2010; House, Landis, & Umberson, 1988).

In the current study, the largest and most consistent improvements were found for measures of social relationships and support among the participants themselves. Specifically, all participants demonstrated large and reliable improvements on the social relationships among team members and closeness and support among team members' subscales of our measure of organizational climate, suggesting that the protocol was effective at improving relationships among intervention participants. This finding is consistent with previous findings for FAP training protocols, where the strongest results often are improvements in relational quality among participants (e.g., Kanter et al., 2013; Keng et al., 2017). However, in those protocols, the relationships that participants form among themselves are more of a by-product of the trainings, which focus on acquisition of therapeutic skill and improved relationship quality with clients. In the current protocol, improved relationships among participants was a direct, primary target.

Encouraging, but not consistently as strong, results were found for downstream effects of these improved relationships. Specifically, five of six participants demonstrated large changes on all three MBI subscales, including--unlike previous burnout intervention research (Maricujoiu et al., 2016)--depersonalization and personal accomplishment, and similar numbers of participants reported large changes on quality of life subscales. Our confidence in these findings is mitigated somewhat in that only half of the participants achieved confidence intervals that did not include R-IRD values indicating small or questionable changes for these measures.

This study has several limitations. A selection bias can be found as participants of the study may have volunteered to take part on it due to their personal interest in FAP. Without a control group, the effects of simply increased attention and caring directed towards the participants during the intervention, and the inclusion of a known FAP expert as the primary trainer, may have produced significant nonspecific benefits that cannot be attributed to the specific FAP protocol per se. Likewise, the codirector of the participant's clinic was directly involved. Although involvement of the director is seen as a strength in terms of fully addressing issues of organizational climate, participants' responding on the self-report measures may have been biased by expectancy effects or allegiance effects due to these influences.

From a behavioral perspective, there are several additional limitations. First, we relied on self-report measures as our primary outcomes, so we do not have concrete evidence that behavior changed over the course of the intervention. The logistics and nature of the study prevented such behavioral measurement. Thus, although the self-report outcomes are encouraging, and we are confident that relationships improved over the course of the intervention, from a behavioral perspective we cannot claim that the hypothesized mechanisms of the intervention were responsible for the reported improvements (i.e., an increased frequency of vulnerable self-disclosure and reinforcing responsiveness in both personal and work contexts for participants). We do have strong evidence that FAP's presumed mechanism (evoking and reinforcing CRB2s) does produce changes in those CRB2s in therapy contexts (Kanter et al., 2017), but this study cannot make that claim given the methodology employed.

Also from a behavioral perspective, the intervention may be seen as limited in that idiographic case conceptualizations were not employed to tailor interventions to individual participants' skill strengths, deficits, and competing sources of stimulus control and reinforcement. Rather, all participants received the same interventions as a group, and it was expected that all participants would benefit regardless of individual skills and deficits. It may be said that, at the group level, the intimate exchanges recommended by the IPM were not occurring and the intervention aimed to increase their frequency of these exchanges at the group level, but future research may benefit from exploring the effects of these interventions on individual behavior more precisely to shed light on individual behavioral analyses and mechanisms of change. In addition, the small sample and specific context in which the intervention occurred limit the generalizability of the findings. It is unclear if results would replicate with other samples, such as psychiatry residents, or in other settings, such as mandated trainings. Furthermore, a full assessment of the organizational climate of this setting was not conducted, so we do not know how this setting compares to other organizational settings or if additional climate factors might need to be addressed in other settings with less favorable climates. Also, the current participants, with previous experience and training in other contextual behavioral approaches, demonstrated considerable receptiveness to the current intervention, and participants with different backgrounds may be less receptive to the nature of the intervention. At the individual level, although all participants appeared to benefit from the intervention, the small sample prevents any meaningful analyses of moderator variables that could inform inclusion criteria for future work. For example, therapist expertise (student, professional, and years of experience), number of clients in the caseload, and degree of preintervention burnout, may be useful variables to explore to characterize the potential of this intervention fully.

Despite these limitations, the current results appear novel and important in establishing the potential of experiential FAP training, which previously has been shown to improve the therapeutic skills (particularly relationship skills) of therapist trainees (as per Kanter et al., 2013; Keng et al., 2017; Maitland et al., 2016), to produce personal and workplace benefits of public health significance for participants when modified into a "Helping the Helper" program. Future research that randomizes participants to intervention or control, recruits a wider range and larger number of participants, and employs a "train the trainer" approach in which known FAP experts do not deliver the training will resolve many of the current study's limitations and explore more definitively the full potential of this promising approach to bumout reduction in high-stress workplaces.

Compliance with Ethical Standards

Conflict of Interest On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical Approval All procedures involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments.

Informed Consent Informed consent was obtained from all individual participants included in the study.

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Michel A. Reyes Ortega (1) * Adam M. Kuczynski (2) [iD] * Jonathan W. Kanter (2) * Ivan Arango de Montis (3) * Maria Magdalena Santos (4)

[mail] Adam M. Kuczynski

adamkucz@uw.edu

https://doi.org/10.1007/s40732-019-00338-5

Published online: 22 March 2019

(1) Contextual Behavioral Science and Therapy Institute, Mexico City, Mexico

(2) University of Washington, 119a Guthrie Hall, Box 351525, Seattle, WA 98195, USA

(3) National Institute of Psychiatry Ramon de la Fuente, Mexico City, Mexico

(4) California State University, San Bernardino, CA, USA

Caption: Fig. 1 Emotional Exhaustion, Depersonalization, Personal Accomplishment, Psychological Health, Social Relationships, and Organizational Climate (total, social relationships, and union and support between colleagues) scores by therapist
Table 1. Means and standard deviations of outcome measures
at pre-, mid-, and postintervention time points

                           Pre                         Mid

                           5-week   3-week   1-week

Burnout                    27.17    30.67    29.17     24.17
Emotional Exhaustion       (9.56)   (8.85)   (11.69)   (6.46)

Bumout                     9.67     10.83    10.33     7.33
Depersonalization          (4.08)   (4.17)   (5.35)    (2.07)

Bumout                     39.83    39.83    39.83     44.83
Personal Accomplishment    (4.40)   (4.07)   (4.17)    (4.54)

Quality of Life            14.89    14.56    14.44     15.67
Psychological Health       (1.72)   (1.07)   (1.82)    (1.72)

Quality of Life            14.00    13.56    13.33     16.22

Social Relationships       (2.02)   (2.14)   (1.89)    (3.31)

Organizational Climate     3.93     3.67     4.06      4.63
Total Score                (0.51)   (0.57)   (0.82)    (0.33)

Organizational Climate     3.72     3.72     4.06      4.95
Social Relationships       (0.71)   (0.68)   (0.77)    (0.13)

Organizational Climate     3.92     3.50     4.00      4.63
Union and Support          (0.75)   (0.67)   (1.13)    (0.44)

                           Post

                           1-week   4-week   7-week

Burnout                    15.33    17.33    15.00
Emotional Exhaustion       (5.57)   (4.41)   (5.62)

Bumout                     5.50     7.67     5.83
Depersonalization          (0.84)   (2.80)   (0.98)

Bumout                     49.50    50.33    49.83
Personal Accomplishment    (5.21)   (5.24)   (6.11)

Quality of Life            17.11    16.89    17.22
Psychological Health       (1.09)   (1.56)   (1.86)

Quality of Life            17.56    18.44    18.67
Social Relationships       (2.85)   (2.72)   (2.67)

Organizational Climate     4.62     4.72     4.27
Total Score                (0.28)   (0.27)   (0.21)

Organizational Climate     4.83     5.00     5.00
Social Relationships       (0.41)   (0.00)   (0.00)

Organizational Climate     4.79     4.83     4.85
Union and Support          (0.25)   (0.20)   (0.14)

Table 2. Robust Improvement Rate Difference scores
and associated 95% confidence intervals

Outcome          Therapist 1            Therapist 2

                 IRI     C[I.sub..95]   IRI     C[I.sub..95]

MBI (DP)         0.71    (0.18, 1.00)   1.00    (1.00, 1.00)
MB I (EE)        0.71    (0.18, 1.00)   1.00    (1.00, 1.00)
MBI (PA)         1.00    (1.00, 1.00)   0.71    (0.18, 1.00)
WHOQOL (PSYCH)   1.00    (1.00, 1.00)   1.00    (1.00, 1.00)
WHOQOL (REL)     1.00    (1.00, 1.00)   1.00    (1.00, 1.00)
MSOC Tot.        1.00    (1.00, 1.00)   1.00    (1.00, 1.00)
MSOC (SR)        1.00    (1.00, 1.00)   1.00    (1.00, 1.00)
MSOC (US)        0.71    (0.18, 1.00)   1.00    (1.00, 1.00)

Outcome          Therapist 3            Therapist 4

                 IRI     C[I.sub..95]   IRI     C[I.sub..95]

MBI (DP)         0.42    (0.00, 1.00)   0.72    (0.18, 1.00)
MB I (EE)        0.71    (0.18, 1.00)   0.42    (0.00, 1.00)
MBI (PA)         1.00    (1.00, 1.00)   1.00    (1.00, 1.00)
WHOQOL (PSYCH)   0.71    (0.18, 1.00)   1.00    (1.00, 1.00)
WHOQOL (REL)     0.71    (0.18, 1.00)   1.00    (1.00, 1.00)
MSOC Tot.        1.00    (1.00, 1.00)   1.00    (1.00, 1.00)
MSOC (SR)        1.00    (1.00, 1.00)   1.00    (1.00, 1.00)
MSOC (US)        0.71    (0.18, 1.00)   1.00    (1.00, 1.00)

Outcome          Therapist 5            Therapist 6

                 IRI     C[I.sub..95]   IRI     C[I.sub..95]

MBI (DP)         1.00    (1.00, 1.00)   0.71    (0.18, 1.00)
MB I (EE)        1.00    (1.00, 1.00)   1.00    (1.00, 1.00)
MBI (PA)         1.00    (1.00, 1.00)   0.42    (0.00, 1.00)
WHOQOL (PSYCH)   0.71    (0.18, 1.00)   0.42    (0.00, 1.00)
WHOQOL (REL)     0.42    (0.00, 1.00)   0.71    (0.18, 1.00)
MSOC Tot.        1.00    (1.00, 1.00)   0.71    (0.18, 1.00)
MSOC (SR)        1.00    (1.00, 1.00)   0.71    (0.18, 1.00)
MSOC (US)        1.00    (1.00, 1.00)   0.71    (0.18, 1.00)

Note. MBI (DP) = Maslach Bumout Inventory, Depersonalization
subscale; MBI (EE) = Maslach Bumout Inventory, Emotional
Exhaustion subscale; MBI (PA) = Maslach Burnout Inventory,
Personal Accomplishment Subscale; WHOQOL (PSYCH) = WHO
Quality of Life-BREF, Psychological Health subscale;
WHOQOL (REL) = WHO Quality of Life-BREF, Social Relationships
subscale; MSOC Tot. = Multidimensional Scale of Organizational
Climate, Total Score; MSOC (SR) = Multidimensional Scale of
Organizational Climate, Social Relationships subscale; MSOC
(US) = Multidimensional Scale of Organizational Climate,
Union and Support Between Colleagues Subscale
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Title Annotation:ORIGINAL ARTICLE
Author:Ortega, Michel A. Reyes; Kuczynski, Adam M.; Kanter, Jonathan W.; de Montis, Ivan Arango; Santos, Ma
Publication:The Psychological Record
Geographic Code:1MEX
Date:Jun 1, 2019
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