The College of New Jersey
Alcohol abuse among police officers is a serious and widespread problem, with some studies estimating that it afflicts one-quarter of all police officers in the U.S. Research has revealed a strong connection between occupational stress and alcohol and drug abuse, but also a strong sub-cultural more among police officers that encourages drinking both for social and stress-reduction purposes. Alcohol consumption among police officers is also correlated with officer suicides and domestic violence, and many departments are beginning to recognize the liability in allowing this problem to go untreated. Mental health professionals have an opportunity to introduce prevention and intervention services to law enforcement agencies, but they must first surmount the wall of suspicion and cynicism that isolates the police sub-culture from the rest of society. This paper explores the nature of the problem of alcohol abuse among police, and also describes several initiatives aimed at reaching the men and women who protect and serve.
Alcoholism Among Law Enforcement Personnel: Its Unique Challenges
Problem drinking in the U.S. costs employers a staggering $10.7 to $2.7 billion per year in accumulated sick pay, lost productivity, accidents, and the consequences of bad workplace decisions. Some 60% of job absenteeism is attributable to alcoholic and other troubled employees, and these employees miss work 16 times more frequently than do their non-troubled colleagues. Moreover, nearly 90% of all industrial accidents are attributed to workers with either substance abuse or mental health issues. Across occupational lines, those employed in law enforcement are especially susceptible, and some studies have estimated that one-quarter of all police officers in the U.S. have serious alcohol problems (Moriarty & Field, 1990). Other health risks associated with police stress include weight gain, insomnia, gastric conditions, and heart disease (Lumb and Breazeale, 2002). A recent Australian study suggested the alcohol abuse rate is as high as 33% for police officers in that nation (Davey, Obst, and Sheehan, 2001). Several studies have corroborated the link between high stress and drinking (and their association with police suicides and domestic violence), and police work is ranked among the highest occupations for work-related stress (Davey, et. al.).
Paradoxically, despite the significantly high risk for alcoholism and other related problems, law enforcement remains one of the most difficult groups to reach with intervention and prevention services, due largely to the insular, clannish nature of police culture (Donovan, 1994). The purpose of this paper is explore the factors that may contribute to this situation and discuss some of ways mental health professionals might effectively reach out to the men and women who protect and serve.
Nature of the Problem
The job of a law enforcer in many respects occupies a unique role in a society. As Beutler, Nussbaum, and Meredith (1988) point out,
Officers must be willing to expose themselves to danger on a daily basis and to confront life-threatening circumstances. They must be willing, on one hand, to comply with a superior’s demands even when disagreeable and, on the other, to withstand the angry efforts of offenders to control them. The need to balance contradictory roles while maintaining a high degree of interpersonal sensitivity may adversely affect an individual over time if he or she does not have unusual skills (p. 503).
The Role of Stress
As previously noted, several studies have established a significant correlation between occupational stress and increased alcohol use by law enforcement personnel (Moriarty and Field, 1990; Violanti, 1985; Davey, et.al., 2001; Kohan and O’Connor, 2002). North Carolina Wesleyan College (n.d.) lists several sources of stress that are unique to police work and which may influence officers to consume alcohol as a means of coping. Stressors internal to the police organization include: Poor supervision (too lenient or too tough); absence of upward mobility; absence of an extrinsic reward system; offensive (annoying or silly) policies and procedures; excessive paperwork; and poor equipment. External stressors include: Absence of career development and lateral entry; jurisdictional turf battles among different law enforcement agencies; an ineffective criminal justice system; biased news reporting; negative minority attitudes towards police; derogatory remarks by the public; political interference; and lack of community resources. Stressors connected with police work include: Role conflict and strain; rotating shifts; fear and danger; relinquishing cases to the detective bureau; victim pain and anguish; and employee review boards (or civilian complaint review boards as they are called in New York City). Additional stressors include greater media and public scrutiny of police work and the ever-increasing sophistication and weaponry of many criminals. Women and minority police officers also face their own, unique stressors: for women, sexual harassment, public stereotypes, and non-acceptance by male peers; and for minorities, racial prejudice from white colleagues along with alienation from their own communities, which often fear and dislike the police (North Carolina Wesleyan College, n.d.).
Police, much like soldiers in combat, often experience the effects of job-related stress in a delayed manner similar to post-traumatic stress disorder (PTSD). But unlike other professionals and executives whose occupational stressors remain fairly constant, law enforcement personnel experience what is known as burst stress: long periods of calm and boredom suddenly interrupted by periods of high activity (North Carolina Wesleyan College, n.d.). Terry (1985) calls this “police stress syndrome.” As many turn to drinking as a means to cope with the challenges of their work, the rates of police suicides and domestic violence are increasing nationwide, with the majority of these cases being alcohol related (Donovan, 1994). In Chicago, for example, alcohol was involved in all police suicides between 1977 and 1979 (Wagner and Brzeczek, as reported by Moriarty and Fields, 1990).
How Stress Affects Police Officers
Lumb and Breazeale (2002) assert that occupational stress, if untreated, can lead to negative changes in police officers, specifically in their self-schemas and in how they perceive the communities in which they serve. This, in turn, puts them at risk for becoming cynical, burning out, turning apathetic, divorcing, abusing alcohol and drugs, and committing suicide. Moriarty and Fields (1990) expand on this point:
The time early in one’s career is particularly stressful since it requires adjustment to the mores of an occupational group that may be quite different from that which is otherwise familiar to the individual. For police officers, this adjustment is particularly difficult since the transition from civilian life to police work involves exposure to stressors that heretofore have not revealed themselves to the recruit. For rookie officers, in particular, there is evidence to suggest that stress from their work causes physiological changes even before the officer himself or herself recognizes that stress is problematic to one’s health (p. 158).
The overreaching impact of stress is corroborated by Beutler’s (1988, as reported by Police-Stress, n.d.) longitudinal, four year study of 25 rookie University of Arizona police officers, which utilized several self-reporting tools including the MacAndrews Alcoholism Scale. The study found that “significant changes” occurred in the psychological makeup of the officers after just a few years on the job, and concluded that “police officers may show signs of stress early in their careers” and that “with greater time in service, somatic signs of stress and risk of substance abuse increase” (Discussion section, para. 2). To wit, respondents’ scores on the MacAndrews Scale increased from 0% for alcohol problems in the first year to 27% by the end of the second year, and to 36% by the fourth year of the study.
Cook (2003), in her anthropological essay written from the perspective of a rookie police officer’s wife, notes that stress begins in the police academy, where recruits receive their first taste of the harsh realities of modern police work. “Recruits are told stories about other cops being sued, becoming alcoholics, druggies, wife beaters, or even worse, committing suicide, so their morale is low even as they enter the profession…Eventually the recruits look at the job as an eventual spiral of pessimism, negativity, and increasing liability” (Cook, The Nocebo Effect and Stress section, para. 1).
Impact of Police Culture
Several researchers have linked negative coping mechanisms with alcoholism and drug abuse in law enforcement personnel (Shanahan, 1992, Elliott and Shanahan, 1994, Violenti, 1993, and Davey, et. al., 2001). Pugh (1985, as cited in Lumb and Breazeale, 2002) suggests that these negative coping skills may be embedded in character traits (specifically, tough-mindedness and aggressiveness) typically associated with the “beat cop,” and which many departments may still look for in recruits despite a rapidly changing social environment. Pugh suggests that these character traits are “constant predictors of superior police performance” in a traditional, reactive law enforcement setting (p. 95). However, the current trend in law enforcement is away from the reactive practices of patrol, rapid response, and investigation and toward a more proactive, community-oriented approach. The new skills required for this new approach include “problem solving, flexibility, good interpersonal and communications abilities, and a demeanor that is authoritative rather than authoritarian” (Lumb and Breazeale, p. 96).
Thus, officers who cling to the “old school” mindset may suffer future shock in a rapidly evolving social climate. Even in the midst of social change, many police departments today continue to embrace many of the traditions of a bygone era, including the acceptance of drinking (Davey, et.al., 2001). Factors such as the availability of alcohol both inside and outside of work, lack of departmental policies on drinking (or if they do exist, lax enforcement), lack of support mechanisms to help members deal with stress, and—not by far the least—peer pressure, all contribute to the problem of drinking among police officers (Davey, et.al., 2001). Bandura’s Social Learning Theory (as cited in DiClemente, 2003) would view drinking as a social cue of the cultural group or subgroup with which one is involved. In the case of police work, drinking has been a time-honored way of “taking the edge off” the stresses of the job since the first New York City patrolmen set out on their nightly rounds in the 1840s. To understand why this is so one must have a basic knowledge of the history of policing in the United States.
From the origins of most big city police forces in 1850s up until the early 20th Century when automobiles emerged as integral law enforcement tools, the lot of the ordinary patrolman was to walk a solitary beat, day and night, outside and under all weather conditions. The conventional wisdom of the time was that a “nip of liquor” would help to insulate one’s body from the bitter cold of winter. Thus, while official department policy may have prohibited drinking while on duty, it was tacitly acceptable for a policeman on foot patrol on cold nights to either carry a personal flask of alcohol or stop in at the bar on his beat for a quick drink. A second point to consider is that Irish-Americans, up until just a few generations ago, dominated the ranks of many big city departments, notably New York City and Chicago, and for them drinking was a big part of their cultural heritage. Furthermore, the tight-knit bond between officers (including strong peer pressure to conform), which still exists today, was forged in an era when police officers would work a 12-hour shift and then be held over at the stationhouse as “reserves” for an additional 12 hours (Lardner and Repetto, 2000). Liquor was typically kept at the stationhouse, and traditional occasions for celebration included: the conclusion of successful operations; promotions, transfers, and retirements; debriefings and workshops; and traditional holidays such as Christmas, New Year’s and of course St. Patrick’s Day (Davey, et.al., 2001).
Modern Police Culture and Drinking
Modern police culture remains insular and tight-knit, and the extent to which drinking has become ingrained in it varies from station to station, department to department. Yet empirically, police officers face heavy pressure to drink, to where non-drinking officers are often viewed as suspicious or anti-social by their colleagues. Davey, et.al. (2001), in a recent survey of police officers found that nearly 25% reported drinking in order to “be part of the team” while 25% reported that they were negatively affected by a co-worker’s drinking (p. 147).
Whereas alcohol abuse, substance abuse, other associated health-related problems can create liability for a police department and compromise its effectiveness, police officials typically do nothing to prevent or mitigate the problems but instead react punitively once a troubled officer’s behaviors get out of hand (Lumb and Breazeale, 2002). There are opportunities for prevention specialists and mental health professionals to partner with police agencies to reduce the incidences of alcohol abuse among law enforcement personnel, providing they are presented in such a way as to overcome officers’ barriers of cynicism and suspicion.
Prevention and Intervention
Employee assistance programs (EAPs) have grown in popularity within the corporate community over the past 20 years, as employers seek ways to mitigate the costs of lost productivity, sick time, and accidents that are associated with troubled employees. Moriarty and Field (1990) advocate the use of EAPs within police organizations to interdict officers’ alcohol abuse and other issues before they escalate. Noting the fact that police culture is often suspicious of outsiders, cynical, and resistant to change, the researchers argue that participation in EAPs should be mandatory for all officers, from the time they begin their law enforcement careers. Rookie officers, upon entering the field portion of their training (which typically begins immediately after police academy graduation), would be required to make contact with an EAP intervention specialist for the purpose of a lifestyle assessment designed to reveal potential risk factors. This is vital as the rookies begin to experience, hands-on, a reality that may well be a paradigm shift from the reality they knew as civilians. Moriarty and Fields (1990) explain the rationale:
The new recruit develops an anticipatory set of beliefs about the nature of police work. These beliefs, however, are not verified by the reality of his or her experience. Soon after employment, another dimension reveals itself to the officer. This creates a need to resolve conflicts between expectations and the reality of the job. How the officer puts this together into a compatible set of beliefs is critical to his or her emotional well being for at least two reasons. First, it represents the prototype for coping with job related stresses that are yet to come in one’s career. Secondly, this is the time that some officers gravitate to those colleagues who have not adjusted well to their profession, the men and women whose cynicism casts a negative shadow on the entire department…Without some exposure on a regular basis to productive and professional styles of adjustment, the rookie officer is often left to commiserate with those colleagues who are too sympathetic to his or her plight and are more than willing to nurture the negative perceptions that the administration, the public, or the world is at fault (p. 157).
Lifestyle assessment looks at aspects of an individual’s lifestyle such as: (a) Personal habits, which include diet, rest, exercise, and personal coping skills; (b) communication styles, both at the personal and professional level; and (c) the individual’s general state of physical and mental fitness. Rookies who score high for risk factors—e.g., poor coping skills, inflexibility, low self-esteem, etc.—would then work with the specialist to develop more effective coping skills aimed at preventing emotional crises and reducing reliance on alcohol as a requisite means of managing stress or gaining acceptance.
Whereas EAPs typically employ mental health clinicians and not law enforcement professionals to work with officers, the New York City Police Department has employed a strategy of using its own to help its own. The Police Organization Providing Peer Assistance (POPPA) program, launched in 1995, is staffed by trained intervention volunteers recruited directly from the ranks of the City’s 38,000-member police force (Police-Stress, n.d.). POPPA operates a 24-hour, confidential helpline for officers. The NYPD reports that the helpline receives between 900 –1200 calls per year, and about 75% of those result in a face-to-face offsite meeting between the caller and a peer counselor. The counselors lend a sympathetic ear and provide referrals to outside mental health providers as necessary, but they do not provide psychotherapy. The program’s rationale is that it takes a cop to know a cop, so a troubled officer is more likely to open up to someone who has himself or herself experienced police stress. The POPPA program has achieved modest success in its first 10 years, with the percentage of callers accepting mental health referrals rising from 30% in 1995 to 45% in 2005 (Police-Stress). There are now a number of programs throughout the U.S. that are modeled on the POPPA initiative.
Recognizing that the changing nature of police work is a major source of stress for many law enforcement officers, Lumb and Breazeale (2002) have proposed a pilot program in which select police department employees would be trained to coach other employees in how to cope with change and better manage occupational stress. The goal of the program is prevention: to provide officers with effective coping strategies and resources before stress can lead to problem behaviors and substance abuse. Although not implemented at the time their article was published, the authors presented the concept to a focus group of law enforcement administrators from various agencies in North and South Carolina, with the majority of participants responding favorably.
St. Michael’s House in Chicago, IL, which opened in 1997 and serves all of Chicago’s 13,000-member police force, is described as “the nation’s only comprehensive treatment program designed solely for law enforcement officers” (Program for Police, p. 4). While not aligned with one particular religious sect, the program is the result of a partnership between the department’s chaplaincy and counseling services and Rush Behavioral Health (a division of Rush Presbyterian-St. Luke’s Medical Center). Services include: (a) Pastoral care; (b) 24-hour hotline; (c) traumatic incident debriefing services; (d) individual, marital, and family therapy; and (e) alcohol and drug treatment, including relapse prevention and aftercare. Plans are also in the works to open a residential drug and alcohol treatment center for police officers in Chicago and surrounding communities.
The problems and stressors facing police officers, especially in this age when law enforcement on the whole is undergoing paradigm changes in how it serves society, present a daunting challenge to mental health providers. As alcoholism rates continue to rise—and with them the associated problems of domestic violence and suicide—there is great need of initiatives that can overcome the typical barriers of suspicion and cynicism that serve to insulate and isolate those in law enforcement. While this paper has highlighted several cutting edge programs, it should be noted that further research on the police subculture is needed.
Beutler, L.E., Nussbaum, P.D., & Meredith, K.E. (1988). Changing personality patterns of police officers. Professional Psychology Research and Practice, 19(5), 503-507.
Bromley, M.L., & Blount, W. (1997). Criminal justice practitioners [Abstract]. In Hutchison, W.S. (Ed.), Employee assistance programs: A basic text (2nd Ed.) (pp. 396-408). Springfield, IL: Charles C. Thomas.
Cook, L. (2003). Police stress: Learning through experience, research, and observation. Retrieved December 9, 2005 from Focus Anthropology Web site: http:///www.focusanthro. org/essays/cook—03-04.html.
Cournos, F., & Goldfinger, S.M. (2005). A confidential peer-based assistance program for police officers. Frontline Reports 56(7). Retrieved December 7, 2005 from Psychiatry Online Web site: http://ps.psychiatryonline.org.
Davey, J.D., Obst, P.L., & Sheehan, M.C. (2001). It goes with the job: Officers’ insights into the impact of stress and culture on alcohol consumption within the policing occupation. Drugs, Education, Prevention, and Policy, 8(2), 141-149.
DiClemente, C.C. (2003). Addiction and Change. New York: The Guilford Press.
Donovan, Ed (1994). Programs need caring touch to reach law enforcers. Alcoholism & Drug Abuse Weekly, 6(35), 3-4.
Kohan, A., & O’Connor, B.P. (2002). Police officer job satisfaction in relation to mood, well-being, and alcohol consumption. The Journal of Psychology, 136(3), 307-318.
Lardner, J., & Repetto, T. (2000). NYPD: A city and its police. New York: Henry Holt & Company.
Lumb, R.C., & Breazeale, R. (2002). Police officer attitudes and community policing implementation: Developing strategies for durable organizational change. Policing and Society, 13(1), 91-106.
Moriarty, A., & Field, M.W. (1990). Proactive intervention: A new approach to police EAP programs. Public Personnel Management, 19(2), 155-161.
North Carolina Wesleyan College (n.d.). Police stress and employee assistance programs. Retrieved from Web site: http://www.faculty.ncwc.edu/toconnor/417/417lect09.htm.
Police-Stress (n.d.). Behind the shield. Retrieved December 9, 2005 from Web site: http://police-stress.com/stress-tests.htm.
Program for police adds dose of street smarts to treatment (1997). Alcoholism & Drug Abuse Weekly, 4(48), 4-5.
James Genovese, Department of Counselor Education, The College of New Jersey.
All correspondence regarding this article should be sent to James Genovese, 123 Elmwood Avenue, Atlantic Highlands, NJ, 07116-2020. Email: email@example.com.
Burnout in Mental Health Occupations: A Trans-Occupational Review
The College of New Jersey
Although those who work at different occupational levels within the mental health field are highly prone to burnout, relatively little empirical research has been conducted on this subject and the body of research that does exist focuses more on graduate level practitioners than on nurses and paraprofessionals. The goals of this paper are to present an overview of this research and to explore the ways in which its causes, treatment, and prevention might have similar application across occupational boundaries. Further empirical research is needed, especially that which examines burnout as it effects mental health workers at all levels and which recommends interventions that might be applicable, in some degree, to all mental health occupations.
The sources used were articles from various professional publications within the counseling and nursing professions.
Burnout in Mental Health Occupations: A Trans-Occupational Review
High levels of stress and burnout have long been associated with occupations that have significant, daily involvement with people in need, and this includes mental health occupations ranging from psychiatrists and psychologists to entry-level human services workers and psychiatric nursing aides (Coffey & Coleman, 2001). While literature on burnout among mental health personnel is relatively scarce compared to similar studies of other stressful occupations (Kilfedder, Power & Wells, 2001), within this milieu the bulk of research has focused on burnout among psychiatrists and psychologists rather than on nurses, counselors, or paraprofessional staff (Donat & Neal, 1991).
Here, then, is an overview of this literature, which includes terms and symptoms related to burnout, how it has been shown to manifest itself within different mental health occupations, and what preventions and interventions are currently available.
Background on Burnout
Definitions of Terms
The term burnout has been widely defined by various researchers and scholars. Thornton (1991) describes it simply as any negative reaction to stress within the work environment, noting that there is a positive relationship between workplace stress and occurrences of burnout. Pines and Maslach (as cited in Emerson and Markos, 1996, Burnout section, para 2) describe burnout as “a condition of physical exhaustion, involving the development of negative self-concept, negative job attitudes, and loss of concern and feeling for clients.”
Maslach (as cited in Thornton, 1991) describes burnout as a syndrome consisting of emotional exhaustion, depersonalization, and reduced personal accomplishment, whereas Pines and Anderson (as cited in Emerson & Markos, 1996, Burnout section, para 2) define it as “physical and emotional exhaustion brought on by involvement over long periods with emotionally demanding situations and weakness.” Schaufeli, Maslach & Marek (as cited in Emerson & Markos, 1996) view burnout as more of a process than an endpoint, which if uncorrected can lead to serious depression, substance abuse, and eventually to “critical impairment.” In the long run, burnout can result in catastrophic consequences including heart attack, stroke, cancer, and suicide (Kesler, 1990).
In summarizing these various definitions of burnout, Thornton (1991) notes that most researchers agree on several key features: burnout occurs at the individual level; it is an internal psychological experience involving feelings, attitudes, motivations, and expectations; and it is a negative experience for the individual, involving problems, distress, discomfort, dysfunction, and/or negative consequences.
Professional impairment is the term used to describe the latter stage of burnout, when patient care becomes compromised. The American Medical Association (as cited in Emerson and Markos, 1996, Definitions section, para 1) defines professional impairment as “the inability to deliver competent patient care resulting from alcoholism, chemical dependency, or mental illness, including burnout or the sense of emotional depletion which comes from stress.” Emerson and Markos note that professional impairment may be outwardly subtle, leaving coworkers and supervisors puzzled and unsure of what interventions, if any, they should take on behalf of an afflicted colleague.
Depression is characterized by the following symptoms: a) withdrawal from interactions with others; b) lack of cheerfulness; c) unwillingness to talk; d) feeling un-needed and useless; e) experiencing disabling anxiety, loneliness, lack of interest in work, and unpredictable moods; and f) an irrational self-schema that “no one cares.” (Emerson & Markos, 1996).
Another term germane to the discussion of burnout is emotional exhaustion, defined as “feelings of helplessness, hopelessness, and entrapment [that lead to] negative attitudes toward self, work, and life itself” (Emerson & Markos, 1996, Burnout section, para 2). Its outward manifestations, Emerson and Markos note, include anger, boredom, cynicism, loss of confidence, impatience, irritability, sense of omnipotence, paranoia, denial of feelings, perceptual rigidity, and even physical ailments (Emerson & Markos, 1996).
Symptoms of Burnout
The process of burnout has its own symptomology as well. Edelwich and Brodsky (as cited in Kesler, 1990) describe a progressive, four-stage burnout model: a) Enthusiasm–a tendency to become overly available and to over-identify with clients; b) Stagnation–when the mental health professional’s or paraprofessional’s expectations shrink from high to normal to discontentment; c) Frustration–when difficulties seem to multiply and boredom, intolerance, lack of sympathy, avoidance, and withdrawal begin to set in; and d) Apathy–which is marked by depression and listlessness. Other symptoms include a reluctance to discuss one’s work with friends or family, not returning clients’ messages, inappropriate delight in missed client appointments, and displaying inappropriate humor (Emerson & Markos, 1996). Increased anxiety, interpersonal conflicts and strained relationships, low morale, low productivity, physical complaints, and a tendency toward substance abuse are also described (Kesler, 1990).
Who Gets Burned Out
As previously acknowledged, Coffey and Coleman note that mental health work produces high levels of stress and burnout that cut across occupational, educational, and experiential boundaries. Kilfedder et al. (2001) state that the bulk of research on this problem focuses on doctoral-level practitioners. The limited research available on impaired counselors tends to be anecdotal rather than empirical and much of that dates from the 1970s and 1980s (Olsheski & Leech, 1996). Studies focusing on stress and burnout among licensed practical nurses (LPN), psychiatric aides, and other mental health workers are generally rarer than similar studies of psychiatric registered nurses (RN) (Kilfedder et al., 2001).
One empirical study of counselors, cited by Emerson & Markos (1996) revealed that 32% of counseling faculty (those teaching in graduate-level counselor training programs) and practicing counselors admitted to having felt burned out at some point in their careers, and 63% said they knew colleagues whose work was affected by burnout. These respondents also gave fear of retaliation as the most common reason why they chose not to intervene on behalf of an impaired colleague.
Boy & Pine (1980) state that agency counselors are prone to burnout because they are often under constant pressure to expand their roles beyond that of actual counseling (i.e., administrative duties) yet still must carry heavy caseloads. The authors add that the quality of good counseling is directly related to the counselor’s ability to assimilate and identify with certain professional goals, and to have a clear sense of who she or he is professionally. Too many non-counseling responsibilities can cause a counselor to lose this perspective and sense of commitment.
Lack of initiatives to prevent and treat counselor burnout is another problem. Witmer and Young (1996) make the case that while other professions such as medicine, nursing, and psychology have conducted research and developed interventions and programs dealing with impairment, few if any exist for counselors per se. They further note several studies that suggest counselors, counseling students, and counseling faculty may have higher levels of psychological disturbance than does the general public. Ironically, counselors are trained in helping their clients deal with the stresses of daily life, yet they receive little training or support in helping themselves avoid burnout (Emerson & Markos, 1996).
Those new to the counseling profession may be especially vulnerable. Graduate counseling students begin their studies filled with idealism that soon turns to disillusionment when they move from the altruistic and humanistic rhetoric of their textbooks into the realities of agency counseling, with its emphasis on short-term treatment and maximizing billable hours (Warnath & Shelton, 1976; Warnath 1979). Warnath (1979, page 327) contends that many graduate counseling programs indoctrinate their students “as if they were going to have the freedoms of a private practitioner, working with affluent clients who have no restrictions on their time or financial resources.” Such programs, Warnath contends, place the focus almost exclusively on counselor-client relationships, rather than on addressing the realities of working as an employee of an agency.
Consequently, the newly-hired agency counselor, struggling with a heavy caseload and under pressure to see as many clients in one day as possible, may begin to feel isolated and lacking control over his or her job, and “have the sense of being on an endless treadmill.” (Warnath & Shelton, 1976, page 174).
Counselors in Other Settings
Specialized counselors face similar stressors to those of their agency counterparts. Rehabilitation counselors burnout from excessive client contact, caseload responsibilities, and positive or negative outcomes (Payne, 1989), while youth counselors succumb to “overexposure to the complicated, confused lives of ‘unruly’, runaway, truant, or delinquent children and their families” (Van Auken, 1989, page 143). Likewise, Kesler (1990) describes school guidance counselors as being particularly susceptible to burnout because of the stresses they face as a result of their role expectations and responsibilities. Kesler adds that school counselors often must contend with ill-defined job duties, unrealistic expectations and lack of understanding on the part of school administrators, teachers, and students and their families.
The National Association of Social Workers (NASW) (as cited in Olsheski & Leech, 1996) acknowledged in 1979 that its members are especially prone to alcohol and drug abuse. So widespread is the problem that NASW now offers an Impaired Social Worker Resource Book as a tool for state associations to use in assisting impaired members.
Psych Nurses and Other Mental Health Paraprofessionals
Mental health workers dealing in direct patient care (e.g., RNs, LPNs, and psych aides) face chronic stress—and a particularly high risk of burnout—as a result of “the numerous, prolonged, and intensive nature of the interpersonal interactions between these helpers and the recipients of their services” (Donat & Neal, 1991, para 2). Ironically, those with the least status, pay, or training (not including RNs, who are generally better educated and better paid) are typically the most heavily involved in direct patient care (Willetts & Leff, 1997; Field & Gatewood, 1976). This discrepancy, according to Donat and Neal, and its accompanying stress, affects caregivers’ emotional stability to the extent that it directly impacts patients’ recovery. Thus LPNs, aides and mental health assistants often see little chance for advancement or career growth. And because many of these workers may live in the same impoverished environments as the clients they serve, they may over-identify with their clients to the point where their objectivity is compromised. Furthermore, lack of sufficient education as to the structure and function of the institutions in which they serve can foster frustration and suspicion in these workers and hinder their ability to adhere to and enforce rules and regulations (Field & Gatewood, 1976).
Quintal (2002, page 49) asserts that lack of adequate indoctrination, education, and training causes many lower-echelon mental health workers to operate with a “high incidence of authoritarian and inflexible styles of working with people who are mentally ill, which increases the likelihood of provocation because of style of personality.” In particular, such staff are likely to experience emotional exhaustion and to depersonalize the patients under their care (Willetts & Leff, 1997).
Willetts & Leff add that a similar situation exists in residential settings, where lower-echelon paraprofessionals frequently live and work with mentally ill clients. In these places, expressed emotion on the part of staff—making critical comments and acting hostile toward clients—is often a problem. This behavior typically arises when poorly trained staff become over-involved with clients, feeling frustrated at what they perceive to be clients’ lack of immediate and discernable progress, and being unwilling or unable to see things from the clients’ perspectives. The authors note that under such circumstances, increased assaults on staff, as well greater likelihood of client relapse–particularly among those afflicted with schizophrenia–can result.
The high risk of patient assault confronts RNs on inpatient psychiatric units as well. A 1996 survey of public sector psychiatric facilities, conducted by Love and Hunter (as cited in Quintal, 2002), reveals injury rates from patient assaults ranging from 146 to 32 per thousand. In addition, 38% of all nonfatal workplace assaults occurred in healthcare settings, and of those, some 41% were against nurses (75% of which occurred on psych units). The survey also found that approximately 75% of all psychiatric nurses reported having been assaulted at least once in their careers. Other stressors endemic to psych nurses include high job demand-low job satisfaction, lack of job clarity and management feedback (Walsh & Walsh, 2002).
Additional stress factors for psych nurses and their paraprofessional coworkers include work schedules, work overload, understaffing, lack of autonomy and power, deficient positive reinforcement, maladaptive coping strategies, to name a few. Kilfedder et al. (2001), however, note that healthcare workers outside psychiatry face similar stressors yet have lower burnout rates. The difference, according to the authors, may be that psychiatric staff face the additional pressure of working closely, often on a long-term basis, with a disturbed patient population.
Interventions and Prevention
Cognitive-Phenomenological Theory of Stress
Much of the research cited herein describes stress—both personal and work-related—as a vital ingredient in the burnout process. Lazarus and Colleagues (as cited in Thornton, 1991) have developed the Cognitive-Phenomenological Theory of Stress, in order to provide a conceptual foundation for the study of stress and its relationship to burnout. This theory identifies two processes that are essential to the appraisal of stress and the ability to cope with it. Cognitive appraisal is the process by which an individual evaluates whether a particular encounter with the environment relates to his well-being. Cognitive appraisal is further broken down into two types: primary appraisal determines whether the encounter is irrelevant, benign-positive, or stressful; in secondary appraisal the individual identifies which coping options and resources are available and what degree of control he has over the stressful situation.
The second process, coping, requires the individual to constantly change his cognitive-behavioral efforts in order to help manage certain external or internal demands which he finds to be particularly taxing (Lazarus and Folkman, as cited in Thornton, 1991). This process is achieved by either problem-focused coping (doing something to change the distress-producing problem) or emotion-focused coping (regulating one’s distressing emotions when the situation cannot be changed).
Thornton implies that training in cognitive appraisal and coping skills may help mental health workers to improve their locus of control over stressful events and their reactions to them, thus reducing the chances of potential burnout.
Multidimensional Approach to Impairment Prevention in Faculty, Students, and Practitioners
Witmer and Young (1996) have constructed a multidimensional approach to preventing burnout in counseling faculty and students as well as those in practice, and which is drawn from the body of wellness, stress management, and coping literature. Regarding the selection and retention of faculty and students, the authors recommend the following: a) require statements of personal wellness and adjustment on all faculty employment and graduate counseling student applications; b) assess personal adjustment and self-development in prospective students, along with skill competencies; c) discuss with students any observed attitudes or behaviors that may put them at risk; d) conduct joint evaluation procedures between a select faculty committee and either students who have potential to become impaired or other faculty members who have potential to become impaired; e) provide conditional retention, including periodic progress, consultation, or time off, for any faculty member or student exhibiting burnout symptoms; f) conditionally dismiss any faculty member or student not in active treatment for burnout, and not allow them back to work or study until specific conditions are met.
Witmer and Young also stress that a graduate counseling curriculum should reflect a wellness philosophy and require all students to agree, in writing, to utilize holistic wellness strategies in order to ensure their personal growth and professional competence. And they suggest that graduate counseling programs themselves develop curricula around a wellness model that encompasses spiritual, intellectual, emotional, and physical health.
For counseling agencies and mental health facilities, Witmer and Young advocate: a) encouraging their staff to use employee assistance programs (EAPs); b) providing staff with workplace childcare, flextime options, and ergonomically sensitive environments; and c) spreading caseloads and most difficult cases more equitably among counseling staff.
Other Initiatives for New Counselors
On the subject of counselor training, Warnath and Shelton (1976) suggest various initiatives to narrow the discrepancy between the idealism of counselor studies and the realities of counseling work. Faculty, they argue, should be required to work one term per every two to three years as a full-time counselor, and while teaching they should continue to carry a small, ongoing caseload. Students should be required to serve one semester (three to four months) in their second year of studies doing full-time, supervised counseling.
The original goal of the Thorne Initiative, as described by Willetts and Leff (1997), was to help psychiatric nurses improve their skill in approaching situations with patients from the patients’ viewpoints. Using this approach would ideally reduce the nurses’ propensity toward expressed emotion and thus diminish the accompanying risk of patient assault. Willetts and Leff argue that the Thorne Initiative has wider application for other paraprofessional staff, namely LPNs, aides, and mental health assistants.
In practice, the Thorne Initiative consists of nine two-hour sessions held once a week. Teaching components include formal instruction, role-playing, group work, feedback and discussion, and evaluation. Session topics follow this schedule: a) Introduction to Mental Illness, b) Problem Solving, c) Improving Communication, d) Specific Problem Behaviors (i.e., negative symptoms, delusions and hallucinations, irritability, and violence), and e) Effective Staff Coping Strategies. Within this framework, the trainer uses a non-critical instructional approach and covertly models a low expressed emotion level for participants.
Willetts and Leff note that while testing of the Thorne Initiative with paraprofessional staff has been preliminary and inconclusive, those who have completed the program demonstrate slightly lower expressed emotion levels and rate the program either useful or very useful.
Help Staff Manage What They Can and Cannot Change
Research shows that level of support and degree of job discretion (the extent to which workers have control over what they do and how they do it) can serve to buffer the negative effects of workplace stress (Walsh and Walsh, 2002). On this topic, Donat and Neal (1991) conducted a study of 100 LPNs and psych aides conducted at a public residential facility in Virginia. Some 39 worksite situations involving eight stress factors were identified using several self-reporting tools. Some of the situations described were potentially changeable by staff members and others were beyond their immediate control. Based on the results, the authors recommend that mental health institutions and organizations: a) build competencies to enable their staff to better manage certain problem behaviors of clients; b) train staff to more accurately gauge the impact they can as well as cannot have on patient outcomes; c) help staff develop effective coping strategies that enable them to accept the realities of what they cannot change; d) educate staff as to possible avenues through which they might have a voice in affecting change within the workplace; e) improve social support among staff by teaching assertiveness and communications skills, which can enable them to achieve greater cohesiveness and collegiality among themselves.
Preventive Measures for Guidance Counselors
Kesler (1990) recommends that school systems provide guidance counselors with shared authority in making guidance decisions, do a better job of informing teachers, students and their parents about the role of guidance counselors, and create working environments for guidance counselors that are more varied, self-actualizing and creative.
Nurses and Paraprofessional Staff
Quintal (2002) argues that reducing the risk of patient assault is a critical factor in lowering levels of burnout among direct care staff. She suggests that hospitals and psychiatric facilities must do a better job of educating staff in empathetic limit setting, therapeutic communications, and non-violent de-escalation techniques. She also recommends these facilities perform complete assessments of patients as to their propensity for violent behavior, establish strict “zero tolerance” policies on patient violence, and clearly communicate these policies to patients during intake. For those staff who have already experienced patient assault, Quintal advocates that employers provide them with effective counseling and emotional support resources.
What Professional Organizations and Associations Can Do
Hazler and Kottler (1996) contend that organizations and associations, such as the American Counseling Association (ACA), have a significant role to play in promoting wellness. Among their recommendations: a) advance research and fund grants to study burnout, with a view toward developing more effective methods of prevention and treatment; b) establish specific committees to identify tasks and establish timelines for program development in this area; and c) create social and emotional support for members, via peer support groups, workshops, conferences, publications, and other means.
BASIC I.D., as reported by Kesler (1990) is a conceptual device to clarify symptoms and consequences of burnout among counselors and provide interventions. The acronym stands for Behavior-Affect-Sensation-Imagery-Cognition-Interpersonal relationships-Drugs/diet. BASIC I.D. operates under the premise that people have multi-dimensional life experiences and that they function on many overlapping levels (e.g., emotions affect thought; images affect behavior, sensations affect physical health, etc.).
Applying BASIC I.D. to burnout prevention involves the following:
Interventions include: a) defining goals by keeping a daily log of stresses, manner of coping, and the success or failure of those strategies; b) educating the service population about what the counselor can and cannot do; c) periodically assessing and modifying role obligations; d) prioritizing counseling duties while limiting non-counseling duties; and e) planning leisure time.
Find an outlet to release stress and to help guard against stress buildup. Humor and tears are two self-directed examples, and others include participating in group therapy and support groups.
Counteract the physical “fight or flight” reaction induced by stress, by attending relaxation training, getting a neuromuscular massage, or participating in music, art, dance, or yoga.
Keep the boundary between work and home life distinct by using imagination, perspective, and intuition to correct faulty schemas and develop a degree of balanced detachment toward work.
Minimize self-criticism and pessimism by acknowledging personal limits, clarifying values, setting goals, and finding the time to self-regulate (cognitive restructuring). Spiritual and philosophical development are part of this process.
Learn to receive help as well as give it, and develop mature, reciprocal, supportive relationships with others.
Drugs and Diet
Maintain a regular, healthy diet, get adequate rest, exercise non-competitively, and avoid misuse of alcohol or drugs.
The literature reviewed herein documents the fact that high risk of burnout exists for virtually all who work in the mental health field, from doctoral level practitioners to entry-level, direct caregivers. Causal factors may differ somewhat from one occupation to the next—for the psychologist a major stressor may be heavy caseload, while for a psych nurse it may be the constant risk of patient assault. However, there is much common ground as well. For example, the idealistic new counselor may feel the same frustration over a client’s perceived lack of progress, as does the mental health aide who has become over-identified and thus over-critical of the client. Also, maladaptive coping strategies and pre-existing psychological problems can lead to impairment for anyone at any level. On this point, Thornton (1991) points out that in order to understand the relationship between burnout, work stress, and the characteristics of those who suffer burnout, one must look to how people differ in the ways they cope with stress.
A significant fact, emerging from the body of literature reviewed herein, is that there is a lack of comprehensive, empirical research on burnout that covers the full gamut of mental health occupations (Kilfedder, et al., 2001; Donat & Deal, 1991; Olsheski & Leech, 1996). Because so much existing research has been linear—focusing on specific occupations or occupational groups—there lacks any definitive answer as to whether some of the prevention and intervention strategies also presented herein might have application across some, most, or even all occupational lines.
Another question is: might some of the stressors ascribed to certain mental health occupations also be experienced, to some degree at least, by people employed in other mental health occupations? To illustrate this point, Quintal (2002) notes the high rate of patient assaults that occur against psychiatric nurses, while Donat & Neal (1991)—as noted earlier—blame burnout in paraprofessional mental health workers on these workers’ long-term, intensive involvement with mentally disturbed patients. Might counselors and psychologists working in certain settings—for example, a high-security forensic psych unit—face these same risks and stresses? Moreover, would a survey of doctoral level practitioners who work in such settings reveal similar, or near-similar rates of patient assaults as those reported for psych nurses?
Clearly, trans-occupational research, in which burnout would be examined within the context of mental health occupations on the whole, would add interesting perspective and, ideally, result in more holistic approaches to minimizing burnout and promoting wellness across the mental health spectrum.
Boy, A., & Pine, G. (1980). Avoiding Counselor Burnout Through Role Renewal. Personnel and Guidance Journal, 56, 161 – 163.
Donat, D., & Neal, B. (1991). Situational Sources of Stress for Direct Care Staff in a Public Psychiatric Hospital. Psychosocial Rehabilitation Journal, 14, 76 – 79.
Emerson, S., & Markos, P. (1996). Signs and Symptoms of the Impaired Counselor. Journal of Humanistic Education and Development, 34, 108 – 117.
Field, H., & Gatewood, R. (1976). The Paraprofessional and the Organization: Some Problems of Mutual Adjustment. Personnel and Guidance Journal, 55, 181 – 185.
Hazler, R., & Kottler, J. (1996). Following Through on the Best of Intentions: Helping Impaired Professionals. Journal of Humanistic Education and Development, 34, 156 – 158.
Kesler, K. (1990). Burnout: A Multimodal Approach to Assessment and Resolution. Elementary School Guidance and Counseling, 24, 303 – 311.
Kilfedder, C., Power, K., & Wells, T. (2001). Burnout in Psychiatric Nursing. Journal of Advanced Nursing, 34, 383 – 396.
Olsheski, J., & Leech, L. (1996). Programmatic Interventions and Treatment of Impaired Professionals. Journal of Humanistic Education and Development, 34, 128 – 140.
Payne, L. (1989). Preventing Rehabilitation Counselor Burnout by Balancing the Caseload. Journal of Rehabilitation, 1989, 20 – 24.
Quintal, S. (2002). Violence Against Psychiatric Nurses. Journal of Psychosocial Nursing, 40, 46 – 52.
Thornton, P. (1991). The Relation of Coping, Appraisal, and Burnout in Mental Health Workers. The Journal of Psychology, 126, 261 – 271.
Van Auken, S. (1979). Youth Counselor Burnout. Personnel and Guidance Journal, 66, 143 – 144.
Walsh, B., & Walsh, S. (2002). Caseload Factors and the Psychological Well-Being of Community Mental Health Staff. Journal of Mental Health, 11, 67 – 78.
Warnath, C. (1979). Counselor Burnout: Existential Crisis or a Problem for the Profession? Personnel and Guidance Journal, 66, 325 – 328.
Warnath, C., & Shelton, J. (1976). The Ultimate Disappointment: The Burned-Out Counselor. Personnel and Guidance Journal, 55, 172 – 175.
Willetts, L & Leff, J. (1997). Expressed Emotion and Schizophrenia: The Efficacy of a Staff Training Programme. Journal of Advanced Nursing, 26, 1125 – 1133.
Witmer, J., & Young, M (1996). Preventing Counselor Impairment: A Wellness Approach. Journal of Humanistic Education and Development, 34, 141 – 155.
James Genovese, Department of Counselor Education, The College of New Jersey.
All correspondence regarding this article should be sent to James Genovese, 123 Elmwood Avenue, Atlantic Highlands, NJ, 07116-2020. Email: firstname.lastname@example.org.
Understanding Obsessive-Compulsive Disorder (OCD)
Obsessive-compulsive disorder is classified as an anxiety disorder and it can present itself in an individual in a variety of ways. Common to most sufferers is an obsessive drive to perform a particular task or group of tasks (termed rituals) in order to ward off feelings of unease or impending doom. It is estimated that some 2.3% of the U.S. population—about 3.3 million Americans—suffer from OCD in any given year.
Many people hold superstitious beliefs (e.g., don’t walk under a ladder, step over cracks in the sidewalk, etc.) but not to the extent that they become pervasive in their everyday lives. OCD sufferers, however, become so preoccupied with these beliefs as to obsess on them and the compulsion to perform what they see as mitigating rituals begins to impact their daily lives. For example, it is a good idea to wash your hands before you eat a meal, in order to reduce your chances of catching a cold or other sickness. For a person with OCD, this sound advice is taken to a ridiculous extreme, wherein he will compulsively wash his hands over and over in order to assuage the fear of contamination.
For the purposes of this presentation, let us operationalize what the terms obsession and compulsion mean, as defined by the DSM-IV, Fourth Edition:
- Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
- The thoughts, impulses, or images are not simply excessive worries about real-life problems.
- The person attempts to ignore such thoughts, impulses, or images, or to neutralize them with some other thought or action.
- The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought intrusion).
- Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
Some common symptoms of OCD
|Fear of contamination from dirt, germs, etc.||Repetitive hand-washing|
|Imagining having harmed self or others||Repeating tasks|
|Imagining losing control or having aggressive urges||Repeated checking|
|Intrusive sexual thoughts or urges||Checking|
|Excessive religious or moral doubt||Counting|
|Forbidden thoughts||Ordering and arranging|
|A need to have things “just so”||Hoarding or saving|
|A need to tell, ask, or confess||Praying|
Other Common Features of OCD
- Obsessive thoughts and compulsive behaviors take up a lot of time, typically more than one hour per day.
- OCD symptoms begin to interfere with the sufferer’s work, social life, and personal relationships.
- Most sufferers will eventually recognize that obsessions are coming from within their own minds and that their compulsions are unreasonable. In such cases they are classified as having OCD with good insight. Children—and a small minority of adult sufferers—do not recognize that their thoughts and behaviors are irrational, and so they are classified s OCD with poor insight.
- How OCD tracks over time varies from individual to individual. For some, symptoms may come and go, for others they may ease over time, and for some they can grow progressively worse both in frequency and intensity.
Who Gets OCD
As noted earlier, more than three million Americans suffer with OCD at any given time, and this affliction occurs equally in women and men. Typical sufferers range in age between 18 and 54 years old, although while a large percentage of persons with OCD (33% to 50%) report its onset during their childhood, it can also begin at any time in young adulthood (age 40 and under). This statistic is somewhat problematic because OCD also tends to be underdiagnosed and undertreated.
There are several reasons why this may be so. First, OCD sufferers may not be forthcoming in describing their symptoms, for fear of embarrassment and social stigma. Second, both sufferers and their healthcare providers may lack the knowledge and insight to recognize the onset of OCD. Third, not every physician or mental health professional is trained specifically in how to treat OCD. This is unfortunate, as early detection and treatment can help victims avoid developing depression and experiencing marital and work difficulties. It is also notable that in 1990 the total social and economic cost of OCD in the U.S. was estimated at $8.4 billion, and nearly 10% of all monies spent on mental treatment that same year was for OCD.
Origins of OCD
Although science is not yet able to pinpoint an “OCD gene”, there is compelling evidence that this disorder is at least partly due to genetics. To wit, research shows that childhood-onset OCD tends to run in families. Other research suggests that OCD is caused by synaptic abnormalities between the frontal part of the brain (orbital cortex) and deeper areas within the brain (basal ganglia), and that the brains of OCD sufferers—for reasons yet unknown—may produce inadequate amounts of serotonin. Serotonin is a neurotransmitter that enables an organism to feel a sense of wellbeing. There is, however, no blood test or other physiological way of testing this hypothesis, and so diagnoses of OCD are typically made based on the sufferer’s presenting symptoms. There is also a growing body of evidence suggesting a connection between abnormal levels of dopamine as well in the onset of OCD.
The once-popular notion that OCD is caused by family problems or attitudes learned in childhood (e.g., one or both parents were cleaning fanatics) is today largely discounted by mounting scientific evidence. For example, brain imaging studies using positron emission tomography (PET) technology have detected abnormal brain activity patterns among test groups of OCD sufferers as compared with control groups of non-OCD sufferers.
OCD and Co-Occurring Disorders
Other disorders that can sometimes accompany OCD include depression, eating disorders, attention deficit hyperactivity disorder (ADHD), and other anxiety disorders. Often, persons who have suffered for years with OCD and have not been treated can eventually develop depression. Such persons may also develop substance abuse and addiction problems when they turn to alcohol and drugs to help control their obsessive thoughts.
Other conditions that may commonly exist along with OCD include Tourette’s Syndrome and the presence of facial tics.
Research conducted by the National Institute of Mental Health and other organizations has shown that behavioral therapy combined with medication are effective approaches to treating OCD. The combination of therapy and medications has been shown in at least one study to produce synaptic changes in the striatum of the brain.
However, one challenge facing healthcare providers and the families of OCD sufferers is helping these patients realize that they have a problem in the first place. Herbert Gravitz, psychologist with the Obsessive-Compulsive Foundation, asserts that the reason some sufferers are reluctant to accept that they have OCD is because they are either misinformed or uninformed, and this in turn creates fear. Gravitz advocates a straightforward, affirming approach. He writes,
These fears and worries are normal and must be addressed. What often helps in all of these situations is to “speak to the fear,” not the person refusing treatment or medication—(e.g., you are not crazy; you have a diagnosable and treatable disorder; your body will adjust to the side effects; you will be more creative, your true self will be more present). Also, mental illness still has much stigma attached to it, so you might try “speaking to the stigma.” (e.g., it takes a courageous person to know when they need help; only strong people seek help).
Gravitz adds that if this approach fails, family members may want to contact their local police or mobile crisis intervention team to initiate the sufferer’s involvement in the mental health system.
Cognitive behavioral therapy (CBT) is widely considered the treatment of choice for children, adolescents, and adults with OCD. Research shows that psychotherapy generally is more effective in controlling OCD symptoms and sustaining long-term absence of symptoms, than is medication alone. One of the goals of CBT is to help the client internalize a lifelong strategy to help him resist obsessive thoughts and their associated compulsive rituals.
CBT generally involves one one-hour session per week over the course of 12 to 20 weeks. An intensive version of CBT also exists, wherein the therapist provides two to three hours of daily therapy for a period of three weeks. For most OCD patients, traditional weekly CBT is indicated.
Within this treatment approach there are several specific therapies that include the following:
Exposure and Response Prevention (E/RP). This form of cognitive behavioral therapy involves exposing the client (with his or her informed consent) to whatever triggers their obsessive thoughts (for example, seeing a crumb on the floor triggers obsessive thoughts about cleaning). The therapist then works with the client to deal with the anxiety and curb the compulsive rituals. Following is a more detailed discussion of how E/RP works:
Exposure. This is based on the principle that one’s anxiety over a triggering object or event will usually diminish with continued contact with it. So if a client obsesses about germs, for example, she is instructed to handle “germy” things such as money, dirty dish sponges, and the like, until she no longer feels anxiety around them.
Response Prevention. As the client is being desensitized through exposure to the things that trigger her anxiety, she is also instructed to not engage in the ritualistic behaviors associated with her being in contact with them. Using the above example, the client would have to refrain from washing her hands after handling the money and the sponges.
E/RP treatment is typically conducted in the therapist’s office, and involves assigning clients weekly homework that is designed around the unique situations and objects that trigger their particular obsessions. Where intensive CBT is prescribed, the therapy may be conducted in the client’s home or workplace. In rare occasions where OCD is particularly severe, intensive CBT may take place in a hospital setting.
Cognitive Therapy. The cognitive portion of CBT is important to helping the client mitigate catastrophic and irrational thinking. For example, a man with OCD believes that if he fails to wash his hands every time he touches a doorknob he will contract a serious illness and die. By using cognitive techniques with this client, this man’s therapist can help him re-examine and challenge the irrationality of his obsessive thought.
Theoretically, once the client has “proof” that his obsession is irrational, he will be better equipped to engage in the E/RP phase of treatment.
Other less widely used (and somewhat less effective) treatment approaches include:
Satiation. A process of therapeutically listening to one’s obsession repeated on a closed-loop cassette tape in order to begin to examine its rationality. Taking the above example of compulsive hand washing, the client—under the therapist’s care and direction—would repeatedly listen to his own, recorded description of his obsession with germs, all the while being challenged by the therapist to examine its logic and validity.
Habit Reversal. In this technique, the therapist helps the client develop a new, non-OCD ritual to replace the ritual associated with her obsession. For example, instead of washing his hands whenever they touch a doorknob, the client would agree to engage in another, more innocuous behavior (such as rubbing his hands together for a second or two) in its place.
Contingency Management. This approach uses token economies (rewards and costs) as incentives to not engaging in ritual behaviors. So in the same example, the client would agree to set $1 dollar aside to treat himself to a steak dinner, every time he resists a compulsive hand-wash, and conversely, he would take away a dollar from this dinner fund every time he gives in to that compulsion.
Efficacy of CBT Therapy in Treating OCD
According to the Obsessive-Compulsive Foundation, those clients who complete cognitive-behavioral therapy (12-20 sessions) report reductions in OCD symptoms by as much as 50% to 80%. “Just as important,” the Foundation notes on its website, “people with OCD who respond to CBT usually stay well, often for years to come.”
Although less effective than psychotherapy, medications do play a part in alleviating OCD symptoms. These prescription medications are broken down into several categories, listed first by generic and parenthetically by brand names:
Selective Serotonin Reuptake Inhibitors (SSRIs). These include: paroxetine (Paxil, Aropax), sertraline (Zoloft), fluoxetine (Prozac), and fluvoxamine.
Tricyclic antidepressants, particularly clomipramine (Anafranil).
Antipsychotic medications, including gabapentin (Neurontin), lamotrigine (Lamictal), olanzapine (Zyprexa), and risperidone (Risperdal).
In addition, anecdotal reports suggest that some OCD sufferers obtain a degree of symptom relief by self-medicating with opiods, in particular Ultram and Vicodin, but this practice is discouraged by medical experts because of those drugs’ addictive properties.
Again, as stated earlier, medications alone do not generally work as well as psychotherapy alone, and research shows that less than 20% of OCD patients treated solely with medications have significant mitigation of symptoms. The best results are when medications are prescribed under a psychiatrist’s care as an adjunct to psychotherapy.
A common frustration with medications is that they (a) take time to build up in the body before they can work (typically three to four weeks), and that (b) usually at least one medication adjustment (i.e., stronger dosage or switching to a different medication) is often needed. This is particularly true with SSRIs.
The downside of medications is that while they are designed to relieve symptoms, they also cause side effects. For SSRI medications, these may include nervousness, insomnia, restlessness, nausea, and diarrhea, and in some cases sexual dysfunction. Antidepressants can cause irregular heartbeats and blood pressure problems. Generally, side effects diminish with regular, long-term use, but if they do not it is important for the user to tell his or her doctor as soon as possible.
Special Consideration: OCD in Children
As previously noted, between 33%-50% of adult OCD sufferers report that their symptoms began in childhood. Typical stressors for children with OCD include fear of germs and fear of foods. Because children are at different developmental stages than are adults, this presents special challenges for them.
Fear that they are “crazy”. Children are very sensitive to fitting in with their peers. Knowing that their friends and classmates do not share in their obsessive thinking or ritualistic behaviors can affect their self-esteem to where they feel they are “bizarre” or “out of control.”
Excessive stress, particularly at morning and at night. A child’s compulsion to do his or her rituals exactly right in the morning can cause them to feel pressured, stressed, and irritable for the rest of the day. At night, they may delay going to bed in order to complete their nighttime rituals, thus leaving them exhausted the following day.
Frequent physical complaints. These include stress-related ailments such as headaches and upset stomachs.
Anger towards parents. This can occur as parents attempt to set boundaries for their children’s compulsive behaviors. For example, a child with a fear of germs becomes angry when his parents do not allow him to shower for hours, or they refuse to wash his clothes a certain way.
Social problems with peers. If a child tries to hide her obsessive-compulsiveness from her friends, she can feel stress over those relationships. When a child’s symptoms are too severe for him to hide, he can become the object of teasing. The child’s constant preoccupation with rituals can also lead to isolation from peers.
Other psychiatric problems. Children with OCD tend to have other psychiatric diagnoses (comorbidity), the most common of which are: panic disorder, social phobia, or other anxiety disorder; depression or dysthymia; disruptive behaviors such as oppositional defiant disorder (ODD) or attention-deficit hyperactivity disorder (ADHD); learning disorders such as dyslexia; tic disorders such as Tourette’s Syndrome; trichotillomania (hair pulling); and body dysmorphic disorder (believing they are ugly or deformed when they are not).
Treatment for Children
As with adults, CBT is recommended. Medications should be given only if the OCD is severe and when CBT is either unavailable or has been only partially effective. Medications for children with OCD are the same as for adults, but the dosages are obviously smaller.
Finding a Good Therapist (Reproduced from Wikipedia.org)
Finding a good therapist who really knows how to use cognitive behavior therapy to treat OCD involves two steps: First, getting some names; and secondly, evaluating their qualifications and ability.
Often the best way to find good therapists in your area is by asking the leaders or members of local OCD support groups. The OC Foundation has a list of support groups on their website [www.ocfoundation.org]. Even if the nearest support group is some distance from you, they may know of good therapists near you.
The OC Foundation can also provide you with a list of professionals in your state who have indicated that they treat OCD. The Association for the Advancement of Behavior Therapy (AABT) and the Anxiety Disorders Association of America (ADAA) also list professionals by geographical area with their areas of expertise on their websites [respectively, www.aabt.org and www.aada.org].
Wikipedia also has links to numerous OCD support groups, treatment facilities, and individual treatment professionals on its website: http://e.wikipedia.org.
You can also contact your state’s mental health, psychological, and psychiatric associations, who generally keep referral lists. If you don’t have health insurance and cannot afford private therapy, these organizations may be able to offer suggestions.
If you live near universities that have graduate programs in mental health (e.g., psychology, psychiatry, social work), find out if they have any clinical training programs where you could receive therapy from their therapists-in-training. Although they are students, they are closely supervised, and the quality of their therapy is usually very good.
Evaluating Qualifications and Ability
You should look for a mental health professional who is licensed to practice in your state. Although their specific academic discipline is not as important as their experience and ability, in general, you will find that cognitive behavior therapy is practiced by psychologists, social workers, licensed professional counselors, and marriage and family therapists. Medications need to be prescribed by MDs.
You should be aware that being listed with OCF, AABT, ADAA, or other professional organizations does not guarantee expertise in treating OCD. Usually all that is required to be listed is proof of state licensure. Often professionals pay a fee to be listed. In a way, then, these are a little bit like yellow page listings—an okay place to start, but not to stop.
Once you have some names of potential therapists, call each of them on the phone. There’s no point in paying for a session to get this information. Try to get past the receptionist to talk with the therapist directly. First, say you’re looking for a therapist who has experience (use that phrase, not “who has expertise” or “who specializes”) in treating OCD. They will all say yes. Then say, “Can I ask what approach you take?” You want to hear “behavioral” or “cognitive-behavioral.”
Be cautious if someone:
- Offers a treatment you’ve never heard of.
- Guarantees their treatment or seems overly confident.
- Talks of “curing” OCD.
- States that treatment will take a specified number of sessions.
- Refuses to give any idea of how long treatment might be expected to take.
Other Similar Anxiety Disorders
Posttraumatic Stress Disorder. When a person repeatedly experiences a past traumatic event and reexperiences it, either through intrusive thoughts, recurrent, distressing dreams, acting or feeling as if the event were happening again (e.g., flashbacks), intense psychological and/or physiological distress when exposed to internal or external cues.
Acute Stress Disorder. When a person has been exposed to a traumatic event in which he/she was confronted with threat of death or serious injury to self or others, and wherein the person’s response involved intense fear, helplessness, or horror (e.g., September 11, 2001). Symptoms include numbing, detachment, lack of emotional response, daze, derealization, depersonalization, and associative amnesia.
General Anxiety Disorder. Excessive anxiety and worry that occur more often than not for at least six months, and which focus on a number of real situations such as work or school performance. Symptoms include restlessness and feeling on edge, becoming easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
Panic Attack. Panic attack itself is not a codable disorder, but is usually associated with other diagnoses such as phobias. It is a discrete period of intense fear or discomfort, characterized by four or more of the following symptoms: heart palpitations, tachycardia, sweating, trembling or shaking, shortness of breath or sensation of smothering; choking sensation, chest pain or discomfort, nausea or abdominal distress, dizziness or unsteadiness, fear of losing control or going crazy, fear of dying, numbness, and/or chills and hot flashes.
Phobias (includes agoraphobia, social phobia, and other specific phobias. These are generally described as “marked and persistent fear of clearly discernable, circumscribed objects or situations. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response…” This response often involves a panic attack. Other characteristics of a phobia are: (a) the person recognizes that the fear is unreasonable (not true for children); (b) they either avoid the stimulus or endure it with great discomfort; (c) this avoidance or distress reaction “interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.”
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Arlington, VA: Author.
Baron, R.A. (2001). Psychology (5th ed.). Needham Heights, MA: A. Pearson Education Company.
Freedom From Fear (n.d.). Obsessive-Compulsive Disorder. Retrieved November 1, 2005 from http://freedomfromfear.org/aanx_factsheet.asp?id=23.
Healthy Place (n.d.). Treatment. Retrieved October 27, 2005 from http://www.healthyplace.com/communities/ocd/nimh/treatment.htm.
Healthy Place (n.d.). What is Obsessive-Compulsive Disorder. Retrieved October 27, 2005 from http://www.healthyplace.com/communities/ocd.htm.
Obsessive-Compulsive Foundation (n.d.). Getting Help for Family Members Who Refuse OCD Treatment. Retrieved October 28, 2005 from http://ocfoundation.org/ocf_0007.htm.
Obsessive-Compulsive Foundation (n.d.). How is OCD Treated? Retrieved October 28, 2005 from http://ocfoundation.org/ocf1030a.htm.
Obsessive-Compulsive Foundation (n.d.). OCD Medication: Adults. Retrieved October 28, 2005 from http://ocfoundation.org/ocf1050a.htm.
Obsessive-Compulsive Foundation (n.d.). OCD in Children. Retrieved October 28, 2005 from http://ocfoundation.org/ocf1060a.htm.
Obsessive-Compulsive Foundation (n.d.). What is OCD? Retrieved October 28, 2005 from http://ocfoundation.org/ocf1010a.htm.
Stein, D.J., (2000). Neurobiology of the Obsessive-Compulsive Spectrum Disorders. Biological Psychiatry, 41, 296-304.
Wikipedia (n.d.). Obsessive-Compulsive Disorder. Retrieved November 1, 2005 from http://en.wikipedia.org/wiki/Obsessive-compulsive_disorder