Behaviour Change | Volume 26 | Number 2 | 2009 | pp. 83–96

Associations Among Therapist Beliefs,Personal Resources and Burnout in Clinical Psychologists

Sally Emery and Tracey D. WadeSchool of Psychology, Flinders University, Australia

Sara McLeanSchool of Psychology, Adelaide University, Australia

There were two aims of the research with 190 Australian clinical psychologists:(1) to investigate the construct validity of the Therapist Belief Scale (TBS), and(2) to examine the relative contribution of demographics, workplace variables,and individual factors to burnout. Construct validity was examined usingexploratory and confirmatory factor analyses and associations between the vari-ables. Multivariate regressions were used to examine the relative contributions toburnout. The TBS showed three factors related to distress, inflexibility, and con-trol, all of which were significantly associated with lower levels of personal accom-plishment. Multivariate analyses showed emotional exhaustion to be associatedbeing a woman, working for the government, having less personal resources, andendorsing more therapist beliefs related to control. Higher levels of personalaccomplishment were significantly associated with a lower annual income, nothaving a mixed caseload, having more personal resources, and endorsing lowerlevels of therapist beliefs related to inflexibility and control.

■ Keywords: therapist beliefs, personal resources, burnout, personal accomplishment

Clinical psychologists are professionals at risk of work stress and burnout. They havebeen shown to be affected both personally and professionally by traumatic eventssuch as patient suicide (Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988), andto have significantly higher levels of emotional exhaustion and depersonalisationcompared with norms provided in the Maslach Burnout Inventory manual (Maslach& Jackson, 1986) for a heterogeneous group of mental health workers including psy-chologists, psychotherapists, counsellors, mental hospital staff, and psychiatrists(Ackerley, Burnell, Holder, & Kurdek, 1988).

Demographic characteristics have been shown to be significantly associated withburnout in therapists, including younger age (Ackerley et al., 1988; Deutsch, 1984;Hoeksma, Guy, Brown, & Brady, 1992), and less work experience (Ackerley, et al.,1988; Kramen-Kahn & Hansen, 1998; Pearlman & Mac Ian, 1995; Ross, Altmaier,& Russell, 1989; Rodolfa, Kraft, & Reilley, 1988), where years of experience areoften strongly correlated with age. Marital status has generally not been associated

Address for correspondence: Professor Tracey Wade, School of Psychology, Flinders University, GPO Box2100, Adelaide, SA, 5001, Australia. E-mail: tracey.wade@flinders.edu.au

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with work stress (Baba, Jamal, & Tourigny, 1998) but married counselling centrestaff experienced more emotional exhaustion than single counsellors (Ross et al.,1989), perhaps because of greater role conflict between family and work. Consistentwith this suggestion, psychotherapists with young children experienced moreburnout than those without children (Hoeksma, et al., 1993).

A variety of worksite factors have also been found to be associated with workstress. Private rather than public work settings (Ackerley et al., 1988; Deutsch,1984) and higher income (Ackerley et al., 1988) have been associated with lesswork stress in psychotherapists, although the psychotherapists working privatelywere also found to be older, earning more, and spending more hours per week indirect psychotherapy services than psychotherapists in the public sector (Raquepaw& Miller, 1989). Working with children was related to greater burnout in traumatherapists than working solely with adults (McLean, Wade, & Encel, 2003).

Additionally, there has been cross-sectional support for the relationship betweenself-care or coping resources and lower work stress, particularly for leisure activities(Hoeksma, et al., 1993), balance between work and personal life (Cherniss, 1995;Kramen-Kahn & Hansen, 1998; Shapiro, Dorman, Burkey, & Welker, 1999),coping skills (Aitken & Schloss, 1994; Sowa, May, & Niles, 1994) and variousaspects of social support (Brown & O’Brien, 1998; Chemtob et al., 1988; Ross et al.,1989; Savicki, 2002).

Psychotherapy additionally contains unique stressors for the therapist that relateto the therapist–client relationship and the practice of therapy. In particular, indi-vidual factors relating to beliefs about therapy or the therapeutic relationship havebeen found to contribute to therapist stress, including the need to work at peak effi-ciency over all situations with all clients; attitudes of rigidity, inflexibility and dog-matism with respect to the application of therapeutic models and process; the needto appear knowledgeable; a low tolerance for ambiguity; the need for emotional andtherapeutic control, and an intolerance for client emotionality (Deutsch, 1984;Forney, Wallace-Schutzman, & Wiggers, 1982; Hellman, Morrison, & Abramowitz,1987; Rodolfa et al., 1988; Murtagh & Wollersheim, 1997). In one of the few longi-tudinal studies of work stress, Cherniss (1995) found professionals with unrealisticexpectations such as perfectionism were those least likely to recover from burnoutwhereas professionals who made better recoveries were more realistic about theirstrengths, weaknesses and work preferences. Beliefs about therapist responsibility forclient welfare have also been rated as stressful (Murtagh & Wollersheim, 1997;Rodolfa et al., 1988). As part of a ‘self-care plan’ for therapists (Saakvitne &Pearlman, 1996; Skovholt, 2001), it has been suggested that the active identifica-tion and challenging of unhelpful beliefs in therapist training and supervision, witha view to developing more adaptive, helpful alternative beliefs, may be important inmaintaining therapist mental health. This may be of particular importance fortrainee or inexperienced therapists who appear to be more susceptible to the symp-toms of intrusion and avoidance.

Many of the previous investigations of therapists’ beliefs about therapy have eitherused unpublished measures (Deutsch, 1984), generic scales of constructs such asflexibility or rigidity (Hellman et al., 1987), or have investigated beliefs about specificissues, such as ethical practice (Pope, Tabachnick, & Keith-Spiegel, 1988). Recently,McLean and colleagues (2003) constructed the Therapist Belief Scale (TBS) con -sisting of a comprehensive list of beliefs that therapists can have about their work.The four-step construction procedure has been described in detail previously (McLean

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et al., 2003), where it was found that the more the trauma therapists identified withunhelpful thoughts, the higher their levels of burnout, where such beliefs made agreater contribution to the variance of burnout than work-related variables.

There were two aims of the current study. The first was to further investigate theconstruct validity of the TBS, which can be used to identify unhelpful therapistbeliefs. This was achieved in two ways: first, we conducted exploratory and confir-matory factor analyses of the TBS with 190 Clinical Psychologists currentlyinvolved in clinical work; second, we examined associations between the TBS,demographic and workplace variables, coping resources and burnout. It was pre-dicted that a higher endorsement of unhelpful therapy-related beliefs would be asso-ciated with higher levels of burnout and a lower level of coping resources. Thesecond aim was to examine the ability of individual factors to independently con-tribute to burnout, where we predicted that the individual factors of therapy-relatedbeliefs and coping resources would account for at least as much of the variance ofburnout as demographics and work factors.

Method

ParticipantsA list of names and addresses of clinical psychologists with Masters or PhD qualifi-cations and who were currently engaged in clinical practice was obtained from theSouth Australian Registration Board. In all, 507 questionnaires were mailed out:210 in early December 2004 and a further 297 in early February 2005. A total of200 questionnaires were returned giving a response rate of 39%. Of these, 10 werereturned incomplete with respondents giving reasons of retirement and not workingin clinical practice, leaving 190 valid responses. The response rate was similar toAmerican studies using mail-outs to members of the American PsychologicalAssociation: 41% (Medeiros & Prochaska, 1988), 35% (Ackerley et al., 1988), 40%(Hoeksma et al., 1993), and 43% (Gilroy, Carroll, & Murra, 2002).

Characteristics of the sample are shown in Table 1. There were fewer male thanfemale psychologists, their average age range was 30 to 39 years, they had an aver-age of 5 to 9 years experience working as psychologists and an average annualincome of $40,000 to $49,000. The majority of the sample held a Masters qualifica-tion or similar, worked full-time, worked mainly with adult clients, and in public(government) settings. When asked with whom they lived, a similar proportion(about one-third) lived with their partner only, as those who had children (eithertheir own or others’ children and with or without a partner) in their household.

ProcedureA survey package compiled of a participant information sheet, three questionnaires,and a reply-paid envelope for return of questionnaires was mailed out to each person.The order of the three questionnaires in the survey package was varied systemati-cally to avoid order effect.

MaterialsDemographics and Worksite FactorsQuestions on background information covered age, gender, professional training,years of professional experience, work status (full-time or part-time), client type(adult, child or both), work setting (government, nongovernment, private), annual

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income and living arrangement (who the respondent lives with). For use in analyses,living arrangement was recoded to living with children (38%) or not living withchildren (62%); work setting was recoded into government setting (45%) or at leastpartly private setting (55%); client type was recoded into single client type, adult orchild (72%) or mixed client type, both adult and child (28%).

Therapist Belief ScaleThe Therapist Belief Scale (TBS; McLean et al., 2003) was modified for the currentstudy. The initial version of the TBS, investigated in 116 therapists, had 56 items,the majority of which clustered around one primary factor (McLean et al., 2003).For the present study, an empirical decision was made to include only those itemsfrom the original study that correlated 0.4 and above with this one factor. Thisincluded 36 items, each of which were rated using a 6-point scale ranging from 1(strongly agree) to 6 (strongly disagree). The wording of four items (items 2, 13, 24,31) was changed and scoring reversed for these items to avoid response bias. A totalscore was obtained by summing the individual item scores, and dividing it by thetotal number of items, with higher scores indicating lower levels of endorsement ofthe stated beliefs or a healthier belief set around therapy.

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TABLE 1

Demographic characteristics and percentage of respondents per category

Characteristic % Characteristic %

Age Sex

20–29 years 17.4 Males 27.9

30–39 years 26.3 Females 71.6

40–49 years 25.3 Work status

50–59 years 21.1 Full-time 62.1

60+ years 9.5 Part-time 37.4

Psych. qualifications Work Setting

Masters or similar 85.8 Government 45.3

PhD or similar 5.8 Nongovernment 2.1

Masters and PhD 7.4 Private 28.4

Annual income Govt. and Private 18.4

< $20,000 5.3 Nongovt. & Private 5.3

$20,000–$29,000 9.5 Living Arrangement

$30,000–$39,000 8.9 No-one 17.4

$40,000–$49,000 8.9 Partner only 37.9

$50,000–$59,000 31.6 Children 37.4

$60,000–$69,000 12.6 Adults (not partner) 5.8

$70,000–$79,000 7.9 Years of Experience

$80,000 + 12.7 < 5 years 31.1

Client type 5–9 years 24.7

Adults 59.5 10–14 years 13.7

Children 28.0 15–19 years 10.0

Both 12.5 20+ years 20.5

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Personal Resources QuestionnaireThe Occupational Stress Inventory — Revised (OSI-R, 1998; Osipow, 1998) con-sists of three scales that measure characteristics of occupational adjustment. In thecurrent study, only the scale measuring coping resources, the Personal ResourcesQuestionnaire (PRQ) was used. The PRQ is a 40-item inventory containing foursubscales of 10 items each: Recreation (recreational activities for pleasure and relax-ation), Self-Care (personal activities for stress reduction; e.g., healthy diet, exer-cise), Social Support (support from those around him/her), and Rational/CognitiveCoping (cognitive skills; e.g., problem solving, prioritising). Each subscale wasscored with a 5-point scale ranging from 1 (Rarely or never true) to 5 (True most ofthe time) and items were summed together from all four subscales to form a totalscore such that a higher score indicated more resources, and which had an internalconsistency of 0.83. In the current study, item 17 was considered confusing andchanged from ‘I avoid eating or drinking things I know are unhealthy (e.g., coffee,tea, cigarettes)’ to ‘I don’t smoke cigarettes’. The PRQ is considered a valid and reli-able scale with acceptable internal consistency (Osipow, 1998). Construct validitywas found for the PRQ in a survey of 150 staff who worked with people with anintellectual disability in an Australian government department, where total PRQwas significantly negatively correlated with anxiety, depression, emotional exhaus-tion and depersonalisation, and significantly positively correlated with personalaccomplishment (Aitken & Schloss, 1994).

Maslach Burnout InventoryThe Maslach Burnout Inventory — Human Services Survey (MBI-HSS; Maslach,Jackson, & Leiter, 1996) consists of three subscales that assess three aspects of theburnout syndrome. The subscales are Emotional Exhaustion (EE; nine itemsassessing feelings of being emotionally overextended and exhausted by work),Depersonalisation (Dp; five items measuring an unfeeling and impersonal responsetoward the recipients of care), and Personal Accomplishment (PA; eight itemsassessing feelings of competence and successful achievement at work). The frequencythat the respondent experiences each item is rated using a 7-point response rangingfrom 0 (Never) to 6 (Every day). Scoring of the subscales involves computing thetotal score of the component items for each scale. A high degree of burnout isreflected in high scores on the EE and Dp subscales and in low scores on the PA sub-scale. The MBI-HSS has demonstrated good convergent and discriminant validity(Maslach & Jackson, 1986; Rafferty, Lemkau, Purdy, & Rudisill, 1986) and in thecurrent study the internal consistency was 0.86 for EE, 0.72 for Dp, and 0.74 for PA.

Statistical AnalysesInvestigation of the construct validity of the TBS was investigated in two ways:using factor analytic approaches and investigating relationships with other vari-ables. First, given that this study was carried out with a larger group of therapiststhan the initial study, which was underpowered to detect stable factors (Tabachnick& Fidell, 2001), another exploratory factor analysis was performed in order to assessthe primary factor profile that existed. Given that there was no a priori expectationthat the factors would be correlated, principal components analysis with a varimaxrotation was carried out, with an identifiable factor requiring an eigenvalue > 1.Items were only included if they correlated 0.4 and above with at least one of the

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identified factors. Confirmatory factor analysis (CFA) was then used to investigatestructures that best fit the observed data, using correlation matrices for all items gener-ated by PRELIS2, which were then examined in a CFA using Lisrel8 (Jöreskog &Sörbom, 1996). Evaluation of goodness of fit was carried out using a variety of indica-tors (as shown in Table 3), including the Tucker-Lewis or Non-Normed Fit Index(NNFI), a statistic that is relatively free from sample size contamination and imposesan appropriate penalty function for the inclusion of additional parameters (Ferguson,Dodds, Ng, & Flannigan, 1994) and the Comparative Fit Index (CFI; Bentler, 1990),an unbiased counterpart of the fit index originally proposed by Bentler and Bonett(1980). The CFI evaluates the adequacy of the specified model in relation to the base-line model (the null model), which specifies no relationship among the observed vari-ables, that is, every item is an indicator of a separate latent variable (Feldman, 1993).

As a second way of investigating the construct validity of the TBS, we examinedthe association between the TBS scores and the demographic and workplace vari-ables, the three burnout subscales and coping resources. The association withdichotomous measures was assessed with an independent t test, and the associationwith continuous variables was assessed with Pearson correlations.

In order to examine the comparative contribution of the different variables tothe three scales related to burnout, standard multiple regression were examinedwhere all measures where entered simultaneously.

Results

DescriptivesData were screened for missing values, normality of distributions and outlyingscores. Fewer than 3% of values were missing from all items — an acceptable level(Tabachnick & Fidell, 2001). Significance tests for skewness and kurtosis plus visualinspection of graphs revealed two variables were significantly skewed and transfor-mations were applied. A reflection and square root transformation was applied tothe negatively skewed MBI personal accomplishment subscale. The MBI deperson-alisation subscale was positively skewed and a log transformation was applied.Inspection of distributions after transformations revealed scores to be more normallydistributed. The mean scores and standard deviations for personal resources and thethree MBI subscales (EE, Dp, and PA) were 139.2 (15.7), 19.2 (8.6), 4.3 (4.0) and38.9 (5.1) respectively. The mean score for the total PRQ was slightly higher thanthose reported for staff in an Australian government department, who worked withpeople with intellectual disabilities, of whom 73% were direct care workers (Aitken& Schloss, 1994), where the mean score was 129 (SD = 21). This same sample alsoreported slightly higher levels of burnout than the sample of psychologists used inthe current study, as did Maslach and Jackson’s 1986 normative sample of doctorsand nurses, with respective means (SD) for emotional exhaustion, depersonalisationand personal accomplishment of 19.6 (11.0) and 22.2 (9.5), 6.0 (5.4) and 7.1 (5.2),31.6 (9.2) and 36.5 (7.3). Therefore, the current sample overall may represent aslightly lower level of experienced burnout than other helping professions.

Factor AnalysesThe exploratory factor analysis indicated four factors with eigenvalues > 1, account-ing for 39.1% of the variance. Seven items were deleted as they correlated < 0.4with any of the identified factors, leaving a total of 29 items, as shown in Table 2.

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TABLE 2

Factor Loadings1 (× 100) for Therapist Belief Scale Items With Principal ComponentsAnalysis Using Varimax Rotation

Scale items Distress Inflexibility Responsibility ControlFactor 1 Factor 2 Factor 3 Factor 4

26. I shouldn’t allow my clients to become distressed, they really want to feel better. 74

22. I must not allow my client to become too distressed in therapy. 70

16. Strong emotions will overwhelm and damage my client because they are 66fragile.

25. If I have strong reactions to my clients it means I’m abnormal. 62 42

19. I must protect my client from reliving painful events. 61

21. If I allow myself to feel what my client feels I’ll be damaged. 60

23. If I am affected by my client’s story it will paralyse me and make me ineffective. 57

12. If I allow my clients to distress me I’m a failure. 47

3. There is no room for mistakes in therapy. 42

1. I must not make mistakes in therapy if I do then I’ve failed. 41

5. If I just stick to one therapeutic model it will solve the problem for me. 69

6. Once I have decided on a treatment model I should stick to it. 68

29. It is unprofessional to take an eclectic approach to therapy. 67

11. If I deviate from the clinical model then I’ve failed. 57

17. I must always adhere strictly to a therapeutic model or I’m unprofessional. 55

32. It is unprofessional to act spontaneously in therapy. 41 51

4. If my clients do not progress it is my responsibility. 61

7. I am responsible if therapy is not 57successful.

30. It is my role to find the solutions to my client’s difficulties. 56

10. The course of therapy should be 55predictable.

15. I should be able to achieve results within a certain time frame. 48

35. I should be emotionally available to my client at all times. 45

Themes of the four factors were: low tolerance of distress, inflexibility with respectto the application of therapeutic models, beliefs of responsibility for outcome, andneed for control in therapy.

Three confirmatory factor analyses were run examining the goodness of fit of thedata to the three hypothesised structures. The first model tested was the one sug-gested by the exploratory factor analysis. As can be seen in Table 3, this did not pro-vide a good fit to the data with an overall χ2 of 1100.52 (df = 371), p < .001. In thesecond model it was decided to only include items that had factor loadings ≥ 0.60from the exploratory factor analysis, which resulted in the inclusion of only threesubscales as the beliefs about responsibility subscale was omitted given that it onlycontained one item loading ≥ 0.60. These subscales included distress (6 items, α =0.81, mean = 4.98, SD = 0.69), inflexibility (3 items, α = 0.69, mean = 5.18, SD =0.84), and control (3 items, α = 0.61, mean = 3.69, SD = 1.04). The overall inter-nal reliability for the total score of these three subscales was 0.78. This provided amuch better fit to the data with a χ2 of 167.38 (df = 51), p < .001. Finally, in orderto ensure that it would not be preferable to simply use the total score, this structurewas tested and had a χ2 of 338.68 (df = 54), p < .001, which was a significantlyworse fit than the previous model (χ2 = 171.30 (df = 3), p < .001). Thus for theremaining analyses the three subscales of the TBS were used.

Associations With Other MeasuresCorrelations between therapist beliefs and other continuous measures were smallbut in the expected directions (see Table 4). That is, fewer unhelpful therapistbeliefs were associated with being older, having more experience, having more per-sonal resources, and less endorsement of the MBI items, where there was a signifi-

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TABLE 2 (continued)

Factor Loadings1 (× 100) for Therapist Belief Scale Items With Principal ComponentsAnalysis Using Varimax Rotation

Scale items Distress Inflexibility Responsibility ControlFactor 1 Factor 2 Factor 3 Factor 4

20. If I work hard enough therapy will always be successful. 41

9. If I don’t understand what happens in therapy I’m extremely uncomfortable. 68

18. If I don’t have all the information I’m uncomfortable with therapy. 64

13. I don’t need to fully understand what happens in therapy in order to help theclient. 64

8. I must fully understand my client or I won’t feel effective. 49

34. I should treat all clients the same way. 48

14. I must work at peak efficiency at all times. 46

Eigenvalue 4.6 3.3 3.2 3.1

% Variance 12.8 9.0 8.8 8.5

Note: 1 Only items with factor loading > 0.4 are shown.

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cant association between the MBI personal accomplishment subscale and all threeTBS subscales. There were no significant associations between the TBS subscalesand income or MBI depersonalisation.

Associations were also examined between the therapist beliefs and categoricaldemographic variables. There were no significant associations with work setting(government or private) or sex. Therapists who worked full-time reported signifi-cantly less endorsement of inflexible therapist beliefs (mean = 5.27, SD = 0.76)than therapists working part-time (mean = 5.02, SD = 0.95), t(183) = 1.97, p = .05.Therapists who had a mixed case load (i.e., child and adult) endorsed significantlymore therapist beliefs related to control (mean = 3.45, SD = 1.00) than therapistswho worked either with adults or children (mean = 3.78, SD = 1.05), t(184) = 1.94,p = .05. Living with children was uniformly related to a higher level of endorsementof therapist beliefs, including distress, t(181)= –1.93, p = .05, inflexibility, t(181) =–2.26, p = .03, and control, t(181) = –2.15, p = .03.

Comparative Associations Between the Burnout and Independent VariablesThe results of the three multiple regression analyses are shown in Table 5. Very littleof the variance of depersonalisation was accounted for by the current mix of variables,with only one variable, workplace, reaching significance. Therapists who workedprimarily in government settings experienced greater depersonalisation. Higher levels

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TABLE 3

Confirmatory Factor Analysis Results for the Therapist Belief Scale

Structure GFI AGFI CFI NNFI RMSEA

4 subscales as per exploratory factor analysis 0.74 0.70 0.71 0.68 0.10

3 subscales where all items loaded ≥ 0.60 0.87 0.81 0.87 0.83 0.11

Total of the 3 subscales 0.76 0.65 0.68 0.60 0.17

Note: GFI = goodness of fit index where > 0.90 is considered a good fit; AGFI = adjusted goodness of fitindex where > 0.80 is considered a good fit; CFI = comparative fit index where > 0.80 is considered amoderate fit; NNFI = non-normed fit index where > 0.90 is considered a good fit; RMSEA = root meansquare error of approximation where values between 0.05–0.08 are considered to be a good fit.

TABLE 4

Pearson Product-Moment Correlations Between the Continuous Variables.

Continuous variables Therapist Beliefs ScaleDistress Inflexibility Control

Age 0.19* 0.11 0.16*

Years of Experience 0.16* 0.03 0.12

Income 0.08 –0.02 –0.03

Personal resources 0.26** 0.11 –0.19

MBI emotional exhaustion –0.10 0.05 –0.19*

MBI Depersonalization –0.13 –0.08 –0.04

MBI personal accomplishment –0.21** –0.22** –0.17*

Note: MBI = Maslach Burnout Inventory*p < .05, **p < .01

of emotional exhaustion were significantly associated with being a woman, workingprimarily for the government, having less personal resources, and endorsing moretherapist beliefs related to control. Higher levels of personal accomplishment weresignificantly associated with a lower annual income, not having a mixed caseload,having more personal resources, and endorsing lower levels of therapist beliefs relatedto inflexibility and control.

Discussion

The current study examined a large sample of South Australian clinical psychologistswith a view to identify the range of variables that are unhelpful to the psychologicalhealth of the therapist, including beliefs about therapy. As such, the first aim was tofurther investigate the construct validity of the Therapist Belief Scale (TBS; McLeanet al., 2003). Exploratory factor analysis indicated four coherent factors that reflectedthemes of therapy-related beliefs previously found to be unhelpful in psychotherapypopulations. The first factor, low tolerance of distress, related both to distress experi-enced by the therapist (e.g., ‘If I allow my clients to distress me I’m a failure’) and dis-tress experienced by the client (e.g., ‘I must protect my client from reliving painfulevents’). Intolerance for client emotionality has previously been found to be associ-ated with increased levels of therapist distress (Deutsch, 1984; Farber, 1983). Thesecond factor, inflexibility with respect to the application of therapeutic models,reflected the belief that only one treatment model or protocol should be used in ther-apy (e.g., ‘It is unprofessional to take an eclectic approach to therapy’). This may

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TABLE 5

Summary of Multiple Standard Regression Analyses With Burnout as the Outcome Variable and the Independent Variables Including (1) Demographics, (2) Work Factors and (3) Individual Factors

Emotional Depersonalisation Personalexhaustion accomplishment

β (p) β (p) β (p)

DemographicsAge –0.03 (.76) –0.16 (.17) –0.13 (.20)Sex 0.17 (.04) 0.03 (.75) –0.03 (.74)

Work factorsYears of experience 0.02 (.82) –0.08 (.47) –0.02 (.80)Full /part time –0.13 (.18) –0.16 (.11) –0.07 (.45)Annual income 0.16 (.09) 0.04 (.69) –0.19 (.03)

Living with childen 0.04 (.60) –0.05 (.57) 0.09 (.19)Work setting –0.19 (.02) –0.16 (.05) –0.27 (< .001)

Caseload (mixed or not) –0.03 (.72) –0.09 (.23) –0.14 (.04)

Individual factorsPersonal resources –0.24 (.002) –0.14 (.09) –0.33 (< .001)

TBS distress –0.06 (.50) –0.06 (.50) 0.01 (.92)TBS inflexibility 0.07 (.37) –0.05 (.50) –0.18 (.009)

TBS control –0.18 (.02) 0.002 (.98) –0.14 (.04)

Adjusted R2 18% 11% 34%

F(p) F(12) = 3.96 (p < .001) F(5) = 2.67 (p = .003) F(12) = 8.08 (p < .001)

Note: Significant associations are bolded.

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reflect the difference between therapy that is driven by protocol rather then principle,such as the contrast described between ‘standard CBT’ and ‘formulation guided treat-ment’ (Persons, Roberts, Zalecki, & Brechwald, 2006), where greater flexibility is seento be the mark of a more competent CBT therapist (Milne, Claydon, Blackburn,James, & Sheikh, 2001). In previous research, inflexibility and dogmatism withrespect to the application of therapeutic models and process has been found to beassociated with distress (Hellman, Morrison, & Abramowitz, 1987; Norcross, 1981).

The third factor, which was not supported in a subsequent confirmatory factoranalysis, related to issues of responsibility to outcome, where the therapist takesresponsibility for a successful and timely progress on behalf of the client (e.g., ‘If myclients do not progress it is my responsibility’). Perfectionistic expectations and idealsregarding performance and treatment outcome has been previously associated withtherapist distress (Pearlman & Saaktvitne, 1995). The fourth and final factor, theneed for control in therapy, reflected the belief of the therapist that full understandingwas required in therapy for a successful outcome (e.g., ‘I must fully understand whathappens in therapy in order to help the client’). The need for emotional and thera-peutic control has been associated with therapist distress (Deutsch, 1984; Hellman etal., 1987; Rodolfa et al., 1988).

Of the three factors supported by the confirmatory factor analysis, a higherendorsement of distress beliefs enumerated in the TBS was associated with being ayounger, less experienced therapist, both of which have previously been found to alsobe associated with higher levels of burnout (e.g., Hoeksma, et al., 1993), as wellhaving less personal resources and lower levels of personal accomplishment.Endorsement of items on the inflexibility scale only had a significant association withlower levels of personal accomplishment. Endorsement of items on the control sub-scale of the TBS was associated with younger age, and higher levels of emotionalexhaustion and lower levels of personal accomplishment. In summary, the constructvalidity of the TBS looks promising but the low internal reliabilities of two of thethree subscales indicates that further work is required in developing these scales.However, the TBS may be a useful tool for supervision purposes, where high endorse-ment of beliefs would indicate a high likelihood of a low sense of personal accomplish-ment. The scale can be used to highlight unhelpful beliefs where alternative beliefscan be generated in supervision and tested with behavioural experiments.

The second aim of the current research, which was to examine the ability of indi-vidual factors to independently contribute to burnout when taking into accountdemographic and work factors, was examined in a multivariate context. While demo-graphic variables were not much implicated as having an association with burnout,one workplace variable was consistently associated with burnout, namely working pri-marily for government mental health services. It was of interest to note that for boththe variance of emotional exhaustion and personal accomplishment it was the per-sonal factors that were as strong or stronger contributors as the demographic andworkplace factors. Higher levels of personal resources were a particularly strong con-tributor, in accordance with previous findings (Aitken & Schloss, 1994; Hoeksma etal., 1993; Sowa et al., 1994). For both constructs, there were significant associationswith beliefs about control in therapy, and inflexibility beliefs had a significant associa-tion with lower levels of personal accomplishment. Overall, these findings give sup-port to a cognitive model of work stress where psychologists’ therapy-related beliefsshould be taken into account along with work factors and personal resources.However, it should be noted that the majority of the variance of each of the burnout

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scales is not accounted for, with only 11% to 34% of the variance explained for anyone measure. Therefore, greater understanding of work stress will require investiga-tion of a wider range of variables.

The results of the current research must be interpreted in the context of fourimportant limitations. First, psychologists are more likely to be trained in the cogni-tive model and hence more aware of, and discriminative of, automatic thoughts thanother mental health workers. Therefore, while results may be generalised to other psy-chologists or therapists trained in the cognitive model they do not necessarily apply tomental health workers in general. Second, participation was voluntary and nonre-sponse may have indicated greater work stress, and although confidentiality wasemphasised there may have been a social desirability bias such that unhelpful thera-pist beliefs and work stress were underreported and coping resources overreported.Third, our cross-sectional research can not inform us as to the direction of relation-ships, namely whether therapist beliefs and lack of coping resources cause work stressit or whether work stress may lead to unhelpful beliefs and a loss of motivation forusing coping resources. Fourth, as a sample, there was an indication that there was aslightly lower level of burnout and higher level of coping resources than some otherpopulations (e.g., Aitken & Schloss, 1994), and therefore a floor effect may exist.

Future research of therapist stress and the contributors to this stress could prof-itably focus on several issues. First, no convergent validity for the TBS exists, where ithas been compared to other measures of cognitive distortion, such as theDysfunctional Belief Scale (Weissman & Beck, 1978), or measures of specific cogni-tive distortions such as perfectionism, or inflexibility. Such an investigation caninform us as to whether the TBS provides a valid but unique measure of unhelpfultherapist beliefs. Second, longitudinal research is required in order that issues ofcausality can be ascertained. Further to this suggestion, a range of variables should beexamined in conjunction with demographic and workplace variables, therapist beliefs,and coping resources, so that a greater proportion of variance in therapist stress can beaccounted for. Variables such as social support (both private and in the therapeuticenvironment), the quality of the physical therapeutic environment, and types of ther-apeutic orientation may be useful to study in relation to therapist stress. Third, theimpact of modifying therapist beliefs and coping resources on levels of therapist stressshould be evaluated. If such research indicates decreasing unhelpful beliefs andincreasing use of coping resources can decrease stress, then this would suggest thatmore emphasis should be placed in training programs on identifying and challengingunhelpful beliefs and expectations that therapists may hold with regard to their roleand work. Therapists with less experience may also benefit from an emphasis on theseissues in supervision and support particularly if working in a government setting.

Acknowledgments

We thank the South Australian Registration Board for support to send out the ques-tionnaires and the psychologists for taking the time to complete the questionnaires.A Flinders URB grant supported the collection of data.

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