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The Drug and Alcohol Forum

PROFESSIONAL BURNOUT

by Abraham Twerski, MD
Co-Founder and Medical Director
Gateway Rehabilitation Center, Aliquippa, PA

Abstract

Professional "burnout" can result from expecting to receive more emotional gratification from our jobs than was intended. While our jobs should account for about 25% of our emotional input, outside sources (e.g., family, friends, hobbies) should provide 75%. This article describes some basic reasons why we might place too much emphasis on our jobs for emotional satisfaction in our lives.

After completing this article, participants will:

  • Understand the relationship between emotional gratification and burnout
  • Recognize the problem of identifying to much with our job
  • Understand the relationship between our unmet emotional needs and the clinical approach we use with our clients

I think "burnout" is an excellent term. To me, it is a very graphic one. I had an opportunity for some insight into this a number of years ago when one of my sons was attending seminary. Students were not allowed to have any electrical appliances in the dormitory because of fire hazards. They were permitted, however, an iron because they did their own laundry which included ironing their clothes. My son’s roommate, a very ingenious young man, solved the problem of not having access to equipment for cooking and making coffee. Use the iron! Turn it upside down, jam the handle in a drawer and one has a hot surface on which to make scrambled eggs, toast, coffee, popcorn – you name it. When my son told me about this, I thought how clever! Why spend money for four or five different appliances in the kitchen – all of which provide heat. Just turn the iron upside down, and you have a griddle, a coffee maker, a popcorn popper. Then I stopped to think what would happen to the iron. The heat for the iron is provided by a tiny, delicate filament, designed to be used an hour or so a week for the purpose of ironing clothes. If, in addition to ironing with it, you choose to use it for other purposes – as a griddle, coffee maker, popcorn popper, space heater, what will happen to that tiny, delicate filament? It will burn out. Just as the iron’s filament will burn out if we put a greater stress on it than it was designed to take, the same thing will happen to us when greater stress is placed on us in our job situation than it was meant to take.

Sources of Emotional Gratification

Let’s think of this in another way. I’ve read that about 75% of our emotional input and emotional gratification should come from non-work related sources – family, friends, hobbies, sports, reading, music, religion. These are all various sources that can provide the lion’s share of our emotional gratification. We are left, then, with about 25% that can come from work, the job situation. Of that 25%, there is some division, perhaps half, between our clients or customers, and the other half is from our peers and supervisors. What happens if an individual is deprived of the emotional input from family, friends, hobbies, etc? They will then put the demand on the work situation to give them all of the emotional gratification they need – maybe as much as 80%, instead of the usual 25%. That’s like asking your iron to function as a griddle, coffee maker and popcorn popper all in one. You are putting too much pressure and demand on your job to provide what it should not. It will behave as the iron filament. The likely result is that you will burn out.

Are "We" Our Jobs?

A job is an opportunity to earn a living as we work to provide services that others need or to make a product. A job was not meant to provide the lion’s share of our emotional gratification. That is probably the single greatest cause for burnout. But why does this happen?

It’s important to consider why our entire identity is being absorbed in our job. Frequently, if you ask people to tell you about themselves, the first thing they will tell you is what they do for a living. "I am an accountant," "I’m a lawyer," ". . . a teacher," ". . . a nurse." And you respond, "I didn’t ask what you do, I asked you to tell me who you are." Consider how many people may not be able to tell you who they are without telling you what they do. I once knew a nurse who was in charge of the alcohol unit in a hospital. She went public and wrote an article about herself and told about her addiction to alcohol and drugs. She said, "I had no other identity than as a nurse. I was not a human being. I was not a person. I was just a nurse. During my entire addiction, my home life went to hell, I had no social life, family ties all went kaput. The only thing that remained intact to the very bitter end was my job, my identity as a nurse because I performed adequately for 18 years of addiction – until the very end."

When our entire identity is too closely linked to our profession and we do not feel adequate as human beings, we put a huge burden on our job. We are expecting our jobs to provide what they cannot provide, and the result will be burnout.

Origins of Job Gratification

Let’s consider where the job gratification originates. Many of us are focusing on the result – the product or end result – to give us our gratification. I remember a long time ago working in the emergency room when I had a chance to be a real hero. Once, an acute asthmatic patient came in gasping for air. I gave the patient the recommended medication at that time and, within minutes, the patient was sitting up and thanking me for saving his life. I was a hero! Another instance was a brittle diabetic who arrived at the emergency room in a coma, in insulin shock. The patient’s family thought that death was impending, and I gave the patient a syringe of 50 cc of 50% glucose. Within minutes, the patient sat up and asked, "Where am I?" Another chance to be a hero! And I loved it. It’s great to have these kinds of results.

More recently in medicine, however, we’re dealing more with chronic conditions as opposed to acute diseases. As a result of Life Line and helicopter rescue, people are being saved from automobile accidents who would have died previously – many who will later suffer from chronic pain. Others survive with chronic pain from malignancies. And frequently, chronic pain is not handled properly as physicians prescribe addictive medications. Treating chronic pain is no fun. It’s very different than treating acute conditions which can be very gratifying because you usually get a good result. When treating chronic conditions, we do not have the gratification of being the hero that our ancestors did.

Our economy is "result oriented." To succeed in most businesses, you must make money. You are then praised for your good results. In medicine, however, we can’t go by results. Consider the physician who was unscrupulous – all that mattered was money, charging a big fee. He told one of his patients he needed a laparotomy. The patient did not need a laparotomy, but a big fee was involved and so the surgeon operated. When he did, the surgeon discovered a cancer that otherwise would not have been detected and saved the man’s life. The surgeon was unscrupulous and unethical, but he saved the man’s life. Another surgeon has a patient that could have surgery. If he doesn’t operate, the man will die in three months. If he does operate, perhaps the man has a 40% chance of living. The surgeon agonizes over this, and finally decides to operate because it is the best decision for the patient. The patient dies. But he is the good physician. The one who saved the patient’s life, strangely enough, is unethical; the one who lost the patient happens to be the good physician. Why? Because we can’t go by results. Depending on outcome is very hazardous because you can’t control results. If you need results to vindicate you, you’re in trouble!

Self Esteem vs Inadequacy

Let me relate some ideas about the problem of self-esteem. I am accredited with writing some twenty books. Not true. I wrote one book in 24 different ways. Everything I’ve written about, all 24 books, are centered on the theme that if you have good self-awareness, self-esteem, self-confidence, then you will adjust to life in a much more constructive fashion. On the other hand, if you are a capable person but are suffering from self-underestimation, which is chronic and epidemic, you are apt to make some type of maladjustments. Of course, I think that addiction is just one maladjustment resulting from a person not feeling capable of coping with life. If you feel strong enough about your coping skills, you don’t have to escape to alcohol or drugs. If you don’t have to escape, you don’t have to resort to many of the escapist techniques.

Instead of dealing with their problem directly and overcoming feelings of inadequacy, some seek to compensate. The problem is that you can never compensate for a condition that does not exist in reality. If it is a true deprivation, such as a handicapped person who has a sight or hearing impairment, the person can compensate for their impairment as other senses become more acute. This is because they are dealing with a true handicap. On the other hand, if there is no deficiency, you’re in trouble. If, in reality, you are a good and capable person, but you’ve got this delusion about yourself that you are unattractive, awkward, dull, inadequate, there is nothing you can do to compensate for it.

This kind of situation can be very serious. I treated a physician in the intensive care unit years ago with a suicidal overdose of barbiturates. After 3 days, I was asked to see her in a psychiatric consultation and found out she was a chronic alcoholic. I said, "Well, you know you’re going to have to do something about that problem." She responded, "I am doing something about it. I’m seeing a psychiatrist." After finding out who the psychiatrist was, a very fine psychoanalyst, I called him to discuss the case. He had started psychoanalysis with her – five days a week for six months. He then decided she wasn’t a good candidate for psychoanalysis and began psychotherapy – twice a week for the last 18 months. But, the psychiatrist didn’t know until last week that she drank! Two years of intensive therapy down the drain because she didn’t admit her alcoholism. This woman was in a prominent position and was afraid of being detected with an odor of alcohol on her breath. When she got up in the morning, because she was tremulous, she drank vanilla extract which didn’t have a tell-tale odor. During the day, she drank vanilla extract at the office until she came home at night to drink vodka. I started treating the patient and found she was superior in every other parameter you could think of, except for her self-image. I once asked her, "Can you tell me something positive about yourself?" "Like what?" she asked. "Anything. Tell me some of your personality strengths," I added. She sat there in dead silence. After a few minutes, I picked up her chart and said, "Here is one undeniable fact. You graduated college summa cum laude and were Phi Beta Kappa. They don’t give those to imbeciles! Now that says something about you." She looked at me with every bit of sincerity and said, "When they told me that I was chosen to Phi Beta Kappa, I knew they’d made a mistake." This is the kind of feeling of negativity that people can have about themselves.

The point of this example is: If we have feelings of inadequacy and don’t recognize them or overcome them, we begin to actively compensate for them. One of the ways to compensate is to earn a degree in order to position some initials behind your name. Earning a degree is socially prestigious. An M.D. or a Ph.D. after your name helps us to tell others, "I’m really somebody." That might not be sufficient, however, and you also may need to have patients vindicate and validate you by telling you how great you are. As I’ve already mentioned, it’s more difficult now to get validation from patients with chronic conditions, as opposed to acute, easily treatable diseases where you could more readily be a hero. When someone tells me they want to go to medical school or into counseling in order "to help humanity," I am a little suspicious. I’d rather they said the reason for entering the field was to earn a good living and afford a Jaguar or a Porsche. I’d tell the luxury car lover, "Hey, that’s good motivation. Just make sure that you practice ethically and deliver good services, and you’re entitled to your luxury automobile." When someone tells me that he wants to help humanity, I might be afraid he’s using the role of a physician or therapist in order to compensate for his feelings of inadequacy.

Dr. A and Dr. B

Let’s consider another physician example: Dr. A and Dr. B, both equally bright, both equally qualified. Dr. A is the self-confident guy who always knew he was a good person. He was one of the luxury car lovers. He went to medical school, became a physician, and he doesn’t need anybody to vindicate him – he knows he is a good doctor. He also knows he’s not God. Dr. B was different. Dr. B grew up feeling that everybody was better than he. When he entered a room, he’d think to himself "I don’t really belong." A nagging feeling always accompanied him, that somehow he was never good enough. He entered medical school because 1) he wanted an M.D. after his name, and 2) he wanted people to tell him how great he was – patients to tell him what kind of a hero and lifesaver he was. Now, let’s take a patient, Bob Smith, with abdominal pain that’s been nagging a little bit. Finally Bob decided to go to a doctor. Let’s assume that he goes to Dr. A for his first visit, and Dr. A takes a good history, a physical exam, and gets some basic laboratory studies. He says to Bob, "You know, Bob, I don’t think you have much to worry about. You may have a little hiatal hernia, but I don’t see that there’s anything to worry about. Let me give you this diet, avoid these irritating foods, and here’s something that will cut down on the acid in your stomach. Come back and tell me about it in two weeks. I’m sure you’ll feel better."

Two weeks go by and Bob comes back and says, "Oh God, doc, isn’t there anything you can do for me? I’ve done what you said and I’ve taken the medication faithfully, but it’s worse than it was before." Dr. A says, "Well, in that case, I think we better get some studies and make sure there’s not something we’re overlooking. Let’s get an upper and lower GI and a sonogram." A few days later, he calls Bob and says, "All the tests are negative. There’s no ulcer there, no obstruction or tumor, no gall stones; there’s no nothing. You know Bob, there is a condition called Irritable Bowel syndrome, and this is probably what’s giving you all that pain. Keep on doing what I told you, and I’m also going to give you an anti-spasmodic. I want you to take it three times a day before meals and at night, and I’m sure in another ten days you’ll be better.

The ten days go by and Bob comes back, doubled up with pain, and says, "Doc, you got to help me. I can’t handle this anymore. I haven’t slept a night since the last time I saw you." Dr. A says, "Bob, I can’t figure out what’s going wrong. All the test seem to be normal, and if you tell me you have pain, I believe you. I’ll tell you what, there are a couple of groups of gastroenterologists in town who are really great. I want to refer you to them. I’ll send along the test results, and they can have the x-rays and whatever else they need. They may be able to pinpoint what I haven’t found. OK?"

That’s the way it should be handled because you see, Dr. A knows he’s a good doctor. He’s done everything he should have. If he’s not been able to help Bob, that’s unfortunate, but that is no reflection on his competence as a doctor.

Now let’s go back to Dr. B. Remember Dr. B? He felt back in sixth grade that he wasn’t any good. In sixth grade? Hell, he thought he was no good in Kindergarten! Dr. B gets Bob in his office, and the first visit is much like Bob’s first visit with Dr. A. He does the same things – history, physical, lab studies, gives him the diet and antacid. The second visit is the same – Dr. B gets the lab studies, tells Bob there’s nothing wrong. Where Dr. A and Dr. B differ is on visit number 3 – where Dr. A sent him to a specialist. But Dr. B is the kind of guy who always felt inadequate about himself. When Bob says to Dr. B, "I’m in so much pain. Can’t you do anything for me?" This registers with Dr. B as "you’re not a good doctor. You haven’t helped me." And that touches a raw nerve because that is what Dr. B has been afraid of all his life. That hurts. Dr. B can not refer Bob to someone else – that would be an admission of failure. He then gets angry at Bob as he thinks, "What the hell is Bob doing not responding the way he should?" What Dr. B hears Bob saying is "You’re not a good doctor."

And, most likely, there’s more to come from Dr. B – several other possible responses. One could be, "Bob, there’s something that we haven’t picked up. I think we better do an exploratory laparotomy and see what’s wrong." Now, I know enough about Dr. B’s subconscious to accuse him of saying "You’re telling me that I am not a good doctor, after all I’ve done for you? You SOB, I’ll show you what I’m going to do to you." And that exploratory laparotomy is just an expression of anger. He’s going to cut the guy up because he told him he’s a lousy physician.

Response number two: "Look here Bob, enough of this foolishness. I’ve shown you that your x-rays are negative; the scibmartoscopic, gall bladder scan and sonogram are all negative. There’s not a damn thing wrong with you, Bob. The whole damn thing is up in your head. This is psychosomatic. I’m going to refer you to a psychiatrist and find out what the hell is wrong with you that you’re going around imagining this pain."

Response number three is, "You know, Bob, I can’t put my finger on what’s wrong with you, but obviously I can’t let you be up every night and suffer with pain, so let me give you this medication. Here’s a prescription for some Percocet. You can take one every three hours if you feel the pain is bad. And you say it’s keeping you up at night? Well, let me give you a little sedative – something for sleep." So, he gives Bob two addictive medications. Do you have any idea when Bob’s pain is going away? I have no idea. All I can tell you is that Bob comes to me three years later, and he’s taking six Restorils at night and twenty Percocets during the day – all because Dr. B could not say "I don’t know what’s wrong with you. Go see a gastroenterologist."

Looking at the Hole instead of the Donut

I can tell you all this about Dr. B since, in many ways, I was Dr. B. It took me awhile to overcome those feelings. Everyone always had something better than I had. I remember when I came into medical school, and my microscope wasn’t as good as the other guys’ microscopes. They all had better ones, especially the guy who had the binocular one! He happened to flunk out, but what’s the difference. I can, therefore, identify with Dr. B.

Before I made my transition to discover that I’m really not a bad guy, I was invited to the University of Southern Carolina to participate in a week-long workshop – Continuing Education for Drug and Alcohol Counselors. I gave a lecture and had 110 counselors attend. When I finished, they filled out the typical evaluation form, and a month later I got the results. As I started reviewing the evaluations, my ego started going through the ceiling. You ought to hear the wonderful things they said about me: ". . . a fascinating lecturer. . .," and I had them "spellbound," ". . . bring him back next year." I looked at 109 fascinating, excellent evaluations! But there was one guy who gave a negative evaluation – zeros all the way through. I was "rambling too much," ". . . told too many stories, ". . .didn’t give scientific information," ". . . didn’t present good statistics." I walked around for over two weeks totally depressed. Somewhere around the third week I realized that 109 to 1 is not a bad score. Those 109 people couldn’t be wrong. This one guy probably just had a very bad day, perhaps a sleepless night or maybe a lot of irritation or aggravation, and maybe he was just angry at himself and hated the whole world so his evaluation came out negative. But that’s not the way I reacted for the first two weeks. My reaction was that I was able to pull the wool over the eyes of 109 people, but this one guy saw through my act. If someone hits a raw nerve in you, that’s how you react. I don’t do that anymore. In fact, I don’t care how you evaluate this article. Sure, it would be nicer if you’re positive about it. You know what my reaction would be if 30% of your evaluations are negative? I’ll decide that 30% of you don’t have good judgment.

A number of years ago I wrote a book about addiction and physicians called It Happens to Doctors, Too. The book was in print for several years, and then I decided to revise it. Instead of talking only about physicians, however, I included nurses, psychologists, pharmacists, lawyers, executives, Rabbi’s, priests, nuns – all kinds of people. I contacted lots of people and asked for their personal stories, and it turned out to be a darn good book. It was rejected by every publisher for over two years. In the olden days, before I had come to a better self-awareness, I would have thrown it away after the second or third rejection. But, this time, I knew it was a good book, and I couldn’t figure out what was wrong with those publishers and their faulty judgment. I kept after them, and last week it was accepted. You see, it depends on how you feel and how you react to any kind of setback.

Process and Outcomes

The gratification from our work has to be from how we do it and what we are doing. We also have gratification from our supervisors and from working with our peers – getting emotional feedback from them on the quality of our work. But if those things aren’t happening, we are putting a huge amount of stress, enormous demand, on the job situation to provide what it cannot possibly provide. Then, we have burnout.

We can’t control outcomes. Whether you’re a social worker, teacher, doctor, nurse, or anyone providing a service, you cannot control outcomes. All you can do is control what you do and do the best job you possibly can. And when you’ve done that, you have been a good service provider. If the patient recovers, that’s wonderful. If the students gets an "A," that’s fine. The gratification from your work, this 25% or whatever you’re supposed to get from work, cannot depend on outcome. It should depend on the knowledge that you are doing a good job. And, if you supervise others, to let them know they are doing a good job.

Are We Hiding at the Office?

We need to think about why we do not have the emotional inputs from family, friends, and other non-job related sources. Many years ago, when I first came to work at St. Francis Hospital, there was a doctor on staff who became my personal physician. He was a great guy, not only an excellent physician, and everybody loved him – the house staff, medical students, his patients. He’d arrive at the hospital at 6:30 in the morning to begin rounds, and you’d find him at the hospital until 11 o’clock most nights. He was thoroughly devoted.

One night I saw him come out of a patient’s room and walk by the nurse’s station. One of the nurses then made a very uncomplimentary remark about his wife to another nurse. The other nurse said, "Why do you say that?" And the other responded, "Why else would a man be avoiding home all the time? I mean he lives here at the hospital; he just doesn’t want to go home."

A few years later, he said to me, "Abe, I wonder if you could do me a favor? My wife’s gone into a kind of depression . . . . I’ve given her some Elavil, but I shouldn’t be treating her. Could you see her?" She came to see me and, before I met her, I had this image of what the nurse had described. But you couldn’t picture a more gentle, wonderful, loving person than this woman – nothing like the nurse had imagined. She said to me, "Dr. Twerski, you know my husband well, and you know how dedicated he is to medicine and to his work. You see I’ve always been a needy person. I’ve always needed a shoulder to put my head on, but he was never there for that. Our children grew up without a father. If they were ever sick, of course, he treated them very effectively. But to help them grow up, to guide them, he was never there. He was always at the hospital." Later on, I talked with him, and it was so evident what was happening. This person had good self-esteem, professionally. He knew his treatment, physical diagnoses, his EKGs; and that’s where he felt competent. The hospital was a great place to be because he felt adequate. But he didn’t feel capable of being a husband and a father, so what did he have to offer at home? He avoided home.

Let’s say you checked into a hotel on a very hot, sultry day when the heat was stifling, and there are two rooms available. The first room you go into doesn’t have any air conditioning, but there’s a room down the hall that’s empty where it’s a comfortable 72 degrees. Well, come on! Where would you go? It’s only normal that you gravitate to a place of maximum comfort. What do people do if they feel they don’t have anything to offer as a human being, other than as a professional? They gravitate to where it’s most comfortable. This is just what this person did. It was a dire shame, too, because he was an excellent human being, but he just didn’t know it. He could have provided comfort and guidance to his children; he could have provided a great deal of support to his wife. He just didn’t believe he had it in him.

We all know there are times when we may have to work longer hours. But, I’m not sure it’s true as often as we think. Sometimes we hide in our office because it’s safer to be there. It’s more convenient, more comfortable because that’s where we know we are good. Whereas, at home, all we have to do is be a human being. If we don’t give ourselves enough credit for being human, we avoid the home. That’s a shame. The issue of self-esteem is a very, very central one to burnout. If we have good feelings about ourselves and good self-esteem, then we are much more likely to be in touch with family, with friends, to have religion – all these kinds of things depend on a good feeling about oneself. If we don’t have that, we end up putting a demand on our job for 87.5% instead of that 25% we’re supposed to. Just imagine if you had no vitamins, no minerals, except from one food that doesn’t provide all the nutrients you need. You’re going to suffer a deficiency syndrome. This is my idea of burnout.

Dealing with Our Own Humanness

Let’s focus on another group of professionals – those who deal with patients’ emotional issues. There is a difference between a medical professional who is solely involved with providing physical services to a physically-ill patient and those who relate to people whose problems are emotional or psychological. In physical illness, there is very likely to be an actual qualitative difference between the provider and the client. Let’s assume that it’s a physician who is treating a diabetic patient, and assume the physician is not diabetic. He can approach the diabetes with complete objectivity. The physician is not personally threatened by anything that happens to the patient.

What do you do in a situation where you are treating someone who has an emotional problem? Anxiety, depression, perfectionism, obsessive-compulsive disorder? That’s no longer a qualitative difference because the difference between mental health and mental illness is quantitative. You mean to say that a person who is perfectly normal mentally never has an anxiety? Or depression? Or doubts? Or all the other kinds of things that we see in panic attacks? Of course we have them. If we have them in a normal amount, that’s fine. It’s when you have an excess that it becomes an abnormality. While there’s a qualitative difference between the patient and the service provider when dealing with physical conditions, the difference is quantitative when it comes to psychological problems. If I’m a non-diabetic and I’m treating a diabetic who begins to have some complications, that’s not a threat to me because my kidneys are fine and my arteries are great. His problems are totally objective, and I can treat them. If I’m treating a patient who is approaching a problem area related to a father-son relationship, that is different. Wait a minute, come on, I got some father-son relationships! I was a son, and I am a father. He’s touching things that are a little too hot to handle for me because that reminds me of some things about myself that are uncomfortable, that I don’t want to think about. I just might happen to steer the patient away from that area. I steer him to areas which are not threatening to me. You know what happens? Areas that the patient should be dealing with get left out – they are unattended. Psychiatrists are supposed to go through personal psychoanalysis to eliminate these potential pitfalls. In theory, this is supposed to work, but in practice it doesn’t. Even a good psychoanalyst doesn’t free you of all your little, perhaps perfectly normal, twinges. Those of us who provide services to a person with any kind of psychological or emotional problem have to deal with a different situation – one that may contribute to professional burnout. These areas become a little too hot to handle.

I found a solution to this and would like to share it with you. There was an accountant, a bookkeeper, who was very, very perfectionistic, extremely dedicated, never came late once to work in 35 years, never missed a day, very methodical, precise, never had any problems, everything always balanced to the last cent. He did, however, have one interesting, curious little ritual. Every day, every morning, he would come to the office, sit down in his chair, unlock the desk drawer, pull it out, look in and nod knowingly, close the drawer, lock it, get out his books and begin to work. And never any problems with his work – always perfect. Everyone wanted to say to him, "Hey, what’s that all about?" After 35 years, he retired. Everybody’s curiosity was going to be satisfied because now the mystery of this ritual was about to be solved. The office gathered around his desk the day after his retirement, opened the desk drawer, and it was empty – except for a little card that said, "the debit column is the one facing the windows." Now that sort of impressed me. It gave me a little clue as to what to do in order to avoid the pitfall. I welcome you to come to my office and open my desk drawer. You’ll find there is a card with some large writing on it that says, "The patient is the one on the other side of the desk." I strongly suggest that all of us who are in that kind of position put a little card like that in our drawer so that any time we get any kind of twinge, we can pull open the drawer.

COMPLETE TEST FOR 1 PCACB–APPROVED CREDIT HOUR

(Record Answers to TWERSKI Test on Answer Sheet)

1. The amount of emotional gratification we receive from our work should be about

a. 10%
b. 25%
c. 75%
d. equal to the amount of responsibility we have in our job

2. If our entire identity is too closely linked to our profession, it may be a result of

a. burnout from too much involvement in non-work related areas
b. feelings of inadequacy in non-job related areas of our lives
c. focusing on the process in our work rather than on outcomes
d. the need for a professional identity

3. Feelings of inadequacy can lead to

a. an inability to deal with qualitative disorders
b. an increase in self-esteem
c. attempts to compensate in different ways
d. dependence on the processes involved with our jobs rather than on the outcomes

4. Focusing on the outcomes of our work, instead of the process involved, can result in

a. avoiding evaluation of the results of our work efforts.
b. expecting a higher level of qualitative results than we should expect
c. placing too much demand on our job situation which could result in burnout
d. suffering from a deficiency in quantitative results.

5. The difference between mental health and mental illness is

a. process oriented
b. product oriented
c. qualitative
d. quantitative