ORIGINAL ARTICLES AND REVIEWS
Fattori interni ed esterni nel burnout professionale tra gli operatori nel campo delle sostanze d'abuso in Croatia
Sanja Tatalović VorkapićI; Jelena MustapićII
IDepartment of Preschool Education, Faculty of Teacher Education, University of Rijeka, Rijeka, Croatia
IIDepartment of Diagnostics, Head Office of Prison System Directorate, Ministry of Justice, Zagreb, Croatia
AIM: In this study, burnout and its internal and external factors were investigated among substance abuse counsellors (no. = 68) who worked in centres for Prevention and Substance Abuse Treatment (no. = 18) in Croatia.
METHODS: Maslach Burnout Inventory was used which measured three burnout dimensions: emotional exhaustion, depersonalization and personal accomplishment; and questionnaire of internal and external burnout factors.
RESULTS: The higher levels of emotional exhaustion and depersonalization, and the higher level of personal accomplishment were determined. Factors such as work conditions, emotions about us and work, work organization and certain personality traits showed significant relationship with three burnout dimensions.
CONCLUSIONS: Overall, findings implicated a certain specificity of professional burnout in substance abuse counsellors, and the need for specific design of mental health care for them.
Key words: professional burnout, substance abuse, counsellors.
SCOPO: In questo studio è stata effettuata un'indagine sul burnout tra gli operatori per le sostanze d'abuso (no. = 68) che avevano lavorato in centri per la prevenzione e trattamento per sostanze d'abuso (no. = 18) in croazia.
METODI: Sono stati considerati i fattori interni ed esterni connessi al burnout. Sono stati utilizzati il Maslach Burnout Inventory che misura tre dimensioni del burnout: esaurimento emozionale, depersonalizzazione e realizzazione personale e un questionario per i fattori interni ed esterni di burnout.
RISULTATI: Sono stati determinati livelli più elevati di esaurimento emozionale e depersonalizzazione, come anche più alti livelli di soddisfazione personale. Una significativa relazione con tre dimensioni del burnout è emersa per fattori quali le condizioni di lavoro, le emozioni, l'organizzazione del lavoro ed alcuni tratti di personalità.
CONCLUSIONI: Nell'insieme, quanto emerso suggerisce una certa specificità di burnout professionale tra gli operatori nel campo delle sostanze d'abuso e la necessità, per loro, di un piano specifico di vigilanza per la salute mentale.
Parole chiave: burnout professionale, sostanze d'abuso, operatori.
Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by three dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment . Exhaustion is described as the feeling of not being able to offer any more of oneself at an emotional level; depersonalization as a distant attitude towards work, clients and colleagues; and reduced personal accomplishment (inefficacy) as the feeling of not performing tasks adequately and of being incompetent at work. In general terms, burnout is the body's response to the failure of the coping strategies that individuals typically utilize to manage stressors at work [2, 3]. It is a gradual process of disillusionment, which starts with enthusiasm, and follows with stagnation; frustration and finally apathy . Burnout equally affects women and men and the prevalence rates range from 10% to 50%, depending on profession, assessment tools and population . Although it can occur in a range of occupations, burnout has been found to occur mostly in people-oriented professions like medicine, nursing, social work, counselling and teaching. Where studied, the prevalence amongst healthcare workers approaches 25% . Gregov, Kovačević and Slišković  determined that emergency physicians experienced significantly more intense and more frequent uncontrollable working situations, conflict between work and family roles, and unfavourable relationships with co-workers than physicians working in health centres. Ogresta, Rusac and Zorec  found that satisfactory wages and rewards, work climate, advancement opportunities, degree of psychological and physical manifestation of occupational stress were significant predictors of emotional exhaustion. Job dissatisfaction, reduced self-efficacy, and low levels of workplace peer support in particular can lead to higher levels of cynicism . Burnout symptoms can partly be explained by some personality traits (perfectionism, idealization of support, self-promotion, the inability to say "no", refusing to share a part of the job demands, unrealistic expectations of the actions taken, etc.) and some external factors: poor work organization, inadequate preparation for concrete work, lack of organizational support, professional isolation, etc. Hudek-Knežević et al.  found that neuroticism positively predicted exhaustion, while agreeableness negatively predicted reduced professional efficacy [10, 11]. One Hungarian study of emotion work and burnout of nurses and physicians showed that significant predictor of emotional exhaustion was emotional dissonance and that significant predictor of depersonalization was display of negative emotions .
Substance abuse counsellors are specifically at risk for developing psychological problems due to work pressure and work related stress [13, 14]. They interacted extensively on a daily basis  with people who have specific health problems, lifestyle, emotional and other problems. After some time a number of professionals start to question their own sense of control over their lives and become traumatized [15, 16]. Several studies indicate that vicarious trauma appears when counsellors experience trauma-related symptoms [17, 18] which happens while they are listening to clients' experiences and assuming responsibility for the well-being of their clients . At the same time, they have to cope with the devastating experiences of others and try to help them with very limited resources and opportunities. Understanding the threats to mental health care providers' wellbeing because of exposure to others' trauma is very important, so specific and adequate prevention program for helpers' mental health care could be designed .
A study of burnout among substance abuse workers in the United Kingdom  revealed high emotional exhaustion and high depersonalization in this sample. A few studies have examined work-related predictors of burnout in substance abuse workers, and these have been limited to the addiction workforce in the United States [22, 23]. Although numerous studies have been conducted on prevalence and pattern of psychological morbidity in different occupational groups and settings, studies of psychological stress among substance abuse professionals rarely describe the nature of burnout and psychological morbidity . High rates of psychological morbidity and burnout in the sample of substance abuse professionals suggested a higher level of vulnerability than in other health professionals . Considering the fact that pathways to psychological morbidity and burnout were partially related, targeted response has been required to manage stress, burnout and psychological morbidity among substance abuse professionals and it should be integral to workforce development. Some organizational factors, such as supervisory support, leadership and philosophical orientation of the substance abuse treatment centres affected the prevalence of burnout . Forbearing communication, staff cohesiveness and clarity of mission were emphasized as key components in organizational dynamics of counsellors that reduced stress in their workplace . Substance abuse counsellors are crucial to the success of treatment interventions. However, despite their importance, they may be one of the most insufficiently understood components of treatment programs .
The main aim of this study was to explore the level of professional burnout and some of its internal and external factors in substance abuse counsellors in centres for Prevention and Substance Abuse Treatment in Croatia. Within that aim, we examined the relationship of internal (feelings, personality characteristics, sex, age and working experience) and external burnout factors (work conditions, work organization, work relationships, job contracts (full/part-time job), and occupation type) with three dimensions of professional burnout: emotional exhaustion (EE), depersonalization (DP) and personalaccomplishment(PA).Finally,weinvestigated possible significant predictors of three MBI(Maslach Burnout Inventory)-dimensions. Considering prior studies, we hypothesized to find higher levels of all three MBI-dimensions and higher internal and external burnout sources. Consequently, it was expected to determine equally significant correlations between those three dimensions and all internal and external burnout factors, no matter to any demographic variables. Finally, the internal factors were expected to be the more significant predictors for MBI-dimensions, than external burnout factors, what should serve for creating the specific mental healthcare guidelines for substance abuse counsellors.
From the 95 counsellors from 20 centres for Prevention and Substance Abuse Treatment in Croatia, a number of 68 counsellors have participated in this research (12 (17.6%) male and 56 (82.4%) female) from 18 centres in: Rijeka (no. = 5), Zagreb (no. = 6), Zadar (no. =5), Šibenik (no. = 4), Poreč(no. = 2), Bjelovar (no. =4), Virovitica (no. = 1), Samobor (no. = 2), Krapina (no. = 2), Dubrovnik (no. = 3), Varaždin (no. = 4), Split (no. = 8), Čakovec (no. = 6), Osijek (no. = 3), Karlovac (no. = 4), Slavonski Brod (no. = 2), Pula (no. = 5) and Gospić(no. = 2). Analyzing the occupation type according to sex, all psychiatrists were male (no. = 5), six general practitioners were male (no. = 17), one psychologist was male (no. = 11). Average age of counsellors was M = 41.6 years (SD = 8.9); for women average age was M = 40.3 (SD = 8.4; ranged from 26-58 years) and for men average age was M = 48.3 (SD = 8.4; ranged from 37-65 years).
Instruments and procedure
The Internal and External Burnout Factors. Questionnaire of internal and external burnout factors has been constructed following the directions given by Ajduković and Ajduković . Authors have collected significant internal and external sources or relevant signs of professional burnout in their manual for therapists and counsellors. It consists of six subscales divided into two main categories. The first subscale FEELINGS (about myself and my job) consists of 17 items (item example: "In my work with addicts so far I have experienced or I am currently experiencing the lack of sense of personal values"); the second subscale PERSONALITY (personality traits that increase the probability of experiencing professional burnout) consists of 13 items (item example: "Regarding to my job, I would describe myself like the person who idealizes her/ his profession"). These two subscales form Internal category of burnout factors. The third sub-scale WO (work organization) consists of 13 items (item example: "Organizational structure is unclear"); the fourth subscale WR (work relationship) consists of 8 items (item example: "There is a lack of a feedback on a job plans and accomplishments"); the fifth subscale Jc (job characteristics) consists of 7 items (item example: "The clients to whom I help have a very high rate of mortality") and the sixth subscale Wc (work conditions) consists of 5 items (item example: "I work in too small, inappropriate and unequipped working space"). Those four subscales form external category of burnout factors. The participants were answering the questions on Likert-type scale ranged from 1-4 (1 = never, 2 = rare, 3 = often, 4 = always), except on the Wc-subscale where they answered with YES or NO. The internal consistency and reliability analysis showed lower but still satisfactory levels of cronbach Alpha (Table 1).
The Professional Burnout. Maslach's Burnout Inventory (MBI ) measures the level of professional burnout and its three dimensions: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). The Croatian adjusted version of MBI showed satisfactory reliability on subscales . The inventory asks respondents to indicate on a 7-point Likert scale (which does not include the word "burnout") the frequency with which they experience certain feelings related to their work (0 = never; 1 = a few times in a year; 2 = once a month; 3 = a few times in a month; 4 = every week; 5 = a few times in a week; 6 = every day). The possible result ranges are: for EE (0-54), for DP (0-30) and for PA (0-48). The norms according to original authors are the following: a) the low EE (0-16), the moderate EE (1727) and the high EE (<28); b) the low DP (0-5), the moderate DP (6-10), and the high DP (<11); c) the low PA (<37) the moderate PA (30-36), and the high PA (0-29), . Besides these two questionnaires, following socio-demographic data have been collected: sex, age, working experience, occupational type, full (part)-time employment and the name of the centre for Prevention and Substance Abuse Treatment participant work in.
All centres have been contacted by the telephone before applying the questionnaires. Questionnaires were sent by mail to the centres and it was told to the centre's managers that after completing the questionnaires, they should send them back by mail to correspondent researcher. The participation in the study was completely voluntarily and anonymously. The completion time for both questionnaires was about 10-15 minutes, and most of the participants completed them on work during break. Collection of data lasted for four months and the cooperation with centres was more than satisfying. All centres were given feedback on results by e-mail. Data were analysed by SPSS 16.0 (SPSS Inc., chicago, IL, USA). Descriptive, correlation and regression analyses were conducted.
Average work experience of participants is M = 84.9 months (SD = 78.4) or approximately 7 years, ranged from 1-360 months. Average work experience of women is M = 74.7 (SD = 63), ranged from 1-300 months, and average work experience of men is M = 131.5 (SD = 120.5), ranged from 12-360 months. N = 42 counsellors are employed full-time (61.8%) and N = 26 counsellors (38.2%) are employed as part-time associates. Number of participants at centres for Prevention and Substance Abuse Treatment ranged from 1 (Virovitica) to 8 (Split). Counsellors who participated in study have different (no. = 13) professional background: psychiatrists (no. = 5 ), general practitioners (no. = 17), psychologists (no. = 11), social workers (no. = 10), nurses (no. = 2), and other occupations (no. = 12; sociologists, pedagogues, criminalists, work therapists, social pedagogues, pedagogues/sociologists).
Higher levels of emotional exhaustion and depersonalization, and the lower level of reduced personal accomplishment were found, as it could be seen in Table 1 and Figure 1. Among three MBI-dimensions, the highest mean level was determined in emotional exhaustion (M = 42.38, SD = 5.13), while depersonalization mean level was something lower (M = 26.91, SD = 2.85). The lowest was the mean level of reduced personal accomplishment (M = 9.31, SD = 5.05).
Comparing the levels of all three MBI-dimensions established in this study and those established in other four studies (Table 2), it could be seen that substance abuse counsellors had the highest levels of emotional exhaustion and depersonalization, and the lowest re duced personal accomplishment. In other words, they are more emotionally exhausted and had a higher cynicism than hospital nurses, emergency physicians or other mental health workers and health care professionals. On the other side, they had the highest personal accomplishment in order to results of other studies.
Substance abuse counsellors have been mostly dissatisfied with the work organization and work conditions, as presented in the Table 1 and at the Figure 2. For better understanding, it is crucial to observe established means in the light of minimum and maximum of results in every scale of analyzed sources of burnout. Exactly from that aspect, it was established that those two sources of burnout have the most dissatisfying influence on substance abuse counsellors.
Furthermore, the Table 3 shows the correlation matrix of three MBI-dimensions, six sources of burnout: feelings and personality traits (internal burnout sources), work conditions, work organization, work relationships and job characteristics (external burnout sources) and socio-demographic variables: sex, age, work experience, full-time job and occupation type. The increase of emotional exhaustion, defined as the individual's perception of diminished emotional resources characterized with subjective feeling of energy loss and weakness, was significantly related with an increase of depersonalization or cynicism and higher level of personal accomplishment (lower results on PA subscale). Stronger feelings of energy loss and weakness were significantly related with the following variables: the poorer work conditions; the feeling better about themselves and work; a better work organization; and perception of their work as an easy one. Higher level of depersonalization was significantly related with better feelings about themselves and their job and significantly negatively related with personality traits characteristic for individuals prone to experience professional burnout, such as: idealization, perfectionism, high expectations, submissive personality to authority and no border according to job responsibility. Increase of reduced personal accomplishment was positively related to unpleasant feelings about themselves and their job, personality characteristic that are prone to burnout and disturbed work relationships (Table 3). Considering demographic variables (sex, age, work experience and full-time job), women showed significantly higher diminishment of personal accomplishment and significantly more personality characteristics prone to burnout than men; and older counsellors showed more pronounced the tendency to achieve greater and more compelling personal accomplishments than the younger ones (Table 3).
Regression analysis was used to estimate the best predictors for three MBI-dimensions as criterion variables. Results are shown in the Table 4. The variables included in the regression analysis were significantly related to dependent variables: emotional exhaustion, depersonalization and personal accomplishment (Table 3). The best predictors of an increase of emotional exhaustion and depersonalization in substance abuse counsellors were Internal (feelings about themselves and about job, personality characteristics) and external (work conditions, work organization, work relationships and job characteristics) burnout sources, as presented in Table 4. Both internal and external burnout sources explained 39% of the emotional exhaustion variance, but none of them significantly. Therefore, burnout sources operationalized in this study did not revealed their different roles within their significant prediction of emotional exhaustion. One of the burnout sources (feelings about themselves and job) explained 20% (11% independently) of the total variance of the depersonalization variable. Feeling better about themselves and their job was the significant predictor of cynicism increase in substance abuse counsellors. Finally, the best predictor of higher diminishment of personal accomplishment was counsellors' age, which explained 12% of the total variance. Burnout factors and demographic variables explained together 31% of the total personal accomplishment variance, but the finding was not significant.
Comparison of three MBI-dimensions showed the higher emotional exhaustion perceived by substance abuse counsellors, lower depersonalization and the lowest level of reduced personal accomplishment. These findings are rather interesting since prior studies [24, 29, 30] mostly showed (the basis for the hypothesis) similar levels of the three MBI-dimensions: higher emotional exhaustion is followed by higher depersonalization and diminished personal accomplishment (higher result on the third sub-scale). It is logical to expect that if a person daily experience negative emotions and attitudes toward clients at workplace that his low job satisfaction would result in diminished personal accomplishment. However, this is not the case in our study. The high level of emotional exhaustion and depersonalization were found but the feeling of personal accomplishment was not diminished. Therefore, the participants reported rather high levels of personal accomplishment beside their negative emotions and attitudes toward clients. One of the explanations could be that they did not have high expectations of their work because positive behavioural changes in drug addicts are relatively rare and slow. Most counsellors have learned to be professionally satisfied with small improvements and lifestyle changes during substance abuse treatment. Centres for Prevention and Substance Abuse Treatment usually provide ambulatory care for drug addicts using pharmacological therapy, mostly methadone-based, and short-term counselling. The main aim of substitution therapy is to stabilize the drug addicts, help them in motivational process of maintaining the abstinence and to educate other family members about addiction problems so they can provide support during treatment. There are many relapses because it would be unrealistic to expect abstinence during outpatient treatment - and the Croatian substance abuse counsellors know that. So, their personal accomplishment is based on some other internal and external factors, rather than on the level of EE and DP. In other words, they are more emotionally exhausted and had a higher cynicism than hospital nurses, emergency physicians or other mental health workers and health care professionals. On the other side, they had the highest personal accomplishment, especially than health care professionals in study of Kovács et al. . These specific results on MBI-dimensions for substance abuse counsellors imply at the specificity of their work, and the possibility of using the specific instrument for measuring the burnout.
Considering the results determined at the burnout sources scales, two factors of work conditions and work organization, it could be seen that they presented rather objective parameters that have a strong influence on the overall job satisfaction. Within work organization, counsellors emphasized unclear organizational structure, insufficient time given for work tasks, undefined work responsibilities and duties, work without lunch breaks, undefined work expectations and inadequate organization of professional education and rewards. Considering work conditions, most of them work in very small, stifling or otherwise inadequate offices. Therefore, the first step in improving mental health of substance abuse counsellors should be changing these troublesome work conditions and work organization.
Although obtained results from correlation analysis concerning the relationship between emotional exhaustion and burnout sources sound controversial, they present the specificity of substance abuse counsellors' job. Substance abuse counsellors does not perceive their energy loss and weakness as something negative - on the contrary, their emotional exhaustion is significantly related with better feelings about themselves and work they do. Since unpleasant feelings about one and her/his work, are the first variables to examine considering professional burnout, could it be possible that emotional exhaustion is not the main dimension of professional burnout in this type of helping profession? Our results indicated that the more counsellors feel emotionally exhausted, the better they feel about themselves and their job and perception of their personal accomplishment is higher. One of the reasons for this finding could be counsellors' explanation of their emotional exhaustion, which they mostly attributed to the nature of their job and specific work conditions. Substance abuse counsellors have strong feelings of personal accomplishment and pleasant feelings about themselves regardless of very small alterations in drug addicts' behavioural patterns and many relapses. Hence, high level of their emotional exhaustion could not be seen as a significant indicator of professional burnout. Another possible explanation could be that counsellors have developed certain protective mechanisms toward clients and their job accomplishments. In addition, it is possible that substance abuse counsellors have very low expectations considering clients' possibilities to change their behavioural patterns or to maintain longer abstinence, so they have accepted the limitations of their own actions. Nevertheless, these presumptions certainly present the subject of future studies.
Increase of depersonalization is defined as a mental distance, loss of idealism about the job and negative attitudes toward the clients. In this study, increase of depersonalization was related with decline of the PA subscale, pleasant feelings and personality traits that were not characteristic for burnout. The cynicism has been very often understood as psychological defence mechanism. Its significant positive correlation with emotional exhaustion and the significant negative correlation with personal accomplishment (Table 3) could sufficiently corroborate prior claims about EE and DP as dimensions of defence mechanisms. Therefore, this maybe presents the relevant reason to revalidate MBI on specific population of substance abuse counsellors and restructure the instrument with some other relevant items that are more specific for them, or to use more adequate instrument such as AESS . This process could result with creating a new instrument for analyzing the level of professional burnout in substance abuse counsellors. Even though former studies on professional stress confirmed three factorial structure of MBI [1, 32-35], our conclusion is in agreement with a number of other reliability and validity studies of MBI [36-39]. Some studies even recommended two factorial structures: first factor was defined by the EE and DP items and was named "the core of Burnout", and the second factor was defined by the PA-items , which is in accordance with our results.
The lower personal accomplishment and more negative perception of work competence and job efficiency they experience, the worse they feel about themselves and their job. Personality characteristics that are prone to burnout were very significantly related to diminish personal accomplishment. According to our results in general, substance abuse counsellors did not experience professional burnout regardless their high levels of emotional exhaustion and depersonalization. Therefore, the EE and DP could not be the only presenters of the core of Burnout and the basis for burnout screening. On the other hand, the level of personal accomplishment in participants was rather high. Significant relationship between PA and individual's emotions and personality characteristics implies more important role of PA as a protective factor in burnout proneness . The core of burnout should be reconsidered in future validating studies of MBI-dimensions, and specific items for substance abuse counsellors should be added. Significant relationship between diminished personal accomplishment and poorer work relations is obvious, since the individuals who have characteristics prone to burnout could hardly maintain constructive relations with co-workers. Individuals' dissatisfaction due to experiencing unpleasant feelings about themselves and their job usually reflects on their relations with others creating negative atmosphere in work environment. Consequently, individuals prone to burnout do not get the needed support from their colleagues, which is very important for efficient work in very demanding working conditions.
The findings, concerning the relationship between sex and MBI-dimensions (Table 3), should be taken with precaution, because of very small number of man participated in the study. Individual's perception of self-competency and job efficiency could be influenced by sex roles in our country. Men attributed job accomplishment mostly to their abilities that are important part of their self-concept, while women attributed job accomplishment to external factors (luck, coincidence, etc.) and find it less important for their self-concept in general. However, future studies should include the equal or similar number of male and female participants.
Furthermore, it was determined that older subjects showed significantly more pronounced tendency to achieve greater and more compelling personal accomplishments. With years of professional experience, individuals become more confident about their work abilities and self-efficiency. Substance abuse counsellors with extensive work experience have reported of significantly better work conditions and worse work organization. Maybe the years of experience make them more critical of their work organization, but more positive to work conditions. Substance abuse counsellors who are been full-time employed estimated their work relationships more positive and felt better about themselves and job. This finding is very important for employment policy in our country, since even more than one third of employees (38.2%) in the centres for Prevention and Substance Abuse Treatment are employed as part-time associates.
Finally, there was no significant relationship found between three MBI-dimensions and burnout sources considering occupation type of substance abuse counsellors. All psychiatrists, psychologists, nurses, doctors, social workers and other professionals who participated in our study have perceived and experienced the similar levels of emotional exhaustion, depersonalization, personal accomplishment and internal and external burnout determinants. Comparing our results to other relevant studies [29, 30, 36], we found that inter-correlations between MBI-dimensions have been very specific for participants in our research, which again accentuate the need for future detailed study of professional burnout in substance abuse counsellors in Croatia. A significant contribution of this study is lying on the fact that it accomplished to include in the research almost all substance abuse counsellors that have been working at a time in our country. However, the determined situation concerning the occupation heterogeneity in the centres for substance abuse prevention and treatment presented one of the interfering factors regarding the best prerequisites to analyze possible differences among them.
The best predictors of an increase of emotional exhaustion and depersonalization in substance abuse counsellors were internal (feelings about themselves and about job, personality characteristics) and external (workconditions,workorganization,workrelationships and job characteristics) burnout sources (Table 4). Even though a rather big part of the emotional exhaustion variance has been explained by both: internal and external burnout sources (39%), none of them showed individual and specific significant contribution. Therefore, they did not reveal their different roles within their significant prediction of emotional exhaustion. The work of Vilardaga et al.  showed that mindfulness and values-based processes had a stronger and more consistent relationship with burnout as compared with work-site factors. They have concluded that interventions, which target experiential avoidance, cognitive fusion, and values commitment, may provide a possible new direction for the reduction of burnout among addiction counsellors. These findings emphasized the need for examining some other personality characteristics that could be stronger predictors for burnout and the different variable operationalization. In addition, concerning depersonalization as criterion variable, the source of feelings about themselves and job explained 20% of its total variance. Feeling better about themselves and their job at centre for substance abuse prevention and treatment was the significant predictor of cynicism increase in substance abuse counsellors. Finally, the best predictor of higher diminishment of personal accomplishment was counsellors' age, which explained 12% of the total variance. Nevertheless, the prediction role of the variable age for personal accomplishment was significant and must be mentioned. As it was discussed earlier within
Correlation analyses, more significant correlation and prediction of emotional exhaustion and depersonalization was associated with burnout sources, while personal accomplishment was related to participant's age. These findings implicate high specificity of professional burnout in substance abuse counsellors and the need for applying specific measuring instruments and specific design of mental health care for counsellors.
Findings in this study indicate very significant role of examined factors in professional burnout of Croatian substance abuse counsellors. Higher levels of EE and DP, and lower level of diminished PA were found. Increase of EE was positively related with increase of DP and PA, worse work conditions, feeling better about themselves and work, better work organization and perception of their work competence. Increase of DP was significantly related with increase of PA, feelings and personality characteristic that were not burnout-prone. Study results also emphasize the role of diminished personal accomplishment. Diminished PA was significantly related to feel more unpleasant and personality characteristic that have been burnout-prone. The best predictors for increase in EE and DP were internal and external burnout sources, especially lower level of negative feelings; for increase in PA the best predictor was age.
We would like to thank all Croatian substance abuse counsellors who participated in the study on their good will, time, effort and great cooperation.
Conflict of interest statement
There are no potential conflicts of interest or any financial or personal relationship with other people or organizations that could inappropriately bias conduct and findings of this study.
1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Ann Rev Psychol 2001; 53:397-422. http://dx.doi.org/10.1146/annurev.psych.52.1.397
2. Montero-Marin J, Garcia-campayo J. A newer and broader definition of burnout: Validation of the "Burnout clinical Subtype Questionnaire (BcSQ-36)". BMC Public Health 2010; 10:302. doi: 10.1186/1471-2458-10-302. http://dx.doi.org/10.1186/1471-2458-10-302
3. Gil-Monte PR. El síndrome de quemarse por el trabajo (burnout). Una enfermedad laboral en la sociedad del bienestar [in Spanish]. Madrid: Pirámide; 2005a.
4. Jaffe PD. Helping the helpers: Tips to avoid burnout reactions and to remain professionally effective. In: Baráth A, Jaffe PD, Jakab G, Szilàrd I, Weekers J (Eds.). The mental health aspects of trafficking in human beings training manual: a set of minimum standards. Budapest: International organization for Migration (IOM); 2004. p.137-83.
5. Brand S, Holsboer-Trachsler E. The burnout syndrome - an overview [in German]. Therapeutische Umschau 2010; 67:561-5. http://dx.doi.org/10.1024/0040-5930/a000095
6. Mateen FJ, Dorji C. Health-care worker burnout and the mental health imperative. Lancet 2009;22:595-7. http://dx.doi.org/10.1016/S0140-6736(09)61483-5
7. Gregov ALj, Kovačević A, Slišković A. Stress among Croatian physicians: comparison between physicians working in emergency medical service and health centres: pilot study. Croat Med J 2011;52:8-15. http://dx.doi.org/10.3325/cmj.2011.52.8
8. Ogresta J, Rusac S, Zorec L. Relation between burnout syndrome and job satisfaction among mental health workers. Croat Med J 2008;49:364-74. http://dx.doi.org/10.3325/cmj.2008.3.364
9. Schaufeli WB, Taris TW, van Rhenen W. Workaholism, burnout, and work engagement: Three of a kind or three different kinds of employee well-being? Appl Psychol an Internat Rev 2008;57:173-203. http://dx.doi.org/10.1111/j.1464-0597.2007.00285.x
10. Hudek-Knežević J, Krapić N, Kardum I. Burnout in dispositional context: the role of personality traits, social support and coping styles. Rev Psychol 2006;13:65-73.
11. Hudek-Knežević J, Kalebić Maglica B, Krapić N. Personality, organizational stress, and attitudes toward work as prospective predictors of professional burnout in hospital nurses. Croat Med J 2011;52:538-49. http://dx.doi.org/10.3325/cmj.2011.52.538
12. Kovàcs M, Kovács E, Hegedűs K. Emotion work and burnout: cross-sectional study of nurses and physicians in Hungary. Croat Med J 2010;51:432-42. http://dx.doi.org/10.3325/cmj.2010.51.432
13. Garner BR, Knight K, Simpson DD. Burnout among corrections-based drug treatment staff: impact of individual and organizational factors. Intern J Offender Ther Compar Criminol 2007;51:510-22. http://dx.doi.org/10.1177/0306624X06298708
14. Broome KM, Knight DK, Edwards JR, Flynn PM. Leadership, burnout, and job satisfaction in outpatient drug-free treatment programs. J Substabuse Treat 2009;37:160-70. http://dx.doi.org/10.1016/j.jsat.2008.12.002
15. Ajduković M. Burnout syndrome at work [in Croatian]. In: Ajduković M, Ajduković D (Ed.). Help and self-help in mental health care for helpers. Zagreb: Society for Psychological Assistance; 1996. p. 21-27.
16. Arambašić L. Stress and trauma [in Croatian]. In: Ajduković M, Ajduković D (Ed.). Help and self-help in mental health care for helpers. Society for Psychological Assistance; Zagreb; 1996. p. 11-19.
17. Bride BE. Prevalence of secondary traumatic stress among social workers. Social Work 2007;52:63-70. http://dx.doi.org/10.1093/sw/52.1.63
18. O'Halloran MS, O'Halloran T. Secondary traumatic stress in the classroom: Ameliorating stress in graduate students. Teaching Psychol 2001;28:92-7.
19. Deighton RM, Gurris N, Traue H. Factors affecting burnout and compassion fatigue in psychotherapists treating torture survivors: Is the therapist's attitude to working through trauma relevant? J Traumatic Stress 2007;20:63-75. http://dx.doi.org/10.1002/jts.20180
20. Ajduković M, Ajduković D. Why is the mental health of the helpers threatened? [in Croatian]. In: Ajduković M, Ajduković D (Ed.). Help and self-help in mental health care for helpers. Zagreb: Society for Psychological Assistance; 1996. p. 3-10.
21. Farmer R. Stress and working with drug misusers. Addiction Res 1995;3:113-22. http://dx.doi.org/10.3109/16066359509005230
22. Knudsen HK, Ducharme LJ, Roman PM. Counselor emotional exhaustion and turnover intention in therapeutic communities. J Subs abuse Treat 2006;31:173-180. http://dx.doi.org/10.1016/j.jsat.2006.04.003
23. Lacoursiere RB. "Burnout" and substance user treatment: The phenomenon and the administrator-clinician's experience. Subs Use Misuse 2001;36:1839-74. http://dx.doi.org/10.1081/JA-100108430
24. Oyefeso A, clancy c, Farmer R. Prevalence and associated factors in burnout and psychological morbidity among substance misuse professionals. 2008. Published online, licensee BioMed Central Ltd. doi: 10.1186/1472-6963-8-39. http://dx.doi.org/10.1186/1472-6963-8-39
25. Kyrouz EM, Humphreys K. Do health care workplaces affect treatment environments? J Commapplied Social Psychol1997; 7:105-118.
26. Joe GW,Broome KM,Simpson DD, Rowan-Szal GA. Counselor Perceptions of Organizational Factors and Innovations Training Experiences. J Subs abuse Treat 2007;33:171-82. http://dx.doi.org/10.1016/j.jsat.2006.12.027
27. Harwood H. Don't forget the workplace. Psychiatr Serv 2007;58:181-90.
28. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory. (3. edition). In: Zalaquett CP, Wood RJ (Ed.). Evaluating Stress: a Book of resources. Lanham, Md., & London: The Scarecrow Press, Inc.; 1997. p. 191-218.
29. Hudek-Knežević J, Krapić N, Rajter L. The relation between emotional control, perceived stress at work and professional burnout in hospital nurses [in Croatian]. Psihologijske teme 2005;14:41-54.
30. Jeleč Kaker D. Work satisfaction and burnout syndrome among health care social workers in the Republic of Slovenia [in Croatian]. Ljetopis Socijalnog Rada 2009;16:13-151.
31. Farmer R, Clancy C, Oyefeso A, Rassool GH. Stress and work with substance misuers: the development and corss-validation of a new instrument to measure staff stress. Drugs-Educ Prev Policy 2002; 9:377-388.
32. Maslach C, Jackson SE. Burnout in organizational settings. In: Oskamp S (Ed.). Applied Social Psychology annual: applications in Organizational Settings, 5. Beverly Hills: Sage; 1984. p.133-53.
33. Maslach C, Jackson SE. Maslach Burnout Inventory (Manual). Palo Alto California: Consulting Psychology Press; 1986.
34. Golembiewski RT, Boudreau RA, Munzenrider RF, Luo H. Global burnout: a worldwide pandemic explored by the phase model. London: JAI Press Inc.; 1996.
35. Boles JS, Dean DH, Ricks JM, Short JC, Wang G. The dimensionality of the Maslach Burnout Inventory across small business owners and educators. JVocational Behav 2000;56:12-34. http://dx.doi.org/10.1006/jvbe.1999.1689
36. Gill-Monte PR. Factorial validity of the Maslach Burnout Inventory (MBI-HSS) among Spanish professionals. Rev Saude Publica 2005b;39:1-8. http://dx.doi.org/10.1590/S0034-89102005000100001
37. Kalliath TJ, O'Driscoll MP, Gillespie DF, Bluedorn Ac. A test of the Maslach Burnout Inventory in three samples of healthcare professionals. Work Stress 2000;14:35-50. http://dx.doi.org/10.1080/026783700417212
38. Byrne B. The Maslach Burnout Inventory: validating factorial structure and invariance across intermediate, secondary, and university educators. Multiv BehavRes 1992;26:583-605. http://dx.doi.org/10.1207/s15327906mbr2604_2
39. Byrne B. The Maslach Burnout Inventory: testing for factorial validity and invariance across elementary, intermediate and secondary teachers. J Occup Organizat Psychol1993;66:197-212. http://dx.doi.org/10.1111/j.2044-8325.1993.tb00532.x
40. Vilardaga R, Luoma JB, Hayes SC, Pistorello J, Levin ME, Hildebrandt MJ, Kohlenberg B, Roget NA, Bond F. Burnout among the addiction counselling workforce: the differential roles of mindfulness and values-based processes and work-site factors. J Substabuse Treat 2011;40:323-35. http://dx.doi.org/10.1016/j.jsat.2010.11.015
▲ Address for correspondence:
Sanja Tatalović Vorkapić
Department of Preschool Education, Faculty of Teacher Education, University of Rijeka
Sveučilišna avenija 6
51000 Rijeka, Croatia
Received on 19 February 2012.
Acceptedon 26 April 2012.