The psychotherapeutic relationship is central

If burnout is defined as a stress-related risk condition for secondary diseases with life management problems, it must be approached holistically as a syndrome. Treatment based on a good therapeutic relationship and strengthening of resilience are promising.

In the ICD-10 diagnostic manual, burnout syndrome is not listed as a separate disease. “It is defined as being burned out and in a state of total exhaustion, as well as a possible factor influencing the development of diseases, and is recorded with the diagnosis code Z73.0,” said Michael Pfaff, MD, chief physician at Clinica Holistica in Susch. The German professional society DGPPN and the Swiss Expert Network Burnout (SEB) also define burnout not as a disease, but as a stress disorder with problems in coping with life and as a non-specific risk condition for secondary diseases. The SEB has also included neurobiological aspects in its position paper and describes burnout also as a dysregulation of the stress hormone axis, a failure of resilience and a regulatory disorder in the CNS that alters the plasticity of the nervous system. “The Swiss professional society recommends tailoring therapy to the individual needs of the patient, treating underlying and secondary conditions in addition to psychotherapeutic interventions, and accompanying the patient in his or her social and professional reintegration,” Dr. Pfaff explained. Burnout treatments are usually billed using the diagnosis “Depression” (F 32.1) and the suffix “Burnout” (Z 73).

Also working on questions of values and meaning

“If burnout is defined as a stress-related risk condition for secondary diseases with life management problems, the syndrome must be addressed holistically,” explained Dr. phil. Dipl-Psych. Martina Belz, psychotherapist and research associate at the University of Bern. In concrete terms, this means for clinics and practices not only working toward improved stress management, but also explicitly discussing questions of meaning and values with the patient. Various approaches of the so-called third wave of behavioral therapy offer good additions and extensions for burnout treatment. This is because it expanded the behavioral and cognitive concepts of the first and second waves of behavior therapy to include mindfulness and acceptance aspects as well as etiological realities. “The burned-out person is seen as an emotional being in need of attachment and meaning,” the psychologist elaborated. Because there are many unanswered questions regarding etiology, definition, and diagnostics in burnout syndrome, and statements about the effectiveness of therapies are only preliminary in nature, treatment must be cross-therapeutic, process-oriented, and individualized. Also central is the therapeutic relationship, which according to Dr. Belz should be the lever of change.

Strengthening resilience

Prof. Dr. med. Gregor Hasler, Chief Physician and Associate Professor of the University Psychiatric Services in Bern, spoke of a turning point, a further development of psychotherapy and the end of the phase of self-centeredness. Since the foundation of psychoanalysis by Sigmund Freud, the individual, his desires and drives have been at the center of psychotherapies. These aim to develop strategies to strengthen individualism. However, Prof. Hasler sees “super-individualism” as the main reason for today’s burnout epidemic. “Extreme self-centeredness fosters inequalities and status struggles that lower resilience, which in the long run leads to burnout and stress-related illnesses in predisposed people,” the expert said. Studies have also identified the ongoing status struggle as the cause of depression.

“In therapy with burnout patients, the main thing is to strengthen the factors that promote health, and not to focus only on the negative and disease-causing factors, as is usually practiced,” Prof. Hasler explained. He cited social relationships as an important resilience-building factor. “In this process, the main role is played by the people who are emotionally and geographically close to us, that is, not only close friends, but also neighbors who are there for us when we need support,” the psychiatrist stressed. The positive experience of community is also psychotherapeutically relevant. In a study of patients with post-traumatic stress disorder, purely interpersonal therapy was more successful than the confrontational therapy often used with trauma patients. Prof. Hasler explained this result with the distinctive reward system in the human brain. This releases opioids when activated and has been shown to be stimulated by positive interpersonal experiences. “To strengthen resilience, it is thus central to focus psychotherapy on positive experiences, on crises overcome, good relationships, and on conflict resolution and growth opportunities,” Prof. Hasler concluded.

Burnout is also an identity crisis

Like Prof. Hasler, Prof. em. Dr. med. Daniel Hell, former medical director of the PUK in Zurich, in modern individualism the main cause for the great increase in burnt-out people. “Because this requires constant self-optimization, which greatly increases the risk of failure and exhaustion,” the psychiatrist explained.
Success orientation and competition make the achiever with a tendency to self-exploitation very vulnerable if recognition is permanently absent. If there is an imbalance between performance and reward over a longer period of time, this leads to a loss of performance (Fig. 1) . “This causes a deep self-uncertainty and identity crisis, which burnout patients very often try to ward off with cynicism,” said Prof. Hell. The identity crisis also triggers a special kind of homesickness that results in a search for lost self-confidence and also awakens feelings of shame about having failed. Behind the shame, Prof. Hell sees a signal for the identity crisis. “But it is also a door opener to the self,” he said. Feelings of shame are therefore also an important aspect of burnout therapy. In order for patients to openly face their shame, inner insecurity and identity crisis, a protected therapeutic resonance space is needed that also conveys a sense of home and security. “The basis for this protected framework is the therapeutic relationship,” the expert emphasized. They account for 30% of the therapeutic effect. Only 15% are due to special techniques and models. 40% include patient variables and extratherapeutic influences. Finally, expectations and placebo effects account for the remaining 15%.

Source: 5th Symposium of Clinica holistica, November 15, 2018, Lavin.