Two New Developments in the Treatment of Burnout

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1 In: Nursing Issues: Psychiatric Nursing, Geriatric Nursing ISBN: Editors: C. D. McLaughlin et al., pp Nova Science Publishers, Inc. The exclusive license for this PDF is limited to personal printing only. No part of this digital document may be reproduced, stored in a retrieval system or transmitted commercially in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services. Chapter VI Two New Developments in the Treatment of Burnout Y. Meesters and C. J. M. van Velzen University Medical Centre Groningen, The Netherlands. Abstract In modern societies, work-stress and burnout complaints are increasingly leading to higher levels of absentee rates at work. Although burnout is not a classified psychiatric disorder, there is a large amount of co-morbidity with psychiatric disorders such as affective disorders. Therefore it is hardly surprising that mental health workers have developed treatment modalities for people suffering from these complaints. This chapter will describe two new developments in the treatment of burnout complaints at the Department of Psychiatry of the University Medical Center Groningen in the Netherlands. 1. In a research project, the effects of light in the treatment of the emotional exhaustion of the burnout syndrome were investigated. The preliminary conclusions of this small pilot study are promising: subjective energy levels increased. 2. At the clinic, a multidisciplinary day-care programme was developed to treat the burnout syndrome. Taking the principles of cognitive behaviour therapy and activation as a starting point, patients developed new coping strategies and social skills in order to become less vulnerable in their daily life and work situations. The effects of this programme were assessed during the programme and in a follow-up session a year later. A significant reduction in burnout symptoms was seen with 74.7 % of the participants being at work one year after having finished the programme.

2 194 Y. Meesters and C. J. M. van Velzen Introduction Work is known to play an important role in psychological health and wellbeing (Blustein, 2008). Job dissatisfaction may lead to work-related stress and psychological and physical dysfunctioning. In modern society, work stress and burnout cause an increasing amount of absentee rates. In the Netherlands, for example, absence caused by work-related psychological problems is a serious matter. 35% of all people unable to work have mental problems (Houtman et. al., 2007). Stress and emotional exhaustion do not only lead to impaired functioning on the job (Maslach and Schaufeli, 1993; Taris, 2006), but also to other problems, such as a significant increase of sick leave (Bekker et. al., 2005). In 36 % of cases, work pressure and workrelated stress are the initial reasons for being absent from work and in 10% for conflicts with colleagues, the management or both (Bakhuys-Roozeboom et al., 2009). As mentioned above, the most well-known work-related complaint is burnout, which has become a serious social problem, with about 4 % of the working population in the Netherlands suffering from severe burnout complaints (Bakker et al., 2000). After having defined the burnout syndrome, we will describe two new developments in the treatment of burnout: light therapy and day treatment. Burnout Burnout (BO) is a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by three dimensions: exhaustion, cynicism and inefficacy (Maslach et al., 2001). The core symptom of burnout is emotional exhaustion (Maslach and Schaufeli, 1993). This symptom in particular leads to impaired functioning on the job (Taris, 2006). Emotional exhaustion is also known to lead to a significant increase of sick leave (Bekker et al., 2005). The term burnout is introduced as a metaphor for a work-related state of being emotionally exhausted and overstressed. By definition, burnout complaints are associated with disfunctioning on the job, with people who have severe burnout complaints being unable to continue their normal work routines. Although severe burnout complaints constitute an emotional state with serious consequences to the individual, this syndrome has not so far been included in any psychiatric classification system. For this reason, mental healthcare institutions are often confused as to accepting and understanding the diagnosis of burnout. This confusion is increased by the fact that the symptoms of the burnout syndrome overlap with those of a number of psychiatric syndromes, particularly those of depression and emotional exhaustion, as described by Schaufeli and Enzman (1998). In a meta-analysis, Glass and McKnight (1996) concluded that burnout and depressive symptoms were not just two different terms for the same dysphoric state nor that they were redundant, mutually exclusive concepts (also see, Schaufeli and Enzman, 1998; Bakker et al., 2000; Schaufeli et al., 2001,Ahola et al., 2005; Sonnenschein et al., 2007a).

3 Two New Developments in the Treatment of Burnout 195 When looking for a diagnosis, healthcare professionals pragmatically select a psychiatric diagnosis from any classification system which has the largest overlap of symptoms with those of burnout complaints. A common definition of burnout is the ICD-10 (WHO, 1994) diagnosis of work-related neurasthenia (Schaufeli and Enzmann, 1998; Schaap et al., 2001; Schaufeli et al., 2001). Others use the DSM-IV diagnosis of undifferentiated somatoform disorder, because of the major problem of exhaustion (Schaap et al., 2001). Although there is little empirical evidence of successful treatment of burnout, activation and cognitive behavioural therapy (CBT) are common treatment procedures (Schaufeli and Enzmann, 1998; Schaap et al., 2001; Willert et al., 2009). These treatments are administered in outpatient clinics or in special, protocolised programmes offered by specialised therapists. Some patients have benefited by this type of programmes, others have not benefited at all or only partially. The most distinct symptom of the burnout syndrome is emotional exhaustion, the lack of energy (Taris, 2006). Individuals suffering from severe burnout experience a continuous, severe fatigue throughout the day; something which is uncommon in healthy persons (Sonnenschein et al., 2007b). Emotional exhaustion or fatigue is one of the central issues of this chapter. Light Therapy Light therapy has been the most successful treatment for people with seasonal affective disorder so far. It has also been shown that mood is not the only aspect that can be improved by light treatment, but that the same holds for energy levels (Rosenthal et al., 1984; Meesters et al., 1993; Avery et al., 2001; Wileman et al., 2001; Golden et al., 2005). In a case study we have described a patient with seasonal fatigue (without mood disorder), who underwent successful treatment by exposure to light (Meesters and Lambers, 1990). In healthy people, exposure to bright light has improved energy levels (Rüger et al., 2005). Similarly, in people who are seriously ill, a relationship has been shown between fatigue and exposure to light during chemotherapy or treatments of the same type (Liu et al., 2005). We assumed that energy deficits make it difficult for people to benefit from therapy. If it were possible to improve energy levels after exposure to bright light. It was hypothesised that energy levels of patients with burnout complaints could also be improved after exposure to bright light. In a pilot study, we investigated the effects in burnout sufferers of light therapy on emotional exhaustion compared to a waiting list condition (Meesters and Waslander, 2009). Day Treatment We developed a day treatment programme for patients with severe work-related psychological complaints, who were not expected to derive adequate benefit from an outpatient programme or who desired a more intensive type of treatment.

4 196 Y. Meesters and C. J. M. van Velzen The goal of this treatment was to analyse patients personal qualities and vulnerabilities when functioning on the job and for patients to learn new coping strategies and social skills in order to make them less vulnerable in stressful situations. We assessed the first results of this treatment programme in several ways en presented the results elsewhere (Meesters et al., 2009). Patients with different work-related complaints were included in the programme, not just those suffering from burnout. For this chapter we selected patients from this group who were suffering from burnout and we will present the results of this sub-group here. The day treatment programme was developed and based on the principles of CBT, combined with non-verbal therapy and activation (Meesters et al., 2009). Patients were included when they had a job to return to. Patients with severe psychiatric disorders were excluded from the study. The treatment programme was offered to groups of 5-8 participants and consisted of nine 8-hour days for the duration of a 13-week period. The treatment was scheduled in two 4-week periods during which the group came together one whole day once a week. Between these two periods, one or two individual sessions were scheduled in another 4-week period. In these individual sessions the first steps in the reintegration process took place. After this intermezzo, participants were expected to be actively engaged in the reintegration to their jobs and group treatment continued in the second period. The programme finished at the end of the second period. Four weeks after the programme had finished a booster day with cognitive therapy, a reintegration session and psychological assessments completed the programme. A follow-up session was scheduled one year after completion of the programme to assess the effects of the treatment. Patients filled out psychological questionnaires and participated in a group session to report about their functioning on the job. The days of the programme each consisted of four 90-minute sessions. Between sessions, group members had coffee, tea or lunch together, without the therapists being present, which made the total length of the treatment day 8 hours. The first period The programme started with an introduction and psycho-education. Every second session of this 4-day period consisted of psychomotor therapy. This therapy was included in the programme for several reasons. In people with burnout complaints activation is known to be an effective treatment modality (Schaap et al., 2001). A protocol was developed in which different aspects of working situations were practised, such as cooperating with others, coping with limited energy levels, coping with work pressure. The sessions were videotaped for feedback of the highlights in the next session. Cognitive therapy is an important part of the treatment (Schaap et al., 2001), as is stress management (including time management and life style aspects). In the first period, both strategies were included in the treatment every day. In two additional sessions, the qualities and limitations of the patients functioning on the job were investigated and discussed. Role playing was frequently used together with videotaped feedback. Also, one reintegration session was scheduled to prepare patients for the reintegration steps that were to follow in the next period.

5 Two New Developments in the Treatment of Burnout 197 In between periods After the first 4-week treatment period, another 4-week period was scheduled without group programme in which participants took the first steps towards the reintegration process. One or two individual therapeutic sessions supported this activity. The second period After this intermezzo, the second part of the group programme focussed on aspects of the participants personality that influence their functioning on the job. In additional sessions, interpersonal strategies related to coping with conflicts were exercised using role plays and videotaped feedback. The cognitive therapy continued during the second period. Art therapy was used as a non-verbal treatment procedure to gain insight into different aspects of functioning in a job (cooperating with others, working with a dominant colleague, protecting your position, etc). Finally, sessions were held concerning the actual reintegration process, and developing a relapse prevention plan, which was designed to protect participants from relapsing in the future. Participants were also stimulated to look for a job coach from their own social circle who would be able to support them in their reintegration process during the following months. Methods In both studies participants were diagnosed by an experienced clinical psychologist. As a definition for burnout we used the criteria of neurasthenia according to the ICD 10 which had to be work-related. This diagnosis had to be confirmed after a short standardised clinical interview for DSM-IV (APA, 1994) and ICD-10 psychiatric disorders (Mini International Neuropsychiatric Interview (M.I.N.I.), Sheehan et al., 1998), with an extra set of questions about burnout complaints containing the criteria of work-related neurasthenia from the ICD- 10.Complaints are work-related if they impair a person s ability to work. Patients filled out a battery of psychological questionnaires using a computer program. Participants who were depressed according to the DSM-IV as assessed by means of the M.I.N.I., were excluded in order to minimize the overlap between burnout complaints and depression. Light therapy In order to be included in the light therapy study, patients did not just have to have the diagnosis of burnout, but also had to score at least 3 on the emotional exhaustion subscale of the UBOS (Utrechtse BurnOut Schaal, Schaufeli & Van Dierendonck, 2000) in order to be included in the light therapy study. After they had been included and had given informed consent, participants were assigned to one of the two conditions. In other studies, it has proved impossible, however, to create a real placebo condition for light treatment. For this reason, the effects of light treatment are often compared to those of other treatment modalities or to waiting list conditions. In this pilot study we have compared the results of the treatment condition to those of a waiting list condition.

6 198 Y. Meesters and C. J. M. van Velzen This trial took 22 days, starting on Fridays. After 3 baseline days, participants in the treatment condition were offered light treatment on 5 workdays, no light treatment during the weekend, and another 5 days of light treatment, after which they were monitored for another 7 days. Participants in the waiting list condition were assessed in the same way as those of the treatment condition, but were not given light treatment. Participants in the waiting list condition received light treatment the week after the investigation period had finished. Participants of the treatment condition were exposed to artificial bright light (full spectrum, without UV, 10,000 lux) at the clinic for 45 minutes on weekdays from a.m. from December 2005 till September This treatment was based on the treatment protocol of our SAD outpatient clinic and on SAD research protocols we had used before (Gordijn et al., 2006). Participants were assessed by weekly self-rating questionnaires they filled out at the clinic. This research protocol had been approved by the hospital s medical ethical committee. Day treatment In the present day treatment study, a selection was taken from the participants of the day treatment programme (Meesters et al., 2009) based on UBOS- emotional exhaustion (UBOS- EE) scores. According to the UBOS manual, burnout sufferers show high scores on the subscale of emotional exhaustion and either high scores at the depersonalisation subscale or low scores on the lack of personal accomplishment subscale (Schaufeli and Van Dierendonck, 2000). Patients with an emotional exhaustion score of at least 2.2, and a depersonalization score of at least 2 or a lack of personal accomplishment score of 3.66 at the highest, were included. These figures are based on the UBOS manual. In this natural field study we looked for the answers to the following question: is the treatment programme effective as measured by the self-rating scales at three assessment times, but also reflected in the number of working hours on the job? Assessment and Instruments In addition to the standardised interview used to assess a diagnosis according to the DSM-IV (APA, 1994) the following questionnaires were filled out by patients in both studies: UBOS The UBOS (Utrecht s Burnout School; Schaufeli & Van Dierendonk, 2000) is a Dutch version of the Maslach Burnout Inventory (MBI, Maslach and Jackson, 1981), which assesses job-related burnout complaints and divides them into three subscales: emotional exhaustion, depersonalization and lack of professional accomplishment. These items all refer to the work situation.

7 Two New Developments in the Treatment of Burnout 199 SFQ The SFQ (Shortened Fatigue Questionnaire; Alberts et al., 1997) is a short, reliable and easily used instrument to determine the intensity of patients' bodily fatigue. BDI-II-NL Although patients diagnosed with depression according to the DSM-IV criteria were excluded, some distortion of mood could still be shown. Therefore, the BDI-II-NL, the Dutch version of the Beck Depression Inventory (Beck et al., 1996; 2002) was used to assess the severity of the depressive mood. Additionally, the following questionnaires were filled out in the day treatment study: SCL-90-R The Symptom CheckList-90 Revised version (Derogatis, 1977; Dutch translation and adaptation: Arrindell and Ettema, 2003) is a self-report inventory designed to screen for psychological distress and global psychopathology during the past week. This instrument does not just give an overall score but also contains 8 sub-scales: anxiety, agoraphobia, depression, somatization, obsessive-compulsive symptoms, paranoid ideation, hostility and sleeping problems. IOA The IOA (Inventarisatielijst Omgang met Anderen, Van Dam-Baggen and Kraaimaat, 1987) is a self-rating questionnaire used to assess social skills in two ways. Firstly, the frequencies with which social skills are used in different social situations and secondly, tensions experienced by the patient when social skills are used. UCL The UCL (Utrechtse Coping Lijst, Schreurs et al., 1993) is a self-report questionnaire which assesses the way people generally react when confronted with problems or unpleasant situations. It contains seven independent subscales measuring: active problem focusing (analyzing problems, acting confidently and in a goal-directed way), palliative reaction pattern (looking for distraction, relaxation, seeking diversions), avoidance (complying in order to avoid problematic situations, adopting a waiting attitude), support-seeking (seeking comfort and sympathy), worrying (being preoccupied with problems, brooding, feeling unable to act), emotional expression (showing frustrations) and comforting cognition (encouraging oneself, creating soothing thoughts). Light therapy In the light therapy study, the psychological self-report questionnaires were filled out on a weekly basis. The scores at day 1 and day 22 were used for the comparison in this chapter. The score on the emotional exhaustion subscale of the UBOS was used as an inclusion criterion (score 3 or higher) and outcome measurement.

8 200 Y. Meesters and C. J. M. van Velzen Table 1. Participants Treatment Waiting list Day treatment Male/female 8/8 8/6 24/22 Age ** yr yr yr Sick leave Partial sick leave Full at work 1 7 Education Low 1 8 Middle High Hours at work* 13 (n=4) 14 (n=2) 9.3 (n=21) Winter/summer 6/10 4/10 -- * Average working hours per week of participants who are still (partial) at work ** Mean score + standard deviation Day treatment In the day treatment programme, patients filled out the questionnaires at the start and at the end of the programme and one year later. The actual hours participants went to work were registered at the three assessment moments. Statistics The proportional improvement scores and effect sizes (Cohen, 1988) were calculated and ANOVA with repeated measures was used to calculate levels of significance. Results Participants in the light therapy study The light treatment condition had 16 participants, the waiting list condition 14. Six participants were still at work, with 5 working part-time because of their complaints. The others reported they were unable to continue their jobs due to their burnout complaints (see Table 1). The two conditions did not differ in age, gender, level of education, timing in the season of participation in the design (winter or summer), and hours at work or sick leave. Neither did the two conditions differ in mood and energy levels before the start of the programme as indicated by the scores on the different self-rating scales. Participants in the day treatment study Patients suffering from burnout and not suffering from a depression according to the DSM-IV and who filled out questionnaires at the three assessment times were selected from our day treatment programme for patients with severe work-related complaints (Meesters, et

9 SFQ scores Two New Developments in the Treatment of Burnout 201 al., 2009). 46 patients were included (see table 1). Duration of sick leave varied from weeks with a mean of 32.3 weeks (+ 31.6) and a median of 21 weeks. Other patient characteristics were: married 54.3 %, divorced 8.7%, living alone 23.9 %; living with partner 30.4%; living with partner and child(ren) 41.3 %; living with child(ren) 2.2%; living with others not mentioned before 2.2 %. Light Therapy The improvement after light treatment as compared to that of the waiting list condition is statistically significant according to the scores on the SFQ (F (1, 3) = 3.66, p = 0,03; see Figure 1). The scores on the UBOS emotional exhaustion subscale (F (1, 3) = 2.45, p = 0.09)) show a trend in the same direction. Although the UBOS emotional exhaustion scores also show some improvement in the treatment condition when comparing it to the waiting list condition, this difference is not significant. Day Treatment Day treatment yields a statistically significant reduction of complaints over time. The effect sizes of the mood and energy scores on the questionnaires are particularly large (see table 2 and figure 1). Social skills and behaviour also showed improvement over time. Coping strategies only improved very slightly to moderately. Reintegration of participants in their jobs measured a Fatigue year after the programme had finished amounted to 74.7 % of the original contract hours (see Figure 3) light treatment, n=16 waiting list, n=14 day treatment, n= before after follow-up Figure 1. Fatigue scores of the SFQ in the two studies. Before in the light therapy study was the assessment at day 1, after the assessment at day 22 (a week after treatment). Before in the day treatment study was the assessment at the start of the programme, after at the end of the programme, and follow up one year after finishing the programme. The scores in the light treatment condition and the day treatment programme improved significantly (p<0.05).

10 hours at work/wk 202 Y. Meesters and C. J. M. van Velzen Participants whose sick leave does not exceed the duration of 21 weeks (median score) show significantly better results in reintegration hours after a year, than those whose sick leave lasts for more than 21 weeks (see Figure 2). Short vs Long sickness leave * significant p< contract before after follow-up 21 weeks or less, n=23 22 weeks or more,n=23 * Figure 2. Weekly hours at work at the start and end of the programme and one year later. Contract = weekly hours patients should work according to the contracts with their employers, n=46; 21 weeks or less = a maximum duration of sick leave of 21 weeks; 22 weeks or more = a minimum sick leave duration of 22 weeks. Emotional exhaustion or fatigue is the most important symptom of the burnout syndrome. Patients with higher levels of fatigue complaints at the start of the programme worked fewer hours than patients with less higher levels of fatigue. The median score on the SFQ was If we use this figure to divide the group on the basis of their fatigue, the subgroup with higher levels of fatigue complaints showed higher levels of sick leave of longer duration (see Figure 3). In the light therapy study, patients were included if they suffered from a certain level of emotional exhaustion as measured by the UBOS. When we apply the same criterion to the day treatment group, this shows that only 6 patients (13%) scored lower than 3 on the UBOS- EE. The more exhausted patients worked fewer hours at the start of the programme, but also at the other assessments times (Figure 4).They also had longer periods of sick leave before the start of the programme.

11 Table 2. Results of the day treatment programme Range Before n=46 After, n=46 Follow-up, n=46 % improvement F df p Effect size SCL anxiety , SCL agoraphobia , SCL depression , SCL somatzation , SCL obsessive compulsive SCL paranoid ideation , , SCL hostility , SCL sleep problems , SCL-90 total ,2 0, BDI-II-NL , UBOS exhaustion , UBOS depersonalization UBOS lack of professional accomplishment , ,

12 Range Before n=46 After, n=46 Table 2. (Continued) Follow-up, n=46 % improvement F df p Effect size SFQ , IOA-frequency , IOA-tension , UCL active problem focussing UCL palliative reaction pattern , , UCL avoidance , UCL support seeking , UCL worrying , UCL emotional expression UCL comforting cognition , , Hours at work/wk , Contract hours at work Job abstinence period in weeks

13 hours at work/wk hours at work/wk Two New Developments in the Treatment of Burnout 205 More or less fatigue in relation to hours at work (1) contract before after follow up sick leave* less tired more tired Figure 3. The median score on the SFQ in the day treatment study is Less tired is an SFQ score of at most 22.5; more tired is an SFQ score above 22.5; * Sick leave duration in weeks before the start of the programme More or less fatigue in relation to hours at work (2) contract before after follow up sick leave* less tired, n=6 more tired, n=40 Figure 4. The inclusion score in the light therapy study on UBOS/EE is 3. The patients of the day treatment study have been divided according this criterion. Less tired have an UBOS-EE score of less than 3, more tired have an UBOS-EE score of at least 3 at the start of the programme; * Duration of sick leave in weeks before the start of the programme

14 hours at work/wk 206 Y. Meesters and C. J. M. van Velzen Improvement of fatigue in relation to hours at work contract before after follow up sick leave ** * improvement, n=19 non improvement, n=27 * significant improvement (p <0.05). ** Duration of sick leave in weeks before the start of the programme Figure 5. Improvement is an improvement of at least 50 % on the SFQ at follow-up compared to the start; Patients who showed an improvement of 50 % or more on SFQ scores during the research project, are seen to work significantly longer at the follow-up moment than those who showed an improvement of less than 50 % (F14.6,df = 1,2, p=0.00; Figure 5). They also had longer periods of sick leave before the start of the programme. Discussion Light therapy This study shows some evidence for the hypothesis that exposure to light improves energy levels of patients suffering from burnout complaints. These results are more or less in line with the results of a study among nurses of a University Hospital, who were exposed to at least 3 h of daylight on a daily basis. This group was compared to a group with less than 3 h of exposure to light. In the group with longer exposure to light, it was found that participants were less stressed and had higher levels of work satisfaction. Longer exposure to light also had an indirect positive effect in the prevention of burnout complaints (Alimoglu and Donmez, 2005). In this study, participants emotional exhaustion was equal in both groups of nurses, who were still at work and were not diagnosed as suffering form burnout complaints. Improvement after light treatment was assessed on a weekly basis with instruments that contained questions about fatigue levels (SFQ). A trend towards improvement was seen after light treatment based on the UBOS-EE subscale. The UBOS assesses a subject s experience of complaints at work during the previous week (Schaufeli and Van Dierendonck, 2000). Most participants did not go to work during the weeks prior to the assessment, but stayed at home because of their complaints. Therefore, the UBOS may not be the questionnaire best

15 Two New Developments in the Treatment of Burnout 207 suited to these participants, which might explain why the results based on this questionnaire are weaker than those based on the other instruments. When comparing the participants of this study to those of other studies (Ahola et al., 2005) more depressive symptoms were reported. We excluded patients with a DSM-IV diagnosis of depression from the study. Nevertheless, participants in both conditions had elevated scores on a depression questionnaire (BDI-II). The trend towards improvement after light treatment, based on the BDI-II scores can be explained by the items about fatigue and energy. The item about depressed mood remained the same after light treatment. The scores on this item were low from the beginning. Apart from the small sample size, another limitation of this study is its lack of a placebo control condition. A waiting list condition followed by light treatment was used instead. When we look at the results of the treatment that was offered after the waiting list period, there was no difference in results after this type of light treatment as compared to the light treatment of the protocol: the participants of the waiting list condition showed the same degree of improvement. Some effects of patients expectations about the result of the treatment cannot be ruled out, however, the effects of the daily visits, and contact with the clinic staff might also account for some of the observed improvements, although the staff were instructed not to talk about the participants complaints. In the control condition, there were no daily visits to the clinic. In spite of these shortcomings, the preliminary results of light treatment are promising when treating the emotional exhaustion of the burnout syndrome. Notwithstanding the small sample size, the effect sizes of light treatment according to the self-rating questionnaires seem promising. Day treatment A short, but intensive day treatment programme and its outcomes for patients suffering from severe burnout were described in this chapter. This treatment was protocolised and had as main objective to reduce the complaints, and to teach patients new and more effective coping strategies and social skills in order to make them less vulnerable in future stressful situations. Emotional exhaustion as part of burnout complaints was often seen to be present. The programme contained different approaches, such as cognitive behavioural therapy, nonverbal therapeutic interventions and activation which, when used together, led to a relapse prevention plan at the end and stimulated patients to reintegrate in their jobs. CBT and related interventions were major parts of the programme. In a recent study, De Vente et al. (2008) came to the conclusion that CBT-based interventions were not successful in the treatment of patients with clinical levels of work-related stress. These findings are in line with those of Blonk et al. (2006) who compared an extensive CBT-therapy, a treatment with brief CBTderived interventions combined with individual-focussed and workplace interventions and a control group of persons with severe work-related psychological complaints. The combination treatment was found to be superior to both the extensive CBT and the control group in shortening the duration of the sick leave. This last finding is probably in line with our own results, in that in our programme, it is not possible to discriminate between the effects of the different elements. In our programme, the total package of interventions might

16 208 Y. Meesters and C. J. M. van Velzen be responsible for the therapeutic outcome. It is not possible to point out a single ingredient of the programme which is responsible for the effect. When looking at the figures of the follow-up assessment, which was held a year after the programme had been completed, and comparing them to those of the beginning of the programme, a significant reduction of symptoms was found and patients performance at their jobs amounted to 74.7 % of their contract hours. Before the start of the programme patients had been absent from their jobs for approximately 30 weeks on average. We therefore conclude that the effects of this programme seem promising. Coping strategies hardly improved at all or very slightly at most. Van Rhenen et al., (2008) showed that active coping strategies are related to the duration of the sick leave. We were unable to confirm these findings; however, there are some differences between the studies. In our study, participants suffer from burnout complaints, whereas in the Van Rhenen study the whole population of a major company was investigated. In our study, the initial mean scores of coping strategies did not differ from the mean scores of a normal population according to the UCL manual (Schreurs et. al, 1993). Therefore, a major improvement of coping strategies is not very realistic. Nevertheless, improvements, if any, are in the desired direction. There are, however, some limitations to this study. It is a natural field study with a lack of homogeneity in the psychopathology and without a single intervention technique being responsible for the effects. Since we did not use a placebo condition, it is still possible that the therapeutic results are not superior to any effects over time without treatment. It is therefore impossible to draw conclusions about the working mechanism of the programme. This programme was developed for and studied with patients in a regular mental healthcare setting, instead of in a randomised controlled scientific laboratory situation. This might increase its chance of being implemented in everyday mental healthcare practice. Conclusions Both studies make it clear that the interventions (light therapy and day treatment) improve emotional exhaustion or fatigue levels. If sick leave is relatively short, patients have a better perspective of improvement and reintegration into their jobs. Patients with higher levels of fatigue at the start of the programme worked less at that time. If fatigue complaints decrease, patients may be able to reintegrate into their jobs. Decreasing fatigue levels may lead to a significantly greater amount of hours of reintegration into the job. The conclusion can be that improving emotional exhaustion or fatigue levels should be one of the core goals in the treatment of burnout. If light treatment indeed has a positive effect on emotional exhaustion or fatigue, it may be assumed that patients can benefit more readily from this treatment if it is administered prior to any other treatment.

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