SECONDARY TRAUMA AND BURNOUT IN MILITARY BEHAVIORAL HEALTH PROVIDERS Beyond the Battlefield Charles C. Benight Secondary Trauma and Burnout in Military Behavioral Health Providers Charles C. Benight Secondary Trauma and Burnout in Military Behavioral Health Providers Beyond the Battlefield Charles C. Benight University Of Colorado - Colorado Spring Colorado Springs, Colorado, USA ISBN 978-1-349-95102-4    ISBN 978-1-349-95103-1 (eBook) DOI 10.1057/978-1-349-95103-1 Library of Congress Control Number: 2016962100 © The Editor(s) (if applicable) and The Author(s) 2016 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Cover illustration: © Kuligssen / Alamy Stock Photo Printed on acid-free paper This Palgrave Macmillan imprint is published by Springer Nature The registered company is Nature America Inc. The registered company address is: 1 New York Plaza, New York, NY 10004, U.S.A. This book is dedicated to the thousands of mental and behavioral health providers who work each and every day to help heal the wounds of war Acknowledgements I would like to express my gratitude to many people who contributed to the completion of this book. First, I would like to thank my wife Carol who has always supported my efforts to make a difference, albeit small, in this world. Second, the contributors to this book, Dr. Judith Bock, Dr. Kotaro Shoji, Dr. Shaun Stearns, and Ms. Carolyn Yeager, were all instrumental from the beginning to the end of this book process; it would not have happened without them. Third, Ms. Pamela Weisman and Ms. Andrea Yetzer were extremely helpful in editing this book and getting it into shape for the final submission. Clinical graduate students Ms. Emily Luther, Ms. Gina Boesdorfer, Ms. Crystal Nichols, Ms. Erin Melville, and Ms. Alli Douglas were extremely helpful during the SupportNet project including writing summaries of articles for the resource room and recruiting participants. I also want to thank Alan Peterson, Ph.D., Bret Moore, Psy.D., Col Bruce E. Crow, and Col Jay E. Earles who were extremely helpful in helping us to reach our participants for our studies. Lastly, I would like to thank the entire SupportNet team who worked so hard to make the project successful. This includes the main contributors listed above and in alphabetical order Dr. Valerie Anderson, Dr. Roman Cieslak, Ms. Lisa Decker, Dr. Robert Durham, Dr. Fred Gibson, Dr. Al Glock, and Ms. Debbie Sagen. This work was funded through a grant from the Telemedicine and Advanced Technology Research Center # W81XWH-11-2-0153. vii Contents 1 Introduction   1 Charles C. Benight 2 Provider Load  11 Kotaro Shoji, Charles C. Benight, and Shaun Stearns 3 The SupportNet Website: A Social Media Self-Care System  41 Carolyn Yeager, Judith Bock, and Charles C. Benight 4 SupportNet Coaching  67 Judith Bock and Charles C. Benight 5 Organizational Factors in Burnout and Secondary Traumatic Stress  85 Shaun Stearns and Charles C. Benight 6 SupportNet: A Randomized Controlled Trial for Military Behavioral Health Burnout 115 Kotaro Shoji, Charles C. Benight, and Shaun Stearns 7 Lessons Learned and Next Steps 147 Charles C. Benight ix x  Contents Appendix 171 About the Author 197 Contributor Notes 199 Index 201 List of Figures Fig. 1.1 Social cognitive job-demands resource model Fig. 2.1 Social cognitive job-demands resource model Fig. 2.2 The mediation effect of self-efficacy change and social support change in the relationship between exhaustion and disengagement (depersonalization) Fig. 3.1 Triadic reciprocal determinism of social cognitive theory Fig. 3.2 SupportNet technology architecture Fig. 3.3 Agile lifecycle used by the SupportNet development team Fig. 3.4 SupportNet home page Fig. 3.5 SupportNet assessment dashboard Fig. 3.6 SupportNet self-assessment history and recommendations for burnout self-efficacy Fig. 3.7 SupportNet life balance wheel Fig. 3.8 SupportNet goal setting module illustrating the creation of goals and social support Fig. 3.9 SupportNet resource room article summary and discussion Fig. 3.10 SupportNet Take 5 Fig. 4.1 SupportNet hybrid web and coaching support system Fig. 5.1 Example of a vertical, mechanistic bureaucracy Fig. 5.2 Example of a flat, organic organization Fig. 6.1 SupportNet landing page Fig. 6.2 CONSORT chart for the SupportNet RCT Fig. 6.3 Interaction effects on exhaustion in ANOVAS comparing coached/delayed and web-only groups in the intent-to-treat analysis 5 13 29 42 46 48 49 52 53 54 55 57 57 68 87 89 118 121 128 xi xii  List of Figures Fig. 6.4 Interaction effects on overall job burnout in ANOVAs comparing coached, delayed (control), and web-only groups in the intent-to-treat analysis Fig. 6.5 Interaction effects on overall job burnout and exhaustion in ANOVAs comparing coached/delayed and web-only groups in the completer analysis Fig. 6.6 Interaction effects on overall job burnout, exhaustion, and depersonalization in ANOVAs comparing coached, delayed (control), and web-only groups in the completer analysis 130 131 134 List Table 2.1 Table 2.2 Table 2.3 Table 2.4 Table 3.1 Table 3.2 Table 4.1 Table 4.2 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 of Tables Demographic and work characteristics of the behavioral health providers participating in the SupportNet study 16 Comparing intensity of intrusion, avoidance, arousal, and total score of Secondary Traumatic Stress Scale in the SupportNet study with results obtained in other studies 19 Comparison of SupportNet job burnout results and results obtained from other studies 22 Averages for STS, job burnout, and other related factors for on-post and off-post providers 25 User profile information 51 Means and standard deviations for engagement 59 Coaching process 73 Descriptive statistics 80 Summary of a staggered intragroup control design 120 Demographic information for participants at pre-test for intent-to-­treat analysis 122 Results of the interaction effect in mixed ANOVAs on job burnout for intent-to-treat analysis (N = 64)127 Means, standard deviations, sample sizes, and effect sizes for each group in the intent-to-treat analysis 129 Means, standard deviations, sample sizes, and effect sizes for each group in the completers analysis 132 Results of the interaction effect in mixed ANOVAs on job burnout for completer analysis 133 xiii CHAPTER 1 Introduction Charles C. Benight A deep-seeded military value is to never leave a comrade behind nor forget the sacrifices of a soldier. It is just as important, though, to not forget those who care for soldiers; caregivers help “bring home” soldiers who have suffered in battle, while experiencing risks of their own. The focus of this book is to provide critical information related to the literature on secondary trauma and burnout in combination with specific findings from our military mental health provider project called SupportNet. It was designed to identify and address these risks directly related to military-­ based caregivers. Collectively, this monograph reports on the important findings of SupportNet, including (a) the prevalence of secondary trauma and burnout among military mental health providers, (b) the development of a web-based support system, (c) details related to a life-balance-based coaching program, (d) challenges and findings related to the first ­randomized controlled trial of an intervention for secondary trauma and burnout in military mental health providers, and (e) critical lessons learned along with recommendations for future directions. In addition, to the specific findings related to the project, each chapter will contextualize the findings relative to the broader literature. C.C. Benight (*) University of Colorado at Colorado Springs, Colorado Springs, CO, USA © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1_1 1 2  C.C. BENIGHT What’s the Problem? Secondary Trauma and Burnout in Military Mental Health Providers The Caregiver Demand.  Over 1.6 million troops have been deployed in Iraq and Afghanistan since the start of the Iraq War in 2003. As of October 4, 2010, the Department of Defense (DOD) estimated 4408 soldiers died in Iraq and 1304 in Afghanistan (Fischer, 2010). At the same time, approximately 31,934 and 8530 were wounded in action in Operation Iraqi Freedom and Operation Enduring Freedom, respectively. Over 90 percent of soldiers wounded in action to date survived their injuries, a rate higher than in any previous war (Gawande, 2004). Tempering this more positive news for combat soldiers, however, is the consequence to caregivers. Support systems for these soldiers have seen a dramatic increase in demand, in the form not only of the number of active duty soldiers and veterans coping with physical challenges, but those suffering psychological difficulties as well. For example, many of the returning soldiers will have suffered traumatic brain injuries (TBI) combined with psychological issues complicating the increased caregiver demand. The Armed Forces Health Surveillance Center (AFHSC, 2015) reported that as of 2014, over 300,000 combat soldiers had been diagnosed with some form of TBI. Although the majority of these injuries are “mild” (approximately 247,000), mild TBI is nevertheless associated with a range of psychological difficulties. Further, it is difficult to determine whether soldiers’ symptoms (such as cognitive difficulties, mood changes, and impulsivity) stem from TBI, post-traumatic stress disorder (PTSD), or both. Estimates of PTSD prevalence among troops deployed to Iraq and Afghanistan vary considerably, likely due to methodological and measurement differences (Ramchand et  al., 2010). Sundin, Fear, Iversen, Rona, and Wessely (2010) conducted a comprehensive review of prevalence studies published from 2004 to 2008, each of which used large (N > 300), nontreatment-seeking samples. These authors found, among these ­methodologically sound studies, rates of PTSD ranging from 10 to 17 percent in studies with samples of line infantry units and 2.1 to 11.6 percent in random-population-based studies. PTSD prevalence among treatment-­ seeking samples appears to be considerably higher (Erbes, Westermeyer, Engdahl, & Johnsen, 2007; Jakupcak, Luterek, Hunt, Conybeare, & McFall, 2008; Seal et al., 2009). Indeed, Seal et al. (2009) INTRODUCTION  3 reported 21.8 percent of Iraq and Afghanistan Veterans who were firsttime users of VA health care between 2002 and 2008 had received a diagnosis of PTSD.  Clearly, PTSD, along with other primary mental health challenges such as major depressive disorder, bipolar disorder, general anxiety disorder, and so on, characterizes a demand for mental health treatment through the DOD, the Veterans Administration, and local communities across the nation that is unprecedented. In sum, both the numerical demands on the mental health system to care for these soldiers and the complexity of these demands are beyond anything previously seen. The Caregiver Consequence.  A major risk to behavioral health providers working with combat veterans is the development of secondary traumatic stress (STS). Secondary exposure to trauma is a widespread phenomenon referring to the different types of indirect exposure to traumatic material, such as contacts with people who have experienced traumatic events, exposure to graphic trauma content (e.g., reported by the survivor), exposure to people’s cruelty to one another, and observation of and participation in traumatic reenactments (Pearlman & Saakvitne, 1995). Indirect exposure may be an inherent hazard for mental health providers, health-care personnel, and social workers who provide clinical services to military combat veterans (Elwood, Mott, Lohr, & Galovsky, 2011). Research suggests indirect exposure is predictive of higher levels of distress (Pearlman & Mac Ian, 1995), job burnout (Ballenger-­Browning et  al., 2011), compassion fatigue (Figley, 2002), and secondary traumatic stress (Elwood et al., 2011). We define secondary traumatic stress (STS) as reactions resembling post-traumatic stress, such as intrusive re-experiencing of the traumatic material, avoidance of trauma triggers and emotions, and increased arousal, all resulting from indirect exposure to trauma. The recent introduction of the DSM-5 provides the opportunity for diagnosing PTSD through indirect exposure (e.g., through client contact) demonstrating the crossover between STS and PTSD (American Psychiatric Association, 2013). STS prevalence rates differ across occupation groups; for example, criteria for a PTSD-like diagnosis of secondary traumatic stress were met by a significant percentage of providers working with trauma survivors including 15.2 percent of social workers (Bride, 2007), 16.3 percent of cancer providers (Quinal, Harford, & Rutledge, 2009), 19 percent of 4  C.C. BENIGHT substance abuse therapists (Bride, Hatcher, & Humble, 2009), 20.8 percent of family or sexual violence counselors (Choi, 2011), 32.8 percent of emergency room nurses (Dominguez-Gomez & Rutledge, 2009), 34 percent of child protective service providers (Bride, Jones, & Macmaster, 2007), and 39 percent of juvenile justice education employees (Hatcher, Bride, Oh, King, & Catrett, 2011). Craig and Sprang (2010) found 6 percent of a national representative sample of clinical psychologists, and clinical social workers reported high levels of compassion fatigue (a construct very similar to STS) and 12 percent reported elevated levels of job burnout (Leiter, Harvie, & Frizzell, 1998). Burnout has been found to substantially contribute to decreased effectiveness and poorer treatment outcomes (Lasalvia et al., 2009). Moreover, it is associated with more frequent voluntary and involuntary hospital admissions among patients of mental health providers and contributes to a more negative attitude toward patients (Holmqvist & Jeanneau, 2006; Priebe, 2004). Burnout also is related to important organizational outcomes including a decreased commitment to the organization, higher levels of absenteeism, greater presenteeism (present, but inefficacious), and greater turnover rates. Clearly, STS and job burnout can substantially impinge on caregivers’ clinical effectiveness, increase turnover, elevate health-care costs, reduce overall morale, and significantly affect a provider’s overall well-being. Specific to military providers, the commitment to force health protection and overall warrior readiness requires these issues be addressed. The SupportNet Response Given the exponential increase in clinical need and potential for secondary exposure to military mental health providers, the initial task for the SupportNet project was to first determine the current levels of STS and burnout in this population. We combined the demands/resource model with the importance of self-regulatory self-appraisals into a theoretical framework to help understand the key risks and resilience factors (see Fig. 1.1) related to both negative and positive outcomes (e.g., burnout, secondary traumatic growth). We then utilized empirical findings from a large sample of providers across the globe in order to provide critical insight into developing an effective support intervention system. Subsequently, we developed and evaluated, a web-based, coach-facilitated system to reduce provider burnout and promote wellness. INTRODUCTION  5 Fig. 1.1  Social cognitive job-demands resource model Book Outline This book is directly relevant to clinical and administrative staff stakeholders. We specifically designed this book to be applied; we want it to be directly relevant and useful for clinical staff working with trauma clients more broadly and of course military clients more specifically. Directors of behavioral health, hospital administrators, and the like—anyone with a vested interest in the health and welfare of clinical staff who are working under enormous pressure to provide best practice for their traumatized clients—will find this book useful. All our chapters have a consistent structure: quick overview information in the beginning, more detailed data in the middle, and clinical implications at the end. The next chapter (Chap. 2) summarizes the most relevant data we gathered related to the prevalence of secondary trauma and burnout in military mental health providers as well as other trauma therapists. In this chapter, we review a number of published papers from our lab as well as relevant research findings from other researchers. We compare our results with other published investigations of different provider populations offering important insights. We report on important differences between on-post and off-post providers. Important clinical implications related to how 6  C.C. BENIGHT to help these military mental health providers based on our findings are offered. Lastly, suggestions for how these findings can help the broader therapeutic community close out this chapter. Chapter 3 is focused on the development of our web-based intervention. This system was designed on the basis of a foundation of evidence-­ based theory regarding the promotion of enhanced social support and self-efficacy. The chapter reviews other interventions described in the literature, followed by a description of our specific approach. We discuss the challenges of developing and deploying a web system that includes a social-media-based platform combined with a life-balance goal-setting system. We also provide important information related to computer engagement in online interventions more broadly, with recommendations for future system enhancements. We end the chapter with a discussion of how this system could be deployed within other provider settings. The fourth chapter covers the development, deployment, and evaluation of our coaching program that was combined with our web-­intervention system. The SupportNet team determined early on that we wanted to incorporate a human component to augment our web-based support program. This chapter reviews the development of our coaching approach, provides an overview of our coaching manual (the complete manual is provided in the Appendix), and summarizes qualitative information from our randomized controlled trial regarding how important this dimension was to participants. The chapter ends with a discussion of clinical implications for future web-based interventions, and how coaching may or may not help. Chapter 5 targets the challenges associated with addressing secondary trauma and job burnout in organizational-level settings (including military, business, and community-based milieu) versus the more common individual-level focus. The military environment, like any large hierarchical bureaucracy (e.g., the VA), is a system that offers advantages and difficulties related to designing and implementing an approach to these challenging provider issues. We make the case for the importance of considering organizations as core factors affecting STS and job burnout. A review of critical organizational structure and cultural factors that affect burnout and potentially STS are offered. Finally, we offer a set of best practices for ameliorating STS and job burnout from an organizational perspective. In the sixth chapter, we detail the randomized controlled trial we conducted to evaluate our intervention program. This chapter is particularly important for administrators and research personnel who want to critically evaluate programs developed for secondary trauma and burnout. INTRODUCTION  7 Analysis  of the literature on web-based and coaching interventions for burnout and STS in mental health providers is offered. We review challenges in the implementation of the research along with an overview of our specific findings. Lastly, important research, clinical and practical implications are highlighted based on our results. Our book ends with a cohesive summary of the major “lessons learned” from our review of the literature and the findings from the SupportNet project. These are presented in a user-friendly manner offering recommendations for future work in this area and how the military in particular, and others in general, might approach these issues in different contexts. We emphasize the next steps necessary for deploying our coaching-web-based support system to enhance social support and self-efficacy. Finally, the book closes with a section of critical resources and links we have gathered over the four years of this project that might be helpful for military providers and their stakeholders as well as the broader therapist community. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Armed Forces Health Surveillance Center (AFHSC). (2015). Absolute and relative morbidity burdens attributable to various illnesses and injuries, U.S. Armed Forces, 2014. MSMR, 22(4), 5–10. Ballenger-Browning, K. K., Schmitz, K. J., Rothacker, J. A., Hammer, P. S., Webb-­ Murphy, J. A., & Johnson, D. C. (2011). Predictors of burnout among military mental health providers. Military Medicine, 176(3), 253–260. doi:10.7205/ MILMED-D-10-00269. Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52(1), 63–70. Bride, B. E., Hatcher, S. S., & Humble, M. N. (2009). Trauma training, trauma practices, and secondary traumatic stress among substance abuse counselors. Traumatology, 15(2), 96–105. doi:10.1177/1534765609336362. Bride, B.  E., Jones, J.  L., & Macmaster, S.  A. (2007). Correlates of secondary traumatic stress in child protective services workers. Journal of Evidence-Based Social Work, 4, 69–80. doi:10.1300/J394v04n03_05. Choi, G.-Y. (2011). Organizational impacts on the secondary traumatic stress of social workers assisting family violence or sexual assault survivors. Administration in Social Work, 35, 225–242. doi:10.1080/03643107.2011.575333. Craig, C. D., & Sprang, G. (2010). Compassion satisfaction, compassion fatigue, and burnout in a national sample of trauma treatment therapists. Anxiety, Stress & Coping, 23(3), 319–339. 8  C.C. BENIGHT Dominguez-Gomez, E., & Rutledge, D. (2009). Prevalence of secondary traumatic stress among emergency nurses. Journal of Emergency Nursing, 35(3), 199–204. Elwood, L. S., Mott, J., Lohr, J. M., & Galovski, T. E. (2011). Secondary trauma symptoms in clinicians: A critical review of the construct, specificity, and implications for trauma-focused treatment. Clinical Psychology Review, 31(1), 25–36. doi:10.1016/j.cpr.2010.09.004. Erbes, C., Westermeyer, J., Engdahl, B., & Johnsen, E. (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine, 172(4), 359–363. doi:10.7205/ MILMED.172.4.359. Figley, C.  R. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Journal of Clinical Psychology, 58(11), 1433–1441. Fischer, H. (2010). U.S. military casualty statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. Gawande, A. (2004). Casualties of war—Military care for the wounded from Iraq and Afghanistan. New England Journal of Medicine, 351(24), 2471–2475. doi:10.1056/NEJMp048317. Hatcher, S. S., Bride, B. E., Oh, H., King, D. M., & Catrett, J. F. (2011). An assessment of secondary traumatic stress in juvenile justice education workers. Journal of Correctional Health Care, 17(3), 208–217. doi:10.1177/1078345811401509. Holmqvist, R., & Jeanneau, M. (2006). Burnout and psychiatric staff’s feelings towards patients. Psychiatry Research, 145(213), 207. doi:10.1016/j. psychres.2004.08.012. Jakupcak, M., Luterek, J., Hunt, S., Conybeare, D., & McFall, M. (2008). Posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan war veterans seeking postdeployment VA health care. The Journal of Nervous and Mental Disease, 196(5), 425–428. doi:10.1097/NMD.0b013e31817108ed. Lasalvia, A., Bonetto, C., Bertani, M., Bissoli, S., Cristofalo, D., Marrella, G., et  al. (2009). Influence of perceived organisational factors on job burnout: Survey of community mental health staff. The British Journal of Psychiatry, 195(6), 537–544. doi:10.1192/bjp.bp.108.060871. Leiter, M.  P., Harvie, P., & Frizzell, C. (1998). The correspondence of patient satisfaction and nurse burnout. Social Science & Medicine, 47(10), 1611–1617. doi:10.1016/S0277-9536(98)00207-X. Pearlman, L. A., & Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice, 26(6), 558–565. doi:10.1037/0735-7028.26.6.558. Pearlman, L.A. & Saakvitne, K.W. (1995). Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In C.R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 150–177). New York: Brunner/Mazel. INTRODUCTION  9 Priebe, S. (2004). Institutionalization revisited—With and without walls. Acta Psychiatrica Scandinavica, 110(2), 81–82. doi:10.1111/j.1600-0047.2004. 00386.x. Quinal, L., Harford, S., & Rutledge, D. N. (2009). Secondary traumatic stress in oncology staff. Cancer Nursing, 32, E1–E7. doi:10.1097/NCC. 0b013e31819ca65a. Ramchand, R., Schell, T.  L., Karney, B.  R., Osilla, K.  C., Burns, R.  M., & Caldarone, L. B. (2010). Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. Journal of Traumatic Stress, 23(1), 59–68. doi:10.1002/jts.20486. Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C. R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. American Journal of Public Health, 99(9), 1651–1658. doi:10.2105/AJPH.2008.150284. Sundin, J., Fear, N. T., Iversen, A., Rona, R. J., & Wessely, S. (2010). PTSD after deployment to Iraq: Conflicting rates, conflicting claims. Psychological Medicine, 40(03), 367–382. doi:10.1017/S0033291709990791. CHAPTER 2 Provider Load Kotaro Shoji, Charles C. Benight, and Shaun Stearns Quick Facts • Military mental health providers are facing an unprecedented clinical demand that includes increases in clinical load as well as complexity of cases. • Approximately 20 percent of clinicians working with military clients report significant levels of secondary traumatic stress (STS) and burnout. • Evidence suggests burnout is a precursor to STS creating a clinician vulnerability to indirect traumatic exposure. • Previous trauma history, younger age, reduced burnout self-efficacy perceptions, STS symptoms, working in the community, higher organizational constraints, and higher interpersonal conflicts are all critical to consider for preventive and intervention programming related to STS and burnout. • Changes in self-efficacy for managing burnout are an important risk factor for how exhaustion can lead to clinical depersonalization (i.e., the detachment from one’s clients). K. Shoji (*) • C.C. Benight • S. Stearns Trauma, Health, and Hazards Center, University of Colorado at Colorado Springs, Colorado Springs, USA © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1_2 11 12   K. SHOJI ET AL. • Greater personal and organizational control is important in enhancing work engagement in this population. • Finally, enhanced self-efficacy for managing STS symptoms and high levels of social support are important in clinicians’ secondary traumatic growth. STS and Burnout in Military Mental Health Providers: The Rest of the Story The number of military or veteran patients seeking mental health care has grown drastically in recent years. The Department of Veterans Affairs (VA) alone has observed a 100 percent increase in the number of patients with post-traumatic stress disorder (PTSD) receiving behavioral health services, from 139,062 in 1997 to 279,256 in 2005 (Rosenheck & Fontana, 2007). Since 2005, this number has continued to climb, increasing 65 percent by 2014 (U.S. Department of Veterans Affairs, 2014). With a growing need for treatment, the VA alone added 4,330 mental health professionals to its workforce as of 2010 (Voss Horrell, Holohan, Didion, & Vance, 2011) and then 1,600 more providers from 2012 to 2013 (U.S. Department of Veterans Affairs, 2014). These statistics show that the population indirectly affected by trauma through providing services for traumatized patients has grown dramatically. The level of distress in this patient population and the complexity of the cases create a very challenging prospect for clinicians. PTSD prevalence among treatment-seeking veteran samples ranges from 12 percent (Erbes, Westermeyer, Engdahl, & Johnsen, 2007) to as high as 37.8 percent (Jakupcak, Luterek, Hunt, Conybeare, & McFall, 2008). Many of these soldiers have lived through the tragedies of war including killing of civilians and children, witnessing fellow soldier death and dismemberment, random improvised explosive device attacks, and so on. Trauma treatment with combat soldiers is unique in that it requires the therapist to confront the societal sanctioning of killing, manage soldiers’ difficulties with survivor guilt, and being exposed to the grotesque details of war, in particular the extreme violence that occurs to fellow soldiers or innocent civilians (Figley, 1978). Because the frequency of interaction between military combat soldier providers and patients has increased, the clinical challenges and selfcare demands for the providers throughout the Department of Defense (DOD), the VA, and local communities across the nation are unprecedented. The SupportNet project was designed to help these providers. PROVIDER LOAD   13 Summary of the SupportNet Research Program The SupportNet study project, funded by the Telemedicine and Advanced Technology Research Center, aimed to understand the prevalence of job burnout and STS among US military mental health providers and develop a supportive intervention. In reviewing the literature on burnout and STS in these providers, it is clear that the evidence is extremely limited and does not utilize a theoretically based approach to understand the adaptive processes involved in managing the extensive psychological challenges of treating combat exposed soldiers with multiple psychological and physical disorders (Bride & Figley, 2009; Tyson, 2007). In addition, no experimentally controlled trial data on prevention programs for secondary trauma and burnout in military behavioral health providers is available. The SupportNet project attempted to fill these voids. We utilized the following theoretical model in our research (Fig. 2.1). The primary variables that we considered in our job demands-resources model approach to understanding both positive and negative aspects of work-related stress included general job resources (e.g., supervisory Fig. 2.1  Social cognitive job-demands resource model 14   K. SHOJI ET AL. s­ upport and general social support), general job demands (e.g., organizational constraints and interpersonal conflict), trauma-specific job demands (e.g., number of trauma-focused clients and indirect trauma exposure), and self-efficacy perceptions (e.g., secondary trauma self-efficacy and job burnout self-efficacy). Self-efficacy is defined as one’s beliefs in one’s own ability to manage environmental demands and exercise control over one’s own functioning (Bandura, 1997). Perceived social support relates to the belief that one can get help from others including coworkers, supervisors, friends, and family. The primary aims for the project were: Objective 1: Conduct an initial needs assessment to determine the level of secondary trauma and burnout in military mental health providers. We accomplished this by utilizing the most reliable and valid measures available in the literature to measure negative and positive emotional states in this population (Chap. 2). Objective 2: We evaluated the utility of social cognitive theory as a framework for understanding the job  demands-resources model of job stress for military mental health providers. Specifically, we tested a longitudinal theoretically based model that incorporated ­environmental challenges, social-based resources, and cognitive self-appraisals leading to both positive and negative psychological outcomes (Chaps. 2 and 5). Objective 3: We developed and evaluated a theoretically based support system called SupportNet to empower behavioral health providers in developing critical self-assessment skills, self-regulatory abilities, and support-seeking capacities. A social media-based platform was developed to work in tandem with a peer-coaching model to provide optimal support for improving provider self-care (Chaps. 2, 3, 4, and 6). A team including research scholars on stress, burnout, and trauma; clinical providers experienced in working with military clients; and computer scientists with specialization in social media-based platforms and database-­driven web design was assembled in order to meet these objectives. In this chapter, we review prevalence information from other investigations as well as our own findings specific to military mental health providers and other health care employees. We look at how self-efficacy perceptions play a role in understanding these important work-related outcomes. We examine the positive outcome of secondary traumatic growth in clinicians. Finally, we offer clinical implications of these important findings. PROVIDER LOAD   15 Research Methods for SupportNet Longitudinal Study The SupportNet longitudinal study was initiated through an email invitation to on-post and off-post providers who work with military patients. The email indicated that the Internet survey was on military mental health providers’ job burnout and STS.  The off-post community therapists received another invitation to the study through an online newsletter sent by TriWest Healthcare Alliance. The providers working within military installations (on-post) were contacted by email sent by the director of the Department of Behavioral Health at Evans Army Community Hospital at Fort Carson, CO, and by the Psychology Consultant to the US Army Surgeon General. As such, the sample included responses from all over the USA and Army installations overseas. A total of 271 of 339 participants who initially consented to the study met the inclusion criteria. Specifically, participants had to be working at least one year as a clinical psychologist, counselor, or social worker; offering services to a military population; and exposed indirectly to traumatic materials through work with patients. History of indirect trauma exposure (e.g., car accident, combat, and sexual assault), work station (e.g., a military installation and community), direct trauma exposure (same list as indirect exposure), occupation (e.g., psychologist, social worker, and psychiatric nurse), type of therapeutic approach used (e.g., cognitive behavioral therapy, cognitive processing therapy, and prolonged exposure therapy), and general demographic information (e.g., gender, age, and highest education) were collected. In addition, we assessed supervisor support, percentage of trauma patients on caseload, burnout coping self-­efficacy, STS self-efficacy, burnout, STS, and secondary traumatic growth. Time 2 data were collected for the same variables six months after Time 1. Email invitations were sent to the providers who participated in the Time 1 survey. Characteristics of Our Military Mental Health Provider Sample.  Most of the military mental health providers who participated in our study were female (71 percent; see Table 2.1 for demographic information) with an average age of 51 years (see Cieslak et  al., 2013 for more detail). On average they reported working as a mental health provider for just over 15 years. Our sample included a nice variation of occupations including clinical psychologists (43 percent), counselors or psychotherapists (22 16   K. SHOJI ET AL. Table 2.1  Demographic and work characteristics of the behavioral health providers participating in the SupportNet study Demographic variables Gender  Male (%)  Female (%) Age: M (SD) Years of experience: M (SD) Caseload: M (SD) Relationship status  Long-term relationship (%)  Not in a long-term relationship (%) Profession  Clinical Psychologist (%)  Counseling (%)  Social Work (%)  Medical (%) Education  Master’s degree (%)  Doctoral degree (%) Employment  Part-time (%)  Full-time (%) Work Setting  On-military installation (%)  Off-military installation (%) Military experience  At least some experience (%)  No experience (%) Deployment history  Yes (%)  No (%) Time 1 (N = 271) Time 2 (N = 117) 91 (29.5) 180 (70.5) 51.04 (12.57) 15.06 (10.04) 56.59 (115.28) 36 (30.8) 81 (69.2) 52.57 (12.27) 16.00 (10.50) 60.13 (120.75) 204 (77.0) 61 (23.0) 82 (70.1) 32 (27.4) 110 (43.4) 57 (22.3) 57 (22.6) 28 (11.1) 47 (40.2) 27 (23.1) 27 (23.1) 9 (7.7) 121 (46.0) 142 (54.0) 56 (47.9) 59 (50.4) 48 (17.7) 223 (82.3) 20 (17.1) 97 (82.9) 178 (65.9) 92 (34.1) 77 (65.8) 40 (34.2) 119 (44.4) 149 (55.6) 48 (41.0) 67 (57.3) 55 (20.4) 214 (79.6) 17 (14.5) 100 (85.5) Note: Time 2 data were collected six months after Time 1 data collection. M mean, SD standard deviation. Caseload indicates the number of active clients. Percentages may not add up to 100 % due to missing data. The number of participants may not add up to the total sample size due to missing data percent), and social workers (23 percent). Level of education was high (master’s degree [46 percent] and doctorate or professional degree [54 percent]). Interestingly, many had some military experience with 44 percent being active or former military members, and 20 percent having been deployed. The remaining 56 percent had no military service experience. PROVIDER LOAD   17 The work settings varied as well. Two-thirds of the sample worked on a military installation with the remainder working in the community. The vast majority of the providers endorsed utilizing a variety of therapeutic techniques including cognitive behavioral therapy (90 percent), cognitive processing therapy (42 percent), prolonged exposure therapy (30 percent), and eye movement desensitization and reprocessing (29 percent). Providers reported receiving limited clinical supervision or consultation averaging just over 2 hours per month (ranging from 0 to 28 hours per month) (Cieslak et al., 2013). Similarly, they received 2.17 hours per month (ranged between 0 and 20 hours) of group clinical supervision or consultation. Lastly, the years of experience reported for the sample was quite broad from 1 year to 45 years. Collectively, this was primarily a female sample that was relatively diverse related to professional affiliation, location of employment, military experience, and years on the job. These characteristics should be taken into account when interpreting the prevalence findings reported next. STS: Indirect Exposure and Prevalence Providers in our sample reported treating a wide variety of trauma survivors (e.g., sexual assault and combat trauma), as well as a large number of survivors (average few hundred). Most treated traumatized patients a few days a week. Providers indicated that during their professional career about 63 percent of their patients were traumatized and 32 percent had experienced military-related traumas. The providers also appraised their indirect exposure as negative (3.34 on 1–7 scale with 3 meaning “somewhat negative”). Also important, the providers in our sample had significant direct exposure to trauma, reporting on average three lifetime traumatic exposures (range 0–10). Prevalence of STS in this sample was determined using the same diagnostic criteria as PTSD in the diagnostic and statistical manual of mental disorder fourth edition (DSM-IV-TR; American Psychiatric Association, 2000). Bride (2007) described that one has to have at least three symptoms of avoidance, two symptoms of arousal, and one symptom of intrusion to be “diagnosed” with STS.  These symptoms were considered 18   K. SHOJI ET AL. endorsed when the provider reported experiencing them “occasionally,” “often,” or “very often” in the past seven days. Based on these criteria, 19.2 percent of our sample reported having all of these STS symptoms (Cieslak et al., 2013). Cieslak et al. (2013) reported the prevalence of experiencing each STS symptom cluster independent of the others, showing that over half (57.6 percent) reported having at least one intrusive symptom, 35.3 percent had at least two arousal symptoms, and 29.9 percent endorsed at least three avoidance symptoms. Thus, a significant percentage of providers are experiencing a lot of trauma-related distress. In contrast, the percentage of the mental health providers who did not report any STS symptoms was 33.9 percent. For comparison, our sample STS scores were comparable to social workers (Bride, 2007), child protective service workers (Bride, Jones, & Macmaster, 2007), and substance abuse counselors (Bride, Smith Hatcher, & Humble, 2009). They were slightly lower than juvenile justice education workers (Smith Hatcher, Bride, Oh, King, & Catrett, 2011). See Table 2.2 for means and standard deviations for these studies. In contrast, a recent study by Kintzie, Yarvis, and Bride (2013) found that only 8 percent of primary and mental health providers from two military hospitals reported higher levels of STS.  The discrepancy with our data may lie in range of providers in the SupportNet study that included hospital-­ based and non-hospital-based military on-post mental health providers as well as community clinicians. Thus, the SupportNet sample of military mental health providers demonstrated similar levels of STS when compared to other populations of trauma survivor therapists. Although 19 percent may not seem like a large percentage, having almost a quarter of one’s workforce struggling with serious STS symptoms that could negatively affect therapeutic effectiveness is indeed concerning. STS Predictors. There is indirect evidence suggesting that human service workers, such as mental health providers, have more symptoms of STS when their clients have higher levels of PTSD (Meffert et al., 2014). Other predictors for STS found in the literature include having difficulty with disturbing material and the frequency of interaction with disturbing information (Craun, Bourke, Bierie, & Williams, 2014). Social support is On-post behavioral health providers (179) Off-post behavioral health providers (92) Social workers (276) Child protective services workers (187) Substance abuse counselors (225) Providers for survivors of family or sexual violence (154) Juvenile justice education workers (89) SupportNet: on-post 13.40 (5.00) 9.10 (2.90) 15.73 (4.90) 13.14 (5.54) 8.83 (3.28) 10.64 (3.19) 12.58 (5.00) 15.64 (5.98) 13.68 (4.86) 13.23 (5.44) Avoidance: total (SD) 8.18 (3.04) 10.97 (4.07) 9.57 (3.01) 8.80 (3.29) Intrusion: total (SD) 11.37 (3.79) 9.5 (3.5) 9.27 (4.10) 8.93 (3.56) 11.58 (4.22) 9.72 (3.35) 9.90 (4.11) Arousal: total (SD) 37.74 (10.74) 32.07 (10.39) 31.20 (12.30) 29.69 (10.74) 38.20 (13.38) 32.97 (10.37) 31.93 (11.90) Total score: total (SD) Note: SD standard deviation. On-post providers are behavioral health providers working on a military installation. Off-post providers are behavioral health providers working outside of a military installation Smith Hatcher, Bride, Oh, Moultrie King, and Franklin Catrett (2011) Bride (2007) Bride, Jones, and Macmaster (2007) Bride, Smith Hatcher, and Humble (2009) Choi (2011) SupportNet: off-post Participants (n) Study Table 2.2  Comparing intensity of intrusion, avoidance, arousal, and total score of Secondary Traumatic Stress Scale in the SupportNet study with results obtained in other studies PROVIDER LOAD   19 20   K. SHOJI ET AL. also important to consider. Among military mental health providers, an increase in social support is correlated with a decrease in STS six months later (Shoji et al., 2014). Having higher levels of self-efficacy appraisals for dealing with STS is also associated with lower levels of STS among military mental health providers. Interestingly, higher burnout may lead to higher STS six months later (Shoji et al., 2015). In the SupportNet study, Pearson’s correlation coefficients were significant between STS at Time 2 and burnout at Time 1 (r = .59), social support at Time 1 (r = −.21), and secondary trauma self-efficacy at Time 1 (r = −.47). We tested burnout, social support, and self-efficacy for dealing with secondary trauma, and several exposure measurements (the number of clients exposed to trauma in the entire career, the frequency of working with traumatized clients, percentages of traumatized clients in the entire career, and percentages of clients expressing graphic military trauma) that were measured at the initial assessment (Time 1) as predictors for STS measured at follow-up (Time 2) using a hierarchical regression analysis. The effect of STS at Time 1 was statistically controlled. Results showed that burnout at Time 1 (B = 3.12, SE = 1.28, β = .20, p = .02) was the only significant predictor for STS at Time 2. These results suggest that these variables with significant correlations lost their effect on STS at Time 2 when all of these variables were included in the analysis. Burnout Definition and Prevalence Job burnout is often conceptualized in a three-factor model including emotional exhaustion, depersonalization, and personal accomplishment (Maslach & Jackson, 1981). A provider experiencing emotional exhaustion will describe feeling emotionally drained or being depleted of personal resources. Depersonalization feelings relate to being detached from one’s clients and becoming more cynical in relation to one’s clinical work. Lastly, burnout can have a large effect on a person’s sense of personal accomplishment leading to feelings of personal failure in working with clients (e.g., lower self-efficacy). This three-factor model of job burnout, however, has been challenged in the literature. A meta-analytic study demonstrated that personal accomplishment (i.e., self-efficacy) was not strongly correlated with emotional exhaustion and depersonalization and perhaps should be thought of as a separate construct (Lee & Ashforth, 1996). Demerouti, Bakker, Nachreiner, and Schaufeli (2001) proposed a two-factor model with only emotional ­exhaustion and PROVIDER LOAD   21 disengagement, separating out self-efficacy. We chose to utilize this approach outlined by Demerouti, Bakker, Nachreiner, and Schaufeli (2001) and investigate self-efficacy as a unique construct in our work. Why worry about burnout levels in military mental health providers at all? The consequences are substantial at the organizational, clinical, and personal levels. The negative impact of burnout is serious, especially when one looks at human service professionals. Lasalvia et al. (2009), for example, found that poor treatment outcomes and decreased clinical effectiveness were substantially related to burnout severity. Moreover, burnout has been related to greater frequency of voluntary and involuntary hospitalizations and poor attitudes toward patients (Holmqvist & Jeanneau, 2006; Priebe, 2004). Systematic reviews have found decreased commitment to the organization, absenteeism, presenteeism (present, but inefficacious), and greater turnover resulting from higher burnout levels (Burke & Richardsen, 2001; Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012). High turnover and absenteeism are extremely costly to behavioral health departments where staff training and clinical demands are critical (i.e., military mental health provider organizations). Moreover, staff leaving the organization and high levels of absenteeism can be highly demoralizing to providers observing this process. This demoralizing cycle can lead to even greater turnover and damaged morale increasing costs associated with recruiting and training new mental or physical health providers (Gray, Phillips, & Normand, 1996; Waldman, Kelly, Arora, & Smith, 2004). In the military system where force health protection and mission readiness are crucial, these issues take on even greater significance. Beyond these organizational and patient care impacts, higher burnout can take a significant personal toll on the providers themselves. Elevated burnout has been found to contribute to circulatory, respiratory, and musculoskeletal system diseases (Mancini et al., 2015; Rollins, Salyers, Tsai, & Lydick, 2009). On the basis of these data ranging from serious organizational and patient care challenges to the health and wellbeing of the providers themselves, it seems clear that understanding the current challenges related to burnout in our military mental health providers is critical. To provide a context for this, we evaluated the prevalence of burnout in other mental health settings. Morse, Salyers, Rollins, Monroe-DeVita, and Pfahler (2012) reported the range for mental health providers reporting significant burnout ranged from 21 percent to 67 percent. This high level of variability is undoubtedly related to client population, organizational setting, provider’s history, and a host of other factors. Determining 22   K. SHOJI ET AL. ­ urnout prevalence and developing prevention efforts in military menb tal health providers facing daunting clinical and caseload demands would seem to be a high priority. Yet until relatively recently little research has been done. Ballenger-Browning et al. (2011) reported that military mental health providers sampled from two installations reported burnout levels similar to civilian counterparts. Utilizing the Marlach Burnout Inventory (MBI), they reported that 27.8 percent of their sample scored high in emotional exhaustion and 18.6 percent high on depersonalization. Our findings demonstrated slightly different results. The most common way to measure burnout has been with the MBI, yet evidence suggests the two construct approach may be preferable (Shoji et al., 2015). We measured burnout with the Oldenberg Burnout Inventory (OLBI) because it provides a more robust assessment of exhaustion and depersonalization. The OLBI scoring is on a 5-point scale with 3 suggesting moderate levels of burnout. Our study found that providers (both on-post and off-post) had on average moderate amounts of overall burnout (M = 2.59, SD = .67), emotional exhaustion (M = 2.68, SD = .72), and depersonalization (i.e., disengagement) (M = 2.49, SD = .72) (see Table 2.3). Table 2.3  Comparison of SupportNet job burnout results and results obtained from other studies Study Participants (n) Emotional exhaustion, M (SD) Disengagement, Total M (SD) burnout, M (SD) SupportNet On-post behavioral health providers (179) Off-post behavioral health providers (92) IT professionals (91) Various (2431) 2.74 (.75) 2.57 (.76) 2.65 (.71) 2.59 (.67) 2.34 (.61) 2.47 (.59) 2.71 (.74) 2.78 (.64) 2.82 (.83) 2.99 (.61) 2.77 (.79) 2.89 (.63) Firefighters (168) 3.29 (.76) 2.96 (.79) 3.13 (.78) Various (2235) Physicians (683) Nurses (717) 2.68 (.75) 2.74 (.74) 2.98 (.73) 2.21 (.77) 2.09 (.67) 2.51 (.8) 2.45 (.76) 2.42 (.71) 2.75 (.77) SupportNet Ford 2013 Halbesleben 2005 (1) Halbesleben 2005 (2) Innstrand 2008 Langballe 2010 Qiao 2011 Note: M mean, SD standard deviation PROVIDER LOAD   23 When comparing with other studies utilizing the OLBI, our findings were similar to other populations of workers. The mean scores for overall burnout and depersonalization were comparable to the means of firefighters (Halbesleben & Demerouti, 2005), physicians (Langballe, Innstrand, Aasland, & Falkum, 2011), nurses (Qiao & Schaufeli, 2011), IT professionals (Ford, Swayze, & Burley, 2013), and a wide collection of workers (Halbesleben & Demerouti, 2005; Innstrand, Langballe, Espnes, Falkum, & Aasland, 2008). However, the mean for emotional exhaustion among our military mental health providers was slightly lower than that of these other populations. Thus, on the basis of our sample of military mental health providers from both on-post and off-post settings from a variety of locations the level of burnout appears to be on average moderate. What is perhaps a more important question is what percentage of these therapists is experiencing high levels of burnout, emotional exhaustion, and depersonalization. We found approximately 20 percent of our sample scored 3.1 or higher on overall burnout suggesting these providers are reporting significant burnout symptoms. Likewise, about 20 percent agreed with specific items related to emotional exhaustion specifically, and slightly less (approximately 17 percent) agreed that they were experiencing significant depersonalization. Burnout Predictors.  The primary predictors for burnout in our sample were younger age, personal history of trauma, higher STS, reduced burnout self-­efficacy perceptions, working in the community, higher organizational constraints, and higher interpersonal conflicts. Whereas the personal factors (younger, more trauma history, STS symptoms, and lower self-efficacy) and organizational context (e.g., organizational constraints and offpost location) make sense, the interpersonal conflict outcome is difficult to explain. Greater interpersonal conflict equated to lower reported burnout. In an attempt to understand this finding we looked at the providers on-­ post and off-post separately. Intriguingly, the relationship between interpersonal conflict and burnout grew even stronger with higher levels of conflict equating to lower levels of burnout in the sub-sample of military on-post clinicians. It may be that in the military culture a provider who is less burned out is more involved with relational conflicts in the workplace. This does not correlate, however, with higher levels of reported work engagement where greater interpersonal conflict was related to lower 24   K. SHOJI ET AL. work engagement, as one would expect (r = −.295, p < .01). This finding awaits further investigation. Interestingly, we also found that individuals who had military experience and had been previously deployed had higher emotional exhaustion than did those without this experience. Moreover, providers who were male, working on a military installation, had military experience, and had been previously deployed had significantly higher disengagement levels than did women who were working off-post, had no previous military experience, and had never been deployed. Finally, somewhat surprisingly, those with a doctoral-level degree reported significantly higher overall burnout. This finding may be due to increased responsibility for these ­providers within military contexts. On the basis of these findings, it is important to look at key differences between on-post and off-post providers. Practice Differences for On-post Versus Off-post.  We evaluated demographic differences between these providers (see Table 2.4) in order to put results related to STS and burnout into more context. More men comprised the on-­post sample compared to a greater percentage of women in the off-post group. On-post providers were also younger (49.2 years old) on average than the off-­post providers (55.1 years old). More off-post providers were master’s level clinicians, whereas on-post therapists reported a greater percentage of doctoral-­level providers. It is unclear if these differences in our sample are reflective of true population differences or a result of self-selection into our study. Finally, there were some differences in the current military status. On-post providers had a higher percentage of the active duty military status (36.7 percent) versus off-post providers (9.6 percent). As expected, significantly more on-post providers (27.5 percent) had experienced a combat zone than off-post providers (6.4 percent), an important fact to keep in mind. Perhaps one of the most important differences reported between on-­ post and off-post therapists was that 93.9 percent of on-post providers reported working 40 hours or more per week compared to only 58.5 percent of off-post providers reporting working this much. The on-post work environment clearly offered heavier workload challenges compared to off-post settings. Given the greater reported time at work, one might expect greater burnout and perhaps lower work engagement in on-post providers. We PROVIDER LOAD   25 did find that job burnout was statistically higher in on-post therapists than off-post therapists (see Table 2.4). This difference appeared to be led by higher depersonalization (behavioral disengagement from work-related activities). There was not a statistical difference in emotional exhaustion between the two groups. We also discovered that on-post providers had significantly lower work engagement than off-post providers. This may be due to a higher level of perceived organizational constraints reported by on-post providers. Somewhat paradoxically, however, on-post clinicians indicated significantly higher perceived support from supervisors than off-post ­clinicians. Table 2.4  Averages for STS, job burnout, and other related factors for on-post and off-post providers Variable Age (years old) Work experience (years) Number of traumatized patients in the career Indirect trauma frequency Number of personal trauma Secondary traumatic stress Job burnout Secondary traumatic growth Work engagement Organizational constraints Interpersonal conflict Percentage of female (%) Range On-post Off-­post t-test 49.18 14.16 5.76 55.11 3.75** 17.10 2.27* 5.50 1.90 6.23 6.11 1.14 3.22 3.07 0.66 1: (never)–5: (very often) 1.88 1.94 0.72 1: (strongly disagree)–5: (strongly disagree) 0: (I did not experience this change)–5: (I experienced this change to a very great degree) 0: (never)–6: (always) 1: (less than once per month or never)–5: (several times per day) 1: (less than once per month or never)–5: (several times per day) 2.65 2.47 2.21* 2.26 2.49 1.41 3.78 1.74 4.01 1.87 1.26 6.48** 5.33 4.63 3.08** 40.9 59.1 1: (none), 2: (1 or 2), 3: (10 or less), 4: (50 or less), 5: (100 or less), 6: (a few hundred), 7: (a few thousand) 1: (never), 2: (a few days a year), 3: (one day a month), 4: (a few days a month), 5: (one day a week), 6: (a few days a week), 7: (every day) 1–10 Note: t-test indicates a difference between on-post and off-post providers. **p < 0.001, *p < 0.05 26   K. SHOJI ET AL. Thus, although on-post providers indicated greater work hours, greater depersonalization, and more organizational constraints, they did feel they had assistance to manage these challenges from their superiors. Organizational constraints are of particular importance to consider within the highly structured bureaucratic system within the military (also see Chap. 5). Organizational constraints are defined as “situations or things that prevent employees from translating ability and effort into high levels of job performance” (Spector & Jex, 1998). A person who scores high on perceived organizational constraints often has work-related challenges including poor equipment or supplies, rigid organizational rules and procedures, difficult supervisors, lack of necessary information about what to do or how to do it, conflicting job demands, and incorrect instructions. The job demands-resources model suggests a delicate balance between these types of organizational demands compared to resources such as social support from supervisors/family/friends needed to promote a healthy organizational climate. In the current on-post sample, the demands from organizational constraints and workload may be tipping this balance limiting the gain from supervisory support. The result is enhanced burnout (depersonalization) and reductions in work engagement. Thus, on-post providers, who were more represented by doctoral-level male therapists, reported higher levels of depersonalization of clients, greater work hours, and higher organizational constraints. The importance of enhanced supervisory support in this context is critical to keep in mind and provides a possible intervention target. Despite this combination of factors working against the on-post providers, the levels of STS were not statistically different between on-post and off-post therapists. Clearly, there are important differences between on-post and off-post clinicians in many ways beyond what we have measured that undoubtedly affect burnout (e.g., client type and job stability). Future research that helps to delineate these differences will provide crucial information to help in the development of the most effective burnout prevention and support systems for different groups of military mental health providers. Moving beyond the location of our sample providers, our longitudinal data offered insight into which comes first, STS or burnout. Which Comes First, STS or Job Burnout?  Job burnout and STS are similar concepts. Both constructs are work-related, and both of them can PROVIDER LOAD   27 c­ o-occur among human service professionals who are indirectly exposed to traumatic information through working with their clients (Voss Horrell, Holohan, Didion, & Vance, 2011). But the research is unclear whether job burnout facilitates the development of STS, or whether STS leads to job burnout. Work-related stressors may deplete one’s resources to cope with critical work demands, specifically incoming traumatic material. The depletion of resources raises the likelihood of developing negative psychological and behavioral consequences such as depression (Hakanen, Schaufeli, & Ahola, 2008) or STS (Shoji et al., 2015). Thus, we hypothesized that work-related demands (e.g., extensive work hours, organizational constraints, and traumatic material) would lead to higher levels of job burnout which would increase the likelihood of developing STS six months later (Shoji et al., 2015). Alternatively, one could argue that STS symptoms might wear a person down leading to greater levels of burnout. The findings of our study suggested that having higher levels of  job burnout increases the risk of developing STS, not the other way around (Shoji et  al., 2015). Our cross-lagged panel analysis demonstrated that STS did not lead to greater levels of burnout. Thus, the toll that burnout takes on an individual may increase vulnerability to traumatic material in military mental health providers leading to increased levels of intrusive thoughts, hyper-arousal and avoidance. This has important implications for intervention programs suggesting targeting burnout in order to assist with vulnerability to STS. Given the importance of burnout in the development of STS, it is imperative to understand how the components of burnout (emotional exhaustion and depersonalization) function, a topic addressed next. Conservation of Resources and Burnout Conservation of resources (COR) theory (Hobfoll, 1989), a theory of stress and coping, suggests that personal and environmental resources are critical in understanding how emotional exhaustion and depersonalization (i.e., detachment) might interact. We directly tested the role of changes in self-efficacy and social support (critical personal and environmental resources) in elucidating how emotional exhaustion and depersonalization operate (Cordes & Dougherty, 1993; Perrewé et al., 2002; Smoktunowicz et al., 2015). 28   K. SHOJI ET AL. Researchers have proposed that personal control beliefs (i.e., self-­ efficacy perceptions) and social support resources consistently influence burnout levels (cf. job demands-control-support [DCS] model, Karasek & Theorell, 1992; also see Fig. 2.1). The lack of these critical personal and environmental resources can lead to negative individual and organizational consequences including overall job burnout or the sub-types of exhaustion and depersonalization (Karasek & Theorell, 1992). Indeed, empirical support has confirmed that self-efficacy and social support independently help to explain disengagement (depersonalization) and exhaustion (Huynh, Xanthopoulou, & Winefield, 2013; Llorens, Schaufeli, Bakker, & Salanova, 2007; Xanthopoulou et al., 2007; Yu, Wang, Zhai, Dai, & Yang, 2015). Yet self-efficacy and social support are not static unchanging resources. They are dynamic, changing across time, rising and falling based on organizational and individual conditions (Bandura, 1997). We tested the importance of these changes in understanding the relationship between exhaustion and depersonalization. COR theory (Hobfoll, 1989, 2011) emphasized the dynamic nature of these resources by arguing that loss or depletion of resources often results in further loss of more resources. An example would be increased job-related demands (e.g., increases in client load) that result in decreased perceptions of supervisory support. This then may cause further loss of a personal sense of self-efficacy. This cycle is referred to as a loss spiral. Thus, for military mental health providers it may be that a high level of exhaustion may in turn lead to a loss spiral resulting in further losses of personal resources such as self-efficacy or perceived social support. Eventually the individual detaches from the work as a way to cope. In reviewing the empirical literature, we identified one longitudinal study with a population of teachers confirming that emotional exhaustion has a negative influence on self-efficacy and that self-efficacy served as a mediator between the relationship of exhaustion and other burnout components (e.g., depersonalization) (Brouwers & Tomic, 2000). This finding makes sense based on the identified sources of self-efficacy (e.g., mastery and somatic/emotional states). Elevated exhaustion and heightened emotional distress can easily result in reduced mastery experiences leading to reductions in self-efficacy perceptions (Bandura, 1997). In our sample of military mental health providers, we found that a decline in self-efficacy across time served as an indirect mediator in the relationship between initial exhaustion levels and subsequent depersonalization six months later (Rogala et al., 2015). Thus, the effect of e­ xhaustion PROVIDER LOAD   Self-Efficacy Change 29 Social Support Change - - Initial Exhaustion Disengagement 6 Months Later Fig. 2.2  The mediation effect of self-efficacy change and social support change in the relationship between exhaustion and disengagement (depersonalization) on provider depersonalization was mediated by reductions in burnout selfefficacy perceptions (see Fig. 2.2). Clinicians faced with mounting clinical demands including indirect trauma exposure, combined with organizational constraints, are likely to experience exhaustion triggering a decline in personal resources (a negative change in self-efficacy beliefs), spawning greater disengagement. Patient care may be the ultimate casualty in this cycle. This negative slide must be identified as providers begin to challenge the perception of capability to manage burnout reactions before they start depersonalizing their clients. It is highly probable that the increase in depersonalization is an attempt to cope with an increasing realization of personal vulnerability related to complete exhaustion and increasing self-­doubt. Provider’s challenges, however, do not always lead to negative ­outcomes. Indeed, many therapists report secondary traumatic growth and high levels of work engagement. Secondary Traumatic Growth Engagement and Work To avoid a “negativity bias” in our work (Seligman, 2002), we also investigated the positive outcome of secondary traumatic growth and work engagement in our sample. As shown in the initial figure in the chapter that displays our theoretical model, STS self-efficacy (i.e., the perceived ability to manage STS), burnout self-efficacy, and social support are important components to consider. Secondary traumatic growth is defined as positive changes in schemas about one’s self and the world resulting from 30   K. SHOJI ET AL. indirect exposure to trauma. In our case, the indirect exposure, of course, results from clinical work with soldiers struggling with the horrors of war. Shoji et al. (2014) focused on the importance of STS distress in predicting secondary traumatic growth. Shoji et al. reported that STS did not lead to lower or greater levels of secondary traumatic growth directly. Instead, we found that STS influenced secondary traumatic growth through an individual’s STS self-efficacy and through social support perceptions. Indeed, one’s perceived capability for managing STS symptoms enabled the individual to cultivate greater social support leading to enhanced secondary traumatic stress growth. Work engagement was also important to consider in this population of providers. In our sample of clinicians, we found that 45 percent indicated they often felt highly engaged at work (4 or greater on the Utrecht Work Engagement Scale), with only about 5 percent indicating they rarely or never felt engaged at work. Higher level of burnout self-efficacy perceptions, greater variation of indirect trauma exposure, lower organizational constraints, and less interpersonal conflict predicted higher work engagement in these providers. These predictors are consistent with other research on health providers in general where personal factors (e.g., self-efficacy or locus of control) and organizational challenges such as relational conflicts or system challenges create a mismatch between the employee and the job resulting in lower work engagement (Fiabane, Giorgi, Sguazzin, & Argentero, 2013). Prevention and Other Clinical Implications The most important clinical finding for our SupportNet data was that around 20 percent of this sample reported high levels of STS and burnout symptoms. These providers are struggling with  burnout and significant STS symptoms including intrusive thoughts, hyper-arousal, and avoidance, potentially  related to indirect exposure through patient trauma narratives. Therapists consistently exposed to high levels of traumatic material over extended periods of time can suffer from a myriad of other negative consequences as well. These include dysregulated affect (Thomas & Wilson, 2004), anxiety (Deutsch, 1984), increases in negative worldview beliefs (Schauben & Frazier, 1995), apathy (Tosone et  al., 2003), depression (Arvay & Uhlemann, 1996), anger, lack of clinical empathy (Skorupa & Agresti, 1993), relationship difficulties (Thoreson, Miller, & Krauskoph, 1989), and career miasma (Emerson & Markos, 1996). Although not all PROVIDER LOAD   31 of this work is beyond scrutiny (Sabin-Farrell & Turpin, 2003), it would seem evident that military mental health providers who are struggling with these issues need preventive and restorative therapeutic interventions. Beyond the personal wellbeing argument for these providers, one could easily make the case for improved care for our soldiers. We were unable to identify any empirical evidence related to prevention or intervention of STS within military mental health providers. We were able to identify two peer-reviewed evaluation studies for secondary trauma not in military providers (Berger & Gelkopf, 2011; Gentry, Baggerly, & Baranowsky, 2004). Gentry et  al. evaluated a “training-as-treatment” approach with mental health providers becoming Certified Compassion Fatigue Specialists. Results demonstrated significant decreases in ­secondary trauma and burnout levels as well as increases in compassion satisfaction in a sample of 83 mental health professionals. Unfortunately, this study did not utilize a comparison group or randomization, making interpretation of the causal influence of the intervention impossible. It is important, however, to review the key components of the types of programs that have been advocated. Most of the recommended interventions promote supervision from a trauma-trained clinician, gaining specialized training in trauma therapies, developing an active spiritual, physical, and psychological self-care program, and enhanced self-awareness including one’s personal trauma history. Berger and Gelkopf (2011) conducted a randomized controlled trial of an intervention to reduce STS among well-baby clinic nurses in Israel. Although similar to well-baby clinics in the USA, these Israeli clinics deal with a large number of highly traumatized children and their families on a regular basis. Berger and Gelkopf’s (2011) intervention included psychoeducation about stress and trauma in these children, learning self-care skills such as breathing, meditation, relaxation, physical exercises, guided imagery, and learning techniques to promote team building and mutual support. The intervention was relatively time intensive with 12 weekly 6-hour sessions. The intervention showed significant reductions in STS and improvements in self-efficacy compared to a waitlist control group. With the recent DSM-5 inclusion of secondary trauma exposure in the PTSD diagnosis, 20 percent of our providers could now be considered to have PTSD. Thus, although the above findings and recommendations would undoubtedly assist in prevention of elevated secondary trauma symptoms, they, in our opinion, would not be enough to treat the extent of the problem. We recommend that a surveillance approach with 32   K. SHOJI ET AL. appropriate clinical referral for evidence-based trauma therapy would be the most appropriate program. Similar to peer support models in other professions (e.g., firefighters and other emergency services), mental health care providers are in an especially good position to function as a peer advocate to help identify challenges and offer supportive clinical and self-care solutions. Perhaps it may not need to get to the level of needing trauma treatment. Our finding that burnout is an important catalyst for the development of STS suggests that early intervention for burnout in these military mental health providers may be important to consider. Helping these providers to enhance their personal resources and augment organizational support may help to reduce the personal vulnerability related to ­exhaustion and depersonalization. Based on this premise, we focused our intervention approach for SupportNet on developing a social media platform website and coaching system that would facilitate personal empowerment and social support. We will address the empirical literature available for burnout interventions in Chap. 6 when we report on our randomized clinical trial of our intervention. Our findings do suggest some unique differences between on-post and off-post providers relative to burnout that are also important to consider. Therapists working on-post report higher levels of burnout and appear to be struggling more with organizational constraints and workload challenges. Utilizing the structure of demands and resources, workload, complexity of work, decisional latitude, and quality of supervision or social climate all contribute to an overall sense of person-job fit (see Chap. 5). More specifically, job demands (e.g., work load, decisional challenges, and learning demands), role issues (e.g., clarity and conflict), perceptions of control (e.g., adequate positive challenge, decisional control, and work pace control), predictability, perceptions of mastery, social support (e.g., supervisor, coworkers, friends, and relatives), and complexity of work have been found to be important predictors in work engagement, job satisfaction, and burnout (Maslach, Schaufeli, & Leiter, 2001; Van der Doef & Maes, 1999). The literature has consistently supported a demand-control model where increases in work-related demands and reduced resources result in decreases in perceived control over critical work-related goals leading to the negative effects of burnout (De Jonge, van Vegchel, Shimazu, Schaufeli, & Dormann, 2010). One could argue that the unique organizational context of a military installation (see Chap. 5) has elements that PROVIDER LOAD   33 promote decreased provider control. Enhanced job demands such as high clinical workload (e.g., working more than 40 hours per week), limited decisional latitude, and high complexity of cases (e.g., traumatic brain injured and PTSD combination clients) are most likely affecting provider burnout levels. Perceptions of control are heavily influenced by self-efficacy beliefs. Bandura (1997) has reviewed countless studies across multiple domains of human functioning that show self-efficacy perceptions are a key determinant to perceptions of control over important environmental demands. Our finding that demonstrates the critical role of changes in self-efficacy perceptions related to burnout as a key mechanism for how exhaustion may lead to depersonalization is important in planning a burnout ­intervention. Organizational processes that can promote enhanced control and thereby promote self-efficacy are important to consider. These might include providing therapists more control over client type and number as well as scheduling. Offering training in best practices for trauma treatment is also important. Summary and Implications for Other Health Care Providers Together our findings from our prevalence and theoretical modeling part of the SupportNet project are consistent with research on other health care providers and offer important implications. The literature suggests that all health care providers are at some risk for STS and burnout (Beck, 2011;  Cieslak et  al., 2013; Dewa, Loong, Bonato, Thanh, & Jacobs, 2014; Kintzle, Yarvis, & Bride, 2013). Research with mental health providers working directly with trauma survivors suggests STS levels are similar (Cieslak et  al., 2013). For nurses the range for those struggling with high levels of STS (or PTSD) seems somewhat higher from 25 percent for forensic nurses up to 78 percent in hospice nurses (Beck, 2011). Interestingly, research has now identified lawyers at risk for STS and burnout (Levin et al., 2011). Somewhat surprisingly, there is a dearth of data available on physician (military or non-military) and STS.  Kintzle et  al. (2013) did include physicians in their military provider sample, yet did not report differentially on rates of STS. However, physicians are at a serious risk for burnout. Dewa, Loong, Bonato, Thanh, and Jacobs (2014) showed that 33–50 percent of physicians of all specialties reported high levels of burnout. 34   K. SHOJI ET AL. Nurses are perhaps one of the most investigated military health providers in relation to burnout and STS. Research has suggested that military nurses are at an increased risk for burnout and STS due to their unique job demands including the care of critically injured service members, patient mortality, providing care in combat situations, delivering medical assistance to enemy combatants, and working with a traumatized population (Gates & Gillespie, 2008). Army nurses logged over 70,000 hours in deployed settings in 2009 alone (Horoho, 2011). Direct exposure to life-threatening situations subjects nurses to an increased risk of PTSD. Although there are no studies specifying prevalence rates of PTSD in nurses from the more recent conflicts in Iraq and Afghanistan, studies from the Vietnam War nurses indicated PTSD rates from 3.3 percent (Stretch, Vail, & Maloney, 1985) to 25 percent following more intensive combat situations with a high number of casualties (Baker, Menard, & Johns, 1989). Burnout studies with military nurses also show critical vulnerability in this population (Ballenger-Browning et al., 2011). More than a quarter of military nurses report high levels of burnout with 28 percent reporting high levels of emotional exhaustion and 19 percent reporting high depersonalization in a convenience sample study (Ballenger-Browning et al., 2011). When compared to their civilian counterparts, Army nurses have higher emotional exhaustion and depersonalization (Lang, Pfister, & Siemens, 2010), particularly when they routinely care for service members. Given their critical role in supporting Army health and wellness, it is somewhat amazing that more empirically based support systems for STS and burnout are not in place and have not been scientifically evaluated. Thus, military nurses and physicians, along with military mental health providers, face unique challenges including possible direct trauma exposure, indirect trauma exposure, high-pressure work environments, and limited resourced work settings. Our project, combined with these findings, underscores the need for more systematic prevention and intervention programming as well as empirical evaluation. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed.  – Text revision). Washington, DC: American Psychiatric Publishing. Arvay, M. J., & Uhlemann, M. R. (1996). Counsellor stress in the field of trauma: A preliminary study. Canadian Journal of Counselling, 30(3), 193–210. PROVIDER LOAD   35 Baker, R. R., Menard, S. W., & Johns, L. A. (1989). The military nurse experience in Vietnam: Stress and impact. Journal of Clinical Psychology, 45(5), 736–744. doi:10.1002/1097-4679(198909)45:5<736::AID-­JCLP2270450508>3.0.C O;2-M. Ballenger-Browning, K. K., Schmitz, K. J., Rothacker, J. A., Hammer, P. S., Webb-­ Murphy, J. A., & Johnson, D. C. (2011). Predictors of burnout among military mental health providers. Military Medicine, 176(3), 253–260. doi:10.7205/ MILMED-D-10-00269. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W H Freeman/ Times Books/Henry Holt & Co.. Beck, C.  T. (2011). Secondary traumatic stress in nurses: A systematic review. Archives of Psychiatric Nursing, 25(1), 1–10. doi:10.1016/j.apnu.2010.05.005. Berger, R., & Gelkopf, M. (2011). An intervention for reducing secondary traumatization and improving professional self-efficacy in well baby clinic nurses following war and terror: A random control group trial. International Journal of Nursing Studies, 48(5), 601–610. doi:10.1016/j.ijnurstu.2010.09.007. Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52(1), 63–70. Bride, B. E., & Figley, C. R. (2009). Secondary trauma and military veteran caregivers. Smith College Studies in Social Work, 79(3–4), 314–329. doi:10.1080/00377310903130357. Bride, B.  E., Jones, J.  L., & Macmaster, S.  A. (2007). Correlates of secondary traumatic stress in child protective services workers. Journal of Evidence-Based Social Work, 4, 69–80. doi:10.1300/J394v04n03_05. Bride, B.  E., Smith Hatcher, S., & Humble, M.  N. (2009). Trauma training, trauma practices, and secondary traumatic stress among substance abuse counselors. Traumatology, 15(2), 96–105. Brouwers, A., & Tomic, W. (2000). A longitudinal study of teacher burnout and perceived self-efficacy in classroom management. Teaching and Teacher Education, 16(2), 239–253. doi:10.1016/S0742-051X(99)00057-8. Burke, R. J., & Richardsen, A. M. (2001). Psychological burnout in organizations: Research and intervention. In R. T. Golembiewski (Eds.), Handbook of organizational behavior (2nd ed., rev. ed., and, exp. ed., pp. 327–363). New York: Marcel Dekker. Choi, G. Y. (2011). Secondary traumatic stress of service providers who practice with survivors of family or sexual violence: A national survey of social workers. Smith College Studies in Social Work, 81, 101–119. doi:10.1080/00377317.20 11.543044. Cieslak, R., Anderson, V., Bock, J., Moore, B.  A., Peterson, A.  L., & Benight, C. C. (2013). Secondary traumatic stress among mental health providers working with the military: Prevalence and its work- and exposure-related correlates. The Journal of Nervous and Mental Disease, 201(11), 917–925. doi:10.1097/ NMD.0000000000000034. 36   K. SHOJI ET AL. Cordes, C. L., & Dougherty, T. W. (1993). A review and an integration of research on job burnout. The Academy of Management Review, 18(4), 621–656. doi:10.2307/258593. Craun, S. W., Bourke, M. L., Bierie, D. M., & Williams, K. S. (2014). A longitudinal examination of secondary traumatic stress among law enforcement. Victims and Offenders, 9(3), 299–316. doi:10.1080/15564886.2013.848828. de Jonge, J., van Vegchel, N., Shimazu, A., Schaufeli, W., & Dormann, C. (2010). A longitudinal test of the demand–control model using specific job demands and specific job control. International Journal of Behavioral Medicine, 17(2), 125–133. doi:10.1007/s12529-010-9081-1. Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001). The job demands-resources model of burnout. Journal of Applied Psychology, 86(3), 499–512. doi:10.1037/0021-9010.86.3.499. Deutsch, C.  J. (1984). Self-reported sources of stress among psychotherapists. Professional Psychology: Research and Practice, 15(6), 833–845. doi:10.1037/0735-7028.15.6.833. Dewa, C. S., Loong, D., Bonato, S., Thanh, N. X., & Jacobs, P. (2014). How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research, 14(325). doi:10.1186/1472-6963-14-325. Emerson, S., & Markos, P. A. (1996). Sings and symptoms of the impaired counselor. Journal of Humanic Education and Development, 34(3), 108–117. doi:10.1002/j.2164-4683.1996.tb00335.x. Erbes, C., Westermeyer, J., Engdahl, B., & Johnsen, E. (2007). Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine, 172(4), 359–363. doi:10.7205/ MILMED.172.4.359. Fiabane, E., Giorgi, I., Sguazzin, C., & Argentero, P. (2013). Work engagement and occupational stress in nurses and other healthcare workers: The role of organisational and personal factors. Journal of Clinical Nursing, 22(17–18), 2614–2624. doi:10.1111/jocn.12084. Figley, C. R. (1978). Symptoms of delayed combat stress among a college sample of Vietnam veterans. Military Medicine, 143(2), 107–110. Ford, V. F., Swayze, S., & Burley, D. L. (2013). An exploratory investigation of the relationship between disengagement, exhaustion and turnover intention among IT professionals employed at a university. Information Resources Management Journal (IRMJ), 26(3), 55–68. doi:10.4018/irmj.2013070104. Gates, D., & Gillespie, G. (2008). Secondary traumatic stress in nurses who care for traumatized women. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 37(2), 243–249. Gentry, J.  E., Baggerly, J., & Baranowsky, A. (2004). Training-as-treatment: Effectiveness of the certified compassion fatigue specialist training. International Journal of Emergency Mental Health, 6(3), 147–155. PROVIDER LOAD   37 Gray, A. M., Phillips, V. L., & Normand, C. (1996). The costs of nursing turnover: Evidence from the British National Health Service. Health Policy, 38(2), 117–128. doi:10.1016/0168-8510(96)00854-8. Hakanen, J. J., Schaufeli, W. B., & Ahola, K. (2008). The job demands-resources model: A three-year cross-lagged study of burnout, depression, commitment, and work engagement. Work and Stress, 22(3), 224–241. doi:10.1080/02678370802379432. Halbesleben, J. R. B., & Demerouti, E. (2005). The construct validity of an alternative measure of burnout: Investigating the English translation of the Oldenburg Burnout Inventory. Work and Stress, 19(3), 208–220. doi:10.1080/02678370500340728. Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44(3), 513–524. doi:10.1037/0003-066X.44.3.513. Hobfoll, S. E. (2011). Conservation of resources theory: Its implication for stress, health, and resilience. In S. Folkman (Ed.), The Oxford handbook of stress, health, and coping (pp. 127–147). New York: Oxford University Press. Holmqvist, R., & Jeanneau, M. (2006). Burnout and psychiatric staff’s feelings towards patients. Psychiatry Research, 145(213), 207. doi:10.1016/j. psychres.2004.08.012. Horoho, P. D. (2011). Army nursing: Transforming for a new century of caring. The United States Army Medical Department Journal, October - December 2011, 4–9. Huynh, J. Y., Xanthopoulou, D., & Winefield, A. H. (2013). Social support moderates the impact of demands on burnout and organizational connectedness: A two-wave study of volunteer firefighters. Journal of Occupational Health Psychology, 18(1), 9–15. doi:10.1037/a0030804. Innstrand, S. T., Langballe, E. M., Espnes, G. A., Falkum, E., & Aasland, O. G. (2008). Positive and negative work–family interaction and burnout: A longitudinal study of reciprocal relations. Work and Stress, 22(1), 1–15. doi:10.1080/02678370801975842. Jakupcak, M., Luterek, J., Hunt, S., Conybeare, D., & McFall, M. (2008). Posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan war veterans seeking postdeployment VA health care. The Journal of Nervous and Mental Disease, 196(5), 425–428. doi:10.1097/NMD.0b013e31817108ed. Karasek, R. A., & Theorell, T. (1992). Healthy work: Stress, productivity, and the reconstruction of working life. New York: Basic Books. Kintzle, S., Yarvis, J. S., & Bride, B. E. (2013). Secondary traumatic stress in military primary and mental health care providers. Military Medicine, 178(12), 1310–1315. doi:10.7205/MILMED-D-13-00087. Lang, G. M., Pfister, E. A., & Siemens, M. J. (2010). Nursing burnout: Cross-­ sectional study at a large Army hospital. Military Medicine, 175(6), 435–441. doi:10.7205/MILMED-D-09-00284. 38   K. SHOJI ET AL. Langballe, E.  M., Innstrand, S.  T., Aasland, O.  G., & Falkum, E. (2011). The predictive value of individual factors, work-related factors, and work–home interaction on burnout in female and male physicians: A longitudinal study. Stress and Health, 27(1), 73–87. doi:10.1002/smi.1321. Lasalvia, A., Bonetto, C., Bertani, M., Bissoli, S., Cristofalo, D., Marrella, G., et  al. (2009). Influence of perceived organisational factors on job burnout: Survey of community mental health staff. The British Journal of Psychiatry, 195(6), 537–544. doi:10.1192/bjp.bp.108.060871. Lee, R. T., & Ashforth, B. E. (1996). A meta-analytic examination of the correlates of the three dimensions of job burnout. Journal of Applied Psychology, 81(2), 123–133. doi:10.1037/0021-9010.81.2.123. Levin, A.  P., Albert, L., Besser, A., Smith, D., Zelenski, A., Rosenkranz, S., & Neria, Y. (2011). Secondary traumatic stress in attorneys and their administrative support staff working with trauma-exposed clients. Journal of Nervous and Mental Disease, 199(12), 946–955. doi:10.1097/NMD.0b013e3182392c26. Llorens, S., Schaufeli, W., Bakker, A., & Salanova, M. (2007). Does a positive gain spiral of resources, efficacy beliefs and engagement exist? Computers in Human Behavior, 23(1), 825–841. doi:10.1016/j.chb.2004.11.012. Mancini, A. D., Moser, L. L., Whitley, R., McHugo, G. J., Bond, G. R., Finnerty, M. T., & Burns, B. J. (2015). Assertive community treatment: Facilitators and barriers to implementation in routine mental health settings. Psychiatric Services. doi:10.1176/ps.2009.60.2.189. Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Organizational Behavior, 2(2), 99–113. doi:10.1002/job. 4030020205. Maslach, C., Schaufeli, W.  B., & Leiter, M.  P. (2001). Job burnout. Annual Review of Psychology, 52(1), 397–422. doi:10.1146/annurev.psych.52.1.397. Meffert, S. M., Henn-Haase, C., Metzler, T. J., Qian, M., Best, S., … & Marmar, C. R. (2014). Prospective study of police officer souse/partners: A new pathway to secondary trauma and relationship violence? PLoS One, 9(7), e100663. doi:10.1371/journal.pone.0100663 Morse, G., Salyers, M.  P., Rollins, A.  L., Monroe-DeVita, M., & Pfahler, C. (2012). Burnout in mental health services: A review of the problem and its remediation. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 341–352. doi:10.1007/s10488-011-0352-1. Perrewé, P. L., Hochwarter, W. A., Rossi, A. M., Wallace, A., Maignan, I., … & Van Deusen, C.  A. (2002). Are work stress relationships universal? A nine-­ region examination of role stressors, general self-efficacy, and burnout. Journal of International Management,8(2), 163–187. doi:10.1016/S1075-4253(02) 00052-2 Priebe, S. (2004). Institutionalization revisited  – With and without walls. Acta Psychiatrica Scandinavica, 110(2), 81–82. doi:10.1111/j.1600-0047.2004. 00386.x. PROVIDER LOAD   39 Qiao, H., & Schaufeli, W.  B. (2011). The convergent validity of four burnout measures in a Chinese sample: A confirmatory factor-analytic approach. Applied Psychology, 60(1), 87–111. doi:10.1111/j.1464-0597.2010.00428.x. Rogala, A., Shoji, K., Luszczynska, A., Kuna, A., Yeager, C., Benight, C., & Cieslak, R. (2015). From exhaustion to disengagement via self-efficacy change: Findings from two longitudinal studies among human services workers. Organizational Psychology, 6(2032). doi:10.3389/fpsyg.2015.02032. Rollins, A. L., Salyers, M. P., Tsai, J., & Lydick, J. M. (2009). Staff turnover in statewide implementation of ACT: Relationship with ACT fidelity and other team characteristics. Administration and Policy in Mental Health and Mental Health Services Research, 37(5), 417–426. doi:10.1007/s10488-009-0257-4. Rosenheck, R.  A., & Fontana, A.  F. (2007). Recent trends In VA treatment of post-traumatic stress disorder and other mental disorders. Health Affairs (Project Hope), 26(6), 1720–1727. doi:10.1377/hlthaff.26.6.1720. Sabin-Farrell, R., & Turpin, G. (2003). Vicarious traumatization: Implications for the mental health of health workers? Clinical Psychology Review, 23(3), 449–480. doi:10.1016/S0272-7358(03)00030-8. Schauben, L. J., & Frazier, P. A. (1995). Vicarious trauma: The effects on female counselors of working with sexual violence survivors. Psychology of Women Quarterly, 19(1), 49–64. doi:10.1111/j.1471-6402.1995.tb00278.x. Seligman, M. E. P. (2002). Positive psychology, positive prevention, and positive therapy. In C. R. Snyder & S. J. Lopez (Eds.), Handbook of positive psychology (pp. 3–9). New York: Oxford University Press. Shoji, K., Bock, J., Cieslak, R., Zukowska, K., Luszczynska, A., & Benight, C. C. (2014). Cultivating secondary traumatic growth among healthcare workers: The role of social support and self-efficacy. Journal of Clinical Psychology, 70(9), 831–846. doi:10.1002/jclp.22070. Shoji, K., Lesnierowska, M., Smoktunowicz, E., Bock, J., Luszczynska, A., Benight, C. C., & Cieslak, R. (2015). What comes first, job burnout or secondary traumatic stress? Findings from two longitudinal studies from the U.S. and Poland. PLoS One, 10(8). doi:10.1371/journal.pone.0136730. Skorupa, J., & Agresti, A. A. (1993). Ethical beliefs about burnout and continued professional practice. Professional Psychology: Research and Practice, 24(3), 281–285. doi:10.1037/0735-7028.24.3.281. Smith Hatcher, S., Bride, B. E., Oh, H., Moultrie King, D., & Franklin Catrett, J. (2011). An assessment of secondary traumatic stress in juvenile justice education workers. Journal of Correctional Health Care, 17(3), 208–217. doi:10.1177/1078345811401509. Smoktunowicz, E., Baka, L., Cieslak, R., Nichols, C.  F., Benight, C.  C., & Luszczynska, A. (2015). Explaining counterproductive work behaviors among police officers: The indirect effects of job demands are mediated by job burnout and moderated by job control and social support. Human Performance, 28(4), 332–350. doi:10.1080/08959285.2015.1021045. 40   K. SHOJI ET AL. Spector, P. E., & Jex, S. M. (1998). Development of four self-report measures of job stressors and strain: Interpersonal Conflict at Work Scale, Organizational Constraints Scale, Quantitative Workload Inventory, and Physical Symptoms Inventory. Journal of Occupational Health Psychology, 3, 356–367. doi:10.1037/1076-8998.3.4.356. Stretch, R. H., Vail, J. D., & Maloney, J. P. (1985). Posttraumatic stress disorder among army nurse corps Vietnam veterans. Journal of Consulting and Clinical Psychology, 53(5), 704–708. doi:10.1037/0022-006X.53.5.704. Thomas, R. B., & Wilson, J. P. (2004). Issues and controversies in the understanding and diagnosis of compassion fatigue, vicarious traumatization, and secondary traumatic stress disorder. International Journal of Emergency Mental Health, 6(2), 81–92. Thoreson, R. W., Miller, M., & Krauskopf, C. J. (1989). The distressed psychologist: Prevalence and treatment considerations. Professional Psychology: Research and Practice, 20(3), 153–158. doi:10.1037/0735-7028.20.3.153. Tosone, C., Lee, M., Bialkin, L., Martinez, A., Campbell, M., … & Stefan, A. (2003). Shared trauma: Group reflection on the September 11th disaster. Psychoanalytic Social Work, 10(1), 57–77. doi:10.1300/j032v10n01_06 Tyson, J. (2007). Compassion fatigue in the treatment of combat-related trauma during wartime. Clinical Social Work Journal, 35(3), 183–192. doi:10.1007/ s10615-007-0095-3. U.S. Department of Veterans Affairs. (2014). VA Mental Health Services: Public Report. Retrieved from: http://www.mentalhealth.va.gov/docs/Mental_ Health_Transparency_Report_11-­24-­14.pdf Van der Doef, M., & Maes, S. (1999). The Job Demand-Control (-Support) model and psychological well-being: A review of 20 years of empirical research. Work & Stress, 13(2), 87–114. doi:10.1080/026783799296084. Voss Horrell, S.  C., Holohan, D.  R., Didion, L.  M., & Vance, G.  T. (2011). Treating traumatized OEF/OIF veterans: How does trauma treatment affect the clinician? Professional Psychology: Research and Practice, 42(1), 79. Waldman, J. D., Kelly, F., Arora, S., & Smith, H. L. (2004). The shocking cost of turnover in health care. Health Care Management Review, 29(1), 2–7. Xanthopoulou, D., Bakker, A. B., Dollard, M. F., Demerouti, E., Schaufeli, W. B., Taris, T. W., & Schreurs, P. G. (2007). When do job demands particularly predict burnout?: The moderating role of job resources. Journal of Managerial Psychology, 22(8), 766–786. doi:10.1108/02683940710837714. Yu, X., Wang, P., Zhai, X., Dai, H., & Yang, Q. (2015). The effect of work stress on job burnout among teachers: The mediating role of self-efficacy. Social Indicators Research, 122(3), 701–708. doi:10.1007/s11205-014-0716-5. CHAPTER 3 The SupportNet Website: A Social Media Self-Care System Carolyn Yeager, Judith Bock, and Charles C. Benight Quick Facts • Web interventions are capable of providing quality, evidence-based care, quick and easy access not limited by geography, and confidentiality without fear of judgment by others. • Although there is no clear agreement on what defines a web intervention for behavioral health, there are a number of studies that support the effectiveness of web interventions, especially those targeting reduction of stress and trauma symptoms and increasing efficacy. • A diverse team that included software developers, researchers, clinicians, and user interface designers worked together to develop a comprehensive website to help address burnout in military behavioral health providers. • The SupportNet web intervention consisted of several interconnected subsystems that include the underlying operating system, the web server, the database server, the application-specific software, and the user’s local browser. C. Yeager (*) • J. Bock • C.C. Benight Trauma, Health, and Hazards Center, University of Colorado at Colorado Springs, Colorado Springs, USA © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1_3 41 42  C. YEAGER ET AL. • The SupportNet web intervention consists of several functional components: authentication and authorization, roles and groups, user profile, assessment, life balance, goal setting, social networking, a resource room, and a place to “take 5”. • All of the SupportNet components were given careful thought not only to their technical design but also to their usability and their promotion of self-efficacy and social support. SupportNet: Our Theoretically Based Web-Support System The SupportNet system was designed using evidence-based theory regarding the promotion of enhanced social support and self-efficacy. Social cognitive theory provides a useful framework to help understand how to develop an intervention for burnout. Bandura (1997) argued that human beings self-regulate through ongoing interactions with environmental conditions and coping adaptations in order to achieve valued goals. This process (see Fig. 3.1) is called triadic reciprocal determinism and offers a useful way to think about helping mental health providers with burnout and secondary traumatic stress (STS). Self-efficacy judgments are extremely important in predicting effective and ineffective coping behaviors (Bandura, 1997). Social support is also an important factor that contributes to the management of stress (Cohen & Syme, 1985). Thus, we focused our intervention on enhancing these two critical resources in order to empower providers to manage the high level of demands they are facing. This chapter briefly reviews other online interventions described in the literature, followed by a description of our specific approach. We discuss the development and deployment process for our web system. Fig. 3.1  Triadic reciprocal determinism of social cognitive theory Behavior Personal Factors Environmental Factors THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  43 We also provide important information related to computer engagement in online interventions more broadly, with recommendations for future system enhancements. We end the chapter with a discussion of how this system could be deployed within other provider settings. Using Web-Based Intervention Health for Behavioral Over the last decade, there has been a massive increase in the use of the Internet. Although many people use the Internet for commercial and informational purposes, there is a trend in delivering web-based interventions to address various health concerns and psychological issues (Fox, 2014; Wells, Mitchell, Finkelhor, & Becker-Blease, 2007). Delivery of these types of services offers several advantages such as reduced costs, management of waiting lists, and decreasing travel time while increasing autonomy, anonymity, and accessibility. Particularly when working with traumatized populations, the act of seeking treatment can be met with reluctance (Litz, Bryant, Williams, Wang, & Engel, 2004). Some barriers to treatment include difficulty accessing a trained mental health-care provider and scheduling and keeping regular appointments (Pepin, Segal, & Coolidge, 2009). Other barriers include financial limitations and geographical constraints. Other research has shown some people do not pursue the care they need due to perceptions about themselves and others, including that one’s symptoms do not necessitate treatment (Hoge et  al., 2004). They also fear being judged by others (Mojtabai et al., 2011). The Internet offers many advantages over traditional care in respect to these barriers. However, not all web interventions are the same. Some web-based interventions include only psychoeducation (Rotondi et  al., 2010), whereas others are more interactive (Benight, Ruzak, & Waldrep, 2008) or include an artificially intelligent web intervention that provides real-­ time feedback (Lisetti, Amani, Yasuvar, & Rishe, 2013). The SupportNet project focused on building the best interactive system for burnout specifically targeting military mental health providers. Our goal was to build a website that would be relevant and provide opportunity for behavioral change to reduce burnout. The principal investigator of the project (C.  Benight) already had experience in website development for trauma (Steinmetz, Benight, Bishop, & James, 2012) offering key insights and “lessons learned”. Early within the project we sought to 44  C. YEAGER ET AL. evaluate key determinants of an effective online intervention for burnout. However, the field of web interventions is unstructured and without standards, making it difficult to make sound comparisons regarding critical components of efficacy. Web interventions can target different symptoms and behaviors and use many different models and mechanisms of change (Dombrowski, Sniehotta, Avenell, & Coyne, 2007). There has been an initiative to promote clarity and consistency in the field. Barak and Klein (2009) suggested the following as a definition of an effective web intervention: …a primarily self-guided intervention program that is executed by means of a prescriptive online program operated through a website and used by consumers seeking health- and mental-health related assistance. The intervention program itself attempts to create positive change and or improve/ enhance knowledge, awareness, and understanding via the provision of sound health-related material and use of interactive Web-based components. (p. 5) The SupportNet team initially focused on Internet intervention research to provide some clarity on what elements make a web intervention effective and then put these findings into the context of what was applicable for a web intervention for burnout specifically in military mental health providers. Although some research of web interventions found no positive effect (Marks et  al., 2006), a majority of web-based interventions for health behavior change have found improvements in psychological, behavioral, and clinical outcomes (Cavanagh et al., 2006; Tate & Zabinski, 2004). The literature was also clear that static websites designed as online mental health “pamphlets” providing only facts about the mental health issue being investigated (e.g., symptoms, treatment, resources) were not as appealing and engaging as websites that included interactive elements (Neve, Collins, & Morgan, 2010). We were especially interested in studies that evaluated interventions for traumatic stress, which we felt had direct applicability to STS and indirect trauma related burnout. There were a number of published studies on this topic that were applicable to the issues of STS and burnout. These studies found that web interventions were capable of yielding effect sizes comparable to traditional psychosocial treatment (Amstadter, Broman-Fulks, Zinzowa, Ruggiero, & Cercone, 2009; Benight, Ruzak, & Waldrep, 2008). THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  45 A meta-analysis including 21 studies across a number of disorders (e.g., post-traumatic stress disorder, social phobia, panic disorder with agoraphobia, arachnophobia, acrophobia, aviophobia) found statistically large weighted effect sizes in the reduction of symptoms (Parsons & Rizzo, 2008). Studies specific to traumatic distress have also been positive. One intervention for the treatment of post-traumatic stress disorder (PTSD) symptoms found large effect sizes for the reduction of intrusion and avoidance symptoms (Lange, van de Ven, & Schrieken, 2003). Another study compared a self-help web intervention for traumatic stress to a wait list condition and found those who used the website had a significant reduction in symptoms of anxiety, depression, and avoidance and significant increases in relaxation and coping self-efficacy (Hirai & Clum, 2005). Finally, researchers found a significant decrease in PTSD symptoms for Iraq citizens with a history of torture or trauma when these people used a therapist-assisted web intervention (Wagner, Schulz, & Knaevelsrud, 2012). In summary, web interventions are capable of providing quality, evidence-­based care, quick and easy access, and confidentiality without fear of judgment by others. Specifically, web interventions addressing traumatic stress have been effective in reducing symptoms. These types of interventions are highly scalable providing cost-effective support for a large group of people. Knowing that military behavioral health providers are large in number while also being located across the globe, a web-based intervention increases the geographical and clinical reach an intervention can have. Developing SupportNet: The Technical Perspective The objective of the SupportNet web intervention was to provide an Internet-based supportive system for mental health providers working with military clients. As discussed in Chap. 2, we targeted mental or behavioral health providers seeking support primarily for job burnout working with traumatized clients. The system was developed in two phases: the first phase focused on self-assessment, goal setting, and social support, and the second phase expanded the capabilities developed in the first phase to include other systems such as relaxation and psychoeducation capabilities. 46  C. YEAGER ET AL. System Architecture In order to provide secure access and cross-platform compatibility, SupportNet was designed as a password protected, web accessible intervention that supported several platforms and browsers including Internet Explorer (v. 11), Google Chrome, Mozilla Firefox (v. 44.0), and Safari. SupportNet was made to be accessible from mobile devices as well as desktops. This scalable and flexible architecture can support the incorporation of additional technologies, such as mobile applications. SupportNet was developed using Visual Studio 2010 Integrated Development Environment (IDE). Web interventions consist of several interconnected components including the underlying operating system, the web server, the database server, the application-specific software, and the user’s local browser. These components are accessed through the Internet and can reside on the same server or on different servers (see Fig. 3.2). The SupportNet application was developed on the Windows Server 2008 R2 operating system running Internet Information Server (IIS). SQL Server 2012, a relational database management system (RDBMS), was used to accommodate secure and simultaneous access by multiple users. The application software was designed to support multiple platforms using Asp.Net 4.5, HTML5, and C# development tools and languages. Components Mul ple Pla orms HTTPS Web Server (IIS) SQL Server Fig. 3.2  SupportNet technology architecture User Profile: Matching with others based on needs, interests THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  47 Security was also a primary concern for us. The system was accessible on multiple platforms via any web browser. All communications between the server and the browser were over a secure, encrypted HyperText Transport Protocol Secure (HTTPS) connection. Three layers of security were implemented on data access (transport layer, access control, and content security) to prevent unauthorized access to the data. The software was developed to minimize security vulnerabilities such as cross-site scripting, SQL injection, crosssite request forgery, invalidated redirects and forwards, and failure to restrict URL access. Users were automatically logged out after a period of inactivity. SupportNet was developed using a data-driven architecture, meaning that application-specific data such as psychoeducation and goals related to burnout were stored in the database rather than hard coding it within the application. In other words, the components (e.g., goal setting, social support) were kept separate from the application-specific content (e.g., burnout psychoeducation). This architecture provides an infrastructure for tailoring to other mental health applications by simply changing the text in the database, rather than modifying the structure of the application. No sophisticated software development is required. For example, to support other mental health concerns such as depression or anxiety, only the database contents (psychoeducation and goals) need to be updated. In essence, the application uses the data to build itself (Yeager & Udy, 1999). Thus, SupportNet can be adapted to a broader arena of provider concerns beyond burnout and STS. Agile Design Methodology In order to incorporate feedback from designers and end-users throughout the development process, the functional components (described below) were delivered as they were developed (see Fig. 3.3). The uniquely integrated SupportNet team consisting of psychologists, user interface designers, and experienced software developers supported a collaborative and iterative development lifecycle where individuals and interactions were prioritized over processes and tools. This iterative process, also known as agile software development, helped the software development team to flexibly deliver user-approved components and incorporate critical modifications during product development rather than after product delivery. The agile lifecycle is especially conducive for a research environment where the fine details of the end product are discovered during the process by supporting an evolution of the requirements through continuous feedback and testing. 48  C. YEAGER ET AL. Continuous Collaboration UCCS Psychologists UCCS Developers Users (Fort Carson) Development Start Meet with Stakeholders Define Requirements Design New Requirements Feedback / Review UCCS Agile Lifecycle Accept [Yes/No] Test/ Release Review Recommendations Fig. 3.3  Agile lifecycle used by the SupportNet development team Web Intervention Components The SupportNet web intervention consists of several components. These include authentication and authorization, roles and groups, user profile, assessment, life balance wheel, goal setting, social connectivity, and other resources. The SupportNet home page is shown in Fig. 3.4. One can see that the system utilizes the social connectivity (i.e., encouragement) and goal setting (i.e., growth) to help users improve their sense of social support and coping self-efficacy. Authentication and Authorization Users must first register to receive authorization to use the SupportNet application. Initially, only authenticated users with a .mil email address were allowed access. The registration process includes basic identifying information such as name, photo, email address, cell phone, location, position, areas of interest, and qualifications. Upon initial registration, users are presented with a disclosure and disclaimer and are asked to comply with the terms of use conditions of the THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  49 Fig. 3.4  SupportNet home page site, the Department of Defense Social Media User Agreement and the standards and practices of the U.S. Army Social Media Handbook (Office of the Chief of Public Affairs, 2013) before they receive authorization to use the system. In addition, users must agree to participate by signing (via a checkbox) an Informed Consent Form describing the study upon which the system is based. Roles and Groups Different users can be assigned one or more different roles within the system. These roles have different capabilities and include administrators, users, and coaches. Through these roles, individuals acquire permissions to perform various intervention related functions. This is recognized as role-based access control (RBAC) and has been endorsed by the US government (National Institute of Standards and Technology, 2007). Administrators are responsible for authorizing and managing users of the system where users are the mental health service providers using SupportNet. Users have access to all functionality but are not allowed to see the activity of other users unless they are invited to do so. Coaches are assigned to several users and can monitor their activity within the system. A coach’s dashboard is provided to improve the visibility and a­ ccountability 50  C. YEAGER ET AL. of assigned users’ activities. Thus, the system offers extensive capacity for an integrated coaching model of support. To support the requirements of a randomized controlled trial (RCT), it was necessary to have the capability to assign participants to different groups. SupportNet offers this feature and provides for the creation of public or private groups. Groups can be nested within one another to support a hierarchical structure. Assignment is done through the coach’s dashboard and provides for segregation and experimental manipulation of various groups. The software can be configured such that different groups can be exposed to different aspects of the intervention. Social support networks can also be limited to a specific groups or subset of groups. Additionally, various RCTs can be using the system separately and simultaneously through the group assignment feature. This group assignment provides a unique feature of SupportNet to allow for ongoing scientific testing if desired. User Profile Initial sign up includes questions about an individual’s interests, needs, and type of support they are willing to offer to others. This information is used to guide social connections and goal selection. Connections are suggested based on an automated match between interests, needs, support, and demographics. Location is considered for interests requiring close proximity (such as exercise partner). These connections can be classified as either personal or professional. Personal connections can be given access to personal information and goals, whereas professional connections can be limited to professional goals (see goal setting below). Example information users are able to provide in each of the areas is shown in the Table 3.1. Assessment The assessment module allows individuals to track how they are doing throughout the intervention. Measures for health and stress levels are provided with a visual indicator of an individual’s current status on the assessment dashboard (see Fig. 3.5). Measures of health include social support, burnout self-efficacy, and work engagement. Measures of stress include secondary traumatic stress, burnout, and perceived stress. Individuals can take the assessments as many times as they would like. THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  51 Table 3.1  User profile information Types of information Individual interests  Exercise  Professional  Hobbies Individual needs  Exercise  Professional  Social Support offered to others  Exercise  Professional  Social Training/experience Examples Hiking, biking, running, swimming, skiing, golfing, etc. Areas of expertise and areas wanting to learn more Reading, riding motorcycles, cooking, dancing, collecting art, etc. Exercise partner, hiking partner, etc. Type and frequency of professional support desired Desires for a partner for various activities Willing to set up exercise program for someone Willing to consult at certain times/ frequency. Offer training or mentoring in certain areas Willingness and availability to participate in various activities EMDR, CPT Contact information (optional) The SupportNet intervention provides the opportunity for individuals to monitor the results of their self-assessments over time. Longitudinal graphs of assessment results reveal long-term trends or even dips and spikes in their mental health providing immediate feedback to individuals regarding how they are progressing toward their goal. Based on their self-­ assessment history, recommendations are provided regarding what type of goals might be appropriate for them to address their specific needs. An example of the self-assessment history for burnout self-efficacy is shown in Fig. 3.6. Life Balance The life balance wheel helps users to better understand how they feel across the different domains of their life. This easy to use tool provides a visual representation of an individual’s life balance and can be used to help users identify self-care goals. The life balance wheel is illustrated in Fig. 3.7. 52  C. YEAGER ET AL. Fig. 3.5  SupportNet assessment dashboard Goal Setting The goal setting section provides an engaging vehicle for users to measure and develop mastery (i.e., self-efficacy) in specific areas. Based on the results of the assessment, relevant goals are suggested to the user. Users can develop goals for various life domains such as career, finances, exercise, relationships, learning, home, and spiritual. It is possible to set up, modify, or delete goals. Users are also able to set professional and/or personal goals, share them with specific people in their social network, track progress, and specify rewards. Utilizing operant conditioning principles, we designed a system that helps the user generate a clear behavioral contract that includes highly THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  53 Fig. 3.6  SupportNet self-assessment history and recommendations for burnout self-efficacy s­pecific details concerning target (measurable) behavior, environmental context (where, with whom), timing (time of day), and potent reinforce(s). Based on these principles, a general overview of the importance of goal setting and how to maximize one’s success is provided. This includes how to set an observable, measureable, and achievable goal; the need for rewards and accountability; common obstacles to achieving a goal; and example goals. Target areas and preloaded targeted goals are available to help guide the user and include such areas as skills acquisition, self-care (exercise, mindfulness, nutrition, and relaxation), internal conflicts, support, and others. Users are encouraged to describe their goals, including what they hope to achieve as well as why it is important to them. For each goal, specifics of the goal including start and ending times, how often, when, 54  C. YEAGER ET AL. Fig. 3.7  SupportNet life balance wheel where, and with whom can be specified (see Fig. 3.8). Goals can be broken down into smaller, more manageable steps. Rewards can be indicated for goals and progress is visually displayed via a progress bar to increase motivation. Those who have been asked to provide support for the goal can monitor progress and offer encouragement to the individual. Individuals can also see others in their social networks who have achieved similar goals THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  55 Fig. 3.8  SupportNet goal setting module illustrating the creation of goals and social support which have been shown to increase self-efficacy through modeling (Bandura, 1997). Context-sensitive examples are provided as individuals step through the goal-setting process. Social Networking Platform The social networking platform provides the user with the ability to identify his/her social and professional networks. Initially the design team was going to use a social networking platform called Communifire. Communifire provides a Facebook-like social networking capability. However, the goals of the social networking component were to help improve burnout coping self-efficacy through mastery experiences, vicarious experiences, and verbal persuasion. In order to provide these experiences, the social networking platform had to be integrated with the components of the SupportNet web intervention. The Communifire interface did not support this; therefore, the decision was made to develop a custom social ­networking platform that could be seamlessly integrated into the components of the intervention to provide effective and confidential social support. 56  C. YEAGER ET AL. The custom social networking platform allows individuals to locate and invite another person to be part of their “social” or “professional” network. The connection can be identified socially as a “friend” or professionally as a “coach” or “supervisor/co-worker”. Additionally, individuals can locate or find “friends” and “coaches” based on the user’s profile and areas of interest and need. Once connected, information on current activities of your social network and discussion groups is made available to the individual. These activities can range from reading articles in the library to setting and achieving goals. In the library, individuals can share meaningful materials with other individuals in their social network to improve mastery experiences. Goals are made more meaningful through the support and encouragement of others. Individuals can link (or remove) individuals from their social network to their goals to increase accountability and vicarious support. Other Static Components There were two other components included in the website functionality that focus on professional information, health and wellness psychoeducation, and self-care quick interventions. The first was called the Resource Room. In this area, a person is provided an overview of current research regarding the clinical treatment of PTSD as well as other professional enhancement resources (see end of Chap. 7). One factor that had been related to a decrease in burnout is the use of evidence-based treatments for trauma (Craig & Sprang, 2010). This section also includes current research on secondary trauma and burnout. The design of the interface in this section facilitates a person’s ability to easily find and digest this information. Providers select a topic area that then presents a listing of relevant journal articles and other resources. For each article, an executive summary is provided and, if desired, a link to the full article or resource is included. Providers can issue comments for each journal article and can recommend articles to individuals in their social network (see Fig. 3.9). The other static area is called Take 5 (see Fig. 3.10). In this area, the provider accesses short activities to help alleviate stress and promote well-­ being. The available activities are in one of two categories: relaxation (agitated or stressed) or energize (exhaustion or low motivation). Each activity THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  Fig. 3.9  SupportNet resource room article summary and discussion Fig. 3.10  SupportNet Take 5 57 58  C. YEAGER ET AL. ranges in duration from 2 to 5 minutes and includes meditation, yoga, tai chi, progressive muscle relaxation, stretching, plus several more (see end of Chap. 7). The reason for identifying and suggesting shorter activities is not only to decrease the time demand on the provider but also to help build a sense of efficacy related to prioritizing self-care. The idea is that even a little time can produce positive results. In summary, the web components are designed to promote self-care, self-efficacy, and enhance a strong sense of community support through an integrated goal setting system with a social media based capability. The next challenge in website development is the issue of user engagement. Engagement As the development of web interventions has increased, so have concerns over issues of engagement (Morrison & Doherty, 2014). A disadvantage of online interventions is the lack of “stickiness” relative to other modes of contact such as in-person support (Couper et al., 2010). As a result, attrition rates of web interventions are high (Eysenbach, 2005) potentially reducing their effectiveness. As Danaher, Boles, Akers, Gordon, and Severson (2006) noted, “a key ingredient in determining the impact of any Web-based behavior change program is the extent to which participants are exposed to the program”. Web interventions can be a rich source of objective data on engagement and dropout, and, consequently, have the potential to inform adherence research (Christensen, Griffiths, & Farrer, 2009). Therefore, an important part of any intervention research is an understanding of how participants engage with the intervention. Research on web intervention engagement represents an important opportunity to guide the development of more effective interventions. This research provides insight into what people are doing and when they are doing it. Technology-delivered interventions offer a rich opportunity to monitor usage patterns of participants in an unobtrusive manner. As a result, most measures of engagement focus on objective measures that can include the number, duration, and pattern of visits to the site, and the number and types of pages viewed (Danaher, Boles, Akers, Gordon, & Severson, 2006). Others use paradata to understand the process of engagement (Couper et al., 2010). This paradata includes both breadth and depth of usage statistics where breadth is a summary of access to all activities on the website and depth measures how deeply individuals engage in a given activity. Few, if any, studies use subjective measures of engagement. THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  59 Our Approach In analyzing participant engagement, we used both objective and subjective measures of engagement (see Table 3.2). The objective measures were a metric that combined Internet server and database usage logs with patterns of usage of the individual components. These metrics measured both exposure and adherence that when combined represented the dosage of the intervention (Brouwer et al., 2011). The objective measures included how many times a user logged in (unique sessions), time online, number of mouse clicks, mean minutes/page, how many unique pages visited, how many goals created, and how many social connections made. The subjective measures were self-reported questions assessing frequency and duration of different components of the system. Table 3.2 lists the means and standard deviations of these measures. Objective Measures In Table 3.2, it is clear that providers in our study demonstrated that users spent just under 2 hours on the site over the course of the six-session Table 3.2  Means and standard deviations for engagement Mean (M) Objective measures Subjective measures Total time online (minutes) 113.56 Mean minutes/page 0.71 Number of  Clicks per login session 123.8  Unique sessions 5.71  Unique pages visited 12.07  Social connections 0.86  Goals 1.14 How many minutes (duration) per component  Goal setting 43.8  Self-assessment 48.0  Resource room 36.0  Social networking 25.8 How often (frequency) each component accessed  SupportNet use in general 3.27  Goal setting 2.33  Self-assessment 2.30  Social networking 1.57  Resource room 2.13 SD 105.60 0.43 68.30 4.23 1.38 1.23 0.95 42.0 33.6 30.6 80.4 1.16 0.98 0.96 1.16 0.99 60  C. YEAGER ET AL. intervention. They visited 12 unique pages in the system and spent just under a minute per page. Time Online.  To estimate the total time spent interacting with the website, the elapsed time between two events (mouse clicks) was attributable to the action that generated the first event. These elapsed times were accumulated to give a total time on the website and may vary slightly from the actual time on the website. For example, some accumulated times may be slightly lower than the time actually spent on the site if the participant closed the browser window and did not explicitly log off as no information was captured for the last event. Additionally, individuals who stepped away from their computer between events may have times higher than that actually spent on the website. Mean Minutes per Page.  Each page in the intervention had a unique page identifier. To approximate the mean minutes a participant spent on a page, the elapsed time between visits between pages was calculated for each participant for each page and averaged across the group. Similar to the problems associated with time online, the calculated minutes per page times may vary from the actual time spent on a page. For example, if the participant closed the browser window without logging off, the last event was not captured; therefore, the calculated time on the last page is lower than the actual time. Additionally, participants who stepped away from their computer while using the intervention may have calculated times higher than actual time spent on a page. Clicks per Login Session. The clicks per login session is another estimate of engagement and suggests active interaction with the components of the intervention. Each click generated an event that was associated with a session ID. To generate this measure, the total events were summed for a given session ID. Unique Sessions.  Each time an individual logged into the website, a unique session identifier (session ID) was generated. These session IDs were used to quantify how many times an individual logged into the intervention. The measure “unique sessions” represents the number of logins and was simply a count of the number of unique session IDs associated with a given individual. Individuals were automatically logged out after 30 minutes if there was no new user-generated activity. If logged out, the user would need to repeat the log-in process, generating another log-in event which can overestimate the number of times an individual logged in. THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  61 Unique Pages Visited. The number of unique pages visited provides a measure of the depth of web intervention engagement. The more an individual explored the intervention, the greater number of unique pages will be visited. To calculate unique pages visited, the SQL server command “DISTINCT” was appended to the database query to generate unique page IDs for a given session ID. Social Connections.  The social component of SupportNet was designed to help participants engage with peers or social networks that can positively affect their behavior. This measure was calculated by summing the ­number of connections specified per activity. Both connections supporting the individual as well as support provided to others are included in this measure. Participants could receive support from others or provide support to others with similar interests using the intervention. This activity provided a measure of adherence as this was an important component for improving burnout self-efficacy, thus reducing burnout, the primary outcome of the intervention. Goals.  Goal setting allows users to define a target they want to reach that can also positively affect their behavior. Therefore, the number of goals is an indication of the adherence to and hence engagement with the intervention. Goals can be simple, consisting of only one or a few steps, or complex, consisting of a number of steps and a possible reward. These goals can be associated with values specified by the individual. Quantifying the level of goal adherence considered both the breadth and depth of the goal participation. As a result, this measure included both the number of goals and the number of steps associated with each goal. Completion rates, coverage of values, and social support associated with each goal were not considered for this measure and should be included in future measures of engagement. Subjective Measures The subjective measures of engagement asked users to indicate their perception of both the length of time (duration) and how often (frequency) they used the various website components. Users were asked how much and how often they set goals, performed self-assessments, visited the resource room, and engaged in social networking (see Table 3.2). According to these selfreport measures, the goal setting and self-assessment c­omponents were used most often. Table 3.2 demonstrates an interesting finding that users’ subjective reporting of website use and the objective data do not directly 62  C. YEAGER ET AL. match up. Indeed, users tend to report higher use than the objective data indicate. For instance, the estimated (i.e., subjective) total time for four of the website’s sections was just over 2.5 hours. The objective assessments suggest a different picture with users spending just under 2 hours total on the site. Future studies that help to understand this discrepancy and delineate the most useful measures of engagement are needed. Future Directions Engagement is a critical issue that should be considered during the design process. For SupportNet, this was not the case; therefore, we relied on post hoc measures of engagement. The measures were summed to give overall measures of engagement. Such cumulative measures do not capture the temporal processes of engagement that may provide additional insight into understanding web intervention usage across time. Donkin and Glozier (2012) have demonstrated that there is not a linear relationship between usage and outcome. Rather, they reported a substantial amount of variance seen in adherence between studies can be explained by the specific interactive technological elements of the web-based intervention. These two findings, taken together, suggest that it is essential to understand the temporal process of engagement as well as consider looking at engagement from a theoretical perspective. Future studies should look at engagement from a psychological process approach rather than simply the specific elements of the intervention that improve engagement. Additionally, the potency of the intervention should be considered in measures of engagement. Some interventions are extremely effective over a short period of time, whereas others do not produce an effect for weeks or months. Highly potent interventions may see what is considered high attrition rates or drop out when in fact the intervention has produced the desired outcome. Future research is needed to quantify potency and communicate that to participants to improve expectations. Summary and Implications for Other Health-Care Providers The SupportNet Internet intervention provides a theoretically based system that integrates community building and self-efficacy enhancement into one website to reduce burnout. The system architecture offers the unique capacity to adapt the system to other providers. The literature THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  63 s­ uggests that all health-care providers are at some risk for STS and burnout (Beck, 2011; Cieslak et al., 2013; Dewa, Loong, Bonato, Thanh, & Jacobs, 2014; Kintzle, Yarvis, & Bride, 2013). Dewa, Loong, Bonato, Thanh, and Jacobs (2014) showed that around a third to a half of physicians from all specialties are burned out. Burnout studies with military nurses suggest they are at particular risk for burnout and STS (Ballenger-­ Browning et al., 2011). More than a quarter of military nurses report high levels of burnout. When compared to their civilian counterparts, Army nurses have higher emotional exhaustion and depersonalization (Lang, Pfister, & Siemens, 2010). Thus, medical providers, in general, would be a logical extension of the SupportNet platform, and Army nurses specifically. Based on our randomized controlled trial data (see Chap. 6), the website combined with a formalized peer coaching model may be helpful in reducing burnout in these populations. The site infrastructure makes it easy to input information directly relevant to these different provider groups without having to “re-tool” the site with extensive programming. References Amstadter, A. B., Broman-Fulks, J., Zinzowa, H., Ruggiero, K. J., & Cercone, J.  (2009). Internet-based interventions for traumatic stress-related mental health problems: A review and suggestion for future research. Clinical Psychology Review, 29, 410–420. Ballenger-Browning, K. K., Schmitz, K. J., Rothacker, J. A., Hammer, P. S., Webb-­ Murphy, J. A., & Johnson, D. C. (2011). Predictors of burnout among military mental health providers. Military Medicine, 176(3), 253–260. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman. Barak, A., & Klein, B. (2009). Defining internet-supported therapeutic interventions. Annals of Behavioral Medicine, 38, 4–17. Beck, C.  T. (2011). Secondary traumatic stress in nurses: A systematic review. Archives of Psychiatric Nursing, 25(1), 1–10. Benight, C. C., Ruzak, J., & Waldrep, E. (2008). Internet interventions for traumatic stress: A review and theoretically based example. Journal of Traumatic Stress, 21(6), 513–520. Brouwer, W., Kroeze, W., Crutzen, R., Nooijer, J. d., Vries, N. d., Brug, J., et al. (2011). Which intervention characteristics are related to more exposure to internet-delivered healthy lifestyle promotion interventions? A systematic review. Journal of Medical Internet Research, 13(1), e2. Cavanagh, K., Shapiro, D. A., Berg, S. V., Swain, S., Barkham, M., & Proudfoot, J. (2006). The effectiveness of computerized cognitive behavioural therapy in routine care. British Journal of Clinical Psychology, 45, 499–514. 64  C. YEAGER ET AL. Christensen, H., Griffiths, K.  M., & Farrer, L. (2009). Adherence in internet interventions for anxiety and depression: Systematic review. Journal of Medical Internet Research, 11(2), e13. Cieslak, R., Anderson, V., Bock, J., Moore, B.  A., Peterson, A.  L., & Benight, C. C. (2013). Secondary traumatic stress among mental health providers working with the military: Prevalence and its work- and exposure-related correlates. The Journal of Nervous and Mental Disease, 201(11), 917–925. Cohen, S., & Syme, L. S. (1985). The study and application of social support. In S. Cohen & L. S. Syme (Eds.), Social support and health (pp. 3–20). Orlando, FL: Academic. Couper, M.  P., Alexander, G.  L., Zhang, N., Little, R.  J., Maddy, N., Nowak, M. A., et al. (2010). Engagement and Retention: Measuring breadth and depth of participant use of an online intervention. Jounral of Medical Internet Research, 12(4), e52. Craig, C., & Sprang, G. (2010). Compassion satisfaction, compassion fatigue, and burnout in a national sample of trauma treatment therapists. Anxiety Stress Coping, 23(3), 319–339. Danaher, B. G., Boles, S. M., Akers, L., Gordon, J. S., & Severson, H. H. (2006). Defining participant exposure measures in web-based health behavior change programs. Journal of Medical Internet Research, 8(3), e15. Dewa, C. S., Loong, D., Bonato, S., Thanh, N. X., & Jacobs, P. (2014). How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research, 14, 325. Dombrowski, S. U., Sniehotta, F., Avenell, A., & Coyne, J. (2007). Current issues and futuTowards a cumulative science of behavior change: Do current conduct and reporting of behavioral interventions fall short of best practice? Psychology and Health, 22(8), 869–874. Donkin, L., & Glozier, N. (2012). Motivators and motivations to persist with online psychological interventions: A qualitative study of treatment completers. Journal of Medical Internet Research, 14(3), e91. Eysenbach, G. (2005). The law of attrition. Journal of Medical Internet Research, 7(1), e11. Fox, S. (2014). The web at 25 in the U.S. Washington, DC: Pew Research Center’s Internet & American Life Project. Hirai, M., & Clum, G. A. (2005). An internet-based self-change program for traumatic event related fear, distress, and maladaptive coping. Journal of Traumatic Stress, 18(6), 631–636. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13–22. Kintzle, S., Yarvis, J. S., & Bride, E. B. (2013). Secondary traumatic stress in military primary and mental health care providers. Military Medicine, 178(12), 1310–1315. THE SUPPORTNET WEBSITE: A SOCIAL MEDIA SELF-CARE SYSTEM  65 Lang, G. M., Pfister, E. A., & Siemens, M. J. (2010). Nursing burnout: Cross-­ sectional study at a large Army hospital. Military Medicine, 175(6), 435–441. Lange, A., van de Ven, J.-P., & Schrieken, B. (2003). Interapy: Treatment of post-­ traumatic stress via the internet. Cognitive Behaviour Therapy, 32(3), 110–124. Lisetti, C., Amani, R., Yasuvar, U., & Rishe, N. (2013). I can help you change! An empathic virtual agent delivers behavior change health interventions. ACM Transactions on Management Information Systems, 4(4), 1–28. Litz, B. T., Bryant, R., Williams, L., Wang, J., & Engel, C. C. (2004). A therapist-­ assisted internet self-help program for traumatic stress. Professional Psychology: Research and Practice, 35(6), 628–634. Marks, J. T., Campbell, M. K., Ward, D. S., Ribisl, K. M., Wildemuth, M. B., & Symons, M. J. (2006). A comparison of web and print media for physical activity promotion among adolescent girls. Journal of Adolescent Health, 39, 96–104. Mojtabai, R., Olfson, M., Sampson, N. A., Jin, R., Druss, B., Wang, P. S., et al. (2011). Barriers to mental health treatment: Results from the national comorbidity survey replication. Psychological Medicine, 41, 1751–1761. Morrison, C., & Doherty, G. (2014). Analyzing engagement in a web-based ­intervention platform through visualizing log-data. Journal of Medical Internet Research, 16(11), e252. National Institute of Standards and Technology. (2007). U.S. National Institute of Standards and Technology. Guide to secure Web services. Gaithersburg, USA: U.S.  Department of Commerce, National Institute of Standards and Technology. Neve, M. J., Collins, C. E., & Morgan, P. J. (2010). Dropout, nonusage attrition, and pretreatment predictors of nonusage attrition in a commercial web-based weight loss program. Journal of Medical Internet Research, 12(4), e69. Office of the Chief of Public Affairs. (2013). The United States army social media handbook. Washington, DC: Online and Social Media Division. Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39, 250–261. Pepin, R., Segal, D. L., & Coolidge, F. L. (2009). Intrinsic and extrinsic barriers to mental health care among community-dwelling younger and older adults. Aging & Mental Health, 13(5), 769–777. Rotondi, A. J., Anderson, C. M., Haas, G. L., Eack, S. M., Spring, M. B., Ganguli, R., et al. (2010). Web-based psychoeducational intervention for persons with schizophrenia and their supporters: One-year outcomes. Psychiatric Services, 61(11), 1099–1105. Steinmetz, S. E., Benight, C. C., Bishop, S. L., & James, L. E. (2012). My disaster recovery: A pilot randomized controlled trial of an internet intervention. Anxiety Stress Coping, 25(5), 593–600. 66  C. YEAGER ET AL. Tate, D.  F., & Zabinski, M.  F. (2004). Computer and internet applications for psychological treatment: Update for clinicians. Journal of Clinical Psychology, 60(2), 209–220. Wagner, B., Schulz, W., & Knaevelsrud, C. (2012). Efficacy of an internet-based intervention for posttraumatic stress disorder in Iraq: A pilot study. Psychiatry Research, 195(1–2), 85–88. Wells, M., Mitchell, K., Finkelhor, D., & Becker-Blease, K. (2007). Online mental health treatment: Concerns and considerations. CyberPsychology & Behavior, 10(3), 453–459. Yeager, C. M., & Udy, J. L. (1999). Patent No. 5,950,190. US. CHAPTER 4 SupportNet Coaching Judith Bock and Charles C. Benight A coach is someone who can give correction without causing resentment. John Wooden Quick Facts • Coaching is a viable model for helping reduce burnout in a number of health-care and nonhealth-care populations. • Coaching combined with web interventions has been effective in promoting well-being and reducing psychological distress. • The SupportNet model for peer coaching and our web intervention targeted increasing self-efficacy and social support to combat burnout. • Utilizing the life balance wheel, users engaged with coaches in identifying tangible and achievable self-care goals. • Military mental health providers were able to complete a six-session coaching system and were able to make important improvements in their self-care behaviors. This chapter covers the development, deployment, and evaluation of our coaching program. The SupportNet team determined early on that we wanted to incorporate a human component to augment our web-based J. Bock (*) • C.C. Benight Department of Psychology, Trauma, Health & Hazards Center, University of Colorado at Colorado Springs, Colorado Springs, CO, USA © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1_4 67 68  J. BOCK AND C.C. BENIGHT support system. This chapter reviews the development of our coaching approach, provides an overview of our coaching manual (the complete manual is located in the book Appendix), and summarizes qualitative and quantitative information from our randomized controlled trial (RCT). The chapter ends with a discussion of clinical implications for future web-­ based interventions and how coaching may or may not help military mental health and other health-care providers. Development of the Coaching Model Figure 4.1 depicts the overall intervention that we utilized for SupportNet. The peer-coaching model was developed to support and augment the utilization of the web intervention. This coaching approach has been utilized extensively in hybrid models of web-support for a host of other psychological difficulties (Andersson & Titov, 2014). The fact that coaching has been utilized with other web-support systems provides one reason for adopting this approach. The other is that there is support for coaching specific to wellness from other disciplines. Cyber Soluon SelfEfficacy Knowledge Social Support Fig.  4.1  SupportNet hybrid web and coaching support system Coaching SUPPORTNET COACHING  69 Coaching has been used to effectively address occupational stress and burnout (Biswas-Diener, 2009; Gazelle, Liebschutz, & Riess, 2014). Specifically, coaching targeting specific goals has been found to be an effective method of facilitating behavioral change (Grant, 2012). A recent meta-analysis demonstrated that professional wellness coaching is effective for enhancing self-efficacy, personal well-being, and goal-directed self-­ regulation (Theeboom, Beersma & van Vianen, 2014). Gazelle, Liebschutz, and Riess (2014) also described a professional coach approach for physician burnout that builds upon the individual strengths of the professional to enhance awareness and refocus on value directed goals. Military mental health providers clearly have an understanding of the need for self-care and personal well-being self-regulation. In evaluating the best possible approach to reduce burnout in these providers, we decided that wellness-oriented coaching combined with our website made the most sense. Beyond the empirical evidence supporting this approach, we felt it was important to have a guiding theoretical model for the development of our intervention. We utilized social cognitive theory (SCT) as the backbone of our model. As discussed in Chap. 3, SCT offers a framework for understanding how people cope with changing environmental challenges. Bandura (1997) described the self-regulatory coping process that includes the interactivity of critical environmental resources (e.g., social support) and personal appraisal factors (e.g., self-efficacy) with behavior, as the process by which individuals attempt to meet desired goals. We focused our coaching model around enhancing social support (environment) and self-­ efficacy (personal appraisals) in the promotion of healthy behavior. Thus, we targeted enhancing these two factors both within the web intervention system and within our coaching approach in order to maximally promote positive self-care behavior. Providers were able to develop a social network tailored specifically to their self-care goals within the website as well as receive social support from peer coaches as they worked on improving their self-care. The coach’s role was to closely monitor the progress (or lack thereof) of the providers and strategically offer positive feedback and encouragement with the intention of providing enhancing perceptions of social support from the coach. Having people care about one’s well-being, either web-based or telephonically, is essential to enabling a greater sense of perceived capability to manage the professional challenges of providing therapy for soldiers. Support alone, however, is not enough. Self-efficacy 70  J. BOCK AND C.C. BENIGHT enhancement (i.e., mastery) is critical for reducing burnout by promoting a greater sense of personal and professional control. As discussed in previous chapters, self-efficacy is a fundamental component to feeling a sense of control in managing stress and personal well-being (Bandura, 1997). As a result of the empirical findings in our longitudinal prevalence study (see Chap. 2), job burnout self-efficacy was found to be a significant concern in this population and the most viable target for our web/coaching intervention. Given the empirical support for coaching as a method to enhance goal attainment expectancy, goal commitment, and actual goal progression (Theeboom et  al., 2014), we focused our coaching on goals related to burnout management. Thus, the coaching intervention was designed to increase provider’s mastery experiences within this particular domain. We also realized that most providers experience a downhill spiral when burnout symptoms rise and self-care efforts decrease. This negative stress/self-care cycle often results in punitive self-appraisals further adding to the burnout challenge. Thus, we also focused on increasing mastery related to self-care self-efficacy in order to enhance a sense of personal well-being and control. Self-care was the primary focus of our SupportNet website utilizing the life balance wheel discussed in Chap. 3 (Gazelle et al., 2014). The life balance wheel connected our website to the providers’ experience of their own life and how they perceived their satisfaction in the domains of day-­to-­day life. This included physical health, spiritual life, finances, and so on. The clinical team viewed increasing self-care behaviors as a way to increase coping with burnout through the enhancement of personal control and mastery (Bandura, 1997). The military mental health work environment is a place where there often is limited control in decision making, workload, or work pace. In contrast, self-care is a domain in which the potential for personal control is much greater. This refocusing of control can be an effective means of helping individuals cope with stress. Ironically, we often do not perceive ourselves as having much control over our self-care behaviors, citing time and energy as being too limited to effectively engage in these behaviors. Our peer coaches specifically emphasized helping providers break through these barriers to self-care in order to increase wellness behaviors that would promote a sense of mastery related to coping with job burnout. Peer modeling provides another critical component to the overall SupportNet intervention. The SupportNet social media platform allowed participants to connect to other providers (imagine Facebook) who may be experiencing the same struggles and triumphs. The role of the peer SUPPORTNET COACHING  71 coach was similar where the peer facilitated providers’ efficacy and social support by being able to understand the therapists’ situation as only a peer can. Indeed, each coach had extensive experience working with military clients and was able to convey a unique understanding of the providers’ situation relative to the challenges they faced. This unique relationship fostered the identification of existing positive strengths and maximized the utilization of more effective self-care behaviors for coping with burnout (Gazelle et al., 2014). Another unique aspect of our hybrid web/coaching program was the opportunity for the coaches to support engagement with the web intervention. The challenge, of course, is the balance between scalability of a web intervention for a large group of people (cost saving) versus the time intensive nature of face-to-face support (cost increase). There is significant research indicating that external support of a web application may improve adherence and important clinical outcomes (Ritterband, Thorndike, Cox, Kovatchec, & Gonder-Frederick, 2009). Thus, a telephonic coaching model seemed to be the best approach to maximize engagement and intervention success, yet limiting the potential costs. Ultimate broader dissemination of this model seemed more possible. Although our approach utilized a peer-coaching model, our coaching sessions were designed to be delivered by licensed mental health providers or nonlicensed lay coaches. This decision was made to make the possibility of future use of the SupportNet model in a multitude of military mental health contexts. Because of the positive literature on coaching and that our clients were mental health professionals themselves, we thought it would be more acceptable to them to provide “coaching” rather than “therapy”. This, we believed, helped to reduce the possible stigma associated with partaking in the intervention. We did not want to pathologize their burnout or their struggles with maintaining a sense of balance in their lives. But figuring out the distinction between coaching and therapy is not always easy. This issue was more than just a practical concern; it was also an ethical one. Because our participants for the RCT were expected to be from across the globe, we had to be sure we were not violating any regulations on multijurisdiction therapy. The guidelines we selected to distinguish between coaching and therapy had to be clear to the clinical team as well as any other future individual or team using the SupportNet model. Hart, Blattner, and Leipsic (2001) offered some very useful guidelines ­delineating the 72  J. BOCK AND C.C. BENIGHT ­ ifference between coaching and therapy. These were divided into four d categories: critical differences, relating, content, and structure. Critical Differences.  Hart et  al. (2001) highlighted that coaching is present/future focused, driven by the coach, and is more informal and task oriented. Therapy, in contrast, is more past focused, client centered, more formal, and less structured. Our approach mirrored this sentiment. We approached our coaching intervention as strictly outcome oriented. Our six limited coaching sessions were very structured to promote clear identified outcomes right from the initial sessions. Evidence from structured web-based interventions with associated coaching suggests that peer coaches can provide more focus on support and practical direction (Andersson & Tivot, 2014). The unique nature of being a peer coach provides interesting opportunities within this unique relationship. Relating.  The peer coaching relationship has looser boundaries between the peer coach and the client creating a quicker establishment of rapport. The coach is considered an insider. Knowing the landscape offers the opportunity to utilize more humor as well as offering insights that can promote change. The coaching relationship often sets quicker and higher expectations than is typical for a therapy client. Content.  The sessions were present focused with a strong emphasis on target behaviors and actions. One coach shared, “We were able to just get right at it!” Due to the focus on burnout, the behaviors and actions were directly related to burnout management and self-care. In contrast to therapy where the therapeutic focus takes time to develop, the coaching model had the intended focus clear from the first session. Structure.  The peer coaching approach we utilized was extremely structured. With only six sessions, five of which were only a half an hour, coaches worked with providers to quickly delve into the challenges with their target self-care goals. The coaching manual was developed to set clear guidelines for our peer coaches to keep them structured and clear about each session’s objectives. When the coaches worked with providers, the team members could easily recall and utilize this framework of the four facets: critical differences, relating, content, and structure. It also helped the members maintain a SUPPORTNET COACHING  73 “self-awareness” of the line between coaching and providing therapy. The providers also were clear that this was not therapy and seemed receptive to this type of peer support. As will be discussed below, the limit between therapy and coaching was an important topic of conversation during the weekly clinical team’s RCT meetings. Deployment of the Coaching Model The session-by-session manual with specific goals for each phone call is provided in the Appendix. As can be seen in the manual, the deployment of the coaching model involved integration of this structured session-by-­ session approach with the idiosyncrasies of our RCT. The clinical team was excited to have the opportunity to help peers achieve a better life balance. However, we felt it was imperative to evaluate an overall intervention that would be short term and cost-effective. In the end, we developed a coaching program that maximized our ability to attain improvement in burnout, self-efficacy beliefs, and social support relatively quickly. Session-by-Session Overview.  Overall, the goal of the coaching was structured to complement the provider’s use of the SupportNet web site – not to be an added set of new intervention components. Table 4.1 provides an overview of the entire coaching approach for each session. Whereas each coaching session had its own specific focus, coaches attempted to promote self-efficacy and social support whenever possible (e.g., when a provider made some progress on setting a self-care goal). The coaching process mirrored the design of the website in its use of self-assessment, the life balance wheel, and the setting and tracking of the provider’s goals. In the following paragraphs, the preparation period and each session are described. It is important to note that some of the coaching manual relies on the steps that were a part of our RCT. Table 4.1  Coaching process Session 1: 60 minutes Session 2: 30 minutes Session 3: 30 minutes Session 4: 30 minutes Session 5: 30 minutes Session 6: 30 minutes Orientation session describing coaching process. Provider’s story/build rapport Life balance wheel/initial goal setting Goal setting obstacles Stress and burnout management Social support development Empowerment and change identification 74  J. BOCK AND C.C. BENIGHT Preparing for the First Session.  As providers were identified for participation in the RCT, the coach was assigned and started gathering information to prepare for the first session. One of the steps taken was to look at the client’s initial (or preintervention) measures of social support, burnout coping self-efficacy, work engagement, secondary traumatic stress, and burnout and perceived stress. These were provided from the RCT data collected during the pre-test (see Chap. 6 for more details). After reviewing these, the scores were transcribed to the Assessment page in the SupportNet Coaching Manual (see p. 1 in the Appendix). We felt strongly that it was necessary to determine if severe secondary traumatic stress symptoms were present before reaching out to the provider. Although none of our clinicians demonstrated this elevated level of STS, we wanted our coaching plan to include a process for helping them get appropriate help for these symptoms. Thus, the coaches were ready to work with providers struggling with STS and help them to reach out to a professional therapist. In addition to referring out for clinical ranges of STS, coaches also remained alert to other referral indicators. Some of the signs and symptoms we looked for included: • Client stuck in victim role • Client stuck in emotional drama (high degree of chaos) • Client distressed mood predominant feature of interaction • No shows • Failure to follow through • Serious distress emotions in more than one session (intensity) • Persistent anger or aggression • Low or blunted affect • Feeling overly responsible for clients on their caseload • Signs of extreme provider dependency on the coach (“You are the only one who cares about me”) • Self-destructive impulses or behaviors • Expression of suicidal ideation or intent (“I just can’t go on anymore”) When any one or more of these indicators were present, the goals were centered on improving self-care by helping the client seek help from a mental health professional in addition to improving other simple selfcare behaviors (e.g., taking time off, making appointments, etc.). We also SUPPORTNET COACHING  75 targeted the importance of increasing social support through friends and family. Finally, in preparation of the first session the coach contacted each provider and asked permission to contact him/her via phone and email and scheduled the date and time of the session. The provider was also given very general information about the RCT and what was expected of the participant. Session 1.  The focus of the first session was to “enhance awareness” in the provider about STS and burnout and to orient him/her to what the coaching process would entail. The session lasted 60 minutes and focused on building rapport through listening to the individual’s current challenges related to work/life balance. The difference between coaching and therapy, the process of the six coaching sessions, how to use the SupportNet website, and the role of homework in the intervention were also discussed. Specifically, individuals’ assessment results (e.g., burnout level, STS scores, social support perceptions, self-efficacy beliefs) were explained and discussed with the providers. This information was utilized as a bridge to detail the SupportNet website and how it could help them with the current challenges they faced. Next, providers were asked to assess the current level of self-care self-efficacy and the coach recorded this in the manual (this is explained in the Data Collection section below). Lastly, the next meeting was scheduled and the therapists were assigned homework to complete the life balance wheel, develop a profile for matching with other providers within the website, and review the materials within the resource library. Session 2.  The focus on the second session was to talk about goals and the challenges associated with achieving them. The session began with a brief check-in and then the life balance wheel homework was specifically reviewed. The other components of the site (support network and resource library) were also discussed. Using the life balance wheel domains that were the lowest in satisfaction for the provider, the coach helped the provider identify one or two short-term goals to help improve that area of his/her life. Coaches provided direct psychoeducation related to effective goal setting focusing on identification of measurable goals, achievability of the 76  J. BOCK AND C.C. BENIGHT goals, and how to track progress. This discussion mirrors the information in the SupportNet website that provides a detailed goal setting process where the user chooses a specific self-care goal that is both measureable and achievable. The individual also is prompted to detail specifics about the goal such as where, when, and with whom they would perform the goal behavior (see Chap. 3). Finally, the system helps the user to figure out a meaningful reward for achieving the goal. Significant focus was placed on helping clinicians to break larger somewhat ambiguous goals (e.g., I should get in better shape) down into a manageable aspiration (e.g., walk 2x next week). At the end of the second session, the coach asked the provider to assess the level of self-care self-efficacy, assigned homework to the provider to set 1–2 goals within the SupportNet web application, and scheduled the next appointment. Session 3. This session focused on the obstacles faced when trying to accomplish the targeted goals. Typically, providers encountered obstacles at this point in their attempts to alter their self-care behavior. The provider moved from the “fantasy” world of goal setting to the practical reality of achieving these goals in the chaos of day-to-day life where conflicts with time, other goals, and other people were clearly part of the burnout challenge. We utilized a set of standard obstacles to help quickly focus the sessions with the provider. These included: • Provider was underestimating the difficulty of achieving goal/setting unrealistic goals. Provider encouraged to: “Set goals you feel confident you can complete. Setting clear and measureable goals and knowing your own time and resources can help you set realistic goals.” • Client not “owning” the goal/not taking the goal seriously. Provider questioned: “Is it your goal or is it something your boss or others want you to do?” Provider encouraged to take responsibility for any goal and to own it. • The goal was not measurable or clear. Provider encouraged to: “Focus on unambiguous goals that are specific and tangible. Write down your goals in specific, measureable detail.” • The provider tried to do the goal alone (no accountability or support). Provider encouraged to: “Share your goals with others and enlist their help to hold you accountable and celebrate your success.” SUPPORTNET COACHING  77 • Provider was procrastinating. Provider encouraged to: “Recognize procrastination early on and write down what you need to do to complete the goal.” Also to “Designate time each day (or each week) to focusing on your goal and commit to it. Do not keep putting things off till tomorrow.” • Provider reported lack of time/resources. Provider encouraged to “Keep a diary or list of how you are spending your time. What takes up the most time? Are there areas or activities in your life you can reprioritize or cut down the time you spend doing them?” Also coach suggested to the client to “Schedule dates and times for your goal and treat that time like an important meeting or appointment.” Finally, the coach recommended “You may want to enlist the help of someone who may have the resources you need.” • Client lacking knowledge/skill. “Seek out the knowledge/skills needed to achieve goal through training, conferences, reading, or coaching.” • Provider reported other people/institutions are getting in the way. Provider encouraged to “Speak to others who have accomplished similar goals. Ask what steps were taken to achieve the goal.” Also coaches suggested to clients to “Make sure your goals can easily be communicated to others. Having an outline that describes how the goal will be executed, what resources are needed, and how long it will take will help you communicate your goal to others who may be resistant.” • Client was setting too many goals. Provider encouraged to “Set priorities. Prioritizing will allow you to give attention to and focus on your most important goals. Eliminate unimportant goals if possible.” • Client struggled with lack of motivation. Provider encouraged to “Identify what is getting in the way of you wanting to accomplish your goals. Is the goal really important to you? Set goals so that are aligned with your life’s values, purpose and passion.” • Provider indicated a lot of distractions. Encouraged to “Set blocks of time to work on accomplishing your goal and let others know you cannot be disturbed during that time will help. Eliminate distractions by going to a quiet place such as an office or library. If in a noisy setting earplugs may help. Also turn off your phone, computer, television, or any other distracters that get in the way.” 78  J. BOCK AND C.C. BENIGHT Following this conversation, the provider is asked to identify the obstacle of most concern and to develop a plan to overcome it. The third coaching session ends with the coach asking the provider to assess the level of self-care self-efficacy, assigning homework to the provider to modify goals based on the session’s discussion and scheduling the next appointment. It should also be noted that the client was also asked to provide support to another person within the SupportNet website (i.e., social network promotion). Research suggests prosocial activity can provide psychological benefits that can help with burnout (Grant & Sonnentag, 2010). Session 4.  The focus of this session was to help providers to develop awareness concerning their satisfaction with where they are in their different life domains and how self-care includes all of these areas. At this point, the provider has been focused on a self-care goal for several weeks. This provided the coaches with the opportunity to highlight the personal accomplishments the clients had achieved as well as the importance of personal commitment to overall self-care within the different life domains (e.g., physical, relational, and financial). The biggest challenge for self-care in all domains expressed by providers was constant stress related to work. The coaches guided the discussion during this session to look at the signs and symptoms of stress and focused the provider on the Take 5 area of the SupportNet web application as a way to combat the daily stress. The tools in Take 5 allow the person to spend 5 minutes (or less in some cases) to practice relaxation techniques including movement-­based as well as sitting-based techniques. For more information on this area, see Chap. 7. The session’s discussion was wrapped up by reviewing the “three S’s”: social support, self-care, and self-efficacy. As with the other sessions, the coach asked the provider to assess the level of self-care self-efficacy, assigned homework to self-monitor stress levels, suggested use of one or more Take 5 techniques during the week, and scheduled the next appointment. The provider was also asked to once again provide support to another person through the SupportNet web application. Session 5.  The focus of session five was on the promotion of social support. After checking in with the provider and reviewing the homework, the coach directed the discussion to the client’s social support network. It  was difficult for many providers to seek help for themselves when needed even though they were caring for so many others. This obstacle is SUPPORTNET COACHING  79 i­mportant to address, and specific obstacles to seeking social support by the provider were identified. Strategies were developed to help the provider overcome them in order to maximize the benefit of social support. The fifth coaching session ended with the coach asking the provider to assess the level of self-care self-efficacy, assigning homework to re-take the self-assessments and life balance wheel in the SupportNet web application, and to reflect on their positive and negative experiences throughout the coaching process. A final session was then scheduled. The provider was also asked to once again provide support to another person within the SupportNet application. Session 6.  The focus of this final session was to consolidate the new skills and changes the client had made through the intervention in order to empower the provider to continue these changes moving forward. The coach reviewed the updated self-assessments and the life balance wheel to see what changes the provider had made. The coach directed the discussion to what these changes meant for the provider and what differences these changes made in his/her life. The coaching sessions were concluded with a discussion about how to maintain the improvements the provider made focusing on what obstacles might get in the way. The session ended with the coach asking the provider to do one final assessment of the level of self-care self-efficacy. Evaluation of Coaching Process We had several ways that we evaluated our coaching program. First, after each session the coaches answered quantitative questions about whether the focus of the session deviated from the manual and a series of targeted questions concerning specifics related to the particular session. Coaches rated the participants’ ability to understand each coaching session’s main topics on a 1 (definitely false) to 6 (definitely true) scale (M = 5.56, SD = .28). Coaches also recorded when any deviations from the planned coaching session occurred. There were 9.1 percent (6 out of 66 sessions) deviations from the protocol. For a more detailed analysis, see Table 4.2. It depicts the results of each question per session. Results showed that overall most clients were able to engage into the coaching process with the website. Mean values for each item were all close to 6. As can be seen with the minimum values for each item, one Coaching session 3 1. Participant identified potential obstacles to goal achievement 2. Participant understands how to overcome obstacles to achieving goals Coaching session 2 1. We have established a collaborative working relationship 2. Participant can identify strengths related to life balance 3. Participant understands impact of burnout on life balance 4. Participant understands impact of STS on life balance areas 5. Participant able to choose 1–2 life balance areas to focus on during coaching 6. Participant understands how to set achievable goals 7. Participant has a plan in place for routine self-care 8. Participant has plan in place for increasing social support Coaching session 1 1. Participant was provided an opportunity to “tell his/her story” 2. Participant understands the coaching process 3. Participant understands the website interface 4. Participant understands results of self-assessment (SA) as related to job burnout 5. Participant understands results of self-assessment (SA) as related to STS (if applicable) 6. Participant understands the importance of social support 7. Participant understands the importance of self-care 8. We have established a collaborative working relationship Table 4.2  Descriptive statistics 11 11 5.00 5.00 4.00 4.00 4.00 11 11 11 5.00 5.00 5.00 11 11 11 4.00 5.00 5.00 4.00 6.00 5.00 7 11 11 11 9 11 6.00 6.00 4.00 5.00 Minimum 11 11 11 11 N 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 Maximum 5.9091 5.6364 5.4545 5.1818 5.2727 5.8182 5.9091 5.4545 5.5556 6.0000 5.7273 5.6364 5.6364 5.8571 6.0000 6.0000 5.2727 5.5455 Mean .30151 .50452 .82020 .75076 .64667 .60302 .30151 .52223 .72648 .00000 .46710 .50452 .50452 .37796 .00000 .00000 .64667 .52223 Std. deviation 80  J. BOCK AND C.C. BENIGHT 4.00 .00 10 11 3 2 10 Coaching session 6 1. Participant achieved 1-month goal 2. Participants can identify successes for session 6 3. Participant can identify next step 4 7 8.00 2.00 4.00 4.00 4.00 11 11 10 10 2.00 5.00 4.00 2.00 4.00 4.00 11 11 11 11 11 11 Coaching session 5 1. Participant is actively engaged in achieving goals 2. Participant is actively engaged in self-monitoring personal indicators of stress 3. Participant continues to be actively engaged in seeking social support 4. Participant actively engaged in self-care behaviors and activities Coaching session 4 1. Participant is actively engaged in achieving goals 2. Participant is actively engaged in self-monitoring personal indicators of stress 3. Participant continues to be actively engaged in seeking social support 4. Participant actively engaged in self-care behaviors and activities 3. Participant understands role of self-regulation in achieving goals 4. Participant is actively engaged in achieving goals 5. Participant is actively engaged in seeking social support 6. Participant is actively engaged in self-care behaviors and activities 8 9 9.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.33 8.00 8.6500 5.3000 5.0000 5.0000 5.4000 5.5455 5.4545 5.2727 5.6364 5.6364 5.6364 5.4545 5.3636 2.082 1.414 .47434 .82327 1.78885 1.63299 .69921 .68755 .68755 1.27208 .50452 .67420 1.20605 .68755 .80904 SUPPORTNET COACHING  81 82  J. BOCK AND C.C. BENIGHT client had particular trouble. This clinician was able to identify a goal (or two) and think about obstacles related to the goal but was not able to initiate working on the goal. Thus, overall the coaching process appeared to function as it was designed with peers leading the providers through the process of utilizing a web-based support system to identify and modify self-care goals. The data provide evidence for the feasibility of this type of system that is cost-­ effective by combining the utility of the Internet with telephonic coaching. Clearly, further study is necessary in different settings to validate our experience. Implications of Coaching Approach to Other Health-Care Providers Given the previous literature that showed 33–50 percent of physicians of all specialties report higher levels of burnout (Dewa, Loong, Bonato, Thanh, & Jacobs, 2014) and that coaching with physicians (Gazelle et al., 2014) can be helpful, it seems logical that a telephonic peer coaching system linked to a social media-based website that promotes self-care management might be valuable for this population. Nurses are also a key group that might benefit from this approach. Military nurses have particular vulnerability to secondary traumatic stress (Gates & Gillespie, 2008) and burnout (Ballenger-Browning et al., 2011). Nurses are utilizing social media at an increasing rate with 60 percent reporting using this technology in 2011 (Schmitt & Lilly, 2012). Obviously, not without potential pitfalls (Green, Willie, & Jackson, 2014), capturing the community support for health-care professionals in promoting self-care would be helpful. Summary Telephonic peer coaching for military mental health providers to reduce burnout appears to be a viable approach to assist in reducing burnout. Our coaching model was easy to implement and relatively quick with a total time allotment of 3.5 hours. The coaching approach integrated well with our social media-based self-care website to help providers set achievable goals to manage their burnout symptoms and improve well-being. The coaching/website intervention may have applicability to other health-care providers who are at risk for burnout and secondary traumatic stress. SUPPORTNET COACHING  83 References Andersson, G., & Titov, N. (2014). Advantages and limitations of internet-based interventions for common mental disorders. World Psychiatry, 13(1), 4–11. doi:10.1002/wps.20083. Ballenger-Browning, K. K., Schmitz, K. J., Rothacker, J. A., Hammer, P. S., Webb-­ Murphy, J. A., & Johnson, D. C. (2011). Predictors of burnout among military mental health providers. Military Medicine, 176(3), 253–260. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W. H. Freeman. Biswas-Diener, R. (2009). Personal coaching as a positive intervention. Journal of Clinical Psychology, 65(5), 544–553. doi:10.1002/jclp.20589. Dewa, C. S., Loong, D., Bonato, S., Thanh, N. X., & Jacobs, P. (2014). How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research, 14(325), 1. doi:10.1186/1472-6963-14-325. Gates, D. M., & Gillespie, G. L. (2008). Secondary traumatic stress in nurses who care for traumatized women. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 37(2), 243–249. doi:10.1111/j.1552-6909.2008.00228.x. Gazelle, G., Liebschutz, J. M., & Riess, H. (2014). Physician burnout: Coaching a way out. Journal of General Internal Medicine, 30(4), 508–513. doi:10.1007/ s11606-014-3144-y. Grant, A. M. (2012). An integrated model of goal-focused coaching: An evidence-­ based framework for teaching and practice. International Coaching Psychology Review, 7(2), 146–165. Grant, A. M., & Sonnentag, S. (2010). Doing good buffers against feeling bad: Prosocial impact compensates for negative task and self-evaluations. Organizational Behavior and Human Decision Processes, 111(1), 13–22. doi:10.1016/j.obhdp.2009.07.003. Green, J., Wyllie, A., & Jackson, D. (2014). Social networking for nurse education: Possibilities, perils and pitfalls. Contemporary Nurse, 47(1–2), 180–189. doi:10.1080/10376178.2014.11081919. Hart, V., Blattner, J., & Leipsic, S. (2001). Coaching versus therapy: A perspective. Consulting Psychology Journal: Practice and Research, 53(4), 229–237. doi:10.1037/1061-4087.53.4.229. Ritterband, L. M., Thorndike, F. P., Cox, D. J., Kovatchev, B. P., & Gonder-­Frederick, L.  A. (2009). A behavior change model for internet interventions. Annals of Behavioral Medicine, 38(1), 18–27. doi:10.1007/s12160-009-9133-4. Schmitt, T. L., & Lilly, K. (2012). Social media use among nurses. Journal of the Dermatology Nurses’ Association, 4(3), 181–187. doi:10.1097/ JDN.0b013e31825627f4. Theeboom, T., Beersma, B., & van Vianen, A. E. (2014). Does coaching work? A meta-analysis on the effects of coaching on individual level outcomes in an organizational context. The Journal of Positive Psychology, 9(1), 1–18. ­doi:10.1080/17439760.2013.837499. CHAPTER 5 Organizational Factors in Burnout and Secondary Traumatic Stress Shaun Stearns and Charles C. Benight Quick Facts • Organizational structure is critical to address to reduce the impact of burnout and secondary traumatic stress (STS). • Mechanistic bureaucratic organizations, including the military, create conditions that can promote STS and burnout. • Horizontal organizations that promote innovation, growth, and clear goals are more effective, promote lower burnout and greater work engagement. • Transformational leadership style is helpful to create a positive engaged workforce. • Organizational change is possible if a top down commitment to provider health and wellness is taken seriously. • Organizational constraints that limit employee decisional latitude, perceptions of control, role clarity, role unambiguity, and a sense of support can all contribute to burnout and STS. S. Stearns (*) • C.C. Benight Trauma, Health, & Hazards Center, University of Colorado, Colorado Springs, CO, USA © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1_5 85 86   S. STEARNS AND C.C. BENIGHT Organizational Systems Contribution and STS to Burnout Burnout was initially conceptualized as a phenomenon that human service professionals experienced (teachers, doctors, nurses, behavioral health-­ care providers, etc.). Human service professionals often have intense interactions with numerous individuals and work long hours (Maslach & Jackson, 1981). As we discussed in the Chap. 2, STS is also a serious concern for many mental health providers exposed to traumatic materials on an ongoing basis (Cieslak et al., 2013). Many human service professionals forego healthy self-care practices in order to help those in need. Indeed, somewhat ironically, at the same time mental health practitioners are promoting connection to friends and family, a healthy meditation practice, and/or healthier lifestyles, they often are not making room for these in their own lives. The problem is that over time these individuals can become emotionally exhausted and cynical toward their clients, which can also lead to a decreased sense of personal accomplishment (decreased self-efficacy). This cascade of consequences has critical implications for the provider, his/ her client, and the organization as a whole. The earlier chapters in this book reviewed the scope of the problem related to burnout and STS in military mental health providers. This chapter targets the importance of the organization in promoting or preventing these negative outcomes. We decided to take an outward-in approach with this material by starting with organizational structure followed by organizational culture and then leadership style. We conclude the chapter with a section focused on organizational constraints that influence individual perceptions of workplace support and quality of work life. We turn our initial focus to the organizational structure. Organizational Structure The structure of an organization plays an important role in promoting or helping to reduce job burnout and STS (Lambert, Hogan, & Jiang, 2010). Organizational structure can promote effective communication, flexibility, efficiency, and productivity (Bowditch & Buono, 2005; Greenberg, 2002). Many large organizations with numerous employees and departments (e.g., US military, Veterans Affairs) can be described as mechanistic bureaucracies (see Fig. 5.1). Mechanistic bureaucracies are ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   Decisional Authority & Autonomy Secretary for Health 87 Communication Chief of Staff Deputy for Operaons and Management ADUSH for Clinical Operaons Mental Health Operaons Mental Health Provider Veterans Health Administraon Assistant Secretary for Human Resources Deputy under Secretary of Health Deputy for Policy and Services Assistant Secretary for Operaons ADUSH for Administrave Operaons Surgical Services Iraq and Afghanistan Veterans of America Disabled Veterans Mental Health Provider Mental Health Provider Fig. 5.1  Example of a vertical, mechanistic bureaucracy highly complex, vertical organizations that emphasize standardization of policies and procedures where information flows from the top to the bottom (Bowditch & Buono, 2005; Greenberg, 2002). This type of organization is highly centralized, where lower-level employees lack significant control and decision-making authority. Mechanistic bureaucracies also struggle with interdepartmental communication. Collectively, employees often report higher alienation in this type of organizational structure. One could easily argue that military and VA hospital-based mental health systems function within this type of organizational structure. Mechanistic bureaucracies are slow to adapt to new trends and therefore lack the innovation that horizontal or organic organizations can achieve. Mechanistic bureaucracies are best fit for routine technology in simple and stable environments that require extensive specialization and formalization such as governmental departments, hospitals, and all branches of military health care. However, the disadvantages of imposing a ­mechanistic 88   S. STEARNS AND C.C. BENIGHT bureaucracy on highly skilled professionals (e.g., mental health professionals) are numerous and originate from difficulties in communication and lack of autonomy. The bureaucratic structure promotes increased demands and decreased job control (decisional latitude and autonomy), role conflicts, role ambiguity, isolation, and reward/effort imbalances (Bowditch & Buono, 2005; Cordes & Dougherty, 1993; Karasek, 1979). Although it is beyond the scope of this chapter, extensive research has targeted the role of organizational structure in military environments to promote uptake of technological and logistical advancements. Bjørnstadt (2011) highlighted the “network organization” as the current focus for the more global and multinational aspects of military engagement (e.g., North American Treaty Organization). In her research, Bjørnstadt concluded that military organizations may benefit from a more decentralized, flatter organizational structure in order to promote greater flexibility and effectiveness (see Fig. 5.2). This may also be the case for mental health care within the military. The key organizational structures that may impact burnout and STS in military mental health providers are complexity, formalization, and centralization. Complexity refers to the number of levels an organization has. It determines the level of differentiation necessary to efficiently run the organization. The more complex an organization becomes, the more time supervisors must spend dealing with communication, coordination, and control, leaving less time for supporting staff working under them. Clearly, the scope and complexity of the US military health-care organization is extensive. Indeed, health-care delivery within this huge bureaucracy is hard to even grasp. To put this in perspective, in 2013 the US Department of Defense had 56 hospitals, 361 ambulatory care clinics, and 249 dental clinics operating worldwide and employing 60,389 civilians and 86,051 military personnel (http://www.defense.gov/Portals/1/Documents/ pubs/140930_MHS_Review_Final_Report_Main_Body.pdf; Department of Defense, 2014). The VA size is even more staggering seeing 55 million veterans a year with over 155 hospitals and a number of outpatient clinics (Hartmann et al., 2009). Formalization is used to describe the extent to which an organization relies on rules and standard procedures to direct the behavior of its employees. One can easily argue that military organizations are on the high end of formalization. High formalization promotes standardized procedures and, conceivably, reliable output for the organization. Thus, ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   89 Veterans Health Administraon Mental Health Operaons Mental Health Provider Mental Health Provider Mental Health Provider Surgical Services Primary Care Operaons Surgeon General Praconer Decisional Authority, Autonomy & Communicaon Fig. 5.2  Example of a flat, organic organization for military mental health providers working within either the DOD or VA, high formalization should foster highly reliable and optimal patient care. However, organizations with a low formalization structure may be more appropriate for positions that require a high degree of skill or abstract reasoning, such as psychological services. When applied appropriately, low formalization improves job satisfaction, decreases absenteeism due to sickness, and decreases personnel turnover (Bakker & Demerouti, 2014; Hackman & Oldham, 1980). The benefits observed with low formalization are accounted for through increased skill variety, task significance, task identity (opposite of role ambiguity), feedback, and autonomy. Thus, standardization of care may be somewhat at odds with the high skill level of mental health providers who value their clinical independence and work autonomy. Centralization refers to locus of decision-making within an organization. Highly centralized organizations (e.g., military and VA health care) have a vertical structure where the leaders or commanders have ultimate decision-making power (Greenberg, 2002). Decentralized organizations (i.e., horizontal) task lower-level directors with high a degree 90   S. STEARNS AND C.C. BENIGHT of ­decision-­making authority, allowing them to flexibly respond to the needs of their employees. It is possible for highly vertical organizations to decentralize by delegating more decisional power to lower-level directors or assigning a proxy that has the decision-making authority of the commander. Beyond the structure of the organization, organizational culture is also critically important to consider. Organizational Culture Beyond the organizational structure, it is important to address the culture of an organization (Goodman, Zammuto, & Gifford, 2001). The culture of an organization reflects the stable beliefs, attitudes, and values that members of the organization hold in common, which often operate without awareness. Due to the unconscious nature of organizational culture, it can be difficult to study (Arbour, Kwantes, Kraft, & Boglarsky, 2014). Organizational culture consists of visible artifacts (physical setting and objects within that setting), the espoused beliefs, rules and behavioral norms of the organization, and underlying “taken-for-granted” assumptions. Researchers often choose to measure behavioral norms as a way to empirically observe organizational climate and is operationally defined as the way employees approach work and interact with others, as well as concern for people and concern for tasks. Hartmann et al. (2009) reviewed the role of organizational culture on important clinical outcomes for hospitals (e.g., the VA). In this paper, they outlined two primary dimensions that can be utilized to capture the climate of an organization: structure (rigid versus flexible) and focus (internal versus external). Four cultural domains were obtained with these primary components including entrepreneurial, group, hierarchical, and rational. Importantly, these authors reported on studies that have demonstrated that these different types of cultures influence critical clinical outcomes (e.g., patient care). The entrepreneurial culture is characterized by innovation, flexibility, risk-taking, and growth. Health-care innovation is important for patients to receive the most up-to-date care in an efficient and caring manner. Evidence exists for the value of an entrepreneurial climate within hospitals directly linked to better outcomes (Davies, Mannion, Jacobs, Powell, & Marshall, 2007; Hartmann et al., 2009). Thus, having a culture that promotes new approaches to care and staff ingenuity appears to be positive. ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   91 The group-oriented culture is typified by collaboration, empowerment, participation, and shared beliefs. Research has demonstrated a positive relationship between this cultural type and better clinical outcomes (Davies et al., 2007), improved safety climate (Hartmann et al., 2009), and improved medical staff satisfaction and morale (Davies et al., 2007; Zazzali, Alexander, Shortell, & Burns, 2007). The hierarchical culture, as mentioned before, values structured processes, standards and regulations that promote efficiencies and predictability. This type of workplace culture has demonstrated difficulties with safety and communication from the bottom up (Hartmann et al., 2009). Interestingly, Hartmann et al. suggested negative effects on patient safety could be due to a strong focus on operating procedures and importance of rank. The application of this idea to the military mental health environment is concerning. Finally, the rational organization has a strong focus on goals and productivity to produce quantifiable outcomes. Such an approach within health care can have some disturbing manifestations. For example, counting the number of patients seen in a clinic as a primary outcome versus clinical improvement could be a problem. However, having quantifiable clinical and functional outcomes for patients should improve care. Hartmann et  al. (2009) reported on several studies that have demonstrated negative associations between the rational culture with important clinical outcomes. Hartmann et  al., however, did not find this in their specific sample of VA hospitals. Collectively, it appears that having a more entrepreneurial and group culture may provide environments that are related to better clinical outcomes within health-care settings, whereas hierarchical cultures tend to demonstrate the opposite. The relationship of culture to burnout and STS, therefore, may be related to clinical effectiveness or lack thereof (Craig & Sprang, 2010). A cohesive group that promotes effective training in the most efficacious trauma interventions, one can hypothesize, would have the best clinical outcomes. Craig and Sprang found in a national random sample of clinical psychologists and social workers that individuals who reported specialized training in trauma treatments reported greater compassion satisfaction and less burnout than those who did not. A hierarchical culture (and structure) would undoubtedly be slower to adopt new approaches and procedures that may be more optimal for a changing clinical landscape. 92   S. STEARNS AND C.C. BENIGHT Another approach to organizational culture may also provide some important lessons for burnout and STS within the military mental health-­ care environment. Arbour et al. (2014) divided organizational culture into three types: constructive cluster, passive/defensive cluster, and aggressive/ defensive cluster. The constructive cluster encourages employees to interact with others and approach tasks in ways that will help them meet higher order satisfaction needs (Cook & Szumal, 1993). Included within the constructive cluster are achievement orientation (goal focused), humanistic approach (person centered, employee participation expected), self-actualizing (individual growth, creativity, and emphasis on quality over quantity), and affiliative focused (prioritizes developing open and positive employee relationships) (Arbour et al., 2014). Findings from Arbour et al. suggested that this cluster is related to lower levels of stress, greater job satisfaction, and reduced intention to leave the organization. Employees who are part of the passive/defensive cluster interact with fellow employees and supervisors in a way that will not threaten their job security. The passive/defensive cluster includes approval orientation (focus on gaining approval and being liked by others), conventionality (conservative and bureaucratic, promotes conformity at the expense of effectiveness), dependent style (hierarchically controlled and discourages employee input), and avoidance (shifts responsibility to others to avoid blame at all costs). Employees consistently report this type of organizational culture generates greater employee stress, reduced job satisfaction, and greater intention to leave the organization (Arbour et al., 2014). Fearing for one’s job is not an effective organizational climate and undoubtedly promotes burnout and possibly STS. The aggressive/defensive cluster, in stark contrast to the passive/defensive cluster, expects employees to confront tasks in a forceful way, protecting their status and security within the organization. The aggressive/defensive cluster includes oppositional norms (negativity and confrontation occur frequently), power orientation (focus on advancement by controlling subordinates and impressing supervisors), competitive stance (focus on success at the expense of fellow employees), and perfectionistic style (mistakes not tolerated, attention to detail and narrowly defined objectives). Arbour et al. (2014) found organizations that reflected an aggressive/defense culture reported lower job satisfaction, higher job stress, and lower intent to stay within the organization. ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   93 These results are consistent with the organizational culture data reported by Hartmann and colleagues that healthier organizations are those that promote greater autonomy, flexibility, cooperation, innovation, empowerment, and growth. In contrast, extremely rigid, hierarchical organizations tend to promote greater stress, more safety concerns, poorer clinical outcomes, and greater staff turnover. The implications for the more hierarchical and rigid military organizations (including the VA) are important to consider relative to burnout and STS. Indeed, it is highly probable that the influx of clinical demands on the military mental health system has extensively stressed the organization, leading to even greater reliance on the existing organizational structure (command and control structure, authority, dependence) raising the level of clinician burnout. Organizational Culture Change Given the information above on the organizational structure and cultures that would best reduce the potential for burnout in military mental health providers, it is important to think about how to promote change. Although highly bureaucratic hierarchical organizations are not amenable to change, Bowditch and Buono (2005) suggested a parallel structure be created that acts independently to assess where structural changes can occur and determine the means by which to enact changes. The parallel structure seeks to fill gaps left by the mechanistic bureaucracy and focuses on employee concerns, data gathering, diagnosis, problem solving, organizational interventions, strategy planning, and implementation. The members of the parallel structure consist of those from the overall organization and, while serving within the parallel structure, have independence from the parent organization. This of course raises some difficulties for military-based organizations that have strict reporting structures. However, it would be possible to have a reporting structure for this separate group that reports to a hospital commander and bypasses some of the typical hierarchy. A parallel structure is only effective if the overall organization does not stifle or suppress new ideas that challenge existing policies and procedures. The five key elements of a parallel structure are as follows. First, the purpose is to improve existing or introduce new organizational practices. Second, a different structure and practicing procedure from the parent organization is necessary. This would mean that the ­communication s­tructure would 94   S. STEARNS AND C.C. BENIGHT need to be relatively flat with low differentiation to ­promote open communication. Third, the parallel structure must consist of members from the parent organization. Fourth, senior-level leaders must control and legitimize the parallel structure. And fifth, there must also be mechanisms that link the parallel organization to the parent organization, commonly accomplished through the use of liaisons. Ideally, the parallel structure would be able to pinpoint where the three main characteristics of the mechanistic bureaucracy are effective and where changes need to be made. For example, high formalization and centralized decision-making may work seamlessly in promoting a uniform scheduling process, but clinical flexibility for providers with difficult cases and need for self-care may be stifled by low decision-making authority. The rigid task focus of the mechanistic bureaucracy, that is very effective in the military for keeping the mission target clear, may create role conflicts, decrease adaptability and consequently promote burnout in mental health providers. The parallel structure would record and report these difficulties, as well as take time to generate targeted interventions and policy changes. If the standard organization can effectively implement the suggestions of the parallel structure, it can maintain the effective aspects of the mechanistic bureaucracy, decentralize decision-making, and decrease formalization where it is needed. The organizational structure and culture are clearly involved with exacerbating or preventing staff burnout and possibly STS in military mental health providers. Another critical factor to consider is leadership style within the organization. Leadership Style Perhaps nowhere else in the world is leadership more emphasized than within the military. Leadership style is a key component to organizational job burnout. High-performing leaders often utilize transformational leadership encouraging employees to contribute to group goals, share responsibility, and develop a sense of ownership within the organization (Bass, Waldman, Avolio, & Bebb, 1987; Lowe, Kroeck, & Sivasubramaniam, 1996; Vallen, 1993). This has also been shown within the military environment (Kane & Tremble, 2000). A leader with a transformational leadership style is excited to be at the job and treats his/her employees like family. Everyone is aware and engaged with the goal(s) they are working toward. Transformational leaders cast a ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   95 vision of what they think the future will be and each employee is cast into a specific role that is of paramount importance to the organization’s success. The personality factors that coalesce into creating a transformational leader include charisma, individualized consideration, and intellectual stimulation (Bass, Waldman, Avolio, & Bebb, 1987). Employees in this environment appreciate feedback and are excited to learn new things and become better at their jobs. The transformational leader provides feedback and resources to assist employees in perfecting their skills. They also provide correction without demoralizing the employee in front of their fellow co-workers. In this environment, employees are fully engaged and job burnout rarely occurs. The only drawback to the transformational leadership style is that it can be energy intensive at first, although it has been found that leaders who use this leadership style experience lower depersonalization and a higher sense of personal accomplishment (Zopiatis & Constanti, 2010). In contrast, moderate- to low-performing leaders generally adopt a transactional leadership style, creating an environment in which the employee feels little responsibility toward organizational goals and is motivated primarily by monetary or some other reciprocal compensation (Bass, Waldman, Avolio, & Bebb, 1987; Vallen, 1993). Transactional leadership emphasizes the clarification of goals, work standards, assignments, and equipment. Ideally, if employees meet the standards set by the transactional leader, they will receive rewards contingent upon their performance. Many transactional leaders remain fairly inactive until an emergency occurs and they must step in to correct an issue; this is known as management by exception. Transactional leadership, executed at the most optimum level, has a negligible effect on job burnout and is well suited for work environments that require low skill or minimal experience (Zopiatis & Constanti, 2010). A transactional leadership style is generally benign and well suited to industrial organizations, although it can become destructive if it converts to being autocratic in nature (Vallen, 1993). The autocratic leader makes all decisions, sets all tasks, and continuously checks whether their subordinates are doing their job. Positive feedback for a job well done is all but absent, whereas mistakes are pointed out and instantly punished. This creates a perfectionistic culture that can undermine moral. Supervisors choose this autocratic style of transactional leadership because it offers a strong sense of control and alleviates the fear many undertrained leaders experience. Autocratic managers use threats, 96   S. STEARNS AND C.C. BENIGHT fear, punishment, and only occasional rewards. This management style ­promotes dissatisfaction, absenteeism, and high turnover. High turnover and absenteeism are very costly to organizations and highly demoralizing to co-workers observing this process. This promotes further turnover and increases the costs associated with recruiting and training new providers (Taris, 2006). It is under autocratic leadership that we see employees who experience a high amount of job burnout. These employees are not engaged in their work and do not feel like they are contributing to an overarching cause. Resources are not provided that would allow them to effectively accomplish their job, and they are often demoralized in front of other employees. Decreased commitment to the organization, absenteeism, “presenteeism” (present but inefficacious), and turnover are highly affected by job burnout (Burke & Richardsen, 2001; Morse, Salyers, Rollins, Monroe-DeVita, & Pfahler, 2012). Presenteeism is particularly troubling, because this phenomenon tarnishes the reputation of the organization, can lead to errors, increases negative word-of-mouth sharing, and promotes dissatisfaction in other employees. The transactional leadership style, and the autocratic version of it, can be seen in many government organizations. The problem occurs when applying a transactional leadership style to military mental health providers, who are highly trained, highly skilled, and need a fair amount of autonomy to do their job effectively. Thus, efforts to reinforce a transformational leadership approach and avoid the controlling and negative aspects of the autocratic transactional style would be extremely beneficial in reducing burnout and possibly STS in these providers. Unlike transformational and transactional leadership styles, the laissez-­faire leadership style generates exclusively negative results. The hallmarks of the laissez-faire leadership are inaction, procrastination, resistance to change, apathy, and avoidance. The originator of the three leadership styles characterize laissez-faire as the worst possible leadership style and with good reason (Bass, Waldman, Avolio, & Bebb, 1987). Skogstad and associates (2007) found that laissez-faire leadership predicted increased role conflict, role ambiguity, conflict with co-workers and bullying. All of these contribute to increased psychological distress in the work environment. Laissez-faire leadership not only hurts the employee and subsequently the organization, but also the leader (Zopiatis, & Consanti, 2010). Supervisors using laissez-faire leadership ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   97 report significantly higher emotional exhaustion, depersonalization, and decreased personal accomplishment. Laissez-faire usually is not a management style that is typically ­chosen, but is the response of a leader who is stretched too thin and overwhelmed; it could be a sign of leader burnout. Laissez-faire leadership is primarily characterized as a lack of response to subordinates needs and performance (Hinkin & Schriesheim, 2008). Indeed, Hinkin and Schriesheim contended that reward and punishment omission are central to the ­ destructive nature of laissez-faire leadership. Reward omission results in decreased job performance over time and has been described by Pithers (1985) as omission conditioning. As a result of this conditioning, the employee learns that his/her effort will not be rewarded and therefore gradually contributes less energy to the organization. Reward omission is by far more harmful than punishment omission, which is considered neutral or slightly positive by fellow co-workers (Hinkin, & Schriesheim, 2008). Reward omission creates an environment that is considered inequitable and unfair. Reward omission is associated with low supervisor effectiveness and low satisfaction with the supervisor. Laissez-faire leadership can also be seen in military settings and can develop when a successful leader has been overwhelmed with nonleadership responsibilities and gradually burns out. In summary, effective leadership that creates a vision for employees where they can see their role in the overall success of the organization is critical to combat job burnout. Military organizations charged with the mental health of our soldiers have a vital mission. Success requires effective leadership that embodies a transformational approach leading to a vibrant work environment that shuns simple transactional methods. A quota system where systemic success is based on the number of soldiers served (akin to number of burgers sold) only compounds the already challenging clinical landscape leaving providers disempowered and exhausted. Hospitals and outpatient clinics within the active duty sector and the VA have an opportunity to develop cutting-edge treatment for posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) that providers can get behind. This would generate clinician resolve and organizational commitment that improves the lives of the soldiers they serve. A by-product of this approach would also be improved provider health and well-being. Leadership style is often related to the context or practice setting where the provider sees patients. 98   S. STEARNS AND C.C. BENIGHT Practice Setting In this section of the chapter, we focus on three primary settings for military mental health providers beyond the on-post clinician. We cover the unique challenges of the deployed mental health clinician, the o ­ ff-­post community provider, and the therapist working within the VA.  The deployed clinician faces very unique challenges that clearly can affect burnout and STS. Challenge of the Deployed Mental Health Provider.  In her book Rule Number Two, Kraft (2007) reported a list of the many positive and negative experiences from her time counseling soldiers at the frontline. The negative experiences she mentioned speak to the physical environment that newly deployed clinicians must manage. She described a number of challenges including poisonous insects and wild animals, wearing full camouflage (long sleeve shirts and pants) in all climates (including the desert), hearing the sounds of firing guns/exploding artillery and not knowing whether the sounds are good or bad, hiding under flak jackets and Kevlar during attacks and the futility of trying to help soldiers with their trauma as they quickly move on to the next combat mission. Additionally, they must also be trained to use basic firearms and contend with the possibility of becoming a combatant; some are even imbedded in Special Forces combat teams (Moore & Reger, 2006). There is also the constant challenge of being bound by two codes of conduct, “Ethical Principles of Psychologists” and the “Officer’s Oath of Office”; however, these two codes of conduct do not always correspond and can contribute to significant role conflict. Overall, deployed mental health providers must combat their own traumatic and transitional experiences, while performing their duties to support and manage the trauma of soldiers returning from the frontlines. These duties are considerably more complex than when one is sitting in an office on a stateside Army post. Deployed behavioral health-care providers have a number of responsibilities on the frontline that are compounded by the challenges just listed. They provide preventative treatment to soldiers returning from intense combat situations, assess soldiers’ ability to return to combat, and provide psychological treatment of combat-related stress and psychiatric disorders (Moore & Reger, 2006). Often a military behavioral health-care provider’s job comes down to determining whether soldiers are fit or unfit for duty, ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   99 as opposed to focusing on the treatment of the traumatized individual. This conflict can create deep moral questions that can exacerbate already traumatic and stressful difficulties. Providers also face communication issues inherent to mechanistic bureaucracies. Requests can go unheard, recommendations can get lost on the way up the chain of command, and responses from decision-making authorities can arrive too late to benefit a particular soldier. These clinicians must perform all these responsibilities while working with limited access to reference materials and being isolated from fellow psychologists. They are also limited in the number of assessments they may use. Under these conditions, the behavioral health-care provider must be prepared to actively deal with the whole spectrum of psychological disorders, not just PTSD. Moreover, deployed clinicians must also strive to not be seen as an outsider. A deployed provider may struggle with patients and superiors if they do not look the part (hair and clothes), learn the military colloquiums, and carry themselves with a military posture (Linnerooth, Mrdjenovich, & Moore, 2011). There is often no escape from clients as well. Providers will encounter patients at meals, showers, restrooms, and chaplain services, to name a few places, challenging ethical boundary standards. Lastly, providers may also have limited time to become entirely comfortable with their environment. The potential to receive command decisions about new locations and missions is constant. They have little to no control over their location and workload; the individual must be ready at all times to relocate and receive new directives. The deployed environment provides extremely unique challenges with high demands, limited resources, low job control, high role conflict, high role ambiguity, and high organizational constraints, which is the recipe for generating job burnout and also accelerating the potential for developing STS. This is compounded by the potential primary trauma exposure these providers face. However, it should be noted that this experience can also be highly meaningful for providers offering a sense of self-sacrifice and contributing to a greater cause. Off-post Providers.  Away from the battlefield, being a behavioral health provider working within a private practice is no guarantee against developing job burnout and STS. One of the benefits of being deployed or on a military base is that the provider can become fully engulfed in the military culture and environment. This can help break down the barriers preventing soldiers from opening up about their experiences. Off-post clinicians 100   S. STEARNS AND C.C. BENIGHT face the problem of being perceived as an outsider, an individual that does not understand the military customs, traditions, hierarchical rules, and social norms (Linnerooth et al., 2011; Luby, 2012). It is always a difficult task to cultivate the trust necessary to develop a therapeutic partnership with trauma survivors and in this case perhaps even more so. Luby (2012) offered concrete methods for increasing military cultural awareness and competence by conducting a self-assessment, attending military events, learning military language/culture, integrating knowledge into treatment and increasing self-care/support activities. Veterans Affairs Mental Health Providers.  Although we have mentioned the VA at different points in this chapter, specific research with VA mental health providers offers more insight into challenges within this system of care. The Veterans Health Administration is a mechanistic bureaucracy and working through this hierarchical organization presents many of the same challenges that we have already identified for clinicians stationed at military bases (Garcia et  al., 2015; Garcia, McGeary, McGeary, Finley & Peterson, 2014). Mental health providers working through the VA reported they have more clinical work than they are able to do, struggle with organizational politics, and the bureaucratic process (low decision-­making authority). These factors negatively affected their ability to perform their job. High workload and low control, as we have indicated, both contribute to higher emotional exhaustion and depersonalization. Garcia et al. (2015) also reported that higher job burnout values for all subscales (exhaustion and cynicism) were associated with intent to leave one’s position in two years, which is very costly considering the amount of resources necessary to train and develop new mental health providers in this system. Consistent with these findings, Salyers and colleagues found that VA clinicians were more likely than community providers to report experiencing difficulties with managerial bureaucracy, organizational issues, numerous administrative meetings, and issues with hospital policies that work against the treatment of veterans (Salyers, Rollins, Kelly, Lysaker, & Williams, 2011). SupportNet Differences Based on Practice Location.  In our SupportNet investigation, we found important and significant differences between on-­ post and off-post providers in terms of burnout (for in-depth review see Chap. 2). Overall, job burnout was statistically higher in on-post t­ herapists ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   101 than off-post therapists. Providers who were male, working at a military installation, had prior military experience, and had been previously deployed had significantly higher disengagement levels than did women who were working off-post, had no previous military experience, and had never been deployed. This difference appeared to be led by higher d ­ epersonalization (behavioral disengagement from ­work-related activities). There was not a statistical difference in emotional exhaustion between the two groups, yet on-post providers had statistically lower work engagement than off-post providers. This may be due to a higher level of perceived organizational constraints reported by on-post providers. However, perceived support from supervisors was statistically higher among on-post providers than off-post, possibly identifying an isolation effect for off-post providers who work with military clients. Although there appears to be a combination of factors promoting greater challenges for on-post providers, the levels of STS were not statistically different between on-post and off-post therapists in our sample. It should be noted, however, that one would expect based on our data that around 20 percent of all military mental health providers (on-post or off-post) are struggling with both significant burnout and STS symptoms. It is important to also mention that our sample was undoubtedly skewed to lower burnout individuals who were able to find the time and energy to complete our surveys, thereby suggesting actual rates of burnout and STS may be higher on average. Clearly, working as a clinician within a highly mechanistic bureaucracy, either on a military installation or within the VA, offers difficult challenges that can result in elevations in burnout symptoms. Evidence suggests that higher burnout levels can create a possible vulnerability to developing STS creating additional difficulties for these providers (Shoji et al., 2015). Given the burden military mental health providers are facing combined with the uniqueness of the military organizational culture, it stands to reason that doing research with this population can be quite difficult. Organizational and Participant Challenges Conducting Burnout Research Conducting burnout and STS research is definitely a challenge. Not surprisingly, providers who are struggling with these difficulties undoubtedly find it unappealing to commit to any extra responsibilities beyond 102   S. STEARNS AND C.C. BENIGHT what they are already juggling. Asking potential participants to do a ­longitudinal survey over a 6-month period of time is simply too much for many. One can imagine few takers when potential participants are asked to be involved with a six-session randomized controlled trial (RCT) where you would possibly be randomized into a time delayed treatment group and must take two baseline surveys. Indeed, for the SupportNet RCT we sent 1720 solicitations to military mental health providers via regular mail and email. Out of this group, we received 101 responses (6 percent), with only 64 meeting the study inclusion criteria. Dropout was also an issue. Only 16 out of the 64 participants randomly assigned to one of three groups actually engaged into the study. Most of the 48 who dropped out of the study did not do anything beyond the initial survey. Clearly running studies with individuals struggling with burnout and STS is difficult. Working within the military environment can also create its own challenges. Military organizations are structured to PCS (permanent change of station) personnel on a rotation basis. As such we were confronted with changes in leadership and points of contact several times during the SupportNet project. For example, when designing our optimal intervention for burnout with input from a local Army installation, we utilized focus groups with providers. During this process, we had several critical personnel changes including director of behavioral health and the hospital commander. The challenges of leadership changes with this process were significant. Clearly, having a local champion for intervention development and research who is consistent within the organization is crucial. One potential solution to this problem would be the development of memorandums of understanding between the military installation and a university that can stand the test of time. This is especially true during heightened times of stress for the military organization where such partnerships may be extremely helpful. This may help to provide external support over time rather than exacerbating the demands to an organization already under siege. Thus far we have covered organizational structure and culture, leadership style, and practice location as important factors to consider when looking at reducing burnout and STS in military mental health providers. Specific aspects of the work environment beyond structure and culture (e.g., organizational constraints) are critical as well. ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   103 Organizational Constraints Organizational constraints are potent predictors of burnout and include poor equipment or supplies, rigid organizational rules and procedures, difficult supervisors, lack of necessary information about what to do or how to do it and conflicting job demands (Lee & Ashforth, 1996; Morse et al., 2012). Organizational constraints are often out of the providers’ control and actively prevent them from performing at expected levels. It has been found that organizational constraints decrease one’s ability to feel recovered at the end of the day and is associated with high emotional exhaustion and low work engagement (Sonnentag, Mojza, Demerouti, & Bakker, 2012). Garcia et al. (2014) found that organizational constraints were associated with higher burnout, higher absenteeism, and intent to leave the organization for VA mental health providers. Moreover, in comparison to community providers, agency or organizational clinicians reported spending more time completing administrative paperwork than independent providers and reported less control over their work environment (Rupert & Morgan, 2005). The unique bureaucracy of military organizations consists of numerous constraints not often observed in other organizations, contributing significantly to increased job burnout (Linnerooth et al., 2011). Organizational constraints abound within highly mechanistic bureaucracies. Imposing this type of system on highly skilled professionals generates difficulties in communication and lack of autonomy. The bureaucratic structure promotes increased demands and decreased job control (decisional latitude and autonomy), role conflicts, role ambiguity, isolation, and reward/effort imbalances (Bowditch & Buono, 2005; Cordes & Dougherty, 1993; Karasek, 1979). Indeed, these increased demands, reduced control, and social support have been extensively studied in relationship to burnout (van der Doef & Maes, 1998), less so for STS. More specifically, job demands (e.g., workload, decisional challenges, and learning demands), role issues (e.g., clarity and conflict), perceptions of control (e.g., adequate positive challenge, decisional control, work pace control), predictability and support (e.g., supervisor, co-workers, friends/ relatives) have been found to be important predictors in work engagement, job satisfaction and burnout (Maslach, Schaufeli, & Leiter, 2001; van der Doef & Maes, 1998). The literature has consistently supported a demand-control model where increases in work related demands and 104   S. STEARNS AND C.C. BENIGHT reduced resources, results in decreases in perceived control over critical work related goals leading to the negative effects of burnout (de Jonge, van Vegchel, Shimazu, Schaufeli, & Dormann, 2010). Elevated levels of burnout, in turn, can lead to greater STS symptoms; thus, a perfect storm for military mental health providers (Shoji et al., 2014). We turn our attention now to the importance of workload as an organizational contributor to burnout and STS. Workload.  The number of military or veteran patients seeking mental health care has grown drastically over the last decade. The Department of Veterans Affairs (VA) alone has observed an astounding 200 percent increase in the number of patients with PTSD receiving behavioral health services in 2005 (Rosenheck & Fontana, 2007). As of 2014, this number had risen another 65 percent (VA Mental Health Services Public Report, 2014). Thus, workload increases have been unprecedented for military mental health providers offering perhaps one of the greatest organizational contributors to provider burnout. But, not only has demand for services increased, so has the complexity of cases. Posttraumatic stress disorder as well as major depression and substance abuse are problematic among this population. In addition to mental disorders, OEF/OIF combat veterans have been found to face a multitude of problems in daily living including impairments at work (Engelhard et al., 2007), psychosocial difficulties (Pietrzak et al., 2010) and family/marital problems (Goff et al., 2007) including domestic violence (Trevillion et al., 2015). Perhaps most concerning is the rate of suicide within this population. In 2008 the rate of suicides for the Army exceeded that of the general population. In a 2010 report, the rates for 2009 continued to be high with 239 suicides across the Army, including reserve units. (http://csf2.army.mil/downloads/HP-RR-SPReport2010. pdf; U.S Army, 2010). Adding to these tragic numbers, 146 active duty deaths were related to high-risk behaviors, including 74 drug-related deaths. Soldiers suffering from the polytrauma clinical triad (PTSD, TBI, and chronic pain) are at even higher suicide risk (Finley et al., 2015). The challenges for mental health providers are daunting. Role Issues.  The clarity and potential conflict in job roles are also all important to consider in relation to burnout (Maslach et al., 2001). Role conflict refers to the experienced incongruity of job demands c­ ommunicated ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   105 by the hiring organization and refers to when two or more role requirements are incompatible or work against each other (Cordes, & Dougherty, 1993). Role conflict contributes to burnout by substantially increasing the demands placed upon the employee and creating a situation where a requirement of the job remains unmet. Role ambiguity refers to having a low sense of security and predictability, especially regarding one’s goals and means of accomplishing them. Many elements contribute to role ambiguity, such as a lack of information and resources necessary to perform one’s job, a lack of ­clarity regarding the proper procedures for performing the job, and not being made aware of one’s performance. A lack of agreement or coordination among supervisors can result in a sense of role ambiguity and leaves the needs and abilities of the employee out of the conversation (Kahn et al., 1964). Role conflict and role ambiguity result in increased job stress, decreased professional performance, and impaired efficiency (Rizzo, House, & Lirtzman, 1970; Lambert & Lambert, 2001). The unique context of the military mental health provider offers even greater challenges related to one’s role. Active duty mental health workers have a very unique professional duty that is not seen in any other mental health-care setting. These providers have a split allegiance. On the one side they are committed to their client’s welfare and want to provide the best possible care for their soldiers. On the other side, these providers have a duty to the larger military system to provide the best possible mental health support for their clients to get them back on the battle field as quickly as possible, where they may be killed or will kill. The allegiance challenge creates clear difficulties with one’s professional role and identity (Daniels, 1969). Figley (1978) underscored this moral dilemma suggesting that the therapist must confront the societal sanctioning of killing, manage soldiers’ difficulties with survivor guilt, and be exposed to the grotesque details of war. Johnson, Bacho, Heim, and Ralph (2006) extended the role challenges faced by military mental health providers by highlighting significant boundary challenges, extra therapy contacts and dual relationships that are encountered by active duty providers. They provided a case in point where an active duty clinical psychologist was treating a young corpsman for depression, only to find them both deployed with the provider serving as the patient’s supervisor in the chain of command. All of these challenges create role confusion and conflicts that elevate the risk for burnout in active duty providers. In contrast, community 106   S. STEARNS AND C.C. BENIGHT ­ ental health clinicians working with military clients do not have the same m organizational challenges related to role confusion; their duty is only to the patient. They may, however, have to manage unique legal challenges related to their military clients in relation to client confidentiality (Prosek & Holm, 2014). They may also struggle with the dilemma that their ­soldier, if active duty, may be redeployed if he/she is fit for duty. Beyond the role difficulties that clinicians face, limited perceptions of control also can cause problems. Employee Control.  Job control is a core component of job burnout and refers to the degree to which employees can choose his/her actions. It is thought to consist of four constructs: decision latitude, decision authority, skill discretion, and autonomy. Decision latitude refers to the ability of an individual to make decisions related to his or her schedule, length of work day, number of patients one has, and so on (Hystad, Eid, & Brevik, 2011). Decision authority is the liberty to make decisions on the job. Skill discretion is the freedom to choose the range of skills used at work (Spector, 1998). Finally, autonomy refers to control over immediate scheduling and how one utilizes their time. As part of the job demand-control theory, the interaction between increased job demands and diminished job control is thought to significantly predict increased job burnout (Karasek, 1979). A recent meta-­ analysis has found that increased job control is a significant predictor of lower depersonalization and a higher sense of personal accomplishment (Park, Jacob, Wagner, & Baiden, 2014). Organizational factors that produce enhanced control include greater decisional control, level of work-related challenge that optimizes engagement, and more latitude in deciding workload/pace (Maslach et  al., 2001). We have been unable to find any literature that has evaluated these control related factors within military mental health clinicians. Military nurses have been studied and greater autonomy over patient care was associated with lower intent to leave the organization and reduced burnout (Patrician, Shang, & Lake, 2010). Through our discussions with providers involved in the SupportNet project, we did hear concerns over the limited control clinicians felt over workload and work flow. Social Support.  Overall, social support is one of the most potent resources for buffering the negative effects of stress and offers protection against traumatic stress, STS, and job burnout. Extensive research provides empirical evidence for the importance of social support in reducing ­burnout ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   107 (Maslach et  al., 2001). However, not all social support is created equal (Leiter, 1988). Support provided from co-workers and supervisors (professional support) has been found to be both alleviating and potentially aggravating of job burnout. Co-worker support was found to predict higher personal accomplishment, as well as higher emotional exhaustion (Leiter, 1988). The type of professional support provided plays a major impact on whether burnout is relieved or not. Professional support related to the implementation and development of skills (resource development) was found to relate to increased personal accomplishment and decreased emotional exhaustion (Leiter, 1991). Receiving positive co-worker support, as one would expect, was related to decreased depersonalization and emotional exhaustion. In contrast, negative social support and interpersonal conflicts have the potential to exacerbate job burnout and have a major impact on decreased quality of life (Lakey, Tardiff, & Drew, 1994). It has also been found that negative social interactions with co-workers and supervisors predicted low self-esteem, low interpersonal trust, decreased external control beliefs, and dysfunctional attitudes toward the organization. In the SupportNet data, we found evidence demonstrating that social support was also important for promoting secondary traumatic growth (i.e., positive self-development related to indirect exposure to trauma) (Shoji et al., 2014). In our longitudinal data, we found that supervisory support at time 1 was negatively correlated with time 2 burnout (r = −.24, p < .01) and STS levels (r = −.21, p < .01). Having a caring supportive environment is clearly helpful for shielding the individual provider from burnout and other negative stress related outcomes. Importantly, so is the predictability of the environment. Predictability.  Predictability has a negative relationship with burnout. The perception of predictability can be influenced in a number of ways. For example, multiple unplanned changes in paper work requirements can compound unpredictable clinical challenges (e.g., suicidal behaviors) that therapists often must manage. We have not been able to identify any studies that have looked at the role of predictability on STS in military mental health providers. In summary, workload, role difficulties, employee control, supervisory support, and predictability may all play an important role in the ­exacerbation or prevention of burnout and STS in military mental health 108   S. STEARNS AND C.C. BENIGHT providers. This is especially true for those working within highly mechanistic ­bureaucratic organizations. Organizational culture more generally may also be valuable to consider, especially within the military itself. Summary and Recommendations The major point of this chapter that is critical to reiterate is that the organizational environment is extremely important to keep in mind when considering options for reducing burnout and STS in military mental health providers (and other medical providers for that matter). Organizations that promote decisional latitude, workflow control, high role clarity, low role conflict, and a manageable workload will go a long way to reducing burnout and STS. This is particularly important given the complexity of the cases returning from contemporary warfare where PTSD and TBI create a difficult combination. Combating the inherent difficulties associated with highly vertical mechanistic bureaucracies is essential, especially under significant organizational stress environments. Transformational leadership style is one way to help move employees to see the overall mission for the group, have a sense of shared responsibility, and develop a sense of ownership within the organization. Lastly, it is essential to have positive supervisory support versus a punitive transactional approach where providers fear punishment for failing to meet some poorly communicated standard. Ultimately, burnout and STS in military mental health providers are organizational challenges that must be addressed from the top commanders to the frontline providers to make helping our soldiers who desperately need the best care something we can ensure. References Arbour, S., Kwantes, C.  T., Kraft, J.  M., & Boglarsky, C.  A. (2014). Person-­ organization fit: Using normative behaviors to predict workplace satisfaction, stress and intentions to stay. Journal of Organizational Culture, Communications & Conflict, 18(1), 41–64. Bakker, A. B., & Demerouti, E. (2014). Job demands-resources theory. In P. Y. Chen & C.  L. Cooper (Eds.), Work and wellbeing (Vol. III, pp.  37–64). Chichester: Wiley-Blackwell. Bass, B. M., Waldman, D. A., Avolio, B. J., & Bebb, M. (1987). Transformational leadership and the falling dominoes effect. Group & Organization Management, 12(1), 73–87. doi:10.1177/105960118701200106. ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   109 Bjørnstad, A.  L. (2011). Exploring network organization in military contexts: Effects of flatter structure and more decentralized processes. Military Psychology, 23(3), 315–331. doi:10.1080/08995605.2011.570595. Bowditch, J. L., & Buono, A. F. (2005). A primer on organizational behavior (6th ed.). Hoboken, NJ: Wiley. Burke, R. J., & Richardsen, A. R. (2001). Psychological burnout in organizations. Research and intervention. In R. T. Golembiewski (Ed.), Handbook of organizational behavior (2nd ed., Revised and Expanded, pp. 327–363). New York: Marcel Dekker. Cieslak, R., Anderson, V., Bock, J., Moore, B.  A., Peterson, A.  L., & Benight, C. C. (2013). Secondary traumatic stress among providers working with the military: Prevalence and its work- and exposure-related correlates. The Journal of Nervous and Mental Disease, 201(11), 917–925. doi:10.1097/ NMD.0000000000000034. Cooke, R. A., & Szumal, J. L. (1993). Measuring normative beliefs and shared behavioral expectations in organizations: The reliability and validity of the organizational culture inventory. Psychological Reports, 72(3c), 1299–1330. doi:10.2466/pr0.1993.72.3c.1299. Cordes, C. L., & Dougherty, T. W. (1993). A review and an integration of research on job burnout. The Academy of Management Review, 18(4), 621–656. doi:10.2307/258593. Craig, C. D., & Sprang, G. (2010). Compassion satisfaction, compassion fatigue, and burnout in a national sample of trauma treatment therapists. Anxiety, Stress, & Coping, 23(3), 319–339. doi:10.1080/10615800903085818. Daniels, A.  K. (1969). The captive professional: Bureaucratic limitations in the practice of military psychiatry. Journal of Health and Social Behavior, 10(4), 255–265. doi:10.2307/2948433. Davies, H. O., Mannion, R., Jacobs, R., Powell, A. E., & Marshall, M. N. (2007). Exploring the relationship between senior management team culture and hospital performance. Medical Care Research and Review, 64(1), 46–65. doi:10.1177/1077558706296240. de Jonge, J., van Vegchel, N., Shimazu, A., Schaufeli, W., & Dormann, C. (2010). A longitudinal test of the demand–control model using specific job demands and specific job control. International Journal of Behavioral Medicine, 17(2), 125–133. doi:10.1007/s12529-010-9081-1. Department of Defense. (2014). Military Health System Review  – Final report (Final report to the Secretary of Defense). Retrieved from http://www. defense.gov/Portals/1/Documents/pubs/140930_MHS_Review_Final_ Report_Main_Body.pdf. Department of Veterans Affairs. (2014). VA mental health services: public report. Retrieved from http://www.mentalhealth.va.gov/docs/Mental_Health_ Transparency_Report_11-­24-­14.pdf 110   S. STEARNS AND C.C. BENIGHT Engelhard, I.  M., van den Hout, M.  A., Weerts, J., Arntz, A., Hox, J.  J., & McNally, R. J. (2007). Deployment-related stress and trauma in Dutch soldiers returning from Iraq prospective study. British Journal of Psychiatry, 191, 140–145. doi:10.1192/bjp.bp.106.034884. Figley, C. R. (1978). Stress disorders among Vietnam veterans: Theory, research, and treatment. New York: Brunner/Mazel. Finley, E. P., Bollinger, M., Noël, P. H., Amuan, M. E., Copeland, L. A., Pugh, J.  A., et  al. (2015). A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan. American Journal of Public Health, 105(2), 380–387. doi:10.2105/AJPH.2014.301957. Garcia, H. A., McGeary, C. A., Finley, E. P., McGeary, D. D., Ketchum, N. S., & Peterson, A. L. (2015). The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder specialty programmes. Psychology and Psychotherapy: Theory, Research and Practice, 1–16. doi:10.1111/ papt.12057. Garcia, H. A., McGeary, C. A., McGeary, D. D., Finley, E. P., & Peterson, A. L. (2014). Burnout in veterans health administration mental health providers in posttraumatic stress clinics. Psychological Services, 11(1), 50–59. doi:10.1037/ a0035643. Goff, B. S. N., Crow, J. R., Reisbig, A. M. J., & Hamilton, S. (2007). The impact of individual trauma symptoms of deployed soldiers on relationship satisfaction. Journal of Family Psychology, 21(3), 344–353. doi:10.1037/0893-3200.21.3.344. Goodman, E. A., Zammuto, R. F., & Gifford, B. D. (2001). The competing values framework: Understanding the impact of organizational culture on the quality of work life. Organization Development Journal, 19(3), 58–68. Greenberg, J.  (2002). Managing behavior in organizations (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Hackman, J.  R., & Oldham, G.  R. (1980). Work redesign. Reading: Addison-Wesley. Hartmann, C. W., Meterko, M., Rosen, A. K., Zhao, S., Shokeen, P., Singer, S., & Gaba, D. M. (2009). Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration. Medical Care Research and Review, 66(3), 320–338. doi:10.1177/1077558709331812. Hinkin, T. R., & Schriesheim, C. A. (2008). An examination of “nonleadership”: From laissez-faire leadership to leader reward omission and punishment omission. Journal of Applied Psychology, 93(6), 1234–1248. doi:10.1037/ a0012875. Hystad, S. W., Eid, J., & Brevik, J. I. (2011). Effects of psychological hardiness, job demands, and job control on sickness absence: A prospective study. Journal of Occupational Health Psychology, 16(3), 265–278. doi:10.1037/a0022904. ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   111 Johnson, W. B., Bacho, R., Heim, M., & Ralph, J. (2006). Multiple-role dilemmas for military mental health care providers. Military Medicine, 171(4), 311–315. Kahn, R. L., Wolfe, D. M., Quinn, R. P., Snoek, J. D., & Rosenthal, R. A. (1964). Organizational stress: Studies in role conflict and ambiguity. Oxford, UK: Wiley. Kane, T. D., & Tremble, T. J. (2000). Transformational leadership effects at different levels of the Army. Military Psychology, 12(2), 137–160. doi:10.1207/ S15327876MP1202_4. Karasek Jr., R. A. (1979). Job demands, job decision latitude, and mental strain: Implications for job redesign. Administrative Science Quarterly, 24(2), 285–308. doi:10.2307/2392498. Kraft, H. S. (2007). Rule number two: Lessons I learned in a combat hospital (1st ed.). New York: Little, Brown and Co. Lakey, B., Tardiff, T.  A., & Drew, J.  B. (1994). Negative social interactions: Assessment and relations to social support, cognition, and psychological distress. Journal of Social and Clinical Psychology, 13(1), 42–62. doi:10.1521/ jscp.1994.13.1.42. Lambert, E. G., Hogan, N. L., & Jiang, S. (2010). A preliminary examination of the relationship between organisational structure and emotional burnout among correctional staff. The Howard Journal of Criminal justice, 49(2), 125–146. doi:10.1111/j.1468-2311.2010.00606.x. Lambert, V. A., & Lambert, C. E. (2001). Literature review of role stress/strain on nurses: An international perspective. Nursing & Health Sciences, 3(3), 161–172. doi:10.1046/j.1442-2018.2001.00086.x. Lee, R. T., & Ashforth, B. E. (1996). A meta-analytic examination of the correlates of the three dimensions of job burnout. Journal of Applied Psychology, 81(2), 123–133. doi:10.1037/0021-9010.81.2.123. Leiter, M. P. (1988). Burnout as a function of communication patterns A study of a multidisciplinary mental health team. Group & Organization Management, 13(1), 111–128. doi:10.1177/105960118801300112. Leiter, M. P. (1991). The dream denied: Professional burnout and the constraints of human service organizations. Canadian Psychology/Psychologie Canadienne, 32(4), 547–558. doi:10.1037/h0079040. Linnerooth, P. J., Mrdjenovich, A. J., & Moore, B. A. (2011). Professional burnout in clinical military psychologists: Recommendations before, during, and after deployment. Professional Psychology: Research and Practice, 42, 87–93. doi:10.1037/a0022295. Lowe, K. B., Kroeck, K. G., & Sivasubramaniam, N. (1996). Effectiveness correlates of transformational and transactional leadership: A meta-analytic review of the MLQ literature. Leadership Quarterly, 7, 385–425. Luby, C.  C. (2012). Promoting military cultural awareness in an off-post community of behavioral and social support service providers. Advances in Social Work, 13(1), 67–82. 112   S. STEARNS AND C.C. BENIGHT Maslach, C., & Jackson, S. E. (1981). The measurement of experienced burnout. Journal of Organizational Behavior, 2(2), 99–113. doi:10.1002/ job.4030020205. Maslach, C., Schaufeli, W.  B., & Leiter, M.  P. (2001). Job burnout. Annual Review of Psychology, 52(1), 397–422. doi:10.1146/annurev.psych.52.1.397. Moore, B. A., & Reger, G. M. (2006). Clinician to frontline soldier: A look at the roles and challenges of army clinical psychologists in Iraq. Journal of Clinical Psychology, 62(3), 395–403. doi:10.1002/jclp.20218. Morse, G., Salyers, M.  P., Rollins, A.  L., Monroe-DeVita, M., & Pfahler, C. (2012). Burnout in mental health services: A review of the problem and its remediation. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 341–352. doi:10.1007/s10488-011-0352-1. Park, H. I., Jacob, A. C., Wagner, S. H., & Baiden, M. (2014). Job control and burnout: A meta-analytic test of the conservation of resources model. Applied Psychology, 63(4), 607–642. doi:10.1111/apps.12008. Patrician, P. A., Shang, J., & Lake, E. T. (2010). Organization determinants of work outcomes and quality care ratings among Army Medical Department registered nurses. Research in Nursing & Health, 33(2), 99–110. doi:10.1002/ nur.20370. Pietrzak, R.  H., Johnson, D.  C., Goldstein, M.  B., Malley, J.  C., Rivers, A.  J., Morgan, C. A., & Southwick, S. M. (2010). Psychosocial buffers of traumatic stress, depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom: The role of resilience, unit support, and postdeployment social support. Journal of Affective Disorders, 120(1), 188–192. doi:10.1016/j.jad.2009.04.015. Pithers, R.  T. (1985). The roles of event contingencies and reinforcement in human autoshaping and omission responding. Learning and Motivation, 16(2), 210–237. doi:10.1016/0023-9690(85)90013-X. Prosek, E. A., & Holm, J. M. (2014). Counselors and the military: When protocol and ethics conflict. The Professional Counselor, 4(2), 93–102. doi:10.15241/ eap.4.2.93. Rizzo, J. R., House, R. J., & Lirtzman, S. I. (1970). Role conflict and ambiguity in complex organizations. Administrative Science Quarterly, 150–163. doi:10.2307/2391486. Rosenheck, R.  A., & Fontana, A.  F. (2007). Recent trends in VA treatment of post-traumatic stress disorder and other mental disorders. Health Affairs, 26(6), 1720–1727. doi:10.1377/hlthaff.26.6.1720. Rupert, P. A., & Morgan, D. J. (2005). Work setting and burnout among professional psychologists. Professional Psychology: Research and Practice, 36(5), 544–550. doi:10.1037/0735-7028.36.5.544. Salyers, M. P., Rollins, A. L., Kelly, Y.-F., Lysaker, P. H., & Williams, J. R. (2011). Job satisfaction and burnout among VA and community mental health workers. Administration and Policy in Mental Health and Mental Health Services Research, 40(2), 69–75. doi:10.1007/s10488-011-0375-7. ORGANIZATIONAL FACTORS IN BURNOUT AND SECONDARY TRAUMATIC...   113 Shoji, K., Bock, J., Cieslak, R., Zukowska, K., Luszczynska, A., & Benight, C. C. (2014). Cultivating secondary traumatic growth among healthcare workers: The role of social support and self-efficacy. Journal of Clinical Psychology, 70(9), 831–846. doi:10.1002/jclp.22070. Shoji, K., Lesnierowska, M., Smoktunowicz, E., Bock, J., Luszczynska, A., Benight, C. C., & Cieslak, R. (2015). What comes first, job burnout or secondary traumatic stress? Findings from two longitudinal studies from the U.S. and Poland. PLOS One, 10(8), e0136730 .http://doi.org/10.1371/journal. pone.0136730 Skogstad, A., Einarsen, S., Torsheim, T., Aasland, M. S., & Hetland, H. (2007). The destructiveness of laissez-faire leadership behavior. Journal of Occupational Health Psychology, 12(1), 80–92. doi:10.1037/1076-8998.12.1.80. Sonnentag, S., Mojza, E. J., Demerouti, E., & Bakker, A. B. (2012). Reciprocal relations between recovery and work engagement: The moderating role of job stressors. Journal of Applied Psychology, 97(4), 842–853. doi:10.1037/ a0028292. Spector, P. E. (1998). A control theory of the job stress process. In C. L. Cooper (Ed.), Theories of organizational stress (pp.  153–169). New  York: Oxford University Press. Taris, T. W. (2006). Is there a relationship between burnout and objective performance? A critical review of 16 studies. Work & Stress, 20(4), 316–334. doi:10.1080/02678370601065893. Trevillion, K., Williamson, E., Thandi, G., Borschmann, R., Oram, S., & Howard, L.  M. (2015). A systematic review of mental disorders and perpetration of domestic violence among military populations. Social Psychiatry and Psychiatric Epidemiology, 50(9), 1329–1346. doi:10.1007/s00127-015-1084-4. U.S. Army. (2010). Army Health Promotion, Risk Reduction and Suicide Prevention (HP/RR/SP) report (report 2010). Retrieved from http://csf2.army.mil/ downloads/HP-RR-SPReport2010.pdf Vallen, G. K. (1993). Organizational climate and burnout. The Cornell Hotel and Restaurant Administration Quarterly, 34(1), 54–59. doi:10.1016/0010-8804(93)90031-D. van der Doef, M., & Maes, S. (1998). The job demand-control(-support) model and physical health outcomes: A review of the strain and buffer hypotheses. Psychology & Health, 13(5), 909–936. doi:10.1080/08870449808407440. Zazzali, J.  L., Alexander, J.  A., Shortell, S.  M., & Burns, L.  R. (2007). Organizational culture and physician satisfaction with dimensions of group practice. Health Services Research, 42(3, part 1), 1150–1176. doi:10.1111/j.1475-6773.2006.00648.x. Zopiatis, A., & Constanti, P. (2010). Leadership styles and burnout: Is there an association? International Journal of Contemporary Hospitality Management, 22(3), 300–320. doi:10.1108/09596111011035927. CHAPTER 6 SupportNet: A Randomized Controlled Trial for Military Behavioral Health Burnout Kotaro Shoji, Charles C. Benight, and Shaun Stearns Quick Facts • To date there has not been a randomized controlled trial for an intervention directly targeting burnout in military mental health providers. • The SupportNet intervention was specifically designed to reduce burnout symptoms in military mental health providers targeting self-­care through a social media-based web system combined with peer coaching. • Significant reductions in burnout symptoms were found in the web/ coaching condition. • Replication of the findings is the necessary next step. The Neglected Military Mental Health Providers Unbelievably, there has not been one randomized controlled trial (RCT) for any burnout or secondary trauma intervention for military mental health providers. As indicated throughout this book, the mental health challenges facing our military are unprecedented. Due to the complexity of cases, level of treatment demand, and numbers of suicides, to name a few critical challenges, mental health providers are stretched to their K. Shoji (*) • C.C. Benight • S. Stearns University of Colorado, Colorado Springs, CO, USA © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1_6 115 116   K. SHOJI ET AL. professional limits. The purpose of this chapter is to present data from the RCT evaluating the SupportNet intervention for burnout that included peer support as well as a social media-based web system. The complexity and severity of mental health cases facing mental health providers working with combat soldiers cannot be overstated. Post-­traumatic stress disorder (PTSD) prevalence among combat soldier treatment seeking samples varies but has reached an astounding 37.8 percent (Jakupcak, Luterek, Hunt, Conybeare, & McFall, 2008). Depression and substance abuse are also commonly seen in these soldiers. In a recent study of Army soldiers from Active Component and National Guard combat units, Thomas et al. (2010) reported rates of depression from 11 percent (National Guard; N = 2,684) to 16 percent (Active Component; N = 4,933) for soldiers assessed three months post deployment, with 5 percent and 8.3 percent, respectively, reporting functional impairment associated with depression. Moreover, 12.4 percent of the National Guard soldiers and 14.5 percent of the active duty reported misuse of alcohol. Importantly, Seal et al. (2009) found that among the 10,676 veterans that had been diagnosed with a mental disorder, approximately 62 percent had more than one diagnosis. To make things worse, many of the patients with PTSD present as hostile and aggressive, thereby increasing provider stress through threat to personal safety (Voss Horrell, Holohan, Didion, & Vance, 2011). Finally, other patient factors unique to the military complicate things even more including traumatic brain injury, multiple deployments, and the likelihood that the client will redeploy to a combat zone following treatment (Voss Horrell et al., 2011). Ultimately, our mental health providers are working under extreme conditions, making intervention efforts for burnout a high priority. Based on our empirical finding that job burnout increases the risk of developing secondary traumatic stress (STS) (see Chap. 2) and that burnout may increase vulnerability to traumatic material in these providers, we developed our intervention targeting burnout in order to assist with vulnerability to STS. The development of an intervention requires a solid conceptual framework. We integrated the job demands-resources (JD-R) model with social cognitive theory (SCT) into our burnout intervention. The JD-R model is currently the most influential theoretical approach to understanding job burnout (Demerouti & Bakker, 2011). Job demands refer to those aspects of the job that require efforts or skills and, therefore, lead to some physiological and psychological costs. Job resources relate to components of the job that are helpful in (a) achieving work-related goals, (b) reducing job demands and costs associated with these demands, and SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   117 (c)  stimulating personal development. Through health impairment and motivational processes, job demands and resources directly, or in interaction with each other, affect job burnout. SCT provides a way to understand the self-regulation processes involved with managing both job demands and psychosocial resources related to job burnout (Benight & Cieslak, 2013). A demand becomes stressful when there is a lack of adequate resources to deal with this demand (Hobfoll, 1989, Lazarus & Folkman, 1984; Schaufeli et al., 2008). The process of regulation between demands and resources is seen as critical for human functioning in many theories of stress (Bandura, 1997; Hobfoll, 1989, 2001; Lazarus & Folkman, 1984). The classical self-regulation mechanisms described in SCT, which include environment, personal resources, and behavior, can be viewed as a dynamic interplay between demands and resources. For example, resilient mental health providers coping with the environmental demands of providing assistance to combat trauma survivors will use all three types of resources (i.e., environmental, personal, and behavioral) to offset clinical demands (e.g., increasing client load, witnessing grotesque details of survivor stories, extremely complex trauma spectrum disorders) in order to achieve positive functioning. Of course, internal demands (e.g., intrusive thoughts associated with secondary traumatic stress, empathetic engagement) must also be managed through available psychosocial resources. The utilization of resources in meeting these demands is achieved through self-regulatory processes, particularly self-evaluation. In the context of a model of self-regulation based on the demand-­ resource balance, self-efficacy beliefs provide a crucial mechanism generated through self-evaluative processing. Self-efficacy beliefs are hypothesized as central to predicting successful adaptation or dysfunction. In a study testing this expectation, both demands- and resources-related self-efficacy should be considered (e.g., “I am capable of effective work even with these extreme trauma cases” and “I am capable of seeking support from friends and colleagues when needed,” respectively). Jing (2008) showed that self-efficacy for specific job demands and for resource utilization mediated the effects of work stressors on job burnout. In the context of a model of self-regulation based on the demand-resource balance, self-efficacy beliefs provide a conduit that is central to predicting resilience or job burnout. Support for this contention was reported in a recent meta-analysis showing an average effect size of -.33 between self-efficacy perceptions and burnout, indicating that high self-efficacy was related to lower burnout (Shoji et al., 2015). 118   K. SHOJI ET AL. SCT also emphasizes the importance of social/environmental resources (e.g., social support) as a key interactive determinant with individual factors for successful adaptation to environmental demands. Decades of research have demonstrated that social support is important to consider in job burnout (Adriaenssens, De Gucht, & Maes, 2015). Thus, as we indicted in Chaps. 3 and 4, we focused our intervention on improving self-regulation by enhancing self-efficacy and social support. SupportNet Intervention In developing the intervention, we decided to focus on a pragmatic and scalable approach that combined a web-based self-care program with one-­on-­ one telephonic peer coaching (see Chaps. 3 and 4 for detailed description of the intervention development). The website, called SupportNet, offered many unique features (see Fig. 6.1) designed for enhancing self-­efficacy for self-care and promoting social support. To enhance social connection and support, the site was designed on a social media-based platform. Users are able to create a network of support with other users (more detail provided below), where they can receive direct encouragement in reaching their selfcare goals as well as helping others in their network with their goals. In Fig. 6.1  SupportNet landing page SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   119 addition, a module called “quick take 5” provides critical self-care skills such as breathing techniques or mindfulness exercises. These self-care skills are offered in easy digestible chunks that take only 5 minutes to complete. A resource library was also included that provides up-to-date information on evidence-based interventions for traumatic stress in an easy-­ to-­digest format (short paragraph summaries). To help providers boost their self-care self-efficacy, the site has a user-friendly goal-setting system designed to assist with setting a specific self-care goal, measuring success, and identification of an appropriate reward. Examples are provided to help the provider develop a targeted self-care improvement plan. A specific self-­ care goal is determined along with when, where, and with whom the person would complete the goal. Goal achievability is emphasized in order to maximize the opportunity for success, given the importance of mastery in enhancing self-efficacy (Bandura, 1997). The website offers the ability to not only set specific goals but also track progress toward the goal. Finally, as indicated above, providers are encouraged to link to others in the network to gain support for their self-care improvement. The coaching process was carefully designed to work in concert with the web intervention. A formalized coaching manual was developed that detailed each session (see Appendix). The overall coaching included providing education about burnout, assisting providers in setting self-care goals to increase coping self-efficacy, and supporting the participants in reaching those goals through utilization of the website. Coaching has been used to effectively address occupational stress and burnout (Biswas-­ Diener, 2009; Gazelle, Liebschutz, & Riess, 2014). Specifically, goal-­ focused coaching has been found to be an effective method of facilitating behavioral change (Grant, 2012). Thus, the web-support intervention combined with the telephonic peer coaching was designed based on the primary principles of SCT, which suggests that enhanced self-efficacy and perceived support are necessary to promote well-being and reduce burnout in stressed mental health providers. In order to evaluate the utility of our web/coaching burnout intervention for military mental health providers, we conducted an RCT. Research Design for the SupportNet RCT.  A staggered intragroup repeated baseline control design was utilized due to ethical considerations of withholding supportive interventions from anyone in the study. 120   K. SHOJI ET AL. Participants were assigned to one of three experimental conditions: coaching plus web intervention, delayed start coaching plus web intervention, or web-only intervention (see Table 6.1). Participants in the delayed group waited 8 weeks (length of the intervention) until starting the web intervention plus coaching. Participants were measured with an immediate post-intervention assessment (8 weeks) and then at a 2-month follow-up. This design allowed us to tease apart the effects of time with our delayed treatment group as well as the effect of coaching on the intervention. Please see Fig. 6.2 for the CONSORT chart depicting the randomization process and final subgroup sample sizes. Based on the assumption that enhanced self-efficacy and perceived social support would reduce burnout levels, we generated the following hypotheses: Hypothesis 1: Participants in the coaching plus web intervention group would have the largest decrease in burnout compared to a web-only group and a delayed treatment group. Hypothesis 2: Individuals in the web-only group would demonstrate greater reductions in burnout than a delayed baseline group. Mental Health Providers Who Participated in the RCT.  A total of 1,720 participants were recruited for the study. Participants were mental health providers who treated US military patients from around the world. Inclusion criteria for the study included the following: (a) have worked as a mental health provider for at least one year, (b) be over the age of 18 years old, and (c) scored greater than 2.00 on the Oldenburg Burnout Inventory (OLBI; Halbesleben & Demerouti, 2005). See the Consort Chart (Fig. 6.2) for details related to recruitment totals, numbers Table 6.1  Summary of a staggered intragroup control design Group Time point Time 1 Group A Group B Group C Pre-test Pre-test 1 Pre-test Time 2 × × Post-test Pre-test 2 Post-test × Time 3 Time 4 Follow-up Post-test Follow-up Follow-up Note: Group A: Immediate web intervention plus coaching; Group B: Delayed web intervention plus coaching; Group C: Web intervention only. A “×” sign indicates the period of receiving treatment SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   121 1720 solicited 101 responded 64 met the inclusion criteria (Random assignment) Coached Group (n = 21) Delayed Group (n = 21) Web-Only Group (n = 22) Received intervention (n = 5) Completed pre-test 2 (n = 10) Received intervention (n = 8) Completed post-test (n = 5) Received intervention (n = 6) Completed post-test (n = 5) Completed follow-up (n = 5) Completed post-test (n = 6) Completed follow-up (n = 4) Completed follow-up (n = 6) Fig. 6.2  CONSORT chart for the SupportNet RCT assigned, and so on. For RCT analyses, one can look at an intent-to-treat sample (i.e., all the participants that began the study) or at a completer sample (i.e., those who completed all the assessments). We provide results for both groups (N = 64 for the intent-to-treat analysis and N = 14 or 15 for the completer analysis, depending on the analysis). Table 6.2 depicts demographic information for the intent-to-treat sample. We sent an email to all the participants who dropped out of the study to ask for reasons for leaving. The reasons reported included: time constraint/too busy (n = 6), simply forgot to complete the surveys (n = 3), and dissatisfied with the website and personal challenges (n = 1). 122   K. SHOJI ET AL. Table 6.2  Demographic information for participants at pre-test for intent-to-­ treat analysis Variable Age (SD) Trauma client % (SD) Female percentage (count) In long-term relationship (count) Profession (count)  Clinical psychologist  Counselor/psychotherapist  Marriage and family therapist  Medical doctor  Physician assistant  Psychiatrist  Social worker Education (count)  Master’s degree  Post-master’s education work  Doctorate/professional degree Current military status (count)  Active duty  Reserves/national guard  Retired/former military  No military service Past deployment experience (count) Coached Delayed-­ coached Web-only 51.76 (10.96) 60.86 (30.07) 71.4 % (15) 71.4 % (15) 48.52 (13.84) 55.20 (30.68) 66.7 % (14) 95.2 % (20) 47.91 (11.29) 9.5 % (2) 33.3 % (7) 4.8 % (1) 4.8 % (1) 4.8 % (1) 9.5 % (2) 19.0 % (4) 19.0 % (4) 33.35 (7) 9.5 % (2) 14.3 % (3) 0.0 % (0) 14.3 % (3) 19.0 % (4) 31.8 % (7) 18.2 % (4) 0.0 % (0) 0.0 % (0) 0.0 % (0) 9.1 % (2) 18.2 % (4) 28.6 % (6) 33.3 % (7) 37.1 % (8) 33.3 % (7) 19.0 % (4) 47.6 % (10) 22.7 % (5) 22.7 % (5) 54.5 % (12) 19.0 % (4) 0.0 % (0) 9.5 % (2) 71.4 % (15) 28.6 % (6) 33.3 % (7) 0.0 % (0) 9.5 % (2) 52.4 % (20) 28.6 % (6) 36.4 % (8) 4.5 % (1) 18.2 % (4) 40.9 % (9) 36.4 % (8) 52.82 (25.99) 72.7 % (14) 68.2 % (15) Potential participants were recruited using two methods: email and phone. Several different mental health provider groups were contacted via an email that contained the online pre-test survey link. The email was sent to 250 participants who had participated in our previous prevalence study (Cieslak et al., 2013) and expressed willingness to participate in the RCT.  A reminder was sent to this group 2 weeks later. This same email was also sent to seven licensed clinical social workers from a US military installation and 437 mental health providers who were located on US military installations throughout the world. Both these groups received a reminder one month later. Finally, we also phoned 1,026 mental health providers located near US military installations and were listed as Tricare Insurance providers. Research assistants introduced our study and asked them to participate in the study. If no person was reached, a voice message was left. SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   123 If a provider agreed to participate in the study, he/she completed the online pre-test survey. Qualified participants were selected based on the inclusion criteria and randomly assigned into one of the three groups. The immediate intervention web plus coaching group received contact from his/her coach to start using the SupportNet website and asked to set up the first coaching session. The web-only group was invited to start using the website immediately for 8 weeks. The delayed group waited 8 weeks and the second baseline assessment until they started using the website with coaching guidance. Immediately post intervention (after 8 weeks), participants were contacted via email to complete the same assessments. Finally, approximately two months after the completion of the intervention, participants were emailed and asked to complete the follow-up survey. As detailed earlier, the SupportNet website is a social media-based support system designed to improve social support and build self-care self-­ efficacy to cope with the effects of working with traumatized individuals. Participants are able to track their progress in eight self-care goal areas: environment, relationship, fun, health/fitness, growth/learning, spirituality, career/work, and money/finance. Participants are also able to use self-assessment tools to follow changes in self-efficacy, work engagement, social support, secondary traumatic stress, burnout, and perceived stress. Finally, users are able to identify a support network of individuals through matching on unique identifiers based on interest (e.g., exercise, reading, nutrition, mindfulness, etc.). Networks are used to seek encouragement for a participant’s own goals and to offer encouragement to others in achieving their goals. Participant Trauma Exposure.  The intent-to-treat sample of mental health providers reported a host of different types of personal trauma. These included lifetime exposures to life-threatening illness or injury (92.2 percent), transportation accident (78.1 percent), sudden unexpected death of someone close (70.3 percent), natural disasters (67.2 percent), sexual assault (46.9 percent), physical assault (42.2 percent), other serious accidents (32.8 percent), military combat (29.7 percent), and other life-­ threatening crimes (26.6 percent). Although often not considered when thinking about our military mental health providers, it is very important to realize that many will have significant trauma histories themselves that undoubtedly interact with critical aspects of job burnout (e.g., number of trauma cases, client load, supervisory support, job control) as well as secondary trauma reactivity. 124   K. SHOJI ET AL. Coaching Intervention.  The coaching process was conducted over the phone and was comprised of a single one-hour session followed by 5 half-­ hour sessions. Sessions were scheduled one-per-week over the course of an 8-week period. A session-by-session manual was developed and used to guide the coaching process (see Chap. 4). Intervention fidelity was tracked after each session with an assessment to note adherence to and deviations from the manual. Coaches met regularly to discuss deviations and protocol challenges. Coaches rated the participants’ ability to understand each coaching session’s main topics on a 1 “definitely false” to 6 “definitely true” scale and found providers rated the sessions as very understandable (M = 5.56, SD = .28). Coaches also recorded when any deviations from the planned coaching session occurred. There were 9.1 percent (6 out of 66 sessions) deviations from the protocol. The initial coaching session focused on enhancing awareness about burnout and describing the coaching process and web intervention. In the second session, using a life-balance exercise, the coach assisted the participant in identifying one or more life domains (finance, career, spirituality, fun, growth, health, relationships, and environment), where the participant was not achieving desired goals. The subsequent four sessions centered on assisting the participant in utilizing the web-support system in setting attainable goals in these life domains, identifying obstacles, and making progress on the goals. Throughout the sessions, the coaches emphasized participant empowerment to promote self-sufficiency around self-care and social support. In addition, coaches also provided support and emphasized self-efficacy by reinforcing and rewarding participants’ goal achievements. RCT Measurements.  Job burnout, secondary traumatic stress, burnout self-efficacy, and demographic information were all measured. The Oldenburg Burnout Inventory (OLBI; Halbesleben & Demerouti, 2005) was utilized to measure job burnout. The OLBI is a 16-item measure assessing emotional exhaustion and behavioral disengagement from work with items such as “I always find new and interesting aspects in my work” and “Sometimes I feel sickened by my work tasks.” Respondents rate their agreeableness to each item on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). The OLBI has good internal reliability. SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   125 The Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988) was used to assess perceived social support. Respondents rate the agreeableness for each statement regarding their perception of social support from family, friends, and significant other on a 7-point scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Participants were asked to respond to each item regarding social support they received to cope with difficulties at work, including items like “I can talk about my problems with my family,” “My friends really try to help me,” and “There is a special person who is around when I am in need.” In this specific study, we used only overall scores. As with the OLBI, the internal reliability and validity of this measure are good. The Burnout Management Self Efficacy Scale was developed for the purpose of this study to measure mental health providers’ self-efficacy specific to managing the challenges of burnout. It is an 11-item measure and consists of a 7-point scale ranging from 1 (very incapable) to 7 (very capable) with items such as “Cope with losing interest in my job” and “Handle the feeling that my job is useless.” For this specific investigation, the internal reliability estimates were .71 for the pre-test, .86 for the post-­ test, and .88 for the follow-up, demonstrating good internal consistency. Finally, demographic information including age, sex, the highest level of education, percentage of trauma clients, relationship status, occupation, military status, history of deployment, and personal trauma history were measured. Data Analytic Approach.  We conducted two main analyses to evaluate the effectiveness of our interventions: the more conservative intent-to-­ treat approach and a completer analysis. Mean scores for job burnout were calculated for all time points. We conducted the intent-to-treat analysis using the last observation carried forward (LOCF) method on the sample of 64 participants. The intent-to-treat analysis is the gold standard to address attrition in an RCT (Nich & Carroll, 2002). The LOCF is the most conservative method among the intent-to-treat analyses in which missing values for dropouts were imputed with the most recent observations (Mazumdar, Liu, Houck, & Iii, 1999). It is important to note that all of our dropouts (except one) left the study immediately after the pre-­ test and did not begin the interventions (e.g., did not contact the coach or did not log into the website). The completer analysis included all participants who engaged in the interventions and completed each assessment. 126   K. SHOJI ET AL. A mixed-design analysis of variance (ANOVA) was conducted for both the intent-to-treat and the completer analyses. First, in order to evaluate the importance of the coaching aspect of the intervention, we conducted a 2 (group: coached/delayed and web-only) by 3 (time: pre-test, post-test, and follow-up) mixed-design ANOVA. We used the second pre-test scores as the pre-test for the delayed group. To test the importance of time, we conducted a 3 (group: coached, delayed, and web-only) by 2 (group: Time 1 and Time 2) mixed-design ANOVA. The delayed group was used as the control group (time) in this analysis. The first pre-test job burnout scores (Time 1) and the second pre-test job burnout scores (Time 2) were used to control for the effects of time. Tests for planned follow-up comparisons were performed to investigate significant omnibus tests to evaluate scores for each group and time point. Due to our smaller final group sample sizes, we analyzed cell differences if the overall omnibus test was significant at the p ≤ .10 level. Cohen’s d for the current study was calculated by subtracting pre-­ treatment from post-treatment scores and dividing by pre-treatment standard deviation (MPost − MPre / SDPre). The pre-score standard deviation was used instead of a pooled standard deviation, because it is unaffected by changes due to treatment and is theoretically more consistent across studies. Cohen’s d was converted to Hedges’ g, which is a less biased estimate for a small sample size. Did the SupportNet Intervention Improve Job Burnout? The short answer to this is, yes. The intent-to-treat analysis was conducted with 2 (group: coached/delayed and web-only) by 3 (time: pre-test, post-­test, and follow-up) mixed-design ANOVAs on total job burnout, exhaustion, and depersonalization. The interaction between time and group was significant for overall job burnout, exhaustion, and depersonalization subscales. The effect sizes for these interactions were medium (η2p range = .05  – .08; see Cohen, 1988; Richardson, 2011). Table 6.3 provides a list of partial eta-squared values. Scheffé’s planned follow-up comparisons were conducted with a critical F value of 4.78. These comparisons indicated that exhaustion was significantly lower at post-test and at follow-up than at pre-test among the coached/delayed group (see Fig. 6.3; see Table 6.4 for means, SDs, and Hedges’ g). These results supported our first hypothesis that the coaching plus website 0.10 0.28 3.21 0.49 5.94 3.28 2 1 2 61 F 1 1.75 1.75 108.72 df Job burnout Note: df = degrees of freedom, η2p = partial eta-squared Coached/delayed vs. web-only  Group  Time  Group × time  Error (time) Coached vs. web-only vs. delayed (control)  Group  Time  Group × time  Error (time) Source .61 .02 .04 .76 .73 .05 p .02 .09 .10 .00 .00 .05 η2p 2 1 2 61 1 1.39 1.39 86.22 df Exhaustion 0.29 7.05 1.58 0.30 1.91 2.85 F .75 .01 .22 .59 .17 .08 p .01 .10 .05 .01 .03 .08 η2p 2 1 2 61 1 2 2 124 df 0.50 3.05 2.35 0.00 0.03 2.80 F Disengagement .61 .09 .10 .99 .97 .07 p Table 6.3  Results of the interaction effect in mixed ANOVAs on job burnout for intent-to-treat analysis (N = 64) .02 .05 .07 .00 .00 .04 η2p SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   127 128   K. SHOJI ET AL. Exhaustion 2.90 Coached/Delayed a 2.70 b c Web-Only 2.50 1.20 1.00 Pre-Test Post-Test Follow-Up Fig. 6.3  Interaction effects on exhaustion in ANOVAS comparing coached/ delayed and web-only groups in the intent-to-treat analysis intervention would be more effective than the website alone for reducing burnout symptoms. There were no other significant differences in the follow-up comparisons. We also found some interesting results related to our intervention and whether participants were simply getting better with time. A series of three 3 (group: coached, delayed, and web-only) by 2 (time: Time 1 and Time 2) mixed-design ANOVAs was performed on overall job burnout, exhaustion, and depersonalization. The second pre-test score for the delayed group was used as a control group for the passage of time. The interaction effect of group by time was significant for overall job burnout, but not for exhaustion and depersonalization (see Table 6.3). The effect sizes for all comparisons indicated a medium effect (η2p range = .05–.10; see Table 6.3). The follow-up comparisons were performed using a critical F value of 2.79, which was corrected for multiple comparisons. A significant reduction in overall job burnout from Time 1 to Time 2 was observed for the coached group and the delayed group (see Fig. 6.4; see Table 6.4 for means, SDs, and Hedges’ g). These results supported hypothesis 1. No other follow-up comparisons were significant. Similar results were found when we only utilized those who completed the entire study. A 2 (group: coached/delayed and web-only) by 3 (time: pre-test, post-test, and follow-up) mixed-design ANOVA showed a significant interaction effect between group and time for overall job burnout and emotional exhaustion, but not for depersonalization (η2p range = .17–.23; see Table 6.3). We conducted Scheffé’s planned follow-up comparisons (critical F-statistic value = 5.62). Within the coached/delayed group, there was significant reduction in overall job burnout from pre-test 0.70 0.75 0.72 0.62 0.65 0.74 0.64 0.69 0.62 0.66 0.77 0.77 2.78 2.72 2.70 2.73 2.79 2.85 2.74 2.59 2.73 2.76 2.93 2.82 0.14 −0.05 0.23 −0.09 −0.19 0.08 0.11 2.05 2.90 2.90 2.89 2.89 2.69 2.90 2.89 2.96 2.89 2.74 2.76 Mean g Mean SD Exhaustion Job burnout 0.88 0.88 0.64 0.69 0.88 0.90 0.64 0.69 0.69 0.87 0.90 0.87 SD 0.17 0.15 g −0.93 0.02 0.22 0.02 −0.09 Note: g = Hedges’ g, SD = standard deviation. Hedges’ g values are values for the comparison with pre-test Coached/delayed vs. web-only  Coached/delayed (n = 42)   Pre-test   Post-test   Follow-up  Web-only (n = 22)   Pre-test   Post-test   Follow-up Coached vs. web-only vs. delayed (control)  Coached (n = 21)   Pre-test   Post-test  Web-only (n = 22)   Pre-test   Post-test  Delayed (n = 21)   Pre-test   Post-test Group 2.81 2.68 2.56 2.61 2.60 2.48 2.56 2.61 2.65 2.64 2.59 2.57 Mean SD 0.75 0.77 0.75 0.79 0.58 0.66 0.75 0.79 0.85 0.67 0.74 0.72 Disengagement Table 6.4  Means, standard deviations, sample sizes, and effect sizes for each group in the intent-to-treat analysis 0.17 −0.06 0.20 −0.06 −0.12 0.07 0.10 g SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   129 130   K. SHOJI ET AL. Overall Job Burnout a 2.70 Coached b 2.90 Delayed (Control) c d 2.50 Web-Only 1.20 1.00 Pre-Test Post-Test Fig. 6.4  Interaction effects on overall job burnout in ANOVAs comparing coached, delayed (control), and web-only groups in the intent-to-treat analysis to post-test and from pre-test to the follow-up test (see Fig. 6.5; see Table 6.5 for means, SDs, and Hedges’ g). In addition, emotional exhaustion declined from pre-test to post-test and from pre-test to follow-up. These results again supported our initial hypothesis that the coaching plus web intervention would be the most effective. In contrast, the web-only group follow-up score for exhaustion was significantly higher than the post-test scores, suggesting a possible worsening of symptoms in this group. This suggests removal of the web-support system may have contributed to increasing exhaustion in the web-only participants. Of course, there may be many other reasons for this finding. There were no other significant simple comparisons. A series of 3 (group: coached, delayed, and web-only) by 2 (time: Time 1 and Time 2) mixed-design ANOVAs also showed the benefit of the coaching plus website intervention. The interaction between group and time was significant for overall job burnout, emotional exhaustion, and depersonalization (η2p range = .25–.45; see Table 6.6). The planned follow-up analyses were conducted with the corrected critical F value at 3.14. The coaching plus website group showed significant improvement with a decline in scores for overall job burnout, exhaustion, and for depersonalization (see Fig. 6.6; see Table 6.5 for means, SDs, and Hedges’ g), supporting hypothesis 1. The delayed coaching plus website group also showed this decline for overall job burnout and exhaustion from Time 1 to Time 2 (see Figs. 6.5 and 6.6). There were no other significant differences identified by the simple comparison tests. SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   131 Overall Job Burnout 2.70 a Coached/Delayed 2.50 2.30 b c Web-Only 2.10 1.20 1.00 Pre-Test a Post-Test Follow-Up Exhaustion e 2.70 Coached/Delayed 2.50 2.30 b/d c Post-Test Follow-Up Web-Only 2.10 1.20 1.00 Pre-Test Fig. 6.5  Interaction effects on overall job burnout and exhaustion in ANOVAs comparing coached/delayed and web-only groups in the completer analysis Given that we focused our intervention design on enhancing self-­efficacy and social support, we also ran some analyses to determine changes in these variables. There were no significant results for these two variables for those who completed the intervention (η2p range: .05–.15). Means of burnout self-efficacy were 5.95 (SD = 0.84) for the coached, 5.40 (SD = 0.67) for the delayed, and 6.13 (SD = 0.52) for the web-only at the pre-test among participants who completed the study, and means at the post-test were 6.23 (SD = 0.69) for the coached, 5.30 (SD = 1.11) for the delayed, and 6.18 (SD = 0.76) for the web-only. For perceived social support among ­participants who completed the study, means at the pre-­test were 5.75 (SD = 1.03), 5.54 (SD = 0.80), and 4.98 (SD = 2.06) for the coached, delayed, and web-only groups, respectively, and means at the post-test were 5.98 (SD = 0.98), 5.47 (SD = 1.00), and 6.00 (SD = 1.19) for the coached, delayed, and web-only groups, respectively. 0.48 0.50 0.40 0.37 0.73 1.05 0.52 0.31 0.34 0.73 0.62 0.57 2.58 2.17 2.18 2.34 2.38 2.61 2.64 2.00 2.39 2.54 2.93 2.69 0.35 −0.35 0.98 −0.08 −0.53 0.78 0.77 3.14 2.81 2.48 2.43 2.88 2.05 2.31 2.22 2.63 2.78 2.22 2.30 Mean g Mean SD Exhaustion Job burnout 0.70 0.71 0.58 0.79 0.72 0.23 0.52 0.51 1.06 0.70 0.51 0.44 SD 0.74 0.63 g 0.43 0.07 0.92 0.12 −0.22 Note: g = Hedges’ g; SD = standard deviation. Hedges’ g values are values for the comparison with pre-test Coached/delayed vs. web-only  Coached/delayed (n = 11)   Pre-test   Post-test   Follow-up  Web-only (n = 4)   Pre-test   Post-test   Follow-up Coached vs. web-only vs. delayed (control)  Coached (n = 5)   Pre-test   Post-test  Web-only (n = 5)   Pre-test   Post-test  Delayed (n = 10)   Pre-test   Post-test Group 2.73 2.46 2.31 2.51 2.40 1.89 2.35 2.39 2.61 2.29 2.10 2.00 Mean SD 0.63 0.60 0.26 0.68 0.45 0.48 0.27 0.72 1.13 0.41 0.61 0.39 Disengagement Table 6.5  Means, standard deviations, sample sizes, and effect sizes for each group in the completers analysis 0.39 −0.61 0.91 −0.11 −0.70 0.43 0.65 g 132   K. SHOJI ET AL. 0.21 1.05 3.47 1.67 10.73 6.89 2 1 2 13 F 1 2 2 26 df Job burnout Note: df = degrees of freedom, η2p = partial eta-squared Coached/delayed vs. web-only  Group  Time  Group × time  Error (time) Coached vs. web-only vs. delayed (control)  Group  Time  Group × time  Error (time) Source .16 <.01 .01 .66 .36 .05 p .16 .39 .45 .02 .08 .21 η2p 2 1 2 13 1 1.41 1.41 18.26 df Exhaustion 1.80 10.45 2.78 0.02 2.13 2.93 F .20 .01 .09 .89 .16 .09 p .17 .38 .25 .00 .14 .18 η2p 2 1 2 13 1 2 2 26 df 1.31 3.78 2.91 1.29 0.15 1.71 F Disengagement Table 6.6  Results of the interaction effect in mixed ANOVAs on job burnout for completer analysis .30 .07 .08 .28 .86 .20 p .13 .18 .26 .09 .01 .12 η2p SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   133 134   K. SHOJI ET AL. Overall Job Burnout 2.80 Coached a 2.50 Delayed (Control) 2.20 b 1.90 1.30 Web-Only 1.00 Pre-Test Post-Test Exhaustion 3.20 2.90 Coached a 2.60 Delayed (Control) 2.30 b 2.00 Web-Only 1.30 1.00 Pre-Test Post-Test Depersonalization 2.70 2.40 c a d Coached Delayed (Control) 2.10 b 1.80 1.20 1.00 Web-Only Pre-Test Post-Test Fig. 6.6  Interaction effects on overall job burnout, exhaustion, and depersonalization in ANOVAs comparing coached, delayed (control), and web-only groups in the completer analysis SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   135 A possible reason for nonsignificant results for burnout self-efficacy and perceived social support is that these providers have high initial levels of these variables (i.e., ceiling effect) at the beginning of the study, as evidenced by the means of these variables. Another possible reason is that job burnout reduced because of a different mechanism than enhancement of burnout self-efficacy and social support. For example, work engagement self-efficacy and work place support might have been more important in reducing job burnout than burnout self-efficacy and general social support. More investigation is needed to figure out the possible mechanism(s) of reducing job burnout through our intervention. The current RCT suggests that the SupportNet web intervention plus coaching was effective in reducing some aspects of burnout when utilizing the more conservative intent-to-treat analysis, as well as with those who completed the intervention. These results indicate that the coaching support combined with a supportive self-care web intervention was effective in reducing job burnout among military mental health providers. The web-only version of the intervention did not significantly reduce burnout, refuting hypothesis two. Our study did not allow us to test whether coaching alone would be just as effective without the website support. This is the first RCT for burnout in military mental health providers of which we are aware. It is important to put these findings in context with other burnout interventions evaluated with human service professionals more broadly. Comparisons Between the SupportNet Intervention and Other Interventions for Human Service Professionals Although there are no other RCT data with military mental health providers to provide a context for our findings, RCTs have been done with other human service professionals. These include interventions such as a  mindfulness, or  acceptance and commitment approach, and a host of alternative interventions. Mindfulness-based interventions have been one of the most studied. Mindfulness-Based Interventions for Job Burnout The last decade has seen an upsurge in mindfulness-based interventions and therapies (Melbourne Academic Mindfulness Interest Group, 2006). According to the Melbourne Academic Mindfulness Interest Group, mind- 136   K. SHOJI ET AL. fulness refers to purposely and nonjudgmentally paying attention to the present moment. Mindfulness is not a goal-oriented activity but emphasizes openness, receptiveness, curiosity, and a nonjudgmental attitude that leads an individual to accept things as they are without changing them. Psychotherapies and interventions based on mindfulness often involve some common techniques such as meditation, mindfulness of movement, and mini-meditation, all of which aim to facilitate everyday mindfulness (Melbourne Academic Mindfulness Interest Group, 2006). Daily meditation involves regular meditation with either sitting or lying down. Mindfulness of movement often refers to yoga and mindful walking. Mini-­ meditation is brief meditation done throughout the day. These techniques aim to promote awareness and being in the present moment. Asuero et al. (2014) conducted an RCT for a mindfulness education program for 68 healthcare professionals (nurses and physicians) in Spain. This intervention consisted of eight weekly sessions that involved four activities to promote the present-moment experience and nonjudgmental bodily sensations, breathing, sounds, and thoughts. These activities included educational presentation, formal mindfulness meditation, narrative and appreciative inquiry exercises, and discussion. The educational presentation referred to presentation of topics on job burnout, end-of-life care, dealing with pleasant and unpleasant events, awareness of thoughts and feelings, and self-care management. Formal mindfulness exercises aimed to reduce participants’ reactivity to challenging situations and increase the ability to be aware of thoughts, feelings, and bodily sensations without any judgments. The narrative and appreciative inquiry exercises involved writing a brief story about a personal medical-related experience talked about in the educational presentation. Participants were asked to talk about their own stories in a small group and listen to others’ stories without interruption. In the discussion, participants shared their experiences with others. After 8 weeks of the intervention, this mindfulness education program significantly reduced job burnout among medical professionals who completed the intervention (i.e., a completer analysis). The effectiveness of this mindfulness education program and the effectiveness of SupportNet intervention were compared by examining the effect sizes from these two RCTs. An effect size measures how big a difference there is between experimental groups, providing important information that goes beyond simple statistical significance. Finding a statistically significant difference between groups relies extensively on a sample size in a study. RCT studies ­usually SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   137 report an effect size as a measure of how much a treatment group improves after an intervention compared to a control group. After going through the 8-week mindfulness treatment group in Asuero et al.’s (2014) study, the effect size for this intervention was 0.54. The effect size for the SupportNet intervention was 0.96 for the completer analysis. It is not easy to directly compare these two RCTs because there are several critical differences between them such as occupation, country, and theoretical framework (mindfulness and SCT), but it is important to note that the SupportNet intervention demonstrated an effect size that was larger than this 8-week mindfulness education program for medical professionals. In another study, Bazarko, Cate, Azocar, and Kreitzer (2013) employed a mindfulness-based intervention to reduce job burnout among 36 nurses working in a large health-care company. This 8-week intervention was delivered by telephone conferences and through a face-to-face retreat in the last week of the program. The intervention involved mindfulness meditation with guided instructions, group discussions, stretching exercises and yoga, daily work and home assignments, and individualized instructions and support. After 8 weeks, job burnout related to personal life, work, and client interactions all decreased from the beginning of the intervention in a completer analysis. The average effect size for this intervention was 0.61. Again, the therapeutic effect was smaller than identified in our RCT for the SupportNet intervention. A similar study was done by Goodman and Schorling (2012) using a mindfulness-based intervention to reduce job burnout among 93 healthcare providers including physicians, nurses, psychologists, and social workers. This intervention was also an 8-week program consisting of body scan, mindful movement, mindful walking, and sitting meditation. Body scan refers to paying attention to a part of the body and body sensations. Similar to the other two mindfulness-based interventions presented, this intervention reduced job burnout from the beginning of the intervention to the end of the intervention, with the average effect size of 0.43 in a completer analysis. Again, the coaching and web-support intervention for SupportNet demonstrated a stronger therapeutic effect by comparison. Acceptance and Commitment Therapy-Based Interventions for Job Burnout Several other studies have been conducted on acceptance and commitment therapy (ACT)-based interventions for burnout. The basic principles of ACT are derived from relational frame theory (Hayes, Barnes-Holmes, 138   K. SHOJI ET AL. & Roche, 2001). Three basic features of relational frame theory are that cognition is a learned behavior; cognition influences behavioral processes; and cognitive relations and cognitive functions are regulated by situations in the environment. Psychological problems occur due to inflexibility in cognition and behavior relative to environmental demands. Based on ACT, burnout would be related to a rigid adherence to a conceptualized past and feared future, elevated levels of experiential avoidance, inability to challenge beliefs or thoughts, attachment to the conceptualized self, lack of clear values, and inaction or impulsivity. The goal of the ACT approach is to increase psychological flexibility through increasing awareness of the present (i.e., mindfulness). When a person has psychological flexibility, he/she is able to access to the present moment as a conscious human being, and able to change his/her behavior when desirable. Psychological flexibility can be achieved through six core processes: acceptance, defusion (i.e., separation of one’s self from one’s thoughts), self as context, contact with the present moment, values, and committed action (Hayes et al., 2006). Hayes et  al. (2004) conducted an ACT intervention for 90 substance abuse counselors. This intervention was a one-day six-hour program that involved exercises such as encouraging to notice the automatic process of negative evaluation of thoughts built into language and teaching methods to reduce the effect of negative thoughts through acceptance, mindfulness, and cognitive defusion. Specific exercises included deliberately bringing up difficult emotions and thoughts related to clients, practicing nonjudgmentally experiencing these emotions and thoughts without avoiding them, and teaching the nature and importance of values. Hayes et al. (2004) reported that job burnout decreased from the beginning of the one-day session to the end of the one-day session with the effect size of 0.50. These researchers measured job burnout three months after the program and also found a lower job burnout compared to the beginning of the program with the effect size of 0.28 in a completer analysis. Of course this was not an RCT, thus limiting the value of these data. An effect size was calculated by (Hedges’ g for an experimental group - Hedges’ g for a comparison group) to compare between the results of the SupportNet study and this previous study. This computation procedure allows the effect of time to be controlled in the effect size. The effect size from the pre-treatment SupportNet intervention to the two-month follow-up measurement was 1.30. In another study, Brinkborg, Michanek, Hesser, and Berglund (2011) conducted an ACT preventive stress management intervention for 106 social workers in Sweden. This intervention consisted of four sessions, SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   139 three hours each. Specific details of the intervention are not available other than the fact that they used the principles of ACT. This ACT-based intervention significantly reduced job burnout among the social workers as measured immediately after the intervention. The effect size of this difference was 0.57 among participants who completed the study. Similarly, Luoma and Vilardaga (2013) conducted an ACT-based intervention to reduce job burnout for 20 mental health professionals. This intervention involved an ACT-based workshop and an ACT-based phone consultation, consisting of six 30-minute sessions over three months. It should be noted that this intervention has some similarities to our peer coaching model. The first phone consultation provided an overview of the program and set up training goals. In the second phone consultation, participants were encouraged to employ ACT techniques and exercises with a client. Participants were also encouraged to use the ACT techniques on themselves in the third phone consultation while working with clients. These techniques included brief meditation, visualization of a sense of distance between themselves and their struggles, and sharing a story. These researchers found small improvement in job burnout after the program, with the effect size of 0.28 among those who completed the study, which is significantly smaller than the effect size found for our intervention. Thus, ACT has been used as an approach for burnout with healthcare providers with some success. The time duration of these interventions has varied considerably. The SupportNet approach consistently yielded higher effect sizes than the ACT interventions. The remaining burnout reduction programs were quite diverse with varied results. Other Types of Interventions There are many other types of interventions that differed in various ways. Here, we present music therapy-based interventions and a psychosocial intervention as examples. Music Therapy-Based Interventions.  Some interventions involve other therapeutic approaches such as music therapy. For example, Brooks, Bradt, Eyre, Hunt, and Dileo (2010) conducted an intervention using a music-guided imagery treatment for 65 medical professionals. This music-­guided intervention consisted of three to six 60-minute weekly sessions that involved body relaxation and imagery experiences while listening to music, drawing mandala, writing about their experiences, and discussions about their experiences with others. This intervention did not 140   K. SHOJI ET AL. s­ ignificantly reduce job burnout. The average effect size for this intervention was −0.21, which indicates that job burnout got slightly worse after the program. In another study using music therapy to reduce job burnout, Hilliard (2006) provided a one-hour music therapy session weekly for 6 weeks to 17 health-care professionals including nurses, social workers, and chaplains working at a hospice. They used live music and encouraged spontaneous musical and verbal expressions. In one treatment group, the primary music therapy technique they used was improvisation, which encouraged spontaneous participants’ creativity. The participants’ music expression was supported by music therapists and was participant centered. In the first session, music instruments were placed in a room, and participants nonverbally explored these instruments and listened to others. They had discussions about musical improvisations and how musical experiences were related to work experiences. In later sessions, participants were encouraged to plan their own sessions. In the other treatment group, music therapists planned music therapy sessions with a more standard structure. The primary technique used in this group was the didactic music therapy approach. The music therapists provided information about stress management, team building, and coping skills. Participants in both groups engaged in guided meditation while listening to live music, breathing exercises while listening to live music, group drumming and chanting, music and movement, lyric analyses, and visualization of the theme of the therapy group. Job burnout was not significantly reduced from the beginning of the sessions to the end of the sessions for either music therapy group. The effect sizes were −0.01 for the music therapy improvisation group and 0.42 for the music therapy group with the didactic approach. Psychosocial Intervention.  In another study investigating the effectiveness of a psychosocial intervention to reduce job burnout, Redhead, Bradshaw, Braynion, and Doyle (2011) provided 16 half-day sessions of a training program over 8 months to 42 nurses working in a low-security mental health unit. The training program involved cognitive behavioral approaches to manage symptoms such as introducing the stress vulnerability model, assessment tools for psychosis, creating a list of problems, strengths, and needs list, case formulation, coping strategy enhancement, working with anxiety, depression, delusions, bipolar, and relapse prevention. Depersonalization (one of SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   141 major characteristics of job burnout) decreased from the beginning of the program to the end of the program, but other characteristics (i.e., exhaustion, personal accomplishment) of job burnout did not significantly change. The overall effect sizes for job burnout and depersonalization were 0.40 and 0.76, respectively, among participants who completed the study. The effect sizes reported for our completer sample in our RCT of the SupportNet intervention were consistently higher than those reported for these other approaches to reduce burnout. It should be noted, however, that the effect sizes were lower in the intent-to-treat analyses compared to those in the completer analyses. Yet these were also typically higher as well than the  other approaches. These previous RCT studies employed various treatment and theoretical methods (e.g., cognitive behavioral therapy, mindfulness, ACT, and art and music therapy). The SupportNet intervention utilized SCT with particular emphasis on self-efficacy and social support. Differences in occupations and theoretical frameworks between the current study and the previous studies make the direct comparisons difficult. Nonetheless, the current study showed that the SupportNet intervention was effective in reducing job burnout among mental health providers working with military personnel. These results, however, must be interpreted with caution due to important study limitations. Limitations of the RCT SupportNet Intervention Results The most critical limitation of the SupportNet study is the limited sample. Although over 1,700 potential providers were contacted to participate in the study, less than 4 percent of those contacted showed interest in the study. Clearly, burnout itself may make doing this type of investigation difficult. As such, the sample in this study is undoubtedly not representative of the overall population of military mental health providers and is probably skewed to lower levels of burnout. This makes interpretation of our findings limited, and further research is necessary on providers with higher levels of burnout. Another limitation of this study is the research design did not include a coaching without the web intervention, thus making it impossible to determine the value of coaching by itself. Although the coaching manual was designed to help providers use the web system to promote self-care, obtain resources, and improve support, it is possible that having a peer 142   K. SHOJI ET AL. coach who helps the provider focus on self-care in general may be just as helpful. Future studies will need to determine the value of coaching by itself in reducing burnout in military mental health providers. Because we did not include a coaching without web support, there is no way to tease apart the importance of the web portion of the intervention. However, our coaches suggested that the use of the website was driven by the coaching sessions. Our study demonstrated the difficulties of conducting intervention research with mental health providers who are stressed and experiencing some level of burnout; participation in a study was one more thing that many chose not to add to their demands, despite the benefits it could offer. However, this is the first RCT ever conducted on any intervention for military mental health providers to help reduce burnout and suggests that a peer coaching model with web support may be beneficial. Given the low sample size for this investigation, the results should be considered preliminary. Summary and Implications for Other Healthcare Providers We started this chapter by depicting the daunting challenges facing our military mental health providers after over a decade of war. In Chap. 2, we presented data suggesting approximately 20 percent of providers are struggling with significant levels of burnout and secondary traumatic stress. We also showed that burnout symptoms appear to put providers at risk for secondary trauma. Thus, the SupportNet intervention was specifically designed to reduce burnout symptoms in these providers, targeting self-care through a social media-based web system combined with peer coaching. We sought to reduce job burnout by enhancing burnout self-efficacy and perceived social support. Despite significant reductions in burnout symptoms, however, the current results showed that neither burnout self-efficacy nor perceived social support significantly increased. The significant decrease in burnout symptoms through a web-support system combined with peer coaching suggests a specific approach that could be replicated for military mental health providers across the country and overseas. Identification of peer “supporters” in each location could offer an opportunity for helping providers to focus on self-care that can help assist in balancing work and personal life goals. Our findings could also be important for medical providers working with military who struggle with burnout and secondary trauma (Beck, 2011; Dewa et al., 2014; SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   143 Gates & Gillespie, 2008). An important difference in population, however, is that our peer coaches were trained mental health professionals, whereas other medical professionals (e.g., nurses and physicians) may have varying skills in providing self-care support. There are exciting possibilities to provide more specific and targeted programs for all health-care providers who face serious work-based challenges that can have devastating career and patient care consequences. The SupportNet model offers an approach that has some empirical foundation, yet clearly awaits further study. In summary, this investigation provides the first step in empirically evaluating an intervention to help military mental health providers with the challenges of burnout as they face unprecedented demands. We must not ignore the challenges these providers face, and future research is critical to determine the most effective means of support. References Adriaenssens, J., De Gucht, V., & Maes, S. (2015). Determinants and prevalence of burnout in emergency nurses: A systematic review of 25 years of research. International Journal of Nursing Studies, 52(2), 649–661. doi:10.1016/j. ijnurstu.2014.11.004. Asuero, A.  M., Queraltó, J.  M., Pujol-Ribera, E., Berenguera, A., Rodriguez-­ Blanco, T., & Epstein, R. M. (2014). Effectiveness of a mindfulness education program in primary health care professionals: A pragmatic controlled trial. Journal of Continuing Education in the Health Professions, 34(1), 4–12. doi:10.1002/chp.21211. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Henry Holt. Bazarko, D., Cate, R. A., Azocar, F., & Kreitzer, M. J. (2013). The impact of an innovative mindfulness-based stress reduction program on the health and well-­ being of nurses employed in a corporate setting. Journal of Workplace Behavioral Health, 28(2), 107–133. doi:10.1080/15555240.2013.779518. Beck, C.  T. (2011). Secondary traumatic stress in nurses: A systematic review. Archives of Psychiatric Nursing, 25(1), 1–10. doi:10.1016/j.apnu.2010.05.005. Benight, C. C., & Cieslak, R. (2013). Professional burnout. In B. A. Moore & J.  E. Barnett (Eds.), Military psychologists’ desk reference (pp.  138–142). New York: Oxford University. Biswas-Diener, R. (2009). Personal coaching as a positive intervention. Journal of Clinical Psychology, 65(5), 544–553. doi:10.1002/jclp.20589. Brinkborg, H., Michanek, J., Hesser, H., & Berglund, G. (2011). Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial. Behaviour Research and Therapy, 49(6–7), 389–398. doi:10.1016/j.brat.2011.03.009. 144   K. SHOJI ET AL. Brooks, D.  M., Bradt, J., Eyre, L., Hunt, A., & Dileo, C. (2010). Creative approaches for reducing burnout in medical personnel. The Arts in Psychotherapy, 37(3), 255–263. doi:10.1016/j.aip.2010.05.001. Cieslak, R., Anderson, V., Bock, J., Moore, B.  A., Peterson, A.  L., & Benight, C. C. (2013). Secondary traumatic stress among mental health providers working with the military: Prevalence and its work- and exposure-related correlates. The Journal of Nervous and Mental Disease, 201(11), 917–925. doi:10.1097/ NMD.0000000000000034. Cohen, J.  (1988). Statistical power analysis for the behavioral sciences (2nd ed.). New York: Routledge Retrieved from http://www.amazon.ca/exec/obidos/ redirect?tag=citeulike09-20&path=ASIN/0805802835. Demerouti, E., & Bakker, A.  B. (2011). The job demands-resources model: Challenges for future research. SA Journal of Industrial Psychology, 37(2), 1–9. Dewa, C. S., Loong, D., Bonato, S., Thanh, N. X., & Jacobs, P. (2014). How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research, 14(325), 1. doi:10.1186/1472-6963-14-325. Gates, D. M., & Gillespie, G. L. (2008). Secondary traumatic stress in nurses who care for traumatized women. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 37(2), 243–249. doi:10.1111/j.1552-6909.2008.00228.x. Gazelle, G., Liebschutz, J. M., & Riess, H. (2014). Physician burnout: Coaching a way out. Journal of General Internal Medicine, 30(4), 508–513. doi:10.1007/ s11606-014-3144-y. Goodman, M. J., & Schorling, J. B. (2012). A mindfulness course decreases burnout and improves well-being among healthcare providers. International Journal of Psychiatry in Medicine, 43(2), 119–128. doi:10.2190/PM.43.2.b. Grant, A. M. (2012). An integrated model of goal-focused coaching: An evidence-­ based framework for teaching and practice. International Coaching Psychology Review, 7(2), 146–165. Halbesleben, J. R. B., & Demerouti, E. (2005). The construct validity of an alternative measure of burnout: Investigating the English translation of the Oldenburg Burnout Inventory. Work and Stress, 19(3), 208–220. doi:10.1080/02678370500340728. Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian account of human language and cognition.  New York, NY: Springer Science & Business Media. Hayes, S.  C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B.  S., Fisher, G., et al. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35(4), 821–835. doi: 10.1016/ S0005-7894(04)80022-4 Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25. doi:10.1016/j.brat.2005.06.006. SUPPORTNET: A RANDOMIZED CONTROLLED TRIAL FOR MILITARY...   145 Hilliard, R. E. (2006). The effect of music therapy sessions on comparison fatigue and team building of professional hospice caregivers. Arts in Psychotherapy, 33(5), 395–401. doi:10.1016/j.aip.2006.06.002. Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American psychologist, 44(3), 513–524. doi:10.1037/0003-066X.44.3.513. Jakupcak, M., Luterek, J., Hunt, S., Conybeare, D., & McFall, M. (2008). Posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA health care. The Journal of nervous and mental disease, 196(5), 425–428. doi:10.1097/ NMD.0b013e31817108ed. Jing, L. I. (2008). An analysis of the causes of university librarians’ job-burnout. Journal of Academic Library and Information Science, 3, 25. Lazarus, R.  S., & Folkman, S. (1984). Stress, appraisal, and coping. New  York: Springer. Luoma, J. B., & Vilardaga, J. P. (2013). Improving therapist psychological flexibility while training acceptance and commitment therapy: A pilot study. Cognitive Behaviour Therapy, 42(1), 1–8. doi:10.1080/16506073.2012.701662. Mazumdar, S., Liu, K. S., Houck, P. R., & Iii, C. F. R. (1999). Intent-to-treat analysis for longitudinal clinical trials: Coping with the challenge of missing values. Journal of Psychiatric Research, 33(2), 87–95. doi:10.1016/ S0022-3956(98)00058-2. Melbourne Academic Mindfulness Interest Group. (2006). Mindfulness-based psychotherapies: A review of conceptual foundations, empirical evidence and practical considerations. Australian and New Zealand Journal of Psychiatry, 40(4), 285–294. doi:10.1080/j.1440-1614.2006.01794.x. Nich, C., & Carroll, K.  M. (2002). “Intention-to-treat” meets “missing data”: Implications of alternate strategies for analyzing clinical trials data. Drug and Alcohol Dependence, 68(2), 121–130. doi:10.1016/S0376-8716(02)00111-4. Redhead, K., Bradshaw, T., Braynion, P., & Doyle, M. (2011). An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit. Journal of Psychiatric and Mental Health Nursing, 18(1), 59–66. doi:10.1111/j.1365-2850.2010.01629.x. Richardson, J. T. E. (2011). Eta squared and partial eta squared as measures of effect size in educational research. Educational Research Review, 6(2), 135–147. doi:10.1016/j.edurev.2010.12.001. Schaufeli, W. B., Taris, T. W., & Van Rhenen, W. (2008). Workaholism, burnout, and work engagement: three of a kind or three different kinds of employee well-being? Applied Psychology, 57(2), 173–203. doi:10.1111/j.1464-0597.2007.00285.x. Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C. R. (2009). Trends and risk factors for mental health diagnoses among Iraq 146   K. SHOJI ET AL. and Afghanistan veterans using Department of Veterans Affairs Health Care, 2002–2008. American Journal of Public Health, 99(9), 1651–1658. doi:10.2105/AJPH.2008.150284. Shoji, K., Cieslak, R., Smoktunowicz, E., Rogala, A., Benight, C.  C., & Luszczynska, A. (2015). Associations between job burnout and self-efficacy: A meta-analysis. Anxiety, Stress, and Coping, Advanced Online Publication. doi:1 0.1080/10615806.2015.1058369. Thomas, J. L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010). Prevalence of mental health problems and functional impairment among active component and national guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry, 67(6), 614–623. doi:10.1001/archgenpsychiatry.2010.54. Voss Horrell, S.  C., Holohan, D.  R., Didion, L.  M., & Vance, G.  T. (2011). Treating traumatized OEF/OIF veterans: How does trauma treatment affect the clinician? Professional Psychology: Research and Practice, 42(1), 79–86. doi:10.1037/a0022297. Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The multidimensional scale of perceived social support. Journal of Personality Assessment, 52(1), 30–41. CHAPTER 7 Lessons Learned and Next Steps Charles C. Benight Lessons Learned Throughout this book we have emphasized the challenges facing our military mental health providers. They are coping with unprecedented clinical demand that includes increases in clinical load as well as complexity of cases. This is not without consequence. The findings we have reported from our own data and the scientific literature suggest that burnout and secondary traumatic stress (STS) are critically important to consider for the health of these clinicians as well as the overall health of our provider organizations (military behavioral health, VA, and community clinics). The lessons learned from our SupportNet project have clear application to providers across the world who are working to bring our soldiers back home so they can lead productive and fulfilling lives. Our findings and the literature reviewed throughout the book have important implications for other health-care providers as well. In Chap. 2, we offered data that showed about 20 percent of clinicians working with military clients may be struggling with at least moderate to severe STS and burnout depending upon where they are working (community setting versus on-post). In general, our findings are consistent C.C. Benight (*) University of Colorado at Colorado Springs , Colorado Springs, CO, USA © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1_7 147 148   C.C. BENIGHT with other health-care providers. Who might be at most risk is also important to consider. Our data indicated that younger clinicians with previous trauma history, lower sense of capability for management of burnout symptoms, working in the community, higher organizational constraints, and higher interpersonal conflicts are all important in predicting burnout and STS symptoms. Coping with burnout or STS is a process that changes across time. Understanding how this process works can assist in the development of effective interventions and prevention programs. Our longitudinal data offered unique opportunities to understand how this process functions over a six-month period. We found that burnout is a precursor to STS and not the other way around. This suggests that burnout may create a vulnerability in clinicians where their ability to keep a protective boundary to the often horrific nature of military trauma is compromised. One way this boundary may be pierced is through changes in clinicians’ perceived capability to manage burnout itself. We found that decreases over time in one’s self-efficacy for managing burnout predicted exhaustion that then led to clinical depersonalization (i.e., the detachment from one’s clients). It remains unclear how depersonalizing clients might be related to the ability to keep effective boundaries. We do know from the literature that depersonalization has important negative effects on care and on the health of the clinician. Future research needs to evaluate the dynamics of this process and how clinicians lose their ability to manage traumatic material. Clearly these findings have implications for clinical effectiveness and overall organizational health. Beyond the negative outcomes of burnout and STS, we also gathered data on positive reactions to indirect traumatic material. We focused on work engagement and secondary traumatic growth in the SupportNet project. Both personal and organizational controls are important in enhancing work engagement in these providers. Secondary traumatic growth was higher in clinicians who reported enhanced self-efficacy for managing STS symptoms and for those with higher levels of social support. Thus, promoting mastery in coping with STS (e.g., providing skill-­ based interventions for STS coping) within a supportive environment appears helpful, enabling clinicians to find greater meaning and personal enrichment in their work. It is important to think beyond the individual clinician and appreciate the contextual contributions to STS and burnout. In Chap. 5 organizational contributors to burnout and STS were reviewed. The literature LESSONS LEARNED AND NEXT STEPS   149 was quite clear on the negative effects associated with the mechanistic and bureaucratic organizations. Horizontal organizations that promote innovation, growth, and clear goals are more effective and promote lower burnout and greater work engagement. Leadership style can also impact the working environment and thereby influence burnout and STS. A transformational leadership style was found to create a positive and engaged workforce, whereas an autocratic or transactional leadership approach typically results in a less committed and poorly engaged set of employees. For any burnout and/or STS intervention program to be successful, organizational leadership must be on board. Top-down commitment is essential. Rhetoric that lacks real action (money where one’s mouth is) is fundamentally detrimental. Clinicians are quite aware of organizational culture that suggests the emotional challenges related to treating trauma are a sign of weakness. Solutions should include organizational structure and cultural interventions that encourage employee decisional control, role clarity, role unambiguity, and greater sense of supervisory support. Leadership should focus on reducing organizational constraints that impede clinician control over workflow and self-care. A web-support system that offers 24/7 opportunities for providers to gain important self-care support is one option that leadership can seize to combat burnout and STS. Designing this system requires extensive cooperation among clinicians, computer programmers, and administration. Our experience with this development offers a lot of key information for development efforts as they move forward. Challenges exist for security of these systems especially within a military environment. All communications between the server and the browser must be over a secure, encrypted HTTPS connection. Three layers of security should be implemented on data access (transport layer, access control, and content security) to prevent unauthorized access to data. Any software must be developed minimizing security vulnerabilities such as cross-site scripting, SQL injection, cross-site request forgery, invalidated redirects and forwards, and failure to restrict URL access. Our program development was built from solid theoretical and empirical evidence that suggests self-efficacy and social support are key determinants for reducing burnout and improving STS. Social cognitive theory offers a useful framework to development teams in order to link important individual and environmental components of an effective system. With this in mind, our cross-disciplinary development team built a social media-based platform (social support) that surrounded a ­self-care goal-­ 150   C.C. BENIGHT setting system (self-efficacy). The development of this system (SupportNet) included an iterative systems development approach involving clinician focus groups and weekly development team meetings. The system functional specs were developed, prototypes built, clinician feedback obtained, and system improvements adopted. This development is expensive, both in terms of time and money. One could argue a national-­based approach to burnout and STS for military mental health providers would be useful moving forward, rather than having a multitude of development teams cropping up in different locations as the need becomes apparent (e.g., higher turnover rates, sick time increases, moral concerns, etc.). A web-based support system, however, may not be enough to maximize improvements in burnout and STS. The literature on Internet interventions for a variety of mental health challenges, although not unequivocal, has suggested some personalized support with the system increases user engagement. We decided early on that a self-care website alone was not enough. We created an integrated coaching model to augment our interactive social media-based system. The scientific literature suggests that coaching is a viable model for helping reduce burnout in a number of health care and non-health care populations. Coaching combined with web interventions has been effective in promoting well-being and reducing psychological distress. The SupportNet model for peer coaching and our web intervention targeted increasing self-efficacy and social support to combat burnout. Users engaged with the coaches in identifying tangible and achievable self-care goals utilizing the life balance wheel. One essential question is how would military mental health providers respond to this type of intervention. Unfortunately, our SupportNet study identified significant challenges in getting providers who are experiencing burnout (and possibly high STS) to engage in our research. Only about 4 percent of solicited clinicians chose to sign up for our study. What we do not know at this point is how a program that is championed by leadership and launched across the entire system of care would be welcomed or not. Our research demonstrated that military mental health providers were able to complete the six-session coaching system and were able to make important improvements in their self-care behaviors. Our preliminary  randomized clinical trial did find important improvements for our clinicians who took part in the intervention. LESSONS LEARNED AND NEXT STEPS   151 The RCT suggested that the SupportNet web intervention plus coaching was effective in reducing some aspects of burnout when utilizing the more ­conservative intent-to-treat analysis (i.e., including dropouts and those who did not even start the intervention) as well as with those who completed the intervention. Importantly, the Internet system without coaching did not significantly reduce burnout. Our study did not allow us to test whether coaching alone would be just as effective without the website support. Future research is critical to evaluate the most cost-effective and clinically effective interventions to support these clinicians. Recommendations Military Settings.  Based on our research findings and the empirical literature, we recommend that the military behavioral health system formulate a system-­wide approach for reducing burnout and STS in clinicians (mental and physical health). The top leadership must take the lead and demonstrate commitment to this issue and set appropriate timelines for implementation for a targeted approach. Challenges of privacy and security must be addressed and “rank and file” clinicians must be engaged in the process. The system that is adopted should be multifaceted including individual-based support (web intervention + coaching) as well as organizational structure and climate changes that promote clinician wellness, role clarity, decisional control, and enhanced supervisory support. Other Clinical Settings.  Beyond the walls of military post hospitals and outpatient clinics are thousands of community-based clinicians who are working to assist our soldiers in managing their traumas. Many of these are private practitioners without any organizational structure to support them. Undoubtedly, they have very high levels of decisional control and job clarity, yet may struggle with isolation and other challenges related to burnout and STS. We recommend that insurance providers (e.g., Tricare) offer systems such as SupportNet for their individual providers who care for our warriors. The expense of this type of system is likely more than offset by improved care for the clients. Burned out and distressed providers who must see a significant client load to make a living can only cost a system in poor clinical outcomes or worse. Future Deployment of SupportNet/Coaching System. The CU: Trauma, Health, and Hazards Center located at the University of Colorado Colorado Springs maintains the SupportNet web system. Faculty and staff in the Center have expertise in 152   C.C. BENIGHT the management of workplace stress and trauma. The Center has the capability to consult and implement nationally the SupportNet system of care (including coaching) for burnout and STS. Please email Dr. Charles Benight at cbenight@uccs.edu to discuss further development or implementation of a program to combat burnout and STS in your providers. Summary.  In summary, we cannot sit back and ignore the health and well-­being of the mental and physical health-care providers who are working with our soldiers as they attempt to manage the horrors of war. It is illogical from a quality of care viewpoint, and arguably not right from a moral perspective. Critical Resources The following section of this final chapter provides material from the SupportNet website that is offered to users within the “Resource Room”. It includes annotated reference material and web content covering evidence-­based care, life balance issues, health status, stress indicators, and a clinician toolkit. Evidence-Based Care A multisite randomized controlled effectiveness trial of cognitive processing therapy (CPT) for military-related posttraumatic stress disorder (PTSD) by Forbes et al. (2012) is a study that examined the effectiveness of CPT when applied to a military population in a community-based setting. For those assigned to the CPT group, the sessions were delivered in two 60-minute sessions over the course of 12 weeks. The results showed the CPT group had greater improvements in anxiety, depression, and relationship functioning when compared to the treatment-as-usual group. This study does provide a good evidence base for showing the effectiveness of CPT with a military population and its broad reach in the various aspects of how PTSD presents. Monson et  al. (2012) published “Changes in social adjustment with cognitive processing therapy: Effects of treatment and association with PTSD symptom change” . The authors used an interesting approach to looking at the efficacy of CPT in the treatment of military veterans diagnosed with PTSD. In addition to examining the effects of CPT on the typical symptoms of arousal and avoidance, these researchers also focused on the effects of CPT on veterans’ social adjustment and how these symptoms LESSONS LEARNED AND NEXT STEPS   153 interact with each other. The results showed that improvements in emotional numbing symptoms were associated with improvements in overall social, extended family, and housework adjustment. These findings show us the important connection between symptoms of arousal and avoidance and social functioning, and it shows how treating the primary symptoms can have positive effects on secondary symptoms of social adjustment. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder by Monson et  al. (2006) examined the effectiveness of CPT with Vietnam War veterans diagnosed with PTSD and receiving treatment in a VA center. After completing treatment, the participants showed significant improvement in PTSD symptoms, and it also showed that 40 percent of those who received treatment reduced PTSD symptomology to sub-clinical levels. These results are promising, especially when applied to a population of veterans who have presumably been experiencing PTSD symptoms for an extended period of time. However, the authors did not do a delayed follow-up with the participants, and it is unknown if these changes were sustained post treatment. A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: Treatment effects and long-term maintenance (van der Kolk et  al., 2007) compared three different approaches in the treatment of PTSD: EMDR, fluoxetine, and placebo. The results suggested that EMDR had larger effects in reducing PTSD symptoms and depression, and also in sustaining these reductions for a longer period of time in participants with adult-onset trauma. However, for adult victims with childhood-onset trauma, the pharmacological treatment was more effective. This raises interesting questions about how trauma develops and changes as a result of the time of onset of the trauma. Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training by Taylor et al. (2003) compared three different treatments for PTSD: EMDR, relaxation training, and prolonged exposure. Although this study used a non-­ military population, it had interesting results in that prolonged exposure was faster at reducing avoidance and produced larger reductions in avoidance, whereas EMDR and relaxation did not differ from one another in terms of speed and effectiveness. Despite questions about its applicability to military populations, it does raise questions about which symptoms improve more quickly as a result of the choice of treatment. 154   C.C. BENIGHT Shapiro and Maxfield (2002) published a paper on EMDR therapy. This journal article provided a comprehensive overview of 20 well-designed studies evaluating EMDR as a treatment approach for PTSD.  It also included a nice summary of the information processing theory underlying EMDR, the eight phases of treatment, and a case study applying these phases. If EMDR is not as familiar to you, this is a good place to start. A naturalistic study of the relation of the psychotherapy process to changes in symptoms, information processing, and physiological activity in complex trauma by D’Andrea and Pole (2012) focused on non-military populations and used a small sample size of women who were victims of extreme interpersonal violence. Although not directly applicable to working with military clients, it presented interesting findings regarding how the different approaches of stress inoculation, prolonged exposure, and psychodynamic affect different symptoms of trauma. Their findings revealed that both psychodynamic and stress inoculation techniques had greater reductions in subjective and physiological symptoms, but less improvement in cognitive symptoms. The prolonged exposure techniques showed worse outcomes with regard to the cognitive symptoms. These findings raise important questions about understanding different presentations of PTSD symptomology and knowing which available evidence-­ based therapies are best suited to treat them. Houram et  al. (2011) published a paper on stress inoculation training (SIT). In this paper titled “Predeployment stress inoculation training for primary prevention of combat-related stress disorders”, the authors used a more traditional application of SIT by training personnel in coping skills to deal with combat stressors and exposure to trauma prior to their deployment. Another interesting aspect of their study was that they used a multimedia stressor environment to deliver the training and used physiological measurements to assess arousal. The findings showed that participants with more PTSD symptoms at baseline showed more capability for improvement. It did also include participants who had been deployed prior to the study, and the findings suggested they also had more capacity for improvement. Life Balance Issues The resource room in the SupportNet website also includes information for clinicians specific to helping them manage their stress load LESSONS LEARNED AND NEXT STEPS   155 more ­effectively. We labeled this the life balance issues area, and it is divided into self-care, well-being, work/home balance, and goal setting. Self-Care.  “Ethics, self-care and well-being for psychologists: Reenvisioning the stress-distress continuum” by Wise, Hersh, and Gibson (2012) focused on the emotional and psychological challenges of being a behavioral health provider and the need, as a profession, to more adequately address these issues. They suggested we expand our notion of the stress-distress continuum and add more positive psychology-based principles and theories to achieve this goal. The article provided specific strategies for self-care, such as therapeutic lifestyle changes and mindfulness-based positive principles and practice that target four principles of self-care the authors believe to be critical: focusing on flourishing versus surviving, intentionality, reciprocity between therapist and client, and integration of self-care practices into our daily routine. The authors highlighted the importance of self-care as being imperative to our ethical obligations as behavioral health professionals. The paper titled “Integrating mindfulness as self-care into counselling and psychotherapy training” by Christopher and Maris (2010) targeted the importance of mindfulness for self-care. Specifically, the authors examined the use of mindfulness as a tool of self-care in the training of behavioral health-care professionals. Using qualitative designs across five studies with graduate students in counseling or psychology programs, the authors found strong support for the benefit of teaching mindfulness to the students. Specifically, students participating in the mindfulness study evidenced changes in how they conceptualized clients, increased levels of self-awareness (emotionally, spiritually, physically), increased mental clarity from meditation, increased comfort with clients during sessions (the silence, the process, being grounded), reduced feelings of inadequacy, and increased ability to tolerate ambiguity and to relinquish control. These findings do highlight the possible use of mindfulness as an integral part of any therapist training program but also remind seasoned professionals of the importance of maintaining these aspects of our therapy with clients. Richards, Campenni, and Muse-Burk (2010) examined the role of mindfulness in the relationship between self-care and well-being in behavioral health-care professionals. Building on prior research that demonstrated various relationships between self-care, awareness, mindfulness, and well-being, the authors decided to clarify these relationships by 156   C.C. BENIGHT ­ esignating mindfulness as a possible mediator between self-care and well-­ d being. Using a sample of 148 behavioral health professionals, the authors’ findings suggested that mindfulness mediated the relationship between self-care importance and well-being. This can be interpreted as: when behavioral health professionals classify self-care as being important, their sense of well-being was enhanced more when the person was also able to achieve a state of mindfulness. The findings also suggested that frequency of self-care was only directly related to well-being, and mindfulness did not mediate this relationship. Although the authors did not address this in the article, it should be noted that other researchers in mindfulness have defined mindfulness as the “cultivation of awareness”. However, in this study, self-awareness is viewed as a path leading to mindfulness. Well-Being. In the paper by Lee (2007) “Mind—body—spirit practice and perceived self-efficacy for mental health promotion: An exploratory study”, the author explored the role of mind-body-spirit (MBS) self-efficacy in psychological wellbeing, health, and spirituality/altruistic behaviors. After also analyzing demographic and mind-body-spirit practices as predictors, the author showed that MBS self-efficacy was a consistently significant predictor of all three domains of physical, psychological, and spiritual well-being. In addition, MBS self-efficacy, along with more frequent meditation practice, was associated with increased spiritual experience and decreased depression, more so than other factors like altruism, life satisfaction, and overall health status. This study is interesting because it uses domain-specific self-efficacy (i.e., MBS self-efficacy) to help promote MBS health behaviors, rather than the traditional use of psychoeducation to promote health behaviors. In the paper titled “The benefits of being present: Mindfulness and its role in psychological wellbeing”, Brown and Ryan (2003) explored the role that consciousness (the ability to attend and to be aware) is important to a person’s sense of well-being. Defining “mindfulness” as the cultivation of awareness and attention, the authors  used this construct to examine how it is related to various constructs of well-being (physical, emotional, neurotic, subjective, eudaimonic). Data analyses from three studies revealed that mindfulness was strongly correlated with all these well-being constructs, that mindfulness was a distinct form of awareness and attention, and that mindfulness, as measured by the Mindful Attention Awareness Scale (MAAS), predicted well-being outcomes. LESSONS LEARNED AND NEXT STEPS   157 Although these authors emphasized the importance of mindfulness in well-being, it is not clear how this construct fits into other theories of well-being. Bakker and Demerouti (2007) provided a comprehensive overview of two major models of employee well-being: the demand-control model (DCM) and the effort-reward imbalance model (ERI). Briefly, high job demand and low job control create lower employee wellbeing in the DCM. In contrast,  job strain is the result of a perceived imbalance between the efforts an employee makes and the reward that the employee receives for those efforts  in the ERI model. The authors criticized these models for taking too simplistic an approach to understanding the factors that lead to well-being and/or job strain. The authors add to the body of literature in this area by describing a new, more comprehensive model that not only included the negative demands of these models, but also the positive contributions, called the job demands-resources model (JD-R). This model acknowledged the personal, organizational, and social resources people use to help manage the demands of the job. They also explained that the model includes direct effects of demands and resources, but, in addition, includes the interactions between the specific elements of the demands and resources. The authors reviewed research that provides some evidence for the JD-R model. “The structure of psychological well-being revisited” by Ryff and Keyes (1995) presented and tested a multidimensional model of wellbeing. Their goal was to move beyond the more simple models of past research that only examined well-being through life satisfaction and well-being as a balance between negative and positive affect. They proposed six dimensions of well-being: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance (descriptions of these are included at the end of the published article). Using a nationwide sample of 1108 people, the results strongly supported that these were indeed six factors of a larger construct of well-being. These authors made a valuable contribution to our understanding of well-being and provided the framework to conduct more research that examines the interaction between these dimensions. 158   C.C. BENIGHT Work-Home Balance.  The article by Voydanof (2005) titled “Toward a conceptualization of perceived work-family fit and balance: A demands and resources approach” viewed the work-family balance issue using a demands-resources approach. More specifically, the author used the concept of “fit” between work life and family life across two dimensions: work demands-family resources and family demands-work resources. Drawing upon the findings of other studies and other theories from person-environment fit, the Voydanof presented a new conceptual model. In addition to using the two dimensions as pathways to achieving a balance, the strategies people employ to help maintain balance were included. The author concluded that a good fit is achieved when work resources meet, offset, or satisfy family demands and when family resources meet, offset, or satisfy work demands. Voydanof recommended this model be tested in a variety of ways to determine its “goodness of fit” with empirical data. Clark (2000) introduced a new theory, the work/family border theory, to explain how people construct the separation and integration of work life and family life. This theory classifies people as “bordercrossers” who are required to make border crossings every day. The theory represents a shift in thinking about work/family balance, because it focuses on the structure of boundaries through relationships and not the emotional boundaries that have been a focus of past theories. Clark described her development of this theory as phenomenological by using her own experiences, qualitative interviews, and focus groups with people who have high work and family demands. She explained the four components of her theory: domains (i.e., work, family), borders (demarcations between domains), border-crossers, and border keepers/ other domain members. Clark also provided a set of eight rules, or propositions, that capture the way these four components interact. The author proposed this theory to not only help individuals conceptualize their own struggles but also to help guide research with this new paradigm. Goal Setting.  Grant (2012) presented a well-written overview of the goal-­setting research and its role in effective coaching. The Golden Rules of Goal Setting (Mind Tools, 2016) article introduced five guidelines for setting goals: set goals that motivate you, set SMART goals, set goals in writing, make an action plan (steps), and stick with it. Two different websites might be useful for goal setting as well. The website 10 Steps to Creating Goals (WikiHow, 2016) provides a good overview of how to set goals and does it in an engaging manner. Finally, the site How to Set Goals that Will Keep You Fulfilled and Focused (Ford & Wortmann, 2013) helps you create goals by appealing to what motivates you in your life. LESSONS LEARNED AND NEXT STEPS   159 Health Status Also in the resource room for clinicians is a section called Health Status. The material in this area was collected to help providers learn about how stress can influence their health. The papers provided include information related to the importance of social support, work engagement, and work addiction. “Functional roles of social support within the stress and coping process: A theoretical and empirical overview” by Schwarzer and Knoll (2007) examined the functional roles of social support through five studies and offered five possible theories to explain this interaction. The first is the enabling hypothesis that suggests that the social support a person receives helps to enable a person’s self-efficacy. The second is the cultivation hypothesis that suggests that self-efficacy serves as a cultivator of social support. Both theories state that the outcome of these processes is a decrease in traumatic symptoms. Another theory they reviewed discussed social support as a predictor of coping, and likewise, there is another theory that suggests effective coping generates the mobilization of social support. Finally, the article introduced the resource hypothesis that views social support as a result of a dyadic process where support is transferred between two members of a partnership. Although the authors are unable to find overwhelming support for only one functional role of social support in their studies, they suggested that different mechanisms of social support may be in operation in different contexts. In another great paper, Halbesleben (2006) conducted a meta-­analysis to more closely examine the relationship between the resource of social support and the three dimensions of burnout (emotional exhaustion, depersonalization, and personal accomplishment). The results of the analysis indicated work social support had a more direct relationship with emotional exhaustion, because work support is more closely related to work demands. The findings also suggested that non-work-related social support was more directly related to depersonalization and personal accomplishment. Halbesleben argued that these findings challenge the Conservation of Resources (COR) model developed by Hobfoll but suggested that modifying this model to include the source of social support would help explain the findings of this study as well as of previous studies. Another important point made by Halbesleben was that no models have been developed or tested that examine the potentially reciprocal nature of social support and burnout. 160   C.C. BENIGHT In the paper “The role of social support in the process of work stress: A meta-analysis” (Viswesvaran, Sanchez, & Fisher, 1999) built on the existing research about the relationship between social support and work stress. The authors evaluated intervening variables that may mediate this relationship. They used a two-study approach, where the first study used a meta-analysis to identify the constructs instrumental in this relationship. The meta-analysis revealed three main constructs: stressors, strains, and social support. In the second study, the authors examined the importance of social support in workplace stress. The results of the second study indicated that social support has a direct effect of reducing work strain, mitigating the stressors, and moderating the relationship between work stress and work strain. However, the data did not support other models of social support as a suppressor, mobilizer, or mediator on work stress and work strain. This research helps us better understand that social support may play more than one role in its relationships with work stress and work strain and that each relationship may be different. Hall (2009) in the paper “Utilizing social support to conserve the fighting strength: Important considerations for military social workers” highlighted the importance of social support when addressing secondary traumatic stress. The author described how a “buddy system”, as borrowed from other areas of the military, could be an effective way to create a protective factor against the development of secondary trauma in military social workers. One drawback about this idea was that it has not been utilized to specifically address secondary traumatic stress and has not been researched in military social workers. However, the author suggested that its success with soldiers in providing tangible, instrumental, informational, and emotional social support to help with the demands of military life could also be of utility for the demands of the military social workers’ lives. Kossek, Pichler, Bodner, and Hammer (2011) completed a meta-­ analysis entitled “Workplace social support and work–family conflict: A meta-analysis clarifying the influence of general and work–family-specific supervisor and organizational support”. The quantitative review examined general versus work-family-specific supervisor and organizational support on the work-family conflicts experienced by employees. The meta-analysis included 85 studies whose total participants were over 72,000 employees. Their findings indicated that work-family-specific support from both supervisors and organizations was indirectly related to w ­ ork-family ­conflict. These findings could significantly change our perspective on effective ways LESSONS LEARNED AND NEXT STEPS   161 supervisors and organizations provide support to their employees. One issue not discussed in this article was how this support affected employee productivity and how negatively or positively the supervisor viewed the employee. “Job demands and resources as antecedents of work engagement: A longitudinal study” by Mauno, Kinnunen, and Ruokolainen (2007) presented the findings of a two-year longitudinal study that examined the antecedents of work engagement through the lens of job demands and resources. Specifically, the job demands measured included perceived job insecurity, time demands at work, work-family conflict, job control, and management quality. The three components of work engagement were absorption, vigor, and dedication. Using a sample of 409 health-care workers in Finland, the researchers found that job resources, especially job control, made the most contribution in positive work engagement. The authors suggested that future researchers should design other research to include different time lags and also to use other occupational groups to see if these findings hold true. In a study focused on the potential consequences of being too engaged with one’s work, Halbesleben, Harvey, and Bolino (2009) examined the personal resource of conscientiousness and its relationship with work engagement and work-family conflict. Their findings indicated that higher work engagement was positively related to higher work-family conflicts, but that personal conscientiousness, when added to high work engagement, led to lower levels of work-family conflict. The authors provided a valuable view into our understanding of work engagement by evaluating this in terms of the effect it may have on people’s ability to meet work-­ family demands. The paper “Workaholism, burnout, and work engagement: Three of a kind or three different kinds of employee well-being?” (Schaufeli, Taris, & van Rhenen, 2008) investigated whether workaholism, burnout, and work engagement are three distinct types of employee well-being or three components of the same construct. The authors stress the significance of this distinction because the confusion of these constructs in the literature has led to an inability to coherently interpret the findings. Using a population of 587 telecom managers, the authors found that workaholism, burnout, and work engagement are actually three different constructs. However, the three constructs are interrelated, where burnout and workaholism are positively correlated and burnout and engagement are n ­ egatively ­correlated. Although this is an intuitive relationship that seems to make sense, the 162   C.C. BENIGHT authors also found that there were external factors that load onto each of these constructs as well. For example, absorption not only contributes to level of work engagement but also to workaholism. The specifics of how these interrelate are areas for future research. The authors stated that an implication of their findings is that the measurement of employee well-­ being must account for these complex interrelationships. Stress Indicators The resource room section targeting stress indicators provides the clinician with important studies directly related to job burnout. Self-education on the negative consequences of burnout as well as the predictors of burnout is important for providers to understand if they are going to be successful in managing this problem. Lee, Lim, Yang, and Lee (2011) completed a meta-analysis of 74 studies in order to examine in more detail the antecedents and consequences of the three dimensions of burnout in psychotherapists as measured by the Maslach Burnout Inventory (MBI). The study had several interesting findings about the antecedents. Their analysis suggested that job stress and over-involvement were positively correlated with emotional exhaustion. However, over-involvement was also positively associated with personal accomplishment. Also as an antecedent, job control was negatively correlated with depersonalization and personal accomplishment. In terms of consequences, the authors found that job satisfaction had the most significant positive correlation with exhaustion, depersonalization, and personal accomplishment. As a result of these findings, the authors recommend that multidimensional approaches be developed for the prevention and treatment of burnout in psychotherapists due to the, sometimes paradoxical, relationships the antecedents have on the dimensions of burnout. Although the authors provided a beneficial view of the data on burnout through a meta-analysis, it is difficult to draw strong conclusions due to the lack of heterogeneity of the populations used in the analyses. It is possible that different work environments and organizational structures lead to different results in terms of antecedents and consequences of burnout. In a great study titled simply “Job burnout”, Maslach, Schaufeli, and Leiter (2001) comprehensively reviewed the job burnout research and issues from the previous 25 years. It provides a brief history of the research, a definition of the construct, the assessment tools used to m ­ easure ­burnout, and LESSONS LEARNED AND NEXT STEPS   163 a review of the situational and individual factors contributing to burnout. In addition, the authors offered suggestions as to the next steps for progressing the research and the theory of burnout with the intention of developing more effective prevention and treatment opportunities. They specifically mentioned the notion of work engagement as being the positive antithesis of burnout that has the most promise for better interventions. One criticism of this article was that the authors focused on only one conceptualization of burnout as having the three dimensions of exhaustion, cynicism, and inefficacy. Although there is research supporting their conceptualization, other theories have been developed to explain the same construct. With more direct relevance to military mental health providers, a paper titled “Professional burnout in clinical military psychologists: Recommendations before, during, and after deployment” examined the unique stressors of clinical military psychologists and the impact of these on professional burnout (Linnerooth, Mrdjenovich, & Moore, 2011). The authors reviewed the various terms for burnout, such as compassion fatigue, vicarious traumatization, and secondary traumatic stress. The most beneficial part of this article was that the authors, two of whom work in the military services, offered specific recommendations for the three phases of deployment (pre-deployment, deployment, and post-­ deployment) to help mitigate the development of professional burnout. In addition, the article briefly addressed organizational tactics that may also benefit clinical military psychologists. Bride and Figley (2009) focused on the need for more research, practice, and policy work regarding military caregiver stress. They reviewed the various terms used to capture the concept of caregiver stress, a model of how this stress develops, special issues with military caregivers, and direction on how to prevent or treat this stress. In addition, the authors highlighted two programs already being used to address caregiver stress. Although Bride and Figley provided a good framework for this discussion and were able to identify areas that need further investigation, it should be noted the caregiver stress model they presented may be premature and may not reflect the findings once further research is conducted in this area. “Treating traumatized OEF/OIF veterans: How does trauma treatment affect the clinician?” by Voss Horrell, Holohan, Didion, and Vance (2011) discussed various components of STS and its antecedents, such as patient factors, clinician factors, and organizational factors. Although the authors only conducted a literature review of these topics, they identified the common findings regarding STS, including the critical roles each of 164   C.C. BENIGHT the following factors play in preventing the onset of STS: allowing clinicians to plan their own appointments, attending to self-care practices, having a supportive team, and using evidence-based practices. All the authors work(ed) in the VA system and were able to bring a real-world sense of these issues to their discussion. Clinician Toolkit Finally, the clinician tool kit segment of the resource room provides educational opportunities and critical information on evidence-based care for clinicians themselves as well as information to provide to clients. For the Clinician. The NCPTSD provides free online CE credit courses to educate professionals about PTSD and its treatments (U.S.  Department of Veterans Affairs, 2016b). Psychology Tools is a website with a number of handouts related to PTSD, cognitive processing therapy (CPT), and prolonged exposure therapy (PET) that you can give to clients (Psychology Tools, 2016). A nice overview from the VA on what type of therapy to try with a client struggling with PTSD can be found at https://www. youtube.com/watch?v=C60IkK-­MFT4 (Veterans Health Administration, 2012a). A very helpful video describing CPT created by the VA can be found at https://www. youtube.com/watch?v=Tx3KdKDZOS8 (Veterans Health Administration, 2012b). Similarly, the VA recorded an overview of EMDR therapy. It can be found at https:// www.youtube.com/watch?v=bnjEr7GVhLo (Veterans Health Administration, 2012c). Lastly, the VA offers an overview of PET at https://www.youtube.com/ watch?v=AUOYFQTm9lE (Veterans Health Administration, 2012d). A clinical manual for CPT specifically for veterans and military clients is available at http://www.alrest.org/pdf/CPT_Manual_-­_Modified_for_ PRRP(2).pdf (Resick, Monson, & Chard, 2006). This manual provides step-by-step details on a 12-session CPT approach and its applicability with veterans and active-duty military. An online training course in CPT is available through the Medical University of South Carolina. The course can be accessed at https://cpt. musc.edu (Medical University of South Carolina, 2009). This course, combined with the structured manual described above, can provide a strong foundation in conducting CPT with veterans and other military clients. Of course, we would recommend that a clinician with limited experience with CPT concepts be supervised by an experienced provider who is used to using CPT with this population. LESSONS LEARNED AND NEXT STEPS   165 The Defense Centers of Excellence provides some very useful monthly webinars that can be found at http://www.dcoe.mil/Training/Monthly_ Webinars.aspx (Defense Centers of Excellence, 2016). Included in this website is an archive that is nicely organized for a variety of topics that would be of interest to most therapists. A clinician’s guide to PTSD treatments for returning veterans is a great article published in 2012. The paper includes information on psychological treatments as well as pharmacological approaches. The NCPTSD also has an overview of pharmacological treatments for PTSD that might be helpful. You can find this at http://www.ptsd.va.gov/PTSD/ptsd_search. asp?SECT=2&QT=pharmacological+&RPP=20 (VA, 2016b). Understanding the neurobiology of trauma can be helpful to have a more comprehensive view of the challenges veterans face. The article “Damaged brain regions protect against PTSD” is a paper in Neurology Today that describes how the amygdala and ventromedial prefrontal cortex play a role in PTSD. They report on findings from Vietnam veterans who had damage to these areas and were less likely to develop PTSD. The paper can be found at http://journals.lww.com/neurotodayonline/Fulltext/2008/02210/ Damaged_Brain_Regions_Protect_Against_PTSD.8.aspx (Schuster, 2008). For the Client.  After Deployment is a website designed to help the soldier to manage his/her reactions to having gone through deployment. The site is designed based on topic areas (e.g., anxiety, mild traumatic brain injury, suicide prevention) and utilizes extensive video personal testimonials, assessments, and self-help materials to help the user to manage these different issues. It can be found at https:// afterdeployment.dcoe.mil (National Center for Telehealth & Technology, 2010). A very nice handout that describes treatment for PTSD is available through the national center for PTSD (NCPTSD). You can find this handout at http://www.ptsd.va.gov/public/pages/handouts-pdf/handout_TreatmentforPTSD.pdf (Hamblen, 2010). Maketheconnection.net is a website to help veterans to not feel alone. This online resource connects veterans, their family members and friends, and other supporters with important information, resources, and solutions to challenges that are affecting their lives. The users can filter the site with their own branch of the military to be able to find those mostly matched to their experience. The site can be found at http://maketheconnection. net/what-is-mtc (U.S. Department of Veterans Affairs, 2016a). 166   C.C. BENIGHT Some clients might like to get deeper information about what PTSD is and how others have managed it. The NCPTSD offers this on their website http://www.ptsd.va.gov/public/index.asp (U.S. Department of Veterans Affairs, 2016c) where they describe what PTSD is and also other links to getting better. The NCPTSD also offers some very useful web and app tools for clients. PTSD Coach Online is available at http://www.ptsd.va.gov/public/treatment/cope/index.asp (VA, 2016b). The mobile app for PTSD Coach can be downloaded from http://www.ptsd.va.gov/public/materials/apps/PTSDCoach.asp (VA, 2016b). For family members, PTSD Family Coach was recently released and can be found at the app store for Apple (free of charge) and soon for Android phones. The path to recovery video can be found at https://www.youtube. com/watch?v=SqjwV-lsVEs (Make the Connection, 2011). This segment includes testimonials from men and women who report how they figured out that they had PTSD. This can be quite helpful to normalize the experience for soldiers who are blaming themselves and feel alone with their symptoms. References Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309–328. doi:10.1108/02683940710733115. Bride, B. E., & Figley, C. R. (2009). Secondary trauma and military veteran caregivers. Smith College Studies in Social Work, 79(3–4), 314–329. doi:10.1080/00377310903130357. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848. doi:10.1037/0022-3514.84.4.822. Christopher, J. C., & Maris, J. A. (2010). Integrating mindfulness as self-care into counselling and psychotherapy training. Counselling & Psychotherapy Research, 10(2), 114–125. doi:10.1080/14733141003750285. Clark, S. C. (2000). Work/family border theory: A new theory of work/family balance. Human Relations, 53(6), 747–770. doi:10.1177/0018726700536001. D’Andrea, W., & Pole, N. (2012). A naturalistic study of the relation of psychotherapy process to changes in symptoms, information processing, and physiological activity in complex trauma. Psychological Trauma: Theory, Research, Practice, and Policy, 4(4), 438–446. doi:10.1037/a0025067. LESSONS LEARNED AND NEXT STEPS   167 Defense Centers of Excellence. (2016, April 21). Monthly Webinars. Retrieved from http://www.dcoe.mil/Training/Monthly_Webinars.aspx Forbes, D., Lloyd, D., Nixon, R. V., Elliott, P., Varker, T., Perry, D., et al. (2012). A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder. Journal of Anxiety Disorders, 26(3), 442–452. doi:10.1016/j.janxdis.2012.01.006 Ford, J., & Wortmann, J. (2013, January). How to set goals that will keep you fulfilled and focused. Fast Company. Retrieved from http://www.fastcompany. com/3003975/how-set-goals-will-keep-you-fulfilled-and-focused Grant, A. M. (2012). An integrated model of goal-focused coaching: An evidence-­ based framework for teaching and practice. International Coaching Psychology Review, 7(2), 146–165. Halbesleben, J. B. (2006). Sources of social support and burnout: A meta-analytic test of the of resources model. Journal of Applied Psychology, 91(5), 1134–1145. doi:10.1037/0021-9010.91.5.1134. Halbesleben, J. B., Harvey, J., & Bolino, M. C. (2009). Too engaged? A conservation of resources view of the relationship between work engagement and work interference with family. Journal of Applied Psychology, 94(6), 1452–1465. doi:10.1037/a0017595. Hall, J.  C. (2009). Utilizing social support to conserve the fighting strength: Important considerations for military social workers. Smith College Studies in Social Work, 79(3–4), 335–343. doi:10.1080/00377310903115465. Hamblen, J. (2010). Treatment of PTSD. National Center for PTSD. Retrieved from http://www.ptsd.va.gov/public/pages/handouts-pdf/handout_ TreatmentforPTSD.pdf Houram, L. L., Kizakevich, P. N., Hubal, R., Spira, J., Strange, L. B., Holiday, D. B., et al. (2011). Predeployment stress inoculation training for primary prevention of combat-related stress disorders. Journal of Cybertherapy and Rehabilitation, 4(1), 101–116. Kossek, E. E., Pichler, S., Bodner, T., & Hammer, L. B. (2011). Workplace social support and work–family conflict: A meta-analysis clarifying the influence of general and work–family-specific supervisor and organizational support. Personnel Psychology, 64(2), 289–313. doi:10.1111/j.1744-6570.2011.01211.x. Lee, E. O. (2007). Mind-body-spirit practice and perceived self-efficacy for mental health promotion: An exploratory study. International Journal of Mental Health Promotion, 9(3), 35–47. doi:10.1080/14623730.2007.9721841. Lee, J., Lim, N., Yang, E., & Lee, S. M. (2011). Antecedents and consequences of three dimensions of burnout in psychotherapists: A meta-analysis. Professional Psychology: Research and Practice, 42(3), 252–258. doi:10.1037/a0023319. Linnerooth, P. J., Mrdjenovich, A. J., & Moore, B. A. (2011). Professional burnout in clinical military psychologists: Recommendations before, during, and 168   C.C. BENIGHT after deployment. Professional Psychology: Research and Practice, 42(1), 87–93. doi:10.1037/a0022295. Make the Connection. (2011, December 12). The path to recovering from PTSD [Video file]. Retrieved from ­https://www.youtube.com/ watch?v=SqjwV-lsVEs Maslach, C., Schaufeli, W.  B., & Leiter, M.  P. (2001). Job burnout. Annual Review of Psychology, 52, 397–422. doi:10.1146/annurev.psych.52.1.397. Mauno, S., Kinnunen, U., & Ruokolainen, M. (2007). Job demands and resources as antecedents of work engagement: A longitudinal study. Journal of Vocational Behavior, 70(1), 149–171. doi:10.1016/j.jvb.2006.09.002. Medical University of South Carolina. (2009). CPTWeb. Retrieved from https:// cpt.musc.edu/ Mind Tools. (2016). Golden rules of goal setting: Five rules to set yourself up for success. Mind Tools. Retrieved from https://www.mindtools.com/pages/article/newHTE_90.htm Monson, C. M., Macdonald, A., Vorstenbosch, V., Shnaider, P., Goldstein, E. R., Ferrier-Auerbach, A. G., et al. (2012). Changes in social adjustment with cognitive processing therapy: Effects of treatment and association with PTSD symptom change. Journal of Traumatic Stress, 25(5), 519-526. doi:10.1002/ jts.21735 Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-­ related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898–907. doi:10.1037/0022-006X.74.5.898. National Center for Telehealth & Technology. (2010). After deployment. Retrieved from https://afterdeployment.dcoe.mil/ Psychology Tools. (2016). Post-traumatic stress disorder (PTSD). Retrieved from http://psychology.tools/ptsd.html Resick, P. A., Monson, C. M., & Chard, K. M. (2006). Cognitive processing therapy veteran/military version. Unpublished therapy manual. Retrieved from http:// www.alrest.org/pdf/CPT_Manual_-_Modified_for_PRRP(2).pdf Richards, K. C., Campenni, C. E., & Muse-Burke, J. L. (2010). Self-care and well-­ being in mental health professionals: The mediating effects of self-awareness and mindfulness. Journal of Mental Health Counseling, 32(3), 247–264. doi:10.17744/mehc.32.3.0n31v88304423806. Ryff, C. D., & Keyes, C. M. (1995). The structure of psychological well-being revisited. Journal of Personality and Social Psychology, 69(4), 719–727. doi:10.1037/0022-3514.69.4.719. Schaufeli, W. B., Taris, T. W., & van Rhenen, W. (2008). Workaholism, burnout, and work engagement: Three of a kind or three different kinds of employee well-being? Applied Psychology: An International Review, 57(2), 173–203. doi:10.1111/j.1464-0597.2007.00285.x. LESSONS LEARNED AND NEXT STEPS   169 Schuster, L. (2008). Damaged brain regions protect against PTSD. Neurology Today, 8(4), 11–12. doi:10.1097/01.NT.0000312106.46090.56. Schwarzer, R., & Knoll, N. (2007). Functional roles of social support within the stress and coping process: A theoretical and empirical overview. International Journal of Psychology, 42(4), 243–252. doi:10.1080/00207590701396641. Shapiro, F., & Maxfield, L. (2002). Eye movement desensitization and reprocessing (EMDR): Information processing in the treatment of trauma. Journal of Clinical Psychology, 58(8), 933–946. doi:10.1002/jclp.10068. Taylor, S., Thordarson, D.  S., Maxfield, L., Fedoroff, I.  C., Lovell, K., & Ogrodniczuk, J.  (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71(2), 330–338. doi:10.1037/0022-006X.71.2.330. U.S.  Department of Veterans Affairs. (2016a). Make the connection. Retrieved from http://maketheconnection.net/what-is-mtc U.S.  Department of Veterans Affairs. (2016b, February 23). PTSD: National Center for PTSD. Retrieved from http://www.ptsd.va.gov/ U.S. Department of Veterans Affairs, (2016c). What is PTSD? Information retreived from http://www.ptsd.va.gov/public/index.asp. van der Kolk, B. A., Spinazzola, J., Blaustein, M. E., Hopper, J. W., Hopper, E. K., Korn, D. L., & Simpson, W. B. (2007). A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: Treatment effects and long-term maintenance. Journal of Clinical Psychiatry, 68(1), 37–46. doi:10.4088/JCP. v68n0105. Veterans Health Administration. (2012a, July 13). How do I decide which treatment [for posttraumatic stress disorder] to try? [Video file]. Retrieved from https://www.youtube.com/watch?v=C60IkK-MFT4 Veterans Health Administration. (2012b, July 13). What is cognitive processing therapy (CPT) [for posttraumatic stress disorder]? [Video file]. Retrieved from https://www.youtube.com/watch?v=Tx3KdKDZOS Veterans Health Administration. (2012c, July 13). What is eye movement desensitization and reprocessing (EMDR) [for posttraumatic stress disorder]? [Video file]. Retrieved from https://www.youtube.com/watch?v=bnjEr7GVhLo Veterans Health Administration. (2012d, July 13). What is prolonged exposure (PE) [for posttraumatic stress disorder]? [Video file]. Retrieved from https:// www.youtube.com/watch?v=AUOYFQTm9lE Viswesvaran, C., Sanchez, J. I., & Fisher, J. (1999). The role of social support in the process of work stress: A meta-analysis. Journal of Vocational Behavior, 54(2), 314–334. doi:10.1006/jvbe.1998.1661. Voss Horrell, S.  C., Holohan, D.  R., Didion, L.  M., & Vance, G.  T. (2011). Treating traumatized OEF/OIF veterens: How does trauma affect the c­ linician? 170   C.C. BENIGHT Professional Psychology: Research and Practice, 42(1), 79–86. doi:10.1037/ a0022297. Voydanoff, P. (2005). Toward a conceptualization of perceived work-family fit and balance: A demands and resources approach. Journal of Marriage and Family, 67(4), 822–836. doi:10.1111/j.1741-3737.2005.00178.x. WikiHow. (2016). How to set goals. WikiHow. Retrieved from ­http://www.wikihow.com/Set-Goals Wise, E. H., Hersh, M. A., & Gibson, C. M. (2012). Ethics, self-care and well-­ being for psychologists: Reenvisioning the stress-distress continuum. Professional Psychology: Research and Practice, 43(5), 487–494. d ­ oi:10.1037/ a0029446.  Appendix: SupportNet Coaching Manual Appendix A: Assessment Date Status SS SE WE STS BO PS NOTES Red Orange Yellow Green Red Orange Yellow Green Red Orange Yellow Green Red Orange Yellow Green SS  – Social Support; SE  – Self-Efficacy; WE  – Work Engagement; STS  – Secondary Traumatic Stress; BO – Burnout; PS – Perceived Stress © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1 171 172   Appendix: SupportNet Coaching Manual Pre-Coaching Checklist – For Coach • Reviewed Assessment results –– ______ STS is significantly present  – mark if present and see Appendix A & B (if score is in the RED area on pie chart—then STS is significantly present) –– Refer to behavioral health services if STS is RED on pie chart (see Appendix C) • Goals of Coaching Intervention become centered around taking care of self (in addition to enhancing self-care and social support) by seeking help from a behavioral health care specialist • Scheduled first 60-minute coaching session to begin on: _________ (date) at ________ (time) –– Encouraged participant to set up profile & review assessment results: explained that there would be a chance to explore the rest of the site and set up goals once coaching begins –– Recommended computer access to the internet during first and second sessions • Verbal OK to contact client via: –– Email: _____________________________________________ –– Phone:______________________________________________ –– Text:_______________________________________________ • Coaches may find it helpful to review “ Goals and Objectives of Coaching Plan” (Appendix D) Appendix: SupportNet Coaching Manual   173 Appendix B: Coaching Session 1 – Enhancing Awareness (Self-Awareness /Commitment) Self-care is a skillful attitude that needs practice throughout the day ~ M. J. Mahoney Questions / Strategies (to use during coaching session): 1. What do you see going on? 2. What would you do differently if nothing stopping you? / What’s holding you back? 3. I can see that things [at work] are really difficult for you right now and yet you have still managed to _______________________. How have you done that? Coach: Please check each box representing what you were able to address this session: • Focused on rapport-building (LISTEN to “their story” especially if STS present) It is imperative that the coach validates and normalizes the participant’s experiences. Reframing their reactions as being an indication that they are a dedicated and compassionate [provider]may be necessary if they are experiencing guilt or shame about their thoughts, emotions, or behaviors (Meichenbaum, 2007) • Introduced coaching model –– Reviewed Elements of Coaching • “Recognizing the nature of your work with military trauma, this is a workplace intervention to minimize / prevent job burnout, secondary traumatic stress and to increase work engagement” • Focus is on gaining awareness • Help you feel more capable to handle work-related stressors • Additional focus on the three S’s (self-care, social support, self-efficacy) –– Improve self-care –– Increase social support 174  Appendix: SupportNet Coaching Manual • Here to help AND to confront you when necessary (coach analogy) • Bottom Line: “You are in control and you are responsible for your own processes and outcomes” (see Appendix E-F) • Reviewed assessment results with participant –– Invited participant to share their perceptions of the assessment results –– Focused on strengths –– Explored with participant their understanding of burnout • Physical and mental exhaustion resulting from excessive, prolonged exposure to stress –– Explored with participant their understanding of STS (if applicable) • Natural consequence of caring for traumatized individuals • Stress associated with helping a traumatized individual • Early identification is important • Promoted specific self-care strategies for healthy lifestyle • Explained how to navigate web application –– Highlighted assessments (self-monitoring) –– Highlighted connections (social support) –– Highlighted goal-setting • Life Balance (links values to goals) • Take-5 (self-care) –– Highlighted library resources • EBTs (CPT, EMDR, PET) • Life Balance (self-care, wellbeing, work home balance, goal setting) • Health Status (self-efficacy, social support, work engagement) • Stress Indicators (Job Burnout, Perceived Stress, STS) • Clinician Toolkit (clinician, client, PTSD meds, neurobiology of PTSD) Appendix: SupportNet Coaching Manual   175 –– Referred participant to tech team if they requested additional support • Assessed current levels of self-care self-efficacy: “Reflecting on your current situation, on a scale of 1 (not at all confident) to 10 (100 percent confident), how confident are you that you can establish some self-­ care goal(s)?” Low 1 2 3 4 5 6 7 8 9 10 High • Assigned Homework –– Profile: develop (if not already completed) –– Explore web application  – Instructional Video (if available), Profile, Assess (user will be provided an opportunity between session 2 and 3 to enter goals and connect with others) –– Resources: Selected readings on Stress Indicators, Health Status, Life Balance Issues –– Goals: complete the Life Balance Wheel  - print a copy for your recs (see Appendix G) • Negotiated level of coach support and contact in between sessions (see Appendix H for log) • Scheduled Session 2 for ____________ (date) at ___________ (time) –– Recommended computer access to the internet during first and second sessions • Coach To Do: –– Complete Goal Survey – see Appendix I for Session 1–6 Goals –– Document session start and end time Session Notes: 176  Appendix: SupportNet Coaching Manual  Appendix C: Coaching Session 2 – Goals / Challenges  Goals for Success “If you don’t know where you are going, you’ll end up someplace else.” ~ Yogi Berra “It is not enough to take steps which may someday lead to a goal; each step must be itself a goal and a step likewise.” ~ Johann Wolfgang von Goethe Coach To Do (preparation for Session 2): • Review Life Balance Wheel Results and document below Questions / Strategies: 1. What are your non-negotiable beliefs and values? How developed? When, where, challenged? (Kemp, 2005) 2. How would life be different for you if [target life balance area] were more balanced? 3. What would you do differently if nothing stopping you? Coach: Please check each box representing what you were able to address this session: • Supported participant process of identifying and utilizing specific self-care strategies (promoting healthy lifestyle) • Reviewed Homework (circle one) Completed: Yes No Partially –– Profile: developed –– Instructional Video (if available), Profile & Assess –– Resources: Selected readings on Stress Indicators, Health Status & Life Balance –– Goals: Complete the Life Balance Wheel (Appendix G) • Environment ____ • Relationships ____ • Growth/Learning____ • Spirituality ____ • Fun ____ • Health/Fitness ____ • Career/Work ____ • Money/Finance____ Appendix: SupportNet Coaching Manual   177 • Explored Life Balance strengths and impact areas –– –– –– –– Relationship to burnout (and STS) Relationship to self-care (boundaries) Relationship to social support (connecting with others) Role of values in influencing targeted life balance area and goals • Facilitated participant choosing 1–2 life balance areas to focus on (values driven) • Explored participant knowledge base and experience with setting achievable goals –– Re: Goal • Emphasized starting with the end in mind • How will the participant know that they have achieved this goal? • Specific and measurable –– Re: Steps • 99 percent achievable • Reward progress along the way (incorporate into steps) • Emphasized importance of incorporating self-care • Encouraged incorporating social support (accountability partner) –– Shared resources on web application to assist with goal development • Behavioral intentions • Resource Room  – relevant sections on goal setting, self-care, social support • Encouraged participant to take steps toward developing a network of social support via Web Application Goal Connections • Assessed current level of self-care self-efficacy: “Reflecting on your current situation, on a scale of 1 (not at all confident) to 10 (100 percent confident), how confident are you that you can establish some goal(s)?” Low 1 2 3 4 5 6 7 8 9 10 High • Assigned Homework –– Resources: read about goals and goal setting (if appropriate) 178  Appendix: SupportNet Coaching Manual –– Goals: identify and enter online 1–2 goals for life balance domain of choice (include self-care and social support and identified accountability partner) –– Connections: identify and establish online social support connections for goals –– Action!!! • Scheduled Session 3 for ____________ (date) at ___________ (time). • Coach to Do: –– Complete Goal Survey – see Appendix I for Session 1–6 Goals –– Send an encouraging message to your participants this week –– Document session start and end time Session Notes: Appendix: SupportNet Coaching Manual    Appendix D: Coaching Session 3 – Goals / Challenge  Overcoming Obstacles 179 “Obstacles are those frightful things you see when you take your eyes off your goals.” ~ Henry Ford “Challenges are what make life interesting and overcoming them is what makes life meaningful.” ~ Joshua J. Marine “Whether you think you can, or you think you can’t—you’re right.” ~ Henry Ford “When everything seems to be going against you, Remember that the airplane takes off against the wind.” ~ Henry Ford Coach To Do (preparation for Session 3): • Review participant’s goals and steps and print a copy for your records if desired • Review participant’s connections • Review and document any updates on assessments Questions / Strategies: 1. Why did you become a behavioral health provider? 2. What would you do differently if nothing was stopping you? 3. Describe your most significant professional achievement to date. What made it significant? (Kelp, 2005) 4. How does self-care influence your ability to meet your life goals? What have been your most rewarding/difficult personal challenges? 5. How do you need to be thinking and perceiving differently to accomplish your goals? (Kemp, 2005) 6. How have you overcome past challenges? 7. How can you apply what you have learned about yourself when facing obstacles/challenges in the past to your current situation? 180  Appendix: SupportNet Coaching Manual Coach: Please check each box representing what you were able to address this session: • Reviewed Homework (circle one) Completed: Yes No Partially –– Resources: read about goals and goal setting (if appropriate) –– Goals: identify and enter online 1–2 goals for life balance domain of choice (include self-care and social support and identified accountability partner) –– Connections: identify and establish online social support connections for goals –– Action!!! How did it go??? • Explored with participant potential obstacles to achieving stated goal(s) –– “What obstacles do you see getting in the way of achieving your goals” –– Explored with participant strengths and successes when facing past challenges –– Supported participant in leveraging strengths to overcome obstacles –– Encouraged realistic expectations of self and others –– Challenged participant’s potential problematic core beliefs / cognitive distortions • Facilitated development of strategies to promote goal attainment such as: –– Identification of obstacles and plan in place to overcome obstacles • Obstacle(s) __________________________________________ • Plan _________________________________________________ –– Self-regulation techniques (monitor goal steps, evaluate goal progress, modify goal/steps) –– Reviewed role of three S’s-social support, self-care, self-efficacy in overcoming obstacles and referred participant to Resource Room for more information • Reminded client to “Celebrate your accomplishments!” –– Role of rewards –– Social posts (form of support) Appendix: SupportNet Coaching Manual   181 • Supported the client in identifying their needs “How can I help/support you?” • Assigned Homework –– Goals: practice self-regulation (monitor, evaluate, modify goals online) –– Connections: encourage others –– Resources: review relevant readings of choice –– Assess: revisit self-assessment (particularly perceived stress scale, if relevant) –– _______________________________________________________ • Assessed current level of self-care self-efficacy: “Reflecting on your current situation, on a scale of 1 (not at all confident) to 10 (100 percent confident), how confident are you that you can achieve your goal(s)?” Low 1 2 3 4 5 6 7 8 9 10 High • Scheduled Session 4 for ____________ (date) at ___________ (time). • Coach To Do: –– Complete Goal Survey – see Appendix I for Session 1–6 Goals –– Document session start and end time –– Document progress toward goals Session Notes: 182  Appendix: SupportNet Coaching Manual Appendix E: Coaching Session 4 – Action / Support Self-Care Knowing is not enough; we must apply. Willing is not enough; we must do.” ~ Johann Wolfgang von Goethe Coach To Do (preparation for Session 4): • Review participant’s goals and steps and print a copy for your records if desired • Review participant’s connections • Review and document any updates on assessments Questions / Strategies: 1. RE: Goals: What is influencing your successes? What is getting in the way of your being successful? What could get in the way? 2. How does self-care influence your ability to meet your life goals? What have been your most rewarding/difficult personal challenges? 3. How have you overcome past challenges? 4. How can you apply what you have learned about yourself when facing obstacles/challenges in the past to your current situation? 5. Describe how you (or others) know you are stressed (i.e., emotional, physical, and behavioral indicators). Coach: (Reminder—session 4 content is reinforced in session 5) Please check each box representing what you were able to address during these sessions: • Reviewed Homework:  (circle one)  Completed:  Yes No Pa rtially –– Goals: practice self-regulation (monitor, evaluate, modify goals online) –– Connections: encourage others –– Resources: review relevant readings of choice –– Assess: revisit self-assessment (particularly perceived stress scale, if relevant) • Encouraged participant to be aware of stress indicators and to practice daily self-care strategies Appendix: SupportNet Coaching Manual   183 –– Self-monitor • Assessed: “On a scale of 1 (not at all) to 10 (completely) how aware of your stress level are you on a daily basis?” ______ • Enhance awareness of emotional, physical, & behavioral indicators of stress –– Stress Reduction Techniques • Take 5 • practice mindfulness and acceptance • relaxation • meditation • visualization • journaling • Continue to encourage development of strategies to promote goal attainment such as: –– Identification of obstacles and plan in place to overcome obstacles • Obstacle _____________________________________________ • Plan _________________________________________________ –– Self-regulation techniques (monitor goal steps, evaluate goal progress, modify goal/steps) –– Three S’s-social support, self-care, self-efficacy • Praised participant for each step taken thus far • Assigned Homework (highly individualized at this point) –– Self-monitor personal indicators of stress –– Take 5: identify and implement Take 5 or other self-care strategy of choice –– Goals: self-regulation (monitor, evaluate, modify goals) –– Connections: encourage others –– Assess: revisit Self-Assessment (particularly perceived stress scale, if relevant) Assessed current level of self-care self-efficacy: “Reflecting on your current situation, on a scale of 1 (not at all confident) to 10 (100 percent confident), how confident are you that you can achieve your goal(s)?” 184  Appendix: SupportNet Coaching Manual Low 1 2 3 4 5 6 7 8 9 10 High • Scheduled Session 5 for ____________ (date) at ___________ (time). • Coach To Do: –– Complete Goal Survey – see Appendix I for Session 1–6 Goals –– Send an encouraging message to participant this week –– Document session start and end time –– Document progress toward goal(s) Session Notes: Appendix: SupportNet Coaching Manual   185 Appendix F: Coaching Session 5 – Action / Support  Social Support Knowing is not enough; we must apply. Willing is not enough; we must do.” ~ Johann Wolfgang von Goethe Coach To Do (preparation for Session 5): • Review participant’s goals and steps and print a copy for your records if desired • Review participant’s connections • Review and document any updates on assessments Questions / Strategies: 1. RE: Goals: What is influencing your successes? What is getting in the way of your being successful? What could get in the way? 2. How can you apply what you have learned about yourself when facing obstacles/challenges in the past to your current situation? 3. How does self-care influence your ability to meet your life goals? Coach: Please check each box representing what you were able to address during these sessions: • Reviewed Homework: (circle one) Completed: Yes No Partially –– Self-monitor personal indicators of stress –– Take 5: identify and implement Take 5 or other self-care strategy of choice –– Goals: self-regulation (monitor, evaluate, modify goals) –– Connections: encourage others –– Assess: revisit Self-Assessment (particularly perceived stress scale, if relevant) • Emphasized importance of social support • Encouraged participant to be aware of stress indicators and to practice daily self-care strategies –– Check-in re: Self-monitoring indicators of stress –– Check-in re: Use of Stress Reduction Techniques • Take 5, mindfulness/acceptance, relaxation, mediation, visualization, journaling 186  Appendix: SupportNet Coaching Manual • Continue to encourage development of strategies to promote goal attainment such as: –– Identification of obstacles and plan in place to overcome obstacles • Obstacle _____________________________________________ • Plan _________________________________________________ –– Self-regulation techniques (monitor goal steps, evaluate goal progress, modify goal/steps) –– Three S’s-social support, self-care, self-efficacy • Praised participant for each step taken thus far • Assigned Homework (highly individualized at this point) • Assess: revisit relevant portions of self-assessment • Take 5: continue Take 5 (or other) stress reduction strategy of choice • Connections: continue encouraging others • Reflect on your successes and what you have gained from this coaching process these past 6 weeks so we can discuss next time • Goals: revisit Life Balance Wheel and print a copy for your records • Assessed current level of self-care self-efficacy: “Reflecting on your current situation, on a scale of 1 (not at all confident) to 10 (100 percent confident), how confident are you that you can achieve your goal(s)?” Low 1 2 3 4 5 6 7 8 9 10 High • Scheduled Session 6 for ____________ (date) at ___________ (time). • Coach To Do: • Complete Goal Survey – see Appendix I for Session 1–6 Goals • Document session start and end time • Document progress toward goals Session Notes: Appendix: SupportNet Coaching Manual   187  Appendix G: Coaching Session 6 – Empowerment  Successes and Beyond “If we are facing the right direction, all we have to do is keep on walking.” ~Zen Proverb “…you have endless ability and unlimited potential, so make your move, start unleashing it and living your dream!!!” ~ Ricardo Housham Coach To Do (preparation for Session 6): • Review participant’s Goals and Steps and print a copy for your records if desired • Review participant’s Connections • Review and document any updates on Assessments • Review and document any updates on Life Balance Wheel Questions / Strategies: 1. What successes have you experienced in the past couple of months? What has changed? What will you take with you from this experience? 2. RE: Life Balance: What is different or what has changed? What needs to happen (or what will you do) to continue (or begin) moving in a forward direction? What obstacles do you see getting in the way? What is your plan for overcoming those obstacles? 3. What do you see as your next step(s)? Coach: Please check each box representing what you were able to address this session: • Reviewed Homework:  (circle one)  Completed:  Yes No Pa rtially –– Assess: revisit relevant portions of self-assessment –– Take 5: continue Take 5 (or other) stress reduction strategy of choice –– Connections: continue encouraging others –– Goals: revisit Life Balance Wheel and print a copy for your records 188  Appendix: SupportNet Coaching Manual –– Reflect on your successes and what you have gained from this coaching process –– _______________________________________________________ • Reviewed Life Balance: –– –– –– –– Domain # 1_______________________________________ ____ (session 2 rating) _____ (current rating) *scale 1–10 Domain # 2_______________________________________ ____ (session 2 rating) _____ (current rating) *scale 1–10 • Reviewed successes • Encouraged participant to identify next steps –– Provided participant opportunity to consider obstacles that could get in the way of longer-term goal attainment and encouraged follow through on plan –– Discussed how to apply to other life domains • Encouraged participant to complete the Time 2 survey. • Informed participant that online platform will be available until May 2, 2014 • Assessed level of self-care/self-efficacy: “Reflecting on your current situation, on a scale of 1 (not at all confident) to 10 (100 percent confident), how confident are you that you can make your self-care changes a long-term part of your lifestyle?” Low 1 2 3 4 5 6 7 8 9 10 High • Coach to Do: –– –– –– –– Document session start and end time Document progress toward goals Complete Goal Survey – see Appendix I for Session 1–6 Goals Provide research team with de-identified documents for analysis: • Completed Data Sheet for Goals Session 1–6 (Appendix I) • Coaching Manual • Emails • Log Sheet Session Notes: Appendix: SupportNet Coaching Manual    Appendix H  Contact Log Log of Contact In Between Coaching Sessions Date Method Length ∎ ∎ ∎ ∎ ∎ ∎ ∎ ∎ ∎ ∎ ∎ ∎ ∎ ∎ Coach Initials: ________ Purpose (content) 189 190  Appendix: SupportNet Coaching Manual Appendix I Data Sheet for Coaching Sessions 1–6 (To be completed by the Coach)  oaching Session 1: C Date_____________ Length of Session: _____ (in minutes) Communication Method: _____Phone _____Skype Coach Initials: ______ Self-care self-efficacy: Document the current level reported by the participant in response to the question: “Reflecting on your current situation, on a scale of 1 (not at all confident) to 10 (100 percent confident), how confident are you that you can establish self-care goals?” Low  1   2   3   4   5   6   7   8   9   10   High Directions: Reflecting on the coaching session just completed, please mark each statement as it applies to your experience with the participant. Definitely False Mostly False A little bit False A little bit True Mostly True F F T T Participant was provided an opportunity to “tell their story” Participant understands the coaching process Participant understands the Web Application interface Participant understands results of self-assessment (SA) as related to job burnout Participant understands results of self-assessment (SA) as related to STS (if applicable) Participant understands the importance of social support Participant understands the importance of self-care We have established a collaborative working relationship Definitely Does True Not Apply T NA F F F T T T NA F F F F F F T T T T T T NA NA F F F T T T NA F F F T T T NA F F F T T T NA F F F F F F T T T T T T NA NA Deviation from protocol (please circle):  YES  NO Notes: Please provide an explanation for any deviations from the protocol or for any items you marked as “Definitely False” above. Also, please document any other relevant information. Appendix: SupportNet Coaching Manual   191 ___________________________________________________________ ___________________________________________________________ ___________________________________________________________  oaching Session 2: C Date_____________ Length of Session: _____ (in minutes) Communication Method: _____Phone _____Skype Coach Initials: ______ Self-care self-efficacy: Document the current level reported by the participant in response to the question: “How confident are you that you can establish self-care goals?” Low  1   2   3   4   5   6   7   8   9   10   High Directions: Reflecting on the coaching session just completed, please mark each statement as it applies to your experience with the participant. Definitely False Mostly False A little bit False A little bit True Mostly True F F F T T We have established a collaborative working relationship Participant can identify strengths related to LB Participant understands impact of B/O on LB areas Participant understands impact of STS on LB areas Participant able to choose 1-2 LB areas to focus on during coaching Participant understands how to set achievable goals Participant has a plan in place for routine self-care Participant has plan in place for increasing social support Definitely Does True Not Apply T NA F F F T T T NA F F F F F F F F F F F F T T T T T T T T T T T T NA NA NA NA F F F F F F F F F T T T T T T T T T NA NA NA Deviation from protocol (please circle):  YES   NO Notes: Please provide an explanation for any deviations from the protocol or for any items you marked as “Definitely False” above. Also, please document any other relevant information. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 192  Appendix: SupportNet Coaching Manual ___________________________________________________________ ___________________________________________________________  oaching Session 3: C Date_____________ Length of Session: _____ (in minutes) Communication Method: _____Phone _____Skype Coach Initials: ______ Self-care self-efficacy: Document the current level reported by the participant in response to the question: “How confident are you that you can achieve your self-care goals?” Low  1   2   3   4   5   6   7   8   9   10   High Directions: Reflecting on the coaching session just completed, please mark each statement as it applies to your experience with the participant. Mostly False Definitely False F F A little bit False F A little bit True T Participant identified potential obstacles to goal achievement Participant understands how to overcome obstacles to achieving goals Participant understands role of self-regulation in achieving goals Participant is actively engaged in achieving goals Participant is actively engaged in seeking social support Participant is actively engaged in self-care behaviors and activities Mostly True Definitely Does True Not Apply T T NA F F F T T T NA F F F T T T NA F F F T T T NA F F F F F F T T T T T T NA NA F F F T T T NA Deviation from protocol (please circle):  YES   NO Notes: Please provide an explanation for any deviations from the protocol or for any items you marked as “Definitely False” above. Also, please document any other relevant. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Appendix: SupportNet Coaching Manual   193  oaching Session 4: C Date_____________ Length of Session: _____ (in minutes) Communication Method: _____Phone _____Skype  Coach Initials: ______ Self-care self-efficacy: Document the current level reported by the participant in response to the question: “How confident are you that you can achieve your self-care goals?” Low 1 2 3 4 5 6 7 8 9 10 High Directions: Reflecting on the coaching session just completed, please mark each statement as it applies to your experience with the participant. Definitely False Mostly False A little bit False A little bit True Mostly True F F F T T Participant is actively engaged in achieving goals Participant is actively engaged in self-monitoring personal indicators of stress Participant continues to be actively engaged in seeking social support Participant actively engaged in self-care behaviors and activities Definitely Does True Not Apply T NA F F F F F F T T T T T T NA NA F F F T T T NA F F F T T T NA Deviation from protocol (please circle): YES NO Notes: Please provide an explanation for any deviations from the protocol or for any items you marked as “Definitely False” above. Also, please document any other relevant information. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 194  Appendix: SupportNet Coaching Manual  oaching Session 5: C Date_____________ Length of Session: _____ (in minutes) Communication Method: _____Phone _____Skype Coach Initials: ______ Self-care self-efficacy: Document the current level reported by the participant in response to the question: “How confident are you that you can achieve your self-care goals?” Low  1   2   3   4   5   6   7   8   9   10   High Directions: Reflecting on the coaching session just completed, please mark each statement as it applies to your experience with the participant. Definitely False F Mostly False A little bit False A little bit True F F T Participant is actively engaged in achieving goals Participant is actively engaged in self-monitoring personal indicators of stress Participant continues to be actively engaged in seeking social support Participant actively engaged in self-care behaviors and activities Mostly True Definitely Does True Not Apply T T NA F F F F F F T T T T T T NA NA F F F T T T NA F F F T T T NA Deviation from protocol (please circle):  YES   NO Notes: Please provide an explanation for any deviations from the protocol or for any items you marked as “Definitely False” above. Also, please document any other relevant information. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Appendix: SupportNet Coaching Manual   195  oaching Session 6: C Date_____________ Length of Session: _____ (in minutes) Communication Method: _____Phone _____Skype Coach Initials: ______  ife Balance: L Domain: ___________________________ Session 2 rating _____Current rating _____ Domain: ___________________________ Session 2 rating _____ Current rating _____ Self-care self-efficacy: Document the current level reported by the participant in response to the question: “How confident are you that you can make your self-care changes a long-term part of your lifestyle?” Low  1   2   3   4   5   6   7   8   9   10   High Directions: Reflecting on the coaching session just completed, please mark each statement as it applies to your experience with the participant. Definitely False F Mostly False F A little bit False F Participant achieved 1-month goals Participant can identify successes Participant can identify next steps A little bit True T Mostly True Definitely Does True Not Apply T F F F T F F F F F F T T T NA T T T T T T NA NA NA Deviation from protocol (please circle):  YES   NO Notes: Please provide an explanation for any deviations from the protocol or for any items you marked as “Definitely False” above. Also, please document any other relevant information. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 196  Appendix: SupportNet Coaching Manual Appendix J Additional Session Notes ∎  About the Author Charles C. Benight, PhD, is the author of more than 50 articles on coping with traumatic stress, and has received funding from the National Science Foundation, the National Institute of Mental Health, the Department of Defense, and the Substance Abuse and Mental Health Services Administration. He holds a PhD from Stanford University and c­ ompleted post-doctoral training in behavioral medicine from the University of Miami. His scientific work applies social cognitive theory to the human adaptation to extreme events. He is a Full Professor, Chair of Veteran Health and Trauma, and a President’s Teaching Scholar at the University of Colorado. He is the recipient of several awards including the Cornelia Sabine Award for Outstanding Contribution to Psychology. In 2011, Benight focused his work on burnout and secondary traumatic stress in our military mental health providers. © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1 197  Contributor Notes Judith Bock, PsyD, works in the Trauma, Health, & Hazards Center, University of Colorado at Colorado Springs, Colorado Springs, Colorado. Dr. Bock is interested in posttraumatic stress, secondary trauma, and burnout with specific focus on military behavioral health providers and first responders. She is also a practicing therapist specializing in the treatment of combat-related PTSD. Kotaro Shoji, PhD, works in the Trauma, Health, & Hazards Center, University of Colorado at Colorado Springs, Colorado Springs, Colorado. Dr. Shoji is interested in research on recovery from traumatic experiences using biological and dynamic systems approaches. His research has focused on secondary trauma among military mental health providers and the development of a web-based intervention system that has machine learning capability to maximize user effectiveness for trauma survivors. Shaun Stearns, PhD, works in the Trauma, Health, & Hazards Center, University of Colorado at Colorado Springs, Colorado Springs, Colorado. Dr. Stearns’s research interests include emotion regulation, biofeedback, stress reactivity, and the psychophysiological correlates of trauma. He has developed an easy relaxation technique employing simple hand movements and has studied how diet can alter emotion and stress reactivity. Currently, he is studying the interaction between professional burnout and secondary traumatic stress in military mental health providers and working on the development of a web-based intervention system for trauma survivors. He is also a reviewer for the Journal of Applied Social Psychology. © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1 199 200  Contributor Notes Carolyn Yeager, MS, MA, is a Ph.D. student in the Department of Psychology, University of Colorado at Colorado Springs, Colorado Springs, Colorado. Ms. Yeager is interested in the design and development of internet interventions for mental health. This interest stems from her background in computer science and her work with survivors of traumatic events. Ms. Yeager is currently working toward a PhD in clinical psychology and her research has focused on machine learning and understanding web-intervention engagement. She is interested in combining psychological theory and practices with state-of-the-art technology to deliver effective and engaging interventions to those who have experienced trauma. Index A acceptance and commitment therapy (ACT) one-day session, effect sizes, 138 preventive stress management intervention, 138–9 principles of, 137–8 psychological flexibility, 138 workshop and phone consultation, 139 agile design methodology, 47, 48 Akers, L., 58 analysis of variance (ANOVA), 126 Armed Forces Health Surveillance Center (AFHSC), 2 autocratic or transactional leadership, 95–6, 149 Azocar, F., 137 B Bacho, R., 105 Bakker, A.B., 20–1, 157 Bandura, A., 33, 42, 69 Barak, A., 44 Bazarko, D., 137 Berger, R., 31 Berglund, G., 138 Blattner, J., 71 Bodner, T., 160 Boles, S.M., 58 Bolino, M.C., 161 Bonato, S., 33 Bowditch, J.L., 93 Bradshaw, T., 140 Bradt, J., 139 Braynion, P., 140 Bride, B.E., 18, 163 Brinkborg, H., 138 Brooks, D.M., 139 Brown, K.W., 156 Buono, A.F., 93 burnout, 4 and conservation of resources, 27–9 definition and prevalence, 20–7 job (see job burnout) negative outcomes, 148 organizational systems, 86 research, organizational and participant challenges, 101–2 Burnout Management Self Efficacy Scale, 125 © The Author(s) 2016 C.C. Benight, Secondary Trauma and Burnout in Military Behavioral Health Providers, DOI 10.1057/978-1-349-95103-1 201 202  INDEX C Campenni, C.E., 155 caregiver consequence, 3 caregiver demand, 2–3 caregiver stress, concept of, 163 Cate, R.A., 137 Christopher, J.C., 155 Cieslak, R., 18 Clark, S.C., 158 clinical depersonalization, 148 clinical settings, 151 clinician tool kit for client, 165–6 for clinician, 164–5 coaching and therapy content, 72 critical differences, 72 guidelines, 71–2 peer coaching relationship, 72 program, 6 self-awareness, 73 sense of balance, 71 structure, 72 cognitive processing therapy (CPT), 152–3, 164 Communifire, 55–6 community setting vs. on-post, 147–8 compassion fatigue, 3 conservation of resources (COR) theory, 159 emotional exhaustion and depersonalization, 27 loss or depletion of resources, 28 military mental health providers, 28–9 negative outcomes, 29 self-efficacy perceptions, 28 co-worker support, 107 Craig, C.D., 4, 91 cross-disciplinary development team, 149–50 custom social networking platform, 56 D Danaher, B.G., 58 D’Andrea, W., 154 demand-control model (DCM), 32, 103, 106, 157 demands-control-support (DCS) model, 28 Demerouti, E., 20–1, 157 Department of Defense (DOD), 2 Department of Defense Social Media User Agreement, 49 Department of Veterans Affairs (VA), 12 depersonalization, 23, 26 deployed mental health provider, challenges, 98–9 depression or anxiety, 47 Dewa, C.S., 33, 63 Didion, L.M., 163 Dileo, C., 139 Donkin, L., 62 Doyle, M., 140 E effort-reward imbalance model (ERI), 157 emotional exhaustion, 20–4, 27–8, 34, 63, 97, 100, 103, 106–7, 124, 128, 130, 159, 162 enhanced burnout. See depersonalization evidence-based care, 45, 152–4, 164 exposure therapy, 15, 17, 153 eye movement desensitization and reprocessing (EMDR), 153–4 Eyre, L., 139 F Fear, N.T., 2 Figley, C.R., 105, 163 fluoxetine and pill placebo, 153 INDEX  G Gazelle, G., 69 Gelkopf, M., 31 Gentry, J.E., 31 Gibson, C.M., 155 Glozier, N., 62 The Golden Rules of Goal Setting, 158 Goodman, M.J., 137 Gordon, J.S., 58 Grant, A.M., 158 H Halbesleben, J.B., 159, 161 Hall, J.C., 160 Hammer, L.B., 160 Hart, V., 71 Harvey, J., 161 health care providers life-threatening situations, 34 military nurses, burnout studies, 34 STS and burnout, 33 health status functional roles of social support, 159 social support and work stress, 159–60 Heim, M., 105 Hersh, M.A., 155 Hesser, H., 138 Hilliard, R.E., 140 Hinkin, T.R., 97 Hobfoll, S.E., 159 Holohan, D.R., 163 Houram, L.L., 154 Hunt, A., 139 I Internet Information Server (IIS), 46 Iversen, A., 2 203 J Jacobs, P., 33 Jing, L.I., 117 job burnout, 3 ACT-based interventions, 137–9 emotional exhaustion, 24 enhanced burnout (depersonalization), 23, 26 exhaustion and depersonalization, 128, 129, 130, 132–3 high turnover and absenteeism, 21 intent-to-treat analysis, ANOVAs, 126–8, 130, 131, 133–4 interpersonal conflict and burnout, 23–4 mindfulness-based interventions, 135–7 negative impact, 21 OBI scoring, 22 on-post and off-post providers, differences, 24–6 organizational constraints, definition, 26 prevalence of, 21–2 primary predictors, 23 RCT, 135 self-efficacy and social support, 131, 135 and STS, 26–7 SupportNet, comparison, 22 three-factor model, 20 two-factor model, 20–1 work-related stressors, 27 job demand-control theory, 106 job demands-resources (JD-R) model, 157 job burnout, 116–17 primary variables, 13–14 social cognitive, 5, 14, 116 Johnson, W.B., 105 204  INDEX K Keyes, C.M., 157 Kinnunen, U., 161 Kintzle, S., 18 Klein, B., 44 Knoll, N., 159 Kossek, E.E., 160 Kraft, H.S., 98 Kreitzer, M.J., 137 L last observation carried forward (LOCF) method, 125 leadership style laissez-faire leadership, 96–7 military organizations, 97 reward omission, 97 transactional, 95–6 transformational, 94–5 Lee, E.O., 156 Lee, J., 162 Lee, S.M., 162 Leipsic, S., 71 Leiter, M.P., 162 Liebschutz, J.M., 69 life balance issues goal setting, 158 self-care, 155–6 SupportNet website, resource room, 154–5 well-being, 156–7 work-home balance, 158 Lim, N., 162 Loong, D., 33 Luoma, J.B., 139 M management by exception, 95 Maris, J.A., 155 Maslach, C., 162 Mauno, S., 161 Maxfield, L., 154 mechanistic bureaucracies, 86–8 Melbourne Academic Mindfulness Interest Group, 135–6 Michanek, J., 138 military mental health providers, 69 complexity and severity, 116 JD-R model, 116–17 peer coaching, 142–3 PTSD prevalence, 116 randomized controlled trial, 115–16 risk of developing STS, 116 self-efficacy beliefs, 117 self-regulation mechanisms, 117 social/environmental resources, 118 social media-based web system, 142 military settings, 151 mindfulness-based interventions completer analysis, 136 effect size, 136–7 psychotherapies and interventions, 136 RCT, 136 and therapies, 135–6 8-week program, 137 Monroe-DeVita, M., 21 Morse, G., 21 Multidimensional Scale of Perceived Social Support (MSPSS), 125 Muse-Burk, J.L., 155 music therapy-based interventions, 139–40 N Nachreiner, F., 20–1 NCPTSD, 164 “network organization,” 88 O objective measures, SupportNet clicks per login session, 60 goal setting, 61 INDEX  mean minutes per page, 60 means and standard deviations for engagement, 59–60 social connections, 61 time online, 60 unique pages visited, 61 unique sessions, 60 off-post providers, 99–100 Oldenburg Burnout Inventory (OLBI), 22, 124 operant conditioning principles, 52–3 Operation Enduring Freedom, 2 Operation Iraqi Freedom, 2 organizational constraints definition, 26 demand-control model, 103 employee control, 106 high mechanistic bureaucracies, 103 predictability, 107 predictors of burnout, 103 role conflict and ambiguity, 104–5 social support, 106–7 workload, 104 organizational culture aggressive/defensive cluster, 92 burnout and STS, 91 clinical outcomes for hospitals, 90 constructive cluster, 92 data collection, 93 entrepreneurial culture, 90 group-oriented organization, 91 hierarchical culture, 91 parallel structure, 93–4 passive/defensive cluster, 92 rational organization, 91 visible artifacts, 90 organizational structure centralization, 89–90 complexity, 88 formalization, 88–9 human service professionals, 86 205 mechanistic bureaucracies, 86–8 negative outcomes, 86 “network organization,” 88, 89 P “PCS” (permanent change of station), 102 peer coaching model, 63, 68–9, 71, 139, 142, 150 peer modeling, 70–1 Pfahler, C., 21 Pichler, S., 160 Pole, N., 154 post-traumatic stress disorder (PTSD) behavioral health services, 12 military mental health providers, 116 prevalence of, 2–3, 12 web-based intervention, 45 prolonged exposure therapy (PET), 15, 17, 153–4, 164 provider load burnout definition and prevalence, 20–7 COR and burnout, 27–9 demand-control model, 32–3 health care providers, 33–4 negative consequences, 30–1 on-post and off-post providers, 32 randomized controlled trial, 31–2 secondary traumatic growth, 29–30 self-efficacy beliefs, 33 STS (see secondary traumatic stress (STS)) symptoms, 30 “training-as-treatment” approach, 31 trauma treatment, 32 psychoeducation, 31, 43, 45, 47, 56, 75, 156 psychosocial intervention, 139–1 psychotherapy process, 154–5 PTSD. See post-traumatic stress disorder (PTSD) 206  INDEX Q “quick take 5,” 119 R Ralph, J., 105 randomized controlled trial (RCT), 6–7, 50, 68, 102 ACT-based interventions, 137–9 health care providers, implications, 142–3 intent-to-treat analysis, 151 military mental health providers, 115–18 mindfulness-based interventions, 135–7 results, limitations of, 141–2 SupportNet intervention, 118–35 types of interventions, 139–41 RCT. See randomized controlled trial (RCT) Redhead, K., 140 relational database management system (RDBMS), 46 relaxation training, 153 resource room, 56, 57 Richards, K.C., 155 Riess, H., 69 role-based access control (RBAC), 49 Rollins, A.L., 21 Rona, R.J., 2 Rule Number Two, 98 Ruokolainen, M., 161 Ryan, R.M., 156 Ryff, C.D., 157 S Salyers, M.P., 21 Schaufeli, W.B., 20–1, 162 Schorling, J.B., 137 Schriesheim, C.A., 97 Schwarzer, R., 159 SCT. See social cognitive theory (SCT) secondary traumatic growth, 3 definition, 29–30 DSM-5 inclusion, 31–2 positive outcome, 29 self-efficacy, 30 work engagement, 30 secondary traumatic stress (STS) and burnout, 12 coping, 148 definition, 3 development of, 3 indirect exposure, 17 and job burnout, challenges, 6 organizational systems, 86 Pearson’s correlation coefficients, 20 predictors for, 18, 20 prevalence of, 17–18 prevalence rates, 3–4, 5–6 scores, means and standard deviations, 18, 19 self-care, 70, 155–6 self-efficacy, 52, 69–70 COR theory, 28 definition, 14 goal setting module, 52 judgments, 42 military mental health providers, 117 secondary traumatic growth, 30 and social support, 131, 135 session-by-session “enhance awareness,” 75 goals and challenges, 75–6 individuals’ assessment results, 75 overview, 73 promotion of social support, 78–9 providers, standard obstacles, 76–8 RCT data, 74, 75 self-assessments and life balance wheel, 79 STS, signs and symptoms, 74 Severson, H.H., 58 Shapiro, F., 154 INDEX  Skogstad, A., 96 SMART goals, 158 social cognitive theory (SCT), 69, 149 job-demands resource model, 5 triadic reciprocal determinism, 42 social networking platform, 55–6 social support, 42 Sprang, G., 4 SQL Server 2012, 46 static components relaxation or energize, 56, 58 resource room, 56, 57 Take 5, 56, 57 stress indicators caregiver stress, concept of, 163 emotional exhaustion, 162 military mental health providers, 163 positive work engagement, 161 potential consequences, 161 self-education, 162 social support, importance of, 160 workaholism and burnout, 161–2 work engagement, notion of, 163 work-family-specific support, 160–1 stress inoculation training (SIT), 154 STS. See secondary traumatic stress (STS) subjective measures, SupportNet, 61–2 Sundin, J., 2 SupportNet coaching deployment, 73–9 descriptive statistics, 80–1 development, 68–73 evaluation, 79, 82 future deployment, 151–2 health-care providers, implications of, 82 telephonic peer coaching, 82 SupportNet goal setting module context-sensitive examples, 54 goals and social support, creation of, 54, 55 207 operant conditioning principles, 52–3 self-efficacy, 52 SupportNet intervention coaching process, 119, 124 coaching-web-based support system, 6–7 data analytic approach, 125–6 differences, 100–1 features, 118 findings of, 1 goal-setting system, 119 improve job burnout, 126–35 and other interventions, comparisons, 135 participant trauma exposure, 123 “quick take 5,” 119 RCT, 119–25 response, 4 telephonic peer coaching, 119 SupportNet life balance, 51, 54 SupportNet longitudinal study demographic information, 15, 16 military mental health providers, characteristics, 15–17 on-post and off-post providers, 15 research methods, 15 SupportNet RCT CONSORT chart, 120, 121 demographic information, 121, 122 email and phone, 122 intragroup control design, 119–20 limitations of, 141–2 measurements, 124–5 mental health providers, 120–1 online pre-test survey, 123 self-assessment tools, 123 SupportNet Research Program assessment, 14 to empower behavioral health providers, 14 208  INDEX job demands-resources model approach, variables, 13–14 self-efficacy perceptions, 14 social cognitive theory, 14 theoretical model, 13 SupportNet website agile design methodology, 47, 48 assessment, 50–1, 52, 53 authentication and authorization, 48–9 development of, 45 engagement, 58, 62 evidence-based theory, 42 goal setting, 52–5 health-care providers, implications for, 62–3 objective measures, 59–61 our approach, 59 roles and groups, 49–50 social networking platform, 55–6 static components, 56–8 subjective measures, 61–2 system architecture, 46–7 user profile, 50, 51 web-based intervention, 43–5, 48 web-support system, 42–3 T Take 5, 56, 57 TBI. See traumatic brain injuries (TBI) telephonic coaching model, 71 one-on-one, 118 peer coaching, 82 Thanh, N.X., 33 “three S’s”: social support, self-care, and self-efficacy, 78 “training-as-treatment” approach, 31 transactional leadership, 95–7, 108, 149 transformational leadership, 94–7, 108, 149 traumatic brain injuries (TBI), 2, 97, 108 triadic reciprocal determinism, 42 TriWest Healthcare Alliance, 15 V Vance, G.T., 163 Veterans Affairs Mental Health Providers, 100 Vilardaga, J.P., 139 Visual Studio 2010 Integrated Development Environment (IDE), 46 Voss Horrell, S.C., 163 Voydanof, P., 158 W web-based intervention, 68 advantages, 43 barriers to treatment, 43 for behavioral health, 43–5 components, 48 cost-effective support, 45 definition, 44 development of, 6 Internet intervention research, 44 for PTSD, 45 SupportNet project, 43–4 theoretically based, 42–3 traumatic stress, 44 web-support system, 42–3, 149–50 well-being, 156–7 Wessely, S., 2 Wise, E.H., 155 workaholism, 161–2 work engagement, 161–3 work-family-specific support, 160–1 work-home balance, 158 Y Yang, E., 162 Yarvis, J.S., 18