Author note: Ronnie Detrich, whose concern for staff well being stretches across a nearly 50-year career in applied behavior analysis, motivated me to write this post.
Rajid first realized something was wrong while recording case notes after a routine session. Rajid felt as if he had just sat down to the computer when a colleague popped in to say he was late starting his next session. In reality, he had been staring at a blank screen for ten minutes, unable to generate a single word. Over time, episodes like this happened more often — even the simplest tasks began to feel like more than he could handle. Rajid had fallen in love with applied behavior analysis (ABA) in his sophomore year of college, and his passion for it had never waned across the subsequent eight years of school and professional practice. Now he began to feel a preemptory exhaustion just from getting ready to go to work in the morning. While at work, he felt increasingly numb and joyless.
This is burnout, which has been reported for workers in a wide variety of occupations as well as for athletes, parents, students, activists (and even possibly explosive-detecting dogs). If you’re familiar with the insufferably cheerful “Happy Working Song” from Disney’s film Enchanted, then you understand what occupational burnout is not.
The Mayo Clinic defines burnout as, “a state of physical or emotional exhaustion that also involves a sense of reduced accomplishment and loss of personal identity.” Burnout is widely assumed to have three general facets: emotional exhaustion (including fatigue and a sense of being overextended); personal accomplishment (including decrements in work performance and enjoyment of work); and depersonalization (including reduced empathy for coworkers and/or clients).
Where There’s Smoke, There’s Fire
The amorphous concept of burnout may give fits to behavior analysts who are accustomed to precise operational definitions and objective behavioral observations, and the condition is often diagnosed using self-report survey methods that behavior analysts tend to distrust. Yet two kinds of objective anchors lend credibility to self-report data. First, according to the Mayo Clinic, measures of burnout correlate with a suite of troubling objective symptoms, including not only compromised job performance but also fatigue, insomnia, high blood pressure, illness frequency, and increase risk of serious health outcomes like heart disease and Type 2 diabetes. Second, as might be anticipated, difficulties associated with the COVID-19 pandemic and its mitigation, which made most service-delivery jobs exponentially more difficult, greatly increased stress and burnout among workers in health care and human services.
What burnout may be, at a precise behavioral level, is something a future post will consider. To foreshadow that discussion, here’s how Dennis Dixon, Chief Clinical Officer of the Center for Autism and Related Disorders, describes one staff member’s experience of feeling trapped in an impossible schedule:
The clinic that she leads is in a fairly remote location and finding BCBAs is hard, yet there are lots of families in need and seeking services. She’s been dealing with the long-term stress of being understaffed. Her heart keeps pulling her to serve as many families as she can, which she ends up doing by pushing herself too far and not taking time to rest and recharge. As I pushed her to take time off and do simple things like fully disconnecting over the weekend, she broke down in tears. She has an autistic child herself and it feels like a betrayal when she tells a family that we can’t get them started.
According to University of Florida Assistant Professor Corina Jimenez-Gomez, burnout flares up at the intersection of demanding work and lean reinforcement:
I think of burnout as the result of continued engagement in effortful behaviors accompanied by restricted access to sources of immediate reinforcement. Sure, you get a paycheck every pay period, but that is extremely delayed. Folks delivering behavioral services often are confronted with many challenging tasks (e.g., managing dangerous behavior of a client for prolonged period of time) and there is often a dearth of immediate reinforcers available. The day-to-day activities are not accompanied by naturally occurring reinforcers, or these are sparse. For example, many people get little to no feedback or support during their workday.
Adds Dixon: “I see the effects of burnout as insidious. It results from the accumulation of many small events through the day of not being able to do your best or cutting corners.” As stressful moments pile up, therefore, they gradually deplete practitioner resilience.
Behaviorally, occupational burnout manifests most vividly as degraded work performance. It goes without saying that anything that leaves behavior analysts at less than their best has unfortunate consequences beyond the significant wear and tear on practitioners themselves. Clients can receive lower quality services, and staff can even begin to avoid them. Organizations can experience disruptive staff turnover, requiring costly hiring and training of replacement staff. With burnout, there are no winners.
Prevalence of Burnout in ABA
Studies from the early 2000s suggested that burnout was relatively uncommon in ABA practitioners (e.g., see here and here). But later studies, conducted prior to the COVID-19 pandemic, found a third or more of practitioners experiencing burnout (see here and here and here) with many considering resigning from their positions. A possible interpretation of the change: Burgeoning demand for ABA services has placed practitioners on an increasingly frantic treadmill. According to the Behavior Analyst Certification Board, job ads seeking a Board Certified Behavior Analyst increased from about 800 in 2010 to almost 50,000 in 2021 — a nearly 600% bump — and there appear to be serious staffing shortages in the discipline. It’s estimated that there exist enough qualified therapists to responsibly serve only about 30% of children with autism. Too many clients and not enough behavior analysts sounds like a recipe for burnout, even if you ignore the possibility that inadequate training and supervision can set many practitioners up to struggle.
The onset of a global pandemic has only made matters worse. In a survey conducted after the outbreak of COVID-19, Jimenez-Gomez et al. (2021) found that 45% of practitioners reported experiencing burnout. Slowiak and DeLongchamp (2022) found self-reported burnout in an astounding 72% of practitioners. These findings suggest a noteworthy increase from pre-COVID times.
COVID may have hit applied behavior analysts particularly hard, says Jimenez-Gomez, because under normal circumstances their work is often isolating. Whether sequestered with a client in a clinic treatment room or delivering services in homes, practitioners find themselves cut off from the support of people (other behavior analysts) who understand and can help with the challenges they face. The pandemic magnified that isolation by forcing services to be hastily retrofitted for delivery in unfamiliar ways (e.g., telehealth). Thus, according to Jimenez-Gomez:
People described being unprepared for addressing things that came up, not receiving access to supervision or guidance in a timely manner, and lack of communication. The lack of communication really stood out to me because people described feeling like they had to navigate unknown terrain without a map. This was not only in reference to dealing with the complexities of the pandemic at a personal level, but also having to provide behavioral services remotely to vulnerable populations for whom they felt responsible.
It’s possible that the end of drastic COVID mitigation strategies will eventually translate into some relief, but Jimenez-Gomez thinks the pandemic has cast a shadow that will remain for the long haul:
COVID seems to have shifted the relative value of reinforcers for many of us. The promise of future gains or opportunities may not be enough to get us to engage in aversive, uncomfortable work for prolonged periods of time. We all need to think hard about how to make our work/learning environments more “appetitive.”
My perspective (and I don’t have data to back it up) is that we’ll see burnout increasing in the coming years. COVID made all of us dig deep and tap into our reserves. During much of 2020, my team and I were working 12 to 16 hour days, 6 days a week. That is what was required to pivot our clinical practices and create new ways to meet the needs of our patients. This was meaningful work but it was exhausting. Our industry slowly exited the pandemic into a tight labor market. Everyone is short staffed. Our BCBAs have big hearts and want to fill all the gaps. This leads to additional exhaustion and “compassion fatigue.” [that will remain with us until we have systems in place to prevent burnout.
A Snake in our Disciplinary Blind Spot
My grandmother used to say, about rather obvious things to which we are oblivious, “If it was a snake, it would have bitten you.” While it’s heartening that behavior analysts are starting to pay explicit attention to the problem of worker stress and burnout, the uncomfortable question is whether we should have seen a burnout crisis coming. Obviously a pandemic is hard to anticipate, but as Jimenez-Gomez suggests that disruptor may have revealed and exacerbated the problem rather than caused it. With the benefit of hindsight, we, as a discipline, probably have invested too little thought and action into assuring that practitioners thrive. To begin with, ABA was never engineered for the benefit of practitioners; it is defined entirely in terms of what’s necessary to achieve socially-important behavior change. For instance, the seminal seven-dimension model of ABA says nothing about how the enterprise affects the well-being of practitioners. Alexandra Rutherford’s awesome book Beyond the Box is a fascinating history of ABA’s formative years, but words like staff, stress, and burnout do not even appear in its subject index.
Occupational burnout may not have been a topic of conversation when ABA first emerged, but the concept was framed soon afterward in explicit reference to the travails of human services workers. And Christina Maslach, who developed the first instrument for measuring burnout, was inspired to do so by her work in mental health settings. As she wrote in a 1976 paper:
Worker burnout… becomes inevitable when a professional must care for too many people. As the ratio increases, the result is higher and higher emotional overload until, like a wire that has too much electricity flowing through it, the worker just burns out and emotionally disconnects.
The earliest attempt I found to measure burnout specifically in ABA was in 1994. Some specific stressors experienced by staff, however, were itemized 20 years earlier in a paper entitled Social psychology of behavior modification: Problems of implementation in natural settings. We have also known for a long time about the extreme stress experienced by parents of children with autism; it seems naive to assume that professionals working with that population would be immune to the same.
Despite all of this, to my knowledge stress-reducing self-care practices have not been a consistent priority of behavior analysis graduate training programs, nor are they demanded in program accreditation standards. For instance, the inset shows Article 7 (Student Services) of the Accreditation Standards of ABAI’s Accreditation Board. The standards require academic due process, academic advising, and professional development but do not mandate attention to mental health issues like burnout.
The Verified Course Sequences that prepare practitioners for certification say nothing about self-care skills to prevent burnout. Ditto for the Behavior Analyst Certification Board’s 5th Edition Task List, which defines the competencies that course sequences presumably are designed to build. Item I.8, under Personnel Supervision and Management, specifies that a behavior analyst must be able to, “Evaluate the effects of supervision (e.g., on client outcomes, on supervisee repertoires).” This could theoretically include promoting and monitoring staff well-being, but that is not expressly indicated.
Once individuals “graduate” into the profession, there are no requirements that they attend to personal well-being. Consider traditional “best practices” procedures for staff management. According to Chapter 17 of the Handbook of Applied Behavior Analysis (2nd Edition), staff management has three components: “(1) training staff in work performance, (2) improving ongoing work performance, and (3) maintaining proficient work performance.” According to the same source, the “prototypical staff training approach” involves these steps:
- Specify target skills.
- Verbally describe the target skills and the rationale for their importance.
- Provide a written summary of the target skills.
- Demonstrate the performance of the target skills.
- Support staff members in practicing the target skills.
- Provide positive and corrective feedback based on staff proficiency in performing the target skills.
- Repeat Steps 4-6 until staff proficiently perform the target skills.
In other words, best practices of staff management give lots of attention to staff proficiency, but not, apparently, to staff well-being.
Another opportunity to promote well-being is through the continuing education process mandated under practitioner certification. The BCBA’s Authorized Continuing Education Provider Handbook states that CE events, “May address any aspect of behavior analysis: practice, science, methodology, theory, or the profession itself.” That last item, “the profession itself,” could include practitioner well-being, but again there is no requirement that this be a focus.
All told, it is clear that we have a disciplinary blind spot. In developing a profession that benefits others we have, on the whole, ignored the needs of practitioners who make those benefits possible. Staff burnout, therefore, is a problem long in the making that seems now to demand a reckoning. What might be done about the problem is not so clear, in part because, as mentioned at the outset, burnout can feel like an ill-defined construct, and abstractions rarely fuel effective prevention and remediation efforts. If we are to do better as a discipline, we need to invest in determining what burnout may be, behaviorally speaking, and to establish systems that prevent and deal with the problem.