John F. Christensen, PhD, and David S. Shen-Miller, PhD
Psychologists engaged in clinical work, like all health professionals, are subject to multiple demands and stressors that at times in their careers can lead to burnout. These stressors include emotional labor of building and maintaining relationships with clients (i.e., attending to their distress, monitoring and regulating one’s own feelings); risk of secondary traumatization in hearing clients’ stories of suffering; managing documentation; keeping up with advances in clinical theory and practice; being mindful of professional liability; the business of clinical practice; time pressures; balancing the demands of career and personal life; and navigating the unique challenges of one’s work setting. Together with the weaknesses stemming from psychologists’ personal histories and current personal and family stressors, these professional stressors create an occupational vulnerability (APA Advisory Committee on Colleague Assistance, http://www.apapracticecentral.org/ce/self-care/vulnerability.aspx).
In this article, we focus on psychologists’ health and well-being, personal and organizational contributors to professional health or burnout, and the mutual influence of both the individual and organization on achieving sustainability.
Traditional Focus on Burnout and Impairment
Professional attention to psychologists’ health has focused historically on the challenges of burnout, as well as the more serious concerns of professional competence problems and and/or professional impairment. The limited focus in the professional literature can create the illusion that burnout and impairment are a problem for the unfortunate few, and that the rest of us are among the healthy ones. This dichotomous view of professional health—that one is either burned out and sliding toward impairment or healthy and flourishing—has been reinforced in our training as psychologists.
Doctoral Training and Dichotomous Views of “Impairment”
Several aspects of graduate training in psychology contribute to this dichotomous perspective. First, most training programs present assessment and maintenance of competence as a personal responsibility, a macro-level expectation embedded in the language of the APA Ethics Code (Johnson et al., 2014). Perhaps as a result, many programs do not conceptualize or discuss competence as an often tenuous continuum. Even developing a life-long learning perspective (embedded in the competency benchmarks) targets only one set of threats to competence—diminishing knowledge after graduate school.
Second, many programs do not discuss with students the importance of self-care. When these discussions do occur, they are not always in atmospheres that promote self-care. In fact, trainers are dealing with their own challenges, and may be modeling workaholism, individualism, perfectionism, and competition. This is unfortunate, given the demonstrated influence of faculty members’ views on trainees’ attitudes and beliefs about help-seeking attitudes and self-care (Dearing, et al., 2005).
A third aspect is developmental: Graduate students are deepening their understanding of competence as they gain skills, experience, and knowledge of competent behavior through program activities and evaluations. When competence problems in trainees emerge, trainers are often silent surrounding remediation and dismissal processes, leaving other students with little information about how trainers identify, address and resolve competence problems (Forrest & Elman, 2014), and heightened anxiety around their own performance.
The Continuum of Professional and Organizational Health
Our belief is that our health as professionals can be conceptualized on a continuum, with well-being at one end and burnout at the other (Figure 1). In some cases, burnout can be a precursor to impairment. This continuum is dynamic, with individual clinicians moving at times toward well-being, at times toward burnout, and unfortunately in some cases into problems of professional competence or outright impairment (e.g., chemical dependency, mental illness, or physical illness).
Healthcare organizations can also be located along this continuum, with some flourishing for long periods as they effectively pursue their mission with sustainable financing. Others may move toward “organizational burnout,” and in some cases become crippled in their ability to sustain their mission.
Clinicians and their organizations are mutually influential in promoting well-being or burnout. In fact there is mounting evidence that healthy clinicians contribute to the health of the organization through optimized performance, patient satisfaction, increased empathy, reduced errors, and reduced staff turnover (Spickard et al., 2002).
Some organizations mindfully promote clinician and staff health and well-being through the way work and work environments are organized. Others offer less intense but some attention to clinician well-being through continuing professional education and other training activities. Unfortunately, some organizations adopt an extractive mentality toward clinician labor, leading eventually to clinician burnout, degraded performance, and discontent. Some even generate or allow a punitive climate that leads to overwork and burnout.
The Organizational Context of Psychologists’ Work
Psychologists work in a variety of organizational settings. Academic institutions, clinical training programs, hospital systems, community mental health centers, integrated behavioral health in primary care and specialty medical clinics, private group psychotherapy practice, correctional institutions, school systems, and organizational consultation are some examples of the environments that exert enormous influence on how we view our work and move through our days. Even psychologists in individual practice are influenced by the culture of professional psychology—licensing boards, professional societies, continuing education, insurance carriers, and colleagues with whom we share emergency calls and clinical cases.
Traditional Focus on Individual Responsibility for Well-Being Ignores Organizational Influence
From an ecological perspective, any examination into psychologists’ distress (and wellness) must include the organizations in which they work. Yet typically researchers have tended to treat well-being as an individual responsibility without considering the influence of organizational factors (e.g., leadership style, workplace efficiency, flexibility/autonomy, colleague availability, workload, isolation, paperwork). No matter how conscientious we may be about self-care practices and time off for personal renewal, an organizational culture that promotes time urgency and reinforces overwork can quickly erode our sense of personal balance. A recent national study of physicians found that 48% reported at least one symptom of burnout (Shanafelt et al., 2012). When almost half the work force is experiencing burnout, this problem more likely reflects a systemic flaw rather than the personal failure or frailty of individual clinicians. Examples of system flaws within organizations include leadership incompetence and ethnocentric or even racist organizational cultures.
In a study of more than 2,800 physicians, leader behaviors accounted for 11% of the variance in burnout and 47% of the variance in satisfaction (Shanafelt et al., 2015). The authors suggested that typically leaders are selected because of reputation, scientific expertise and clinical skills and not leadership qualities; researchers have raised similar concerns within psychology about supervisors who lack appropriate training or experience (Kaslow, Falender, & Grus, 2012).
Psychologist satisfaction is also deeply affected by organizational multicultural competence, particularly when organizations operate from ethnocentric and/or racist perspectives.
Organization-wide assumptions that treatments apply universally to all clients can lead individual psychologists to ignore or downplay important social, cultural, political and economic realities affecting clients. In turn, such assumptions can raise concerns among clinicians about client care, stifle opportunities to advocate for clients, and generate feelings of isolation, ineffectiveness and powerlessness. Similarly, absence of people of color or other visible minority statuses can convey messages to current and prospective employees that people who are different are not welcome, will not be comfortable if they come, and have limits in terms of advancement (Sue, 2010).
An Ecological Model of Professional and Organizational Sustainability
When looking at the sustainability of an ecosystem, environmental science employs the concept of carrying capacity, which refers to the maximum population size of a species that the environment can sustain indefinitely, given the food, habitat, water, and other necessities available. When land use planners consider the amount of additional human population a region can absorb, they employ an equation C – L = M (Capacity – Load = Margin). Here capacity refers to the carrying capacity of the land to accommodate human development. Load refers to the incremental burden of additional human population and activity on the land (e.g., human footprint). Margin is the indicator of whether population growth and development in a particular region are sustainable. When capacity exceeds the additional load, growth is sustainable. When the load exceeds capacity, growth is unsustainable, resulting in gradual degradation of the landscape and depletion of natural resources until people realize that the area is “unlivable.”
On a macro scale this same equation, C - L = M, applies to the carrying capacity of the Earth. With a current global human population of 7.4 billion, estimates are that the population will peak at about 10 billion around 2050, either as a result of population planning or limits imposed by the carrying capacity in the form of starvation, disease, and resource wars. There are compelling indicators that human activity is negatively impacting the health of the planet and that current levels of human growth and activity are unsustainable. The load is exceeding the earth’s capacity. These indicators of the earth’s negative margin status are by now quite familiar: climate change, accompanied by the melting of glaciers and the Greenland and Antarctic ice sheets, rising sea levels, and more destructive storms; emergence of a world water deficit resulting from the draining of rivers for irrigation and the over-pumping of water tables; collapse of world fisheries; shrinking of forests; deteriorating rangelands; soil erosion; and species extinction at a rate far exceeding natural background rates. World leaders are recognizing and urging nations to attend to these warning signs of planetary burnout (Pope Francis, 2015; Paris Agreement, 2015). Even the world economy, which traditionally has been pitted against environmental concerns, is now seen as dependent upon honoring rather than eroding the natural processes of nature (Brown, 2001).
What does this have to do with psychologists’ well-being? Since we as individuals and the organizations that employ us are complex systems, the same basic equation of sustainability (C – L = M) applies to our own lives and work settings. When our workload exceeds our carrying capacity, we are in a negative margin condition, and our lives become unsustainable. Conversely, when we maintain the appropriate balance to insure that our carrying capacity exceeds the load, then our lives are sustainable.
What are the signs of negative margin, of an unsustainable professional life? On a physical level we may experience sleep deprivation, fatigue, muscle tension, or restricted breathing. Emotionally we may become exhausted to the point that we are irritable with colleagues, family members, and sometimes patients; or we may dissociate from feelings and become numb to our responses to pleasurable or distressing events. Cognitively we may be less certain of our judgment, or begin to doubt our competence as professionals. Our attitudes toward the workplace and people we serve may become cynical, and we may depersonalize or “de-contextualize” others, relating to them instrumentally insofar as they advance or impede our own objectives. These indicators, sometimes described as burnout, are as significant as the global indicators of planetary distress mentioned above.
How about sustainability in healthcare organizations in which we work? Negative margin indicators include decreased patient satisfaction, lowered professional satisfaction within the health care team, clinician and other staff turnover, difficulty recruiting new professionals, absenteeism among support staff, and an exclusive focus by the organization on measuring and incentivizing “instrumental behavior,” (i.e., activities oriented merely to keeping the organization going). When conditions like these prevail over extended periods of time, they indicate that the load assumed by the organization is exceeding its “carrying capacity.” The healthcare enterprise in the U.S. is embedded in a larger approach to commerce that historically is exploitive and depleting of the environment. It is as if our economy was based upon drawing off the principal of the earth’s natural wealth, rather than living off the interest. The same unconscious dynamics may drive our individual and organizational behavior in providing health care.
How can we restore sustainability in our personal lives and in our organizations? How can we renew the health of our planet and of the ecosystems we inhabit? Individually and collectively we must step back and become aware of the habits of thinking about our work and ourselves that undermine our well-being. The equation C – L = M might provide a simple but useful tool to examine these habits.
Promoting the Well-Being of Psychologists
As mentioned above, best practices for promoting psychologist well-being include both individual and organizational behaviors. These efforts seek to expand our carrying capacity and decrease the loads we carry. Developing the knowledge, attitudes, and practices to promote one’s own health and avoid burnout is the responsibility of all clinicians to have a sustainable career and the life satisfaction that endures after one’s career journey has ended, and is an essential component of professionalism.
Several psychologists (e.g., Barnett et al., 2007; Wise, et al., 2012) advocated self-care as essential to the ethical responsibility of maintaining competence.
Equally important is the responsibility of healthcare organizations to create work environments and work processes that allow clinicians to flourish. Supporting clinicians in leading sustainable careers is vital to the success of the organization, both clinically and financially. Just as the responsibility of individual clinicians to attend to their own well-being and work-life balance is considered part of their professionalism, efforts of organizations to improve the health and well-being of the healthcare workforce can be considered an essential component of organizational professionalism (Egener, et al., 2012). There are defined competencies for organizations to master in their pursuit of optimal performance, and attention to clinician well-being is one of them. A growing evidence base points to best practices in both individual and organizational responsibilities.
Individual Best Practices to Promote Well-Being
Health professionals have at their disposal a vast and growing evidence base associated with well-being and flourishing. It is beyond the scope of this article to enumerate all the variables associated with personal well-being. It is worth mentioning, however, two recent lines of research that provide guidance on how to cultivate the good life. The first comes from positive psychology, which in the last two decades has gleaned characteristics of people who are thriving. This movement was highlighted in a special issue of American Psychologist, “Happiness, excellence, and optimal human functioning” (Seligman & Csikszentmihalyi, 2000). Positive psychology has identified several features of human happiness, which can be summarized as “the pleasant life” (cultivating positive experiences and emotions), “the good life,” (cultivating engagement and immersion in activities, a sense of “flow” in chosen activities, and self-efficacy), and “the meaningful life,” (cultivating a sense of belonging and affiliation with others, purpose in life, and connection with something larger than oneself).
The second line of research is in studies of professional well-being. This evidence base has grown geometrically in the last two decades ranging from studies on clinician burnout to the characteristics of clinicians who are thriving (Christensen & Feldman, 2001; Wise et al., 2012). Many recommendations coming out of this literature focus on balancing capacity and load. Examples of capacity-building practices include cultivating self-awareness, fostering emotional intelligence (e.g., the ability to self-regulate, self-disclose, express empathy and gratitude), attention to physical needs (e.g., adequate nutrition, exercise, sleep), developing capacity for intimacy and enhancing intimate partner relationships, engaging in creative pursuits, cultivating the practice of mindfulness, spending time in nature, and developing capacity for opening to meaning and transcendence in one’s life (Walsh, 2011). Examples of load-limiting practices include developing partnership and teamwork with others, learning to manage time and values, developing assertiveness, setting limits, learning to discern the difference between control and influence, and simplifying one’s life.
Organizational Best Practices to Promote Well-Being
There is a wide array of behaviors and practices available to healthcare organizations to advance the well-being of their clinician workforce and prevent burnout and associated organizational costs. The evidence base for the effectiveness of these practices is growing, both in industry outside healthcare and more recently in the healthcare industry. One resource worth exploring is the Center for Positive Organizations at the University of Michigan School of Business (http://positiveorgs.bus.umich.edu). Faculty at this center have helped advance the emerging field of “positive organizational scholarship (POS),” which focuses on organizations that are thriving. Whereas traditional organizational development tries to identify deficit gaps, (e.g., how to make an unprofitable organization profitable), POS looks at “abundance gaps,” (e.g. how to make a profitable organization benevolent.) It identifies organizational dynamics that lead to developing human strength, producing resilience and restoration, fostering vitality, and cultivating extraordinary individuals (Cameron & McNaughtan, 2014).
Measurement of Clinician Burnout and Well-Being
Given the relationship between clinician health and organizational performance, researchers are calling for organizations to measure levels of clinician burnout and well-being as a quality indicator (Wallace et al., 2009).
The “Triple Aim” (enhancing patient experience, improving population health, and reducing cost) is a widely accepted compass for healthcare organizations to optimize performance. However, often these efforts increase clinician burnout, which eventually impairs organizational performance. Bodenheimer and Sinsky (2014) suggested adding clinician and staff well-being as the “Fourth Aim,” essential to realizing the other three.
For an organization to chart its course and take routine compass bearings, progress on all four aims must be measured. Some well-validated brief instruments are available to assess both the burnout and flourishing ends of the clinician health continuum. A standard measure of burnout is the Maslach Burnout Inventory (MBI), with subscales of emotional exhaustion, depersonalization, and perceived clinical ineffectiveness. Maslach and Leiter (2008) developed the Areas of Worklife Survey to measure “engagement” as the end of the continuum opposite “burnout.”
Restructuring of Work Process and Environment
Although measurement of well-being is a necessary tool, it is not sufficient to address the growing burden on health professionals reflected in national studies (Shanafelt et al, 2012). Whatever the organizational setting, attention to psychologists’ workload is vital. Ensuring that their overall caseload is manageable, that the pace of therapy sessions allows some periods of restoration for the therapist, minimizing and streamlining required documentation, promoting team approaches to clinical work, and ensuring that the electronic health record is consistent with actual clinical workflows can all reduce unnecessary load on clinicians. Other potential organizational initiatives include encouraging feedback at all levels of leadership and staff, transparency in leadership decisions, income stability and predictability, greater autonomy (allowing clinicians to customize their work schedules to balance clinical and non-clinical time), and increasing time and space opportunities during the workday for clinicians to gather.
Positive Organizational Culture
Organizations that have achieved excellence in performance and profitability stand out in a dimension described as “organizational virtuousness.” These organizations have institutionalized positive practices such as compassionate support for employees at times of family distress or illness, forgiving mistakes and avoiding blame, fostering the meaningfulness of work, expressing frequent gratitude, showing kindness, fostering collegiality, and expressing interest in employees’ life goals and values (Cameron & McNaughtan, 2014).
Workload demands and limited time have led many health professionals to hunker down with their work and process tasks with minimal socialization with coworkers. Burnout leads to depersonalization and annoyance at others’ intrusions into one’s workflow.
Yet communion with peers and the ability to socialize and support each other clinically is an important stress buffer.
Professional isolation can be diminished by periodic support group sessions in which clinicians can discuss difficult patient encounters, disclose the emotional impact of errors or patient loss, learn from others’ experiences, and share meaningful aspects of their work. Some organizations have a system of peer mentoring in which an older or more experienced clinician is available for guidance and wisdom to a junior colleague. An example of a formally organized support process is the Finding Meaning Discussion Groups for healthcare professionals developed by Rachel Remen and the Institute for the Study of Health and Illness (ISHI). These peer-facilitated, no-cost, monthly meetings provide a setting where colleagues share meaningful dialogue on a chosen topic related to the fundamental experience of providing clinical care—topics such as grief, grace, healing, courage, mystery, intimacy, and service, among others. Each person contributes a story from their own healthcare practice on the topic drawn, or reads a poem or a piece from world literature on the meeting topic. A resource guide can be downloaded from the ISHI website: http://www.ishiprograms.org/programs/all-healthcare-professionals/.
This approach is similar to Johnson and colleagues’ (2013, 2014) concept of competence constellations, which are “cluster(s) of relationships with people who take an active interest in and engage in action to advance a professional’s well-being and professional competence” (2013, p. 343). These are similar to the Discussion Groups noted above, and include the additional component of shifting focus from individual to community responsibility for psychologist competence and optimal functioning, emphasizing interdependent views of the professional self as essential to competence and self-care. Such a perspective is also a move away from individualistic approaches to competence and toward communitarian approaches, involving more relational and generative approaches to colleague care, which in turn can transform the workplace. Organizations may consider providing time and space for practitioners to develop these competence constellations as an investment in developing community among practitioners, creating safety nets, promoting optimal functioning, and improving and sustaining organizational health.
The need for clinicians to have ongoing education about ways to enhance their well-being both in and out of the workplace is apparent. Continuing education is not just informational; it entails building a community of shared wisdom with colleagues about how to pursue a healthy, balanced life in the midst of a busy profession. Organizations can develop a curriculum of well-being topics from the research literature mentioned above and ensure that these topics are inserted periodically into medical grand rounds, health professional wellness conferences, webinars, and other venues.
Beyond the periodic continuing education opportunities through well-being conferences, extended 2-3 day retreats allow for deeper periods of reflection and renewal that are essential for the human spirit to flourish. These retreats, especially if offered in a relaxed venue away from the work setting with easy access to nature, allow participants to set aside the devices and concerns that are part of one’s daily mental traffic and enter more deeply into one’s life journey. Periods of silence can enhance inner reflections, and often can lead to richer and more meaningful discussions with other colleagues who are on retreat. It is important that these retreats allow a mix of activities from the more contemplative to the more active, and build a bridge from the renewal of the retreat back into the intensity of the workplace.
Individual Counseling and Coaching
Confidential, no or low cost counseling is another important component of an organization’s well-being toolbox. Having this resource available to clinicians in the incipient stages of burnout can be invaluable in preventing a slide into more severe burnout or impairment. For this service to be readily used by busy health professionals, there should be ease of access, a confidential private setting, minimal paperwork, and confidentiality without the threat of reporting to professional regulatory bodies or employers.
Reciprocal Influence of Individual and Organizational Well-Being
Some studies have demonstrated that organizational interventions with work-flow and environment contribute to clinician well-being. In one study, a 5-year period of organizational efforts to improve clinicians’ control, order, and meaning in their work led to a significant decrease in emotional and work-related exhaustion (Dunn et al., 2007). Similarly, Krasner and colleagues (2009) examined the effect of a primary care organization-sponsored retreat on physician burnout and empathy. Participants underwent intensive training in mindfulness that included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase involving 2.5 hour sessions per week and a one-day retreat was followed by a 10-month maintenance phase of 2.5 hours a month. At posttest, significant outcomes included improvements in mindfulness, reduction in burnout, decrease in mood disturbance, increased empathy toward patients, and improvement in personality factors of conscientiousness and emotional stability. All of these outcomes are known correlates of organizational effectiveness, and represent a significant return on the investment the organization put into this training.
Other studies have shown a positive impact on organizational performance and profitability from efforts to improve clinician well-being. Group Health of Puget Sound reported that organizational changes in the early 2000s to implement a medical home model initially had the unintended consequence of increasing clinician burnout, reducing quality, and increasing patient utilization of health services downstream from primary care. In response the organization selected one clinic for organizational changes to enhance the work life of clinicians and study it as a prototype. They reduced the panel size per physician from 2300 to 1800, increased staff size, and lengthened the standard visit duration from 20 to 30 minutes. After two years, clinician burnout scores (emotional exhaustion and depersonalization) dropped significantly to one-half the scores in the control clinics, quality improvement scores surpassed those of the control clinics, cost savings per member per month were $10.30, and overall patient utilization pattern changes led to a $1.50 return on investment (ROI) for every $1.00 spent (Reid, et al., 2010).
The Great Wave off Kanagawa
Figure 2. Great Wave off Kanagawa (Katsushika, circa 1830).
The woodblock print seen above, The Great Wave off Kanagawa, by the artist Katsushika Hokusai, is from a series entitled “36 Views of Mt. Fuji.” It captures several of the elements of personal and organizational well-being discussed above. The first and most obvious element is the waves, which are relentlessly chaotic and threaten to capsize the boats. The waves call to mind the ongoing challenges and uncertainty of clinical training and practice, as well as turbulent changes in the U.S. healthcare system, including how psychological services are organized and reimbursed. The second element is Mt. Fuji, at first indistinguishable from the waves, which in its deeply grounded stability provides the still point in the center of this image around which the chaos revolves. Mindfulness and self-awareness can provide such inner stillness, allowing us to rest at the deepest center of ourselves as we continually adjust our balance to catch the next wave. The third element is the people in the boats, who require cohesion, teamwork, and ongoing communication to keep the boats headed into the waves and moving forward successfully on their journey. Our colleagues and team working alongside us are a vital resource for navigating each day of patient care and the developmental hurdles of professional formation. A healthy organization provides such collaboration for its members, so that no one person bears the sole burden of responsibility.
Working as psychologists in this complex, information- and choice-rich era of human history requires new skills not required of previous generations. At the same time, to sustain ourselves as persons we must draw upon the “practical wisdom” of previous generations. This wisdom, what Aristotle called phronesis, incorporates the cognitive, emotional, behavioral, and interpersonal skills to expand our capacity as persons and reduce or eliminate the unnecessary loads that erode our spirits. We also need to develop a practical wisdom of working within healthcare systems that is mindful of the factors that promote sustainability, such as expanding our capacity for service through teamwork, clarifying the organization’s values, and establishing structures and processes that promote the well-being of healthcare workers. This perspective is the responsibility of all psychologists, including those in training. Developing the practical wisdom to engage in this work in a sustainable way is our personal and collective challenge.
John F. Christensen, PhD, is a clinical psychologist and consultant in behavioral medicine, graduate medical education, and physician well-being. For 29 years he directed behavioral medicine training in the internal medicine residency at Legacy Health in Portland, Oregon, where he also had a private practice of psychotherapy. He facilitates retreats and training in physician well-being, communication skills, and managing medical errors for healthcare organizations. Dr. Christensen is co-editor with Mitchell Feldman, M.D., of Behavioral Medicine: A Guide for Clinical Practice, 4th edition, published by McGraw-Hill in 2014. They have co-edited this textbook since the first edition in 1997. He and his wife, Julie Burns Christensen, live on a forested farm in the Columbia River Gorge, where they facilitate occasional retreats for personal renewal.
David Shen-Miller, PhD, received his doctorate in counseling psychology from the University of Oregon and is currently an associate professor of counseling and health psychology at Bastyr University. He served on APA's Advisory Committee on Colleague Assistance from 2013-2015 and co-chaired that committee from 2014-2015. His research interests include the development, assessment, and remediation of trainee and practitioner competence in an ecological context, multicultural issues in supervision, training, and education, and the influence of masculine socialization on men's health behaviors. He is the author of more than 25 articles and book chapters, and two edited books.
APA Advisory Committee on Colleague Assistance (n.d.) Occupational vulnerability for psychologists. Retrieved from: http://www.apapracticecentral.org/ce/self-care/vulnerability.aspx
Barnett, J. E., Baker, E. K., Elman, N. S., & Schoener, G. R. (2007). In pursuit of wellness: The self-care imperative. Professional Psychology: Research and Practice, 38(6), 603a.
Bodenheimer T, & Sinsky C. (2014). From Triple to Quadruple Aim: care of the patient requires care of the provider. Annals of Family Medicine, 12, 573-576. http://dx.doi.org/10.1370/afm.1713
Brown L. R. (2001). Eco-Economy. W. W. Norton. Retrieved from: www.earth-policy.org
Cameron, K., & McNaughtan, J. (2014). Positive Organizational Change. The Journal of Applied Behavioral Sciences, 50, 445–462. http://dx.doi.org/10.1177/0021886314549922
Christensen J. F., & Feldman M. D. (2001). Recapturing the spirit of medicine (Special issue on physician well-being). Western Journal of Medicine, 174, 1-80. Retrieved from: www.ncbi.nlm.nih.gov/pmc/issues/116276/
Dearing, R. L., Maddux, J. E., & Tangney, J. P. (2005). Predictors of psychological help seeking in clinical and counseling psychology graduate students. Professional Psychology: Research and Practice, 36(3), 323. http://dx.doi.org/10.1037/0735-7028.36.3.323
Dunn, P. M., Arnetz B.B., Christensen, J.F., & Homer, L. (2007). Meeting the imperative to improve physician well-being: assessment of an innovative program. Journal of General Internal Medicine, 22, 1544-1552. http://dx.doi.org/10.1007/s11606-007-0363-5
Egener, B., McDonald, W., Rosof, B., & Gullen, D. (2012). Organizational professionalism: relevant competencies and behaviors. Academic Medicine, 87, 668-674. http://dx.doi.org/10.1097/ACM.0b013e31824d4b67
Forrest, L., & Elman, N. (2014). Trainees with problems of professional competence. In W. B.
Johnson & N. J. Kaslow (Eds.), Oxford handbook of education and training in professional psychology (pp. 314–335). New York, NY: Oxford.
Johnson, W. B., Barnett, J. E., Elman, N. S., Forrest, L., & Kaslow, N. J. (2013). The competence constellation: A developmental network model for psychologists. Professional Psychology: Research and Practice, 44, 343–354. http://dx.doi.org/10.1037/a0033131
Johnson, W. B., Barnett, J. E., Elman, N. S., Forrest, L., Schwartz-Mette, R., & Kaslow, N. J.
(2014). Preparing trainees for lifelong competence: Creating a communitarian training culture. Training and Education in Professional Psychology, 8(4), 211. http://dx.doi.org/10.1037/tep0000048
Kaslow, N. J., Falender, C. A., & Grus, C. (2012). Valuing and practicing competency-based supervision: A transformational leadership perspective. Training and Education in Professional Psychology, 6, 47–54. doi:10.1037/a0026704
Krasner, M. S., Epstein, R. M., Beckman, H., Suchman, A. L., Chapman, B., Mooney, C. J., &
Quill, T. E. (2009). Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA, 302, 1284-1293. http://dx.doi.org/10.1001/jama.2009.1384
Maslach, C., & Leiter, M. P. (2008). Early predictors of job burnout and engagement. Journal of applied psychology, 93, 498. http://dx.doi.org/10.1037/0021-9010.93.3.498
Pope Francis, (2015). Encyclical Laudato Si: On the Care of Our Common Home. Retrieved from: https://w2.vatican.va/content/dam/francesco/pdf/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si_en.pdf
Reid, R. J., Coleman, K., Johnson, E. A., Fishman, P. A., Hsu, C., Soman, M. P., Trescott C.E.,
Erickson M., & Larson, E. B. (2010). The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Affairs, 29, 835–843. http://dx.doi.org/10.1377/hlthaff.2010.0158
Seligman, M. E. P., & Csikszentmihalyi, M. (Eds.). (2000). Happiness, excellence, and optimal human functioning. A special issue of the American Psychologist, 55, 5-183. http://dx.doi.org/10.1037/0003-066X.55.1.5
Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., ... & Oreskovich, M. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of internal medicine, 172, 1377-1385. http://dx.doi.org/10.1001/archinternmed.2012.3199
Shanafelt, T. D., Gorringe, G., Menaker, R., Storz, K. A., Reeves, D., Buskirk, S. J., ... & Swensen, S. J. (2015). Impact of organizational leadership on physician burnout and satisfaction. Mayo Clinic Proceedings, 90, 432-440. http://dx.doi.org/10.1016/j.mayocp.2015.01.012
Spickard Jr, A., Gabbe, S. G., & Christensen, J. F. (2002). Mid-career burnout in generalist and specialist physicians. JAMA, 288(12), 1447-1450. http://dx.doi.org/10.1001/jama.288.12.1447
Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. Hoboken, NJ: John Wiley & Sons.
United Nations Framework Convention on Climate Change. (2015). Paris Agreement. Retrieved from: http://unfccc.int/2860.php
Wallace J.E., Lemaire J.B., & Ghali W. A. (2009). Physician wellness: a missing quality indicator. Lancet, 374, 1714-1721. http://dx.doi.org/10.1016/S0140-6736(09)61424-0
Walsh, R. (2011). Lifestyle and mental health. American Psychologist, 66(7), 579. doi: 10.1037/a0021769
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, 487–494. doi:10.1037/a0029446