Active stimulation of positive affect and mobilisation of psychological resources during burn out treatment

People can suffer from burn out complaints as a result of organisational
factors and an imbalance of non sufficient coping, increasing demands and/or
lack of social support at work which can lead to burn out. Burn out is known as
a serious risk for employees who work under chronic stress. The majority of the
literature on occupational mental health focused burn out, the underlying
mechanisms and methods to prevent high stress-levels. In the recent years
there*s increasing attention, under influence of positive psychology, for
processes that also may contribute to the overall wellbeing of employees.
Several balanced occupational health models include negative (burn out) as well
as positive (work engagement) aspects of wellbeing. The potentially positive
effects of work are thereby taken into account.

Although burn out is not included as a psychiatric syndrom in current
diagnostic classification systems like DSM-IV, it is usually defined as a
syndrome of exhaustion, cynicism, and lack of professional ef*cacy. However,
accumulating evidence indicates that exhaustion and cynicism are considered the
essence or **core** of the burnout syndrome.
In the case positive aspects of wellbeing, the term (work) engagement is often
used. Engagement can be defined as a positive, fulfilling, work-related state
of mind characterized by vigor, dedication and absorption Rather than a
momentary and specific state, engagement refers to a more persistent and
pervasive affective-motivational state that is not focused on any particular
object, event, individual or behaviour.

Burn out is considered to result from stressors at work, mediated by personal
coping or the ability to deal with environmental stressors at a personal level.
Work engagement can be seen as a related construct to positive affect (PA).
Recent research suggests that more daily positive experiences lead to an
increase of work engagement and less occupational stress. Translated in
emotional terms, this will result in higher levels of PA en decreased levels of
NA. On the other hand daily negative events can lead to great amounts of
negative affect (NA) and reduction in positive affect (PA) which gives a high
risk for development of burn out symptoms.

Measurement of emotion and emotional responses must take place at those moments
in which an individual interacts with his environment to provide ecological
valid information. The Experience Sampling Method (ESM) is suitable for this
purpose. Several studies of depression have been performed with the ESM
paradigm, and this procedure is not only ecologically valid but proves to have
a good validity and reliability. The validity and reliability of ESM for the
measurement of direct effects of daily stressors on mood has also been
demonstrated. New technology to electronically monitor the patients* dynamic
daily life responses to their personal context for extended periods (4-6 weeks)
has recently become available and is patented by our group under the name
*PsyMate*. This device is not only suitable for ESM, but it can also
electronically summarize the information of daily life situations, behaviour,
cognitions and feelings. This creates the possibility to provide feedback to
subjects on their patterns of emotional responses to daily life (working)
situations. Receiving feedback on behaviour can result in emotional and
behavioural change, as is already known from the field of behavioural therapy.
Feedback may create an active and possibly therapeutic context for the burn out
patient and people at risk. Feedback can be given to both patient and
therapist. For the patient, feedback can result in an increased insight in
personal functioning, awareness of small improvements leading to more control
over possible causes of burn out, and finally an increased use of the patient*s
personal resources. For the therapist, feedback can result in a better
monitoring of both compliance and the effect of the treatment. Additionally the
application of detailed, ecologically more valid feedback on daily life
behaviour, as measured with the PsyMate, may improve therapeutic efficacy with
an active resource-mobilizing therapeutic context.

Most therapy approaches of individual burn out treatment are based on cognitive
behavioural principles such as stress-management and cognitive therapy. In the
current study we form two groups of subjects in a randomized controlled trial.
The control group receives CBT and the experimental group CBT and an additional
PsyMate intervention. The experimental group receives during 6 weeks
person-tailored feedback on (positive) affect and appraisals of situations in a
work-related context and other daily life situations. The feedback aims to
increase insight into what specific patterns of activities are associated with
what level of positive (work) experiences. This may help create effective
person-tailored strategies to reshape daily life behavioural (work) patterns to
those that lead to more positive emotions and work engagement, The feedback is
therefore focused on PA and activity patterns that are positively associated
with aspects of work engagement, such as making successful use of job
resources.

The following objectives are examined in a randomized controlled trial whether:
1) Person-tailored feedback on appraisals of work-related activities, NA and
PA, (as measured with the PsyMate) during CBT has an additional effect in terms
of immediate decrease of burn out symptomatology (as measured with the UBOS)
and increase of the work engagement level (as measured with the UWES).

2) the use of Psymate feedback on (work-related) situations leads to an
increase in Positive Affect (PA), a decrease in Negative Affect (NA) and more
effective person-tailored strategies in work-related contexts.

(3) Person-tailored feedback on daily life (work) situations (as measured with
the PsyMate) reduces symptoms and relapse risk for future burn out (as measured
with the UBOS) and a higher level of work engagement (as measured with the
UWES) at follow up.

(4) Additional person-tailored feedback on relevant dynamic daily life
emotional experiences in work-related contexts (as measured with the PsyMate)
during CBT is cost-effective. The cost effectiveness of the PsyMate
intervention is measured with the TiC-P, PRODISQ and EQ-5D.

(5) Changes in daily life experiences such as increasing levels of PA (both in
the experimental and the control condition) predict future outcome (in terms of
relapse risk and symptoms).

6) As part of a larger data collection of momentary assessment data and genetic
information it will be examined how genetic differences are associated with
prospectively measured momentary emotional experiences in interplay with daily
life contexts.

A randomized controlled trial will be conducted with two intervention arms:

- The experimental arm (PsyMate intervention; n=30) receives receives 5-day
pre- and post PsyMate assesments and continuous Psymate assessment (each week
3-days PsyMate measurement during a 6- weeks period) with feedback (to both
patient and therapist) during treatment as usual (TAU= Cognitive Behavioural
Therapy) with the aim of stimulating PA and Work Engagement. This is the
experimental group.

- The control group ( n= 30) receives 5-day pre- and post PsyMate assessments
but no additional intervention during TAU.

The Psymate intervention contains feedback about activities that lead to an
increase of the different aspects of Work Engagement, namely vigor, dedication
and absorption.

The first and second session are focused on building up PA and the energy level
(vigor) by giving feedback on activities, sleeping pattern, relaxation but also
the amount of tiresome or stress-inducing activities. Feedback is given about
the relation between the content of activities and the amount of positive
emotions and their energy level. The focus lies on activities which lead to an
increase in energy and/or positive emotions and decrease in stress level.

The third and fourth session are focused on mastery experiences. Successes
build a robust belief in one's personal efficacy, absorption and higher
dedication to work. Feedback is given about the amount of appreciation they
feel at their current activity. Little successes and activities in which they
feel appreciation of others for their effort, lead to positive emotions. It
also reinforces ones professional efficacy and result in higher dedication to
work (when the situation took place in a work-related context).

Session five and six are focused on positive emotions in social work
interactions. Behaving friendly, sharing good news and success with others,
investing in social contact with colleagues and friends leads to positive
emotions, vigor, improved self-efficacy and higher dedication to work.
Information is given on the amount of momentary positive emotions in relation
to the different kind of social contacts and their progress in initiating
contact over time in social situations at work and at home. Again, at the end,
they also receive information on their energy level and (sessions 1 & 2) and
progress in mastery experiences (sessions 3 & 4) accompanied by visual aids.


The therapist communicates this information in such a way that the participant
understands what it means and how it relates to his/her daily life behaviour.
Furthermore, the therapist and subject look at ways the participant can change
his/her daily life activities in a way that would lead to more positive
emotions. The therapist can additionally support the participant in modifying
his/her working behaviour towards situations of more positive emotions, work
engagement and adjust therapeutic strategy or advice.

There are no health risks associated with the research.


Burden for the patients is investment of time. They have to fill out some
questionnaires, and also have to spit some saliva in a tube. In addition, all
subjects participate twice (before and after the intervention period) in the
PsyMate measurements (5-day period of filling in dairies concerning daily life
events and mood). PsyMate measurement takes places in the actual living
environment of the patient during which they engage in their normal daily
activities, and as such reduces the burden for the patient. Before the start of
the PsyMate measurements receive specific instructions related to this
procedure and the PsyMate by their therapist. On top of this, subjects in the
experimental group additionally have to complete the PsyMate measurements for 3
days a week during a 6-week period ( 3 days a week, 10 times a day, each time
approximately 2 minutes), and have weekly contact with the therapist to receive
feedback from the PsyMate during this 6-weeks period. After a screening
procedure (3 hours), the time investment for subjects is approximately 4 hours
comprising self-report questionnaires (distributed over 7 meetings), beside the
time spend on filling in questions on the PsyMate.