From Burnout to Balance An qualitative study on the experienced effects of an holistic burnout intervention

Yvette Buist

(Picture by J. Gamblin, at Pt. Reyes, California)

Master Thesis

From Burnout to Balance An qualitative study on the experienced effects of an holistic burnout intervention

HSO-80333

Yvette Buist 900226144090

Supervisor: Carlijn Wentink September, 2015

Commissioned by Vitaal aan het werk

Wageningen University Wageningen

Abstract Background: Nowadays occupational stress and burnout receive a lot of attention in society and in research. However, various scholars note that there is a knowledge gap with regard to research of burnout interventions. There are investigations on the effectiveness of interventions, however reason for (in)effectiveness is not given. Vitaal aan het werk is an organisation specialised in interventions focussing on recovery of (work)stress related issues. Their intervention ‘Vitaal Leiderschap’ is the starting point of this research. Objective: The objective of this study is to evaluate the mechanisms in the burnout intervention Vitaal Leiderschap by Vitaal aan het werk and connect this to what is known in literature about effective mechanisms for treatment of burnout. By doing so, this study aims to is to build practice based evidence. Methods: A literature study and a qualitative research including semi-structured interview were conducted simultaneously. In the literature study the online data bases PubMed, Scopus and Web of Science were searched. This search identified 776 articles of which three articles could be used for analyses. For the qualitative study four former clients and five therapists were interviewed, guided by a semi-structured interview format. These interviews were transcribed and analysed using coding and selection techniques. Results: The literature study found that effective mechanisms within coaching or counselling are; insight in boundary setting and prioritization, increased self-compassion, self-care and self-awareness and reduction in emotion focused coping and in job stress. Mechanisms within a mindfulness intervention are; cognitive and emotional reactivity, mindfulness and repetitive negative thinking. The analysis of the interviews shows the process from (self)awareness and insight towards a change in self-management and coping. This process is supported by (physical) experience. In addition to this process also the intensity of the intervention, dedication of practitioners and vision of clients and practitioners seemed to influence the effectiveness of the intervention. Conclusion: The results show that the effective mechanism in the burnout intervention Vitaal Leiderschap is the process from (self)awareness and insight towards self-management and coping, supported by (physical) experience. The studies that were found on effective mechanises in burnout interventions also mention self-awareness, insight and coping strategies. However, a very limited amount of studies are available on effective mechanises in burnout interventions, therefore no strong conclusions can be drawn from the literature study.

Key words: Burnout, stress, intervention, coaching, exercise, relaxation, mechanisms.

Samenvatting Achtergrond: In de samenleving en in onderzoek krijgen beroepsgerelateerde stress en burn-out tegenwoordig veel aandacht. Desondanks merken verschillende onderzoekers op dat er een achterstand is met betrekking tot onderzoek van burn-out interventies. Zo zijn er diverse onderzoeken die ingaan op de effectiviteit van interventies, maar de uitleg over waarom een interventie al dan niet werkt achterwege laten. Vitaal aan het werk is een organisatie die gespecialiseerd is in interventies die gericht zijn op het herstel van problemen die gerelateerd zijn aan (werk)stress. De interventie ‘Vitaal Leiderschap’ is het uitgangspunt van dit onderzoek. Doelstelling: Het doel van deze studie is het achterhalen van de mechanismen in de interventie Vitaal Leiderschap van Vitaal Aan het werk, en om te kijken hoe dit aansluit op wat er bekend is in de literatuur over effectieve mechanismen in burn-out interventies. Het overkoepelende doel is het creëren van ‘evidence based practice’. Methode: De literatuurstudie en een kwalitatief onderzoek zijn gelijktijdig uitgevoerd. In de literatuurstudie zijn aan de hand van zoekwoorden drie online databanken doorzocht: PubMed, Scopus en Web of Science. Hiermee werden 776 artikelen geïdentificeerd, waarvan drie artikelen gebruikt konden worden voor analyse. In het kwalitatieve onderzoek zijn vier voormalig cliënten en vijf therapeuten geïnterviewd door middel van semigestructureerde interviews. Deze interviews zijn getranscribeerd en geanalyseerd het behulp van coderings- en selectietechnieken. Resultaten: Uit de literatuur studie is gebleken dat ‘inzicht in grenzen en prioriteiten’, ‘verhoogde zelfcompassie, zelfzorg en zelfbewustzijn’ en ‘vermindering van het emotioneel gericht handelen en werkstress’, effectieve mechanisme binnen coaching en counseling zijn. Mechanismen binnen een mindfulness interventie zijn: cognitieve en emotionele reactiviteit, mindfulness en verandering in herhaaldelijk negatief denken. Uit analyse van de interviews blijkt dat het proces van (zelf)bewustzijn en inzicht naar verandering in zelfmanagement en coping-strategieën een effectieve mechanismen is. Dit proces wordt ondersteund door (fysieke) ervaringen. Naast dit proces hebben ook de intensiteit van de interventie, toewijding van therapeuten en de visie van cliënten en therapeuten invloed op de effectiviteit van de interventie. Conclusie: Het mechanisme in de burn-out interventie Vitaal Leiderschap is het proces van (zelf)bewustzijn en inzicht naar verandering in zelfmanagement en coping-strategieën, ondersteund door (fysieke) ervaringen. De literatuur benoemt ook zelfbewustzijn, inzicht en verandering in coping-strategieën als effectieve mechanismes in burn-out interventies, maar omdat een zeer beperkte hoeveelheid studies gevonden zijn, kunnen hier geen harde conclusies aan verbonden worden.

Trefwoorden: Burn-out, stress, interventie, coaching, beweging, ontspanning, mechanismen.

Preface Eight months ago I started this research as part of the master’s program Health and Society at Wageningen University. The research was executed based on the request of the working field of stress and burnout. The organisation Vitaal aan het werk, specialised in work stress and burnout interventions, wondered what the effective mechanisms of the Vitaal Leiderschap intervention were and how this related to literature. This was the starting point of this research.

Supervised by Carlijn Wentink and with support of Marcel Hoiting I explored literature on stress and burnout and I interviewed clients and practitioners. The research process was a very instructive process, both professionally and privately (although I would not dear to define the difference between the two). I learned how to work on the creation of practiced based evidence and I saw that practice can develop quite independent from research. It was great to observe practice and to learn from practice. I admire the passion and conviction with which the practitioners of Vitaal aan het werk were talking about their profession.

This is already a little spoiler, but in this report is it mentioned that work, exercise and relaxation must be balanced. While working on this thesis I personally experienced some dis-balance. Due to overenthusiasm I put some extra energy into my work, while neglecting exercise and relaxation. This resulted in some repetitive strain issues. With exercises and relaxation I reached a more balanced state of body and mind and I could finish this report. I think ‘balance’ is the key word of this thesis. I hope you enjoy reading.

Acknowledgements Credits go to the paper “how do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies” by Gu, Strauss, Bond, and Cavanagh (2015). This paper gave me a great insight in how to research mediating factors. The clear structure and careful explanations served as inspiration for writing this thesis.

I would also like to thank a few people who supported me during the research process. I would like to thank Carlijn Wentink for supervision, feedback, support, advise and time. I am grateful for you energy and confidence in me. This made the research process pleasant. I also would like to express my appreciation to Marcel Hoiting for the opportunity to conduct the research at Vitaal aan het werk. I am thankful for your frankness and enthusiasm. Also, I would like to thank all participants who contributed to this research. I am grateful for your openness and willingness to share personal stories. Last, I would like to thanks family and friend for their support. Especially Bart, thank you for putting things in perspective every now and then. I am also incredible thankful for the desk you made perfectly adjusted to my preferences. Thank you!

Yvette Buist

Wageningen, September 2015

Table of contents 1.

Introduction ..................................................................................................................................... 1

2.

Theoretical background ................................................................................................................... 3 2.1 Historical development burnout .................................................................................................... 3 2.2 What is burnout ............................................................................................................................. 3 2.3 Burnout and stress ......................................................................................................................... 5 2.4 Models describing burnout ............................................................................................................ 6 2.5 Factors leading to burnout ............................................................................................................. 9 2.6 Connecting paradigm’s................................................................................................................ 12 2.7 Burnout intervention studies ....................................................................................................... 13

3.

Problem statement & research questions ....................................................................................... 15 3.1 Problem statement ....................................................................................................................... 15 3.2 Aim and research questions ......................................................................................................... 19

4.

Methodology ................................................................................................................................. 20 4.1 Literature study............................................................................................................................ 20 4.2 Qualitative research: semi-structured interviews with former clients and practitioners ............. 24

5.

Results ........................................................................................................................................... 27 5.1 Literature study............................................................................................................................ 27 5.1.1 Impact of coaching and mindfulness .................................................................................... 27 5.1.2 Aggregated results literature study ....................................................................................... 29 5.2 Results qualitative research: semi-structured interviews with former clients and practitioners.. 30 5.2.1. Results semi-structured interviews clients .......................................................................... 30 5.2.2. Results semi-structured interviews practitioners ................................................................. 35 5.2.3 Aggregated results semi-structured interviews..................................................................... 39 5.3 Aggregated results literature study and qualitative research: semi-structured interviews.......... 40

6.

Discussion ..................................................................................................................................... 42 6.1 Theoretical discussion ................................................................................................................. 42 6.2 Methodological discussion .......................................................................................................... 45 6.3 Discussion intervention Vitaal Leiderschap ................................................................................ 46 6.4 Recommendations for practice .................................................................................................... 48 6.5 Further research ........................................................................................................................... 49

7.

Conclusions ................................................................................................................................... 51

References Appendix

A.

Vitaal aan het werk

B.

Literature Survey Tally Matrix

C.

Literature Survey Tally Matrix documentation

D.

Semi structured questionnaire

E.

Informed consent

F.

Code tree: translated and unedited analysis

List of figures Figure 1 Different types of burnout (Montero-Marín et al., 2009), version of (Kakiashvili et al., 2013) 4 Figure 2 The three stages of the general adaptation syndrome .............................................................. 5 Figure 3 The revisited Job Demands-Resources (JD-R) model (Schaufeli & Bakker, 2004) ................. 7 Figure 4 Schematic representation of the ERI-model ............................................................................ 8 Figure 5 Model of workload and capacity (Dijk et al., 1990), translation Donders (2005) ................... 9 Figure 6 The preconditions for development of burnout (Kaschka et al., 2011)................................... 10 Figure 7 A model of the quality of working life, integrating the dominant theories of occupational stress (Kenny & McIntyre, 2005) .......................................................................................................... 12 Figure 8 Mediation analysis (Rucker et al., 2011) ................................................................................ 16 Figure 9 Example of implementation mediation analysis ..................................................................... 17 Figure 10 Connection of explanatory theory, change theory and interventions in relation to burnout . 18 Figure 11 Diagram depicting the flow of literature search in review process ....................................... 23 Figure 12 Vitaal Leiderschap intervention process and outcome ......................................................... 39 Figure 13 Aggregated results mechanisms in burnout interventions .................................................... 42

List of tables Table 1 Example of open coding process .............................................................................................. 25 Table 2 Fragment of code tree ............................................................................................................... 26 Table 3 Proposed mechanisms to enhance well-being and reduce burnout .......................................... 28 Table 4 Proposed mindfulness mechanisms .......................................................................................... 29 Table 5 Structure of Vitaal leadership self-awareness and insight interacting with (physical) experience.............................................................................................................................................. 38

1. Introduction In Europe 25% of the employees say they experience work-related stress for a large part of their working time (EU-OSHA, 2014, p. 40). These employees also report that their work has a negative impact on their health. Within the Netherlands it is calculated that about half of the absenteeism from work are partly or completely stress related (TNO, 2014). One third of the sick leaves are due to occupational stress. According to the Dutch Centre for Occupational Diseases (NCvB) burnout and nervous exhaustion is the most prevalent occupational psychological disorder in the Netherlands in recent years (Van der Molen et al., 2014). Nowadays occupational stress and burnout have received attention from employers, researchers and society at large (Goldberger & Breznitz, 2010; O’Driscoll & Cooper, 2002; Scheid & Brown, 2010). Moreover, a broad range of interventions are developed to support individuals, employers and organizations affected with work-related stress and burnout (Bährer-Kohler, 2012).

This research is executed based on a request from the working field of stress and burnout. The organization Vitaal aan het werk is an organisation specialised in interventions focussing on recovery of (work)stress related issues. In this thesis the focal point is their individual Vitaal Leiderschap intervention.

In the Vitaal Leiderschap intervention applies an holistic approach. Holism implies that the whole is greater than the sum of parts (Smuts, 1926), and that the world in itself is a whole in which all elements are interconnected (Rogers, 1970). Holism in healthcare is often used to denote the interconnectedness between body, mind and spirit (Mark & Lyons, 2010). Holistic care takes a broader perspective on health than just looking at the symptoms (Chan, Ying Ho, & Chow, 2002). Holistic healthcare considers items such as nutrition, environment, mental and spiritual wellbeing and interpersonal relations (Lowenberg & Davis, 1994). It adds conceptions such as balance, integration and more traditional ideas of psychological, physical and social wellbeing (Saylor, 2004).

The intervention Vitaal Leiderschap includes alternating sessions with a coach, a personal trainer and a relaxation therapist. The direct aim of the Vitaal Leiderschap intervention is to create sustainable employability. The indirect aim is to make clients aware of specific patterns and coping strategies, to identify passions and talents and to create a balanced body, mind and lifestyle, in which exercise and relaxation is incorporated. A more detailed description of the intervention Vitaal Leiderschap can be found in appendix A.

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The organization Vitaal aan het werk questioned if there is research which supports their approach towards stress and burnout, and whether the mechanism of the intervention Vital Leiderschap could be identified. This question was the starting point for this research. The general research question is: “From the point of view of the clients and practitioners, what are effective mechanisms in the burnout intervention Vitaal Leiderschap by Vitaal aan het werk and how does this relate to what is known in literature about effective mechanisms.” The establishment of this research question is described in the chapter three, problem statement & research question.

There seem to be major differences in the understanding of the terms stress and burnout (Goldberger & Breznitz, 2010; Schaufeli, Leiter, & Maslach, 2009; Scheid & Brown, 2010; Selye, 2013). In order to avoid confusion and form a starting point for this research, first the research field of work-related stress and burnout will be described in the theoretical background. The aim of this theoretical background is not to give a complete overview of all burnout literature, rather it creates a baseline from which the research is executed. In the theoretical background I will mention the origins of the concept burnout, various definitions explaining burnout, the relation between burnout and stress, burnout models, factors leading to burnout, burnout intervention studies and I will end with an overview in which paradigms are connected. After the theoretical background I will continue with the problem statement and the research questions. Then I will describe the methodology, followed by a description of the results, the discussion and I will end with a conclusion. Other terms for work-related stress are occupational stress and job stress. In this paper I will use the word occupational stress.

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2. Theoretical background 2.1 Historical development burnout The term burnout origins from an English metaphor that refers to a state of psychological exhaustion (Taris, Houtman, & Schaufeli, 2013). The phenomenon burnout probably exists for a long time and in different cultures. Descriptions of what we call burnout today can be even be found in the Old Testament. Exodus 18 describes the “weariness of Elijah” (Burisch, 2010). Also, in the famous novel A Burned Out Case (1960) by Graham Green, a character is described who would qualify for a burnout diagnoses nowadays (Schaufeli & Maslach, 1993). A salient feature for the way in which burnout is ‘discovered’ and conceptualized is that it first appeared as a social problem, and not as an academic construct. Burnout and the contemporary meaning of the term was used for the first time in the mid-1970s (Freudenberger, 1974; Maslach & Leiter, 1976). Maslach and Schaufeli (1993) note that the initial developmental phase of the concept burnout had several characteristics. First, the interpretation of the concept burnout varied from scholar to scholar. Second, the term burnout was used to denote all kinds of mental states and issues. It started to encompass more phenomena than initially indicated. A third and major distinctive feature of the early literature on burnout was the non-empirical character. Scholars mainly used observations and individual case studies to try to understand burnout (Schaufeli & Maslach, 1993). Hence, there were speculations but there was limited scientific evidence about burnout. This changed in the 1980s. In that time a more empirical phase started which is the basis for how we understand burnout nowadays.

2.2 What is burnout Burnout literally means that someone stopped burning. There used to be a fire (motivation, energy, commitment), but this fire is now gone. The result is that a person affected by a burnout has no longer the capacity to continue to work. There were many definitions proposed in the past years (Farber, 2000; Halbesleben & Demerouti, 2005; Maslach, Schaufeli, & Leiter, 2001; Schaufeli & Enzmann, 1998), but the most widely used definition is by Maslach. In the three-dimensional view burnout is defined as a “.. psychological syndrome of emotional exhaustion, depersonalisation, and reduction of personal accomplishment” (Maslach & Leiter, 1997). Usually burnout is seen as a consequence of a prolonged emotional and social stressor within a job, which occurs when there is a mismatch between the employee and the job context (Maslach & Goldberg, 1998; Maslach & Leiter, 1997).

An older, but connective definition of burnout comes from Cherniss (1980). He described burnout as “...a process that begins with excessive and prolonged levels of job tension. This stress produces strain in the worker (feelings of tension, irritability, and fatigue). The process is completed when the 3

workers defensively cope with the occupational stress by psychologically detaching themselves from the job and becoming apathetic, cynical and rigid” (Cherniss, 1980, p. 40). Although there are numerous definitions, they have a couple of characteristics in common. Most of the definitions describe symptoms of depression, they put accent on behavioural symptoms which relate to work, the symptoms appear in a person that did not suffer from psychopathology before and result in reduced effectiveness in work (Schaufeli & Maslach, 1993).

As a clinical condition burnout is documented in the tenth revision of the international classification of diseases. Here burnout is defined as “state of vital exhaustion” (WHO, 2015). Burnout is not recognised in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In summary, the way burnout it is most often used and best understood is as “chronic work-related stress” (Montero-Marín, García-Campayo, Mera, & López, 2009).

In everyday talk different variations on burnout are used, such as worn-out, overworked and stressed (Schaufeli, Taris, & Van Rhenen, 2008). In Figure 1 these different sub-types of burnout are put together (Kakiashvili, Leszek, & Rutkowski, 2013; Montero-Marín & García-Campayo, 2010; Montero-Marín et al., 2009).

Figure 1 Different types of burnout (Montero-Marín et al., 2009), version of (Kakiashvili et al., 2013)

The frenetic subtype refers to a very involved and ambitious employee, who is possibly a workaholic and likely to deplete energy resources through excessive devotion (Schaufeli et al., 2008). The underchallenged subtype denotes a bored employee who is not able to develop any further. Due to loss of interest and satisfaction this type is often cynical. The worn-out type of burnout refers to an employee who experiences a lack of control and acknowledgement. This leads to neglecting 4

responsibilities. These subtypes are related to all three elements of burnout mentioned by Maslach (exhaustion, cynicism and inefficiency). When different types of burnout are distinguished, interventional treatments can be applied with more focus (Kakiashvili et al., 2013; Montero-Marín & García-Campayo, 2010).

2.3 Burnout and stress As mentioned in the definition by Cherniss (1980) burnout and stress can be seen as interrelated, and often they are also researched within the same framework (Bruce, 2009; Cooper, Dewe, & O'Driscoll, 2001; Dewe, O’Driscoll, & Cooper, 2010; Hobfoll & Shirom, 2001; Maslach et al., 2001; Pines & Keinan, 2005; Weber & Jaekel-Reinhard, 2000). However some scholars argue that there are major differences (Pines & Keinan, 2005). Nevertheless, in this thesis it will be considered as two concepts that are related to each other, since this is how stress and burnout are most often approached in literature.

The concept of stress already existed in prehistoric times, when people felt exhausted after hard work, while exposed to extreme weather conditions or when they feared disease (Selye, 2013). This feeling of stress was probably not conscious, but people experienced that this event was something that exceeded their coping limit (Selye, 2013). Selye, a scholar involved in physiological and biomedical research, was one of the first scholars defining stress in the nineties (Koolhaas et al., 2011). Selye (1950) defined stress as “the nonspecific response of the body to any demand”. He developed the theory of the ‘general adaptation syndrome’, which explains the three stages of stress (Figure 2). When the body is exposed to a stressor, it shows changes and simultaneously the resistance is reduced. When the stressor is strong, death can be a result. A stressor is a causal environmental characteristic that is the reason for the stress response (Beehr, 1995).

Figure 2 The three stages of the general adaptation syndrome

Later stress was redefined by making a distinction between the ‘stressor’ and the ‘stress response’ (Koolhaas et al., 2011). All living organisms maintain a balance, also called ‘homeostasis’. This homeostasis is continuously challenged, by internal or external stimuli (Chrousos, 2009). These stimuli are now called stressors. Therefore stress is now defined as “a state in which homeostasis is

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actually threatened or perceived to be so; homeostasis is re-established by a complex repertoire of behavioural and physiological adaptive responses of the organism” (Chrousos, 2009). One of the earliest and most fundamental insights on psychological stress came from psychologist Lazarus. He developed the Transactional Model of Stress (Lazarus, 1990). According to this model stress is connected to appraisal (evaluation). If an environmental situation is evaluated beyond one’s recourses (cooping possibilities) it is seen as a threat to wellbeing (Holroyd & Lazarus, 1982). Transactions in this context means that stress not merely comes from a person or the environment in itself, but that it is caused by an transaction between the person and environment (Lazarus, 1990). This indicates that stress is an interactional process between the individual and the environment. Appraisal is the assumption that stress and emotions are depending on how a person evaluates/ appraises transaction with the surroundings (Lazarus, 2006). This also relates to how burnout is often conceptualised, as a consequence of an imbalance within the interaction between society and working environment (Weber & Jaekel-Reinhard, 2000).

Emotion, coping, stress and burnout Stress and emotions are interdepended, stress does not come without emotions (Lazarus, 2006). Although emotions cover a much broader and more detailed scope of states and adaptation techniques then stress, in literature stress and emotions are usually regarded as independent fields of research (Lazarus, 2006). According to Lazarus the concept of stress tells us little about the struggle of a person to adapt to situations (Lazarus, 2006). In contrast, each emotion tells us something about the way a person appraises what is happening, and how that person is coping with it (Lazarus, 2006). It is argued that emotions should be in the centre when analysing psychological topics, such as stress (Goldberger & Breznitz, 2010). In this research the premise was that emotions and stress are interconnected. Nevertheless the concepts stress and emotions will be discussed from the research field of occupational stress and burnout. The same holds for the concept of coping. There is a large body of research with regard to coping (Dewe et al., 2010), but in this research coping is only covered from the perspective of occupational stress.

2.4 Models describing burnout In order to understand and describe burnout several models have been developed. Some models that are frequently used in literature are explained here.

Person-Environmental Fit An early model that is especially recognised in the field of occupational health and wellbeing, is the Person- Environmental Fit perspective (Edwards, Caplan, & Van Harrison, 1998). This model origins from investigation of the American Institute for Social Research (ISR), in social environment and mental health programs (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964). From this perspective 6

health is seen as the function of the (perceived) ‘fit’ between the characteristics of the person and the environment (Edwards et al., 1998). According to the model job-related stress can be defined as the ‘misfit’ between the personal needs and the resources within the working environment, or as a ‘misfit’ between the personal capabilities and the job-demands (Dewe, O’Driscoll, & Cooper, 2012). A misfit causes strain and will eventually reduce the (sense of) wellbeing.

Job Demands- resources model A model often used specifically in relation to occupational stress is the Job Demands-Resources model (JD-R model). The JD-R model was originally developed by Demerouti, Bakker, Nachreiner, and Schaufeli (2001), but was in 2004 revisited and updated by Schaufeli and Bakker (2004). Only the revisited model is discussed here (Figure 3).

Figure 3 The revisited Job Demands-Resources (JD-R) model (Schaufeli & Bakker, 2004)

The origins of the JD-R model are the job demands and resources retrieved from the Maslach Burnout Inventory, which is an instrument to measure burnout (Schaufeli & Taris, 2013). The JD- model was originally developed to give an insight in the causes of burnout. Job demands are defined as “...those physical, social, or organizational aspects of the job that require sustained physical or mental effort and are therefore associated with certain physiological and psychological costs” (Demerouti et al., 2001). These demands are not necessarily stressful. It is only stressful when the efforts to meet the requirements are too high or when the recovery is insufficient. These demands can be seen as environmental stressors. The resources are “...those physical, social, or organizational aspects of the job that may do any of the following: (a) be functional in achieving work goals; (b) reduce job demands and the associated physiological and psychological costs; (c) stimulate personal growth and development” (Demerouti et al., 2001). According to this model there are two processes that play a role in the development of a burnout (Schaufeli & Bakker, 2004). First, when the work demands increase the employees must work under extra pressure which requires extra energy. Subsequently a compensation is needed, for example taking a break or lowering work speed. If employees are not able to recover sufficiently, this eventually may lead to mental and physical 7

exhaustion. Secondly, a lack of energy sources lead to a decrease in adaptability of the employee to meet the requirements, resulting in unmet objectives. Another aspect of the model is engagement, which aims to give more insight by a more positive way of reasoning. Engagement is related to the feeling of satisfaction characterised by vigor and dedication. It leads to positive outcomes such as commitment, loyalty and high performance (Schaufeli & Taris, 2013). In summary the presence of demands and the absence of resources (energy) lead to a decline of mental energy, which can eventually lead to a burnout. Engagement mediates between the relation of resources and on the other hand positive attitude towards the organization (Schaufeli & Bakker, 2013).

Effort Reward Imbalance The Effort Reward Imbalance model (ERI) is also used to investigate occupational stress. The ERI model is based on social reciprocity (Siegrist, 1996). Social reciprocity is a mutual commitment and investment within a relationship to answer a gift with the return of a gift. If a relationship is equivalent there is reciprocity. When this norm of reciprocity is not acknowledged, stress could be a result. According to the ERI model there needs to be a balance in efforts and rewards (Siegrist, 2012). The ERI model suggests that an imbalance between effort and reward (non-reciprocity), is a threat to health. A disturbed balance can result in negative emotions and in a sustained stress responds. The three rewards mentioned are money, esteem and promotion (Siegrist, 2012). It is hypothesised that an imbalance (high effort and low reward), can increase the risk of reduced health and therefore overcommitted employees are at an increased risk to reduce health. However the combination of high effort, low reward and over-commitment, creates the highest risk of reduced health (Siegrist, 2012).

Figure 4 Schematic representation of the ERI-model

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Model of workload and capacity A model that is used in the Netherlands for policies to explain the measurement of working condition is the model by Dijk, Van Dormolen, Van Kompier, and Meijman (1990) (Klein Hesselink & Houtman, 2012; Kuiper, 2005). Dijk et al. (1990) developed ‘Het belasting-belastbaarheidsmodel’, freely translated this is the model of workload and capacity (Figure 5).

Figure 5 Model of workload and capacity (Dijk et al., 1990), translation Donders (2005)

This model describes the effects of working conditions on health. The model assumes that absenteeism from work relates to a discrepancy between the demands of the employer (job demand) and the capacities of an individual to meet those requirements (individual capacity). When the job demands and the individual capacity are out of balance for a long time, along with insufficient time for recovery, a harmful accumulation can be the effect. As a result employees can develop health problems, prolonged sickness and even a permanent disability. This is in line with the theoretical perspective of stress. Stressors in the workplace (working overtime, high demands) result in stress symptoms (sleeplessness, exhaustion) and these result in stress consequences (temporary and long-term unfit for work) (Schaufeli & Bakker, 2013). In this model emphasis is put on the dynamics between labour, environment and person (De Keijser, 2009).

In summary, the models that were just mentioned, explain the relationship between the employee, work and stress. They have in common that stress is the result of both personal characteristics and job characteristics. Stress is seen as a result from disturbance in the interaction process between resources, efforts, characteristics versus demands, rewards, capacity.

2.5 Factors leading to burnout There are several factors that are placing people at a higher risk of getting a burnout. Usually burnout cannot be attributed to just one characteristic, but rather as an outcome of an interaction between personal and environmental factors (Kaschka, Korczak, & Broich, 2011). This is also displayed in Figure 6 The preconditions for development of burnout. As mentioned before there are different types of burnout. Consequently different characteristics lead to different types of burnout. The different

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characteristics are here divided into in job, family, individual and modern-day characteristics. Each one of these characteristics will be addressed briefly.

Figure 6 The preconditions for development of burnout (Kaschka et al., 2011)

Job characteristics Initially burnout was related exclusively to human services, for example teaching and nursing (Demerouti et al., 2001). Nowadays, it seems to be acknowledged that burnout also appears beyond human services (Schaufeli et al., 2009). However, people working in caring professions are still in specifically vulnerable to burnout (Sanchez, Mahmoudi, Moronne, Camonin, & Novella, 2014; Skovholt & Trotter-Mathison, 2014). It is suggested that it can be a challenge in these types of occupations to find a balance between care for others and care for one self (Skovholt & TrotterMathison, 2014). There are several characteristic within a job that are positively related to burnout. Some are already suggested in the burnout models. In line with the effort-reward model it is found that an imbalance between effort and reward at work increased the risk of poor health (Siegrist et al., 2004), and as the Job-demand resource model suggested it is found that high job demands and too little resources are related to high levels of burnout (Schaufeli & Taris, 2013). Other processes that may reinforce burnout are: - High external regulation from organization (Ten Brummelhuis, ter Hoeven, Bakker, & Peper, 2011); - Decreased job satisfaction (De Oliveira et al., 2011; Peng et al., 2014); - A high workload (Leiter, Frank, & Matheson, 2009; Xiaoming, Ma, Chang, & Shieh, 2014); - A lack of feedback and job autonomy (E. G. Lambert, Hogan, Dial, Jiang, & Khondaker, 2012); - Bullying in the working place (Allen, Holland, & Reynolds, 2015; Sá & Fleming, 2008); - Poor teamwork (Kaschka et al., 2011); - Low involvement in decision making (Gray-Stanley & Muramatsu, 2011; Kaschka et al., 2011).

Family characteristics Burnout is usually related to the work environment, however some scholars claim that it can also be linked to the family environment (Peeters, Montgomery, Bakker, & Schaufeli, 2005). For example a 10

conflict situation in managing a household, raising children, informal care for family and a demanding job can be a trigger for a burnout (Peeters et al., 2005).

Individual characteristics Some people are more sensitive to get a burnout than others. Armon, Shirom, and Melamed (2012) found that people with high levels of neuroticism are at an increased level of getting a burnout. Among others because they seem to avoid useful coping strategies, such as problem solving and proactive behaviour (Bakker, Van Der Zee, Lewig, & Dollard, 2006). It is also found that young, low educated employees have relatively little job resources, poorer health and performances and a higher level of exhaustion, which is linked to an increased risk of getting a burnout (Akkermans, Brenninkmeijer, Blonk, & Koppes, 2009; Akkermans, Brenninkmeijer, van den Bossche, Blonk, & Schaufeli, 2013). Likewise, individuals who are perfectionistic are associated with higher risk of burnout, possibly because their working pattern drains mental energy (Taris, van Beek, & Schaufeli, 2010). Although gender is not a characteristic, it is often said that women are at a higher risk to get a burnout compared to man, however there is no consensus in literature. It is likely that in some areas of employment in which women are more present, burnout is more probable to occur (Aydemir & Icelli, 2013). In contrast extraversion is negatively related burnout (Michielsen, Willemsen, Croon, de Vries, & Van Heck, 2004). Bakker et al. (2006) suggest that this is the case since extraversion is associated with optimism and positivity. Hence, it is not always clear which psychological processes are responsible for the relation between individual characteristics and burnout. However, it can be concluded that some specific individual characteristics are relative strong predictors for burnout (Taris et al., 2013).

Modern-day characteristics From an existential perspective people seek meaning in the things they do. The search for meaning is seen as a motivation for humans (Frankl, 1985). Therefore, people need to find meaning also in their job. From this point of view a failure to find meaning in work can be a cause of a burnout (Pines & Keinan, 2005). Iacovides, Fountoulakis, Kaprinis, and Kaprinis (2003) note that people not work just to generate income, but it is also considers as an important aspect of someone’s social status and it gives meaning to someone’s live. In particularly when religion is rejected as a source of meaning, a sense of meaning can be obtained through work (Pines & Maslach, 2002). In this way work can become more important, and serve as a significant element of meaning for a person’s entire life. Bruce (2009) suggests that the current accessibility through telephone and email could also be a risk factor for burnout. Through the fulltime reachability it can becomes harder to detach from stressors from work (Bruce, 2009). Also an “increased pace of business life” is mentioned as a significant risk factor for burnout (Hudson Highland Group, 2005). 11

2.6 Connecting paradigm’s As mentioned before this theoretical background is not a complete overview of all burnout literature. Also it does not contain all different perspectives on the items. Within the scope of this thesis this would be unmanageable, but also with respect to the different cultural perspectives and paradigm’s on stress and burnout it would be unachievable. Kenny and McIntyre (2005) faced similar issues while constructing and conceptualizing a theoretical framework for occupational stress, however they attempted to connect occupational stress paradigm’s in a model (Figure 7).

Figure 7 A model of the quality of working life, integrating the dominant theories of occupational stress (Kenny & McIntyre, 2005)

In this figure most common factors related to quality of working life are displayed. The upper left side is the side of the employer /supervisor. On top are the general characteristics of society, such as the political and economic climate. The general factors influence organizational culture and characteristics. These general and organizational characteristics, together with innate characteristics, previous and current life/work experiences of the employer /supervisor, make up for the management and leadership style and skills of the employer/supervisor. This points towards the quality of management.

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The right side of the figure is the side in which the employee is presented. The development of skills and resources interacts with life and work experiences. Both also interact with appraisal of work and coping repertoire, which are connected to work behaviour, attitudes and relationships. Al of these factors are related to the employee are also influenced by innate characteristics. All arrows somehow relate to quality of employee working life, which is displayed on the left side. The factors related to employer /supervisor and the factors related to the employee come together in the quality of employee working life. Also, specific job related factors on the left influence quality of employee working life. Below the quality of employee working life and overview of models explaining quality of employee working life is displayed. Concluding, quality of working life is influenced by a wide variety of aspects, such as personal factors, characteristics of employer /supervisor, general factors and work characteristics.

2.7 Burnout intervention studies Although the last decades there was public interest in stress and burnout, not so many interventions were developed (Maslach & Leiter, 2014b). This was probably due to difficulties in research itself and publishing of interventions studies. Additionally applied studies are often viewed as less prestigious than basic research (Maslach & Leiter, 2014b). Although the quantity of the research papers might not at a desired level, still a certain amount of research is conducted. The current interventions can roughly be divided into two approaches, the organizational approach and the individual approach (Le Blanc & Schaufeli, 2008).

The organizational approach focuses on the stressors within the workplace. An example of this type of interventions is ‘Job Redesign’. This approach used as an instrument to reduce workload and increase creativity and innovative initiatives of employees within their the job (Berg, Hansson, & Hallberg, 1994). However effectiveness of the job redesign intervention is doubted (Melchior et al., 1996). Another organizational intervention is ‘Co-worker support’ which is based on the finding that expressing and sharing feelings with colleagues contributes to problem solving (Maslach & Leiter, 1976). Although interventions at organizational level could have great potential, more research in this field is needed (Le Blanc & Schaufeli, 2008).

There is a wide range of interventions focused on individuals, such as aerobic (Gerber et al., 2013), relaxation therapy (Kaspereen, 2012), coaching (Gazelle, Liebschutz, & Riess, 2014), cognitive therapy and mindfulness (Gu et al., 2015; Regehr, Glancy, Pitts, & LeBlanc, 2014). Also more creative approaches to reduce stress are applied, such as the use of massage, music, yoga, art and writing (Repar & Patton, 2007). Besides these interventions burnout is also being treated with antidepressants. However the use of medication to treat burnout is rather controversial, since the effectiveness is questioned and only symptoms are treated (Ahola et al., 2007; Kakiashvili et al., 2013). 13

Also non-pharmaceutical methods, such as nutrients and botanicals to balance neurotransmitters are used to reduce stress and enhance a restful sleep (Sleep, 2009). For both, more studies are needed to determine the effectiveness in burnout patients (Kakiashvili et al., 2013).

What might be even more desirable than interventions are effective prevention methods. These can also be applied at organisational or at individual level. Fritz, Sonnentag, Spector, and McInroe (2010) found that sufficient relaxation during the weekend reduced tension during work in the following week. Sanz-Vergel, Demerouti, Moreno-Jiménez, and Mayo (2010) showed that conversation with family, friends and colleagues about positive emotions have a constructive influence on vitality and enhance a positive relationship between working live and family. Other more general preventive methods are self-reflection, training in social skills, training and practicing of self- management behaviour and integration of beneficial coping strategies (Turnovska, Dimova, Tilov, Bakova, & Harizanova, 2014).

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3. Problem statement & research questions 3.1 Problem statement Although research on stress and burnout interventions evolved over the last decades, still various scholars researching burnout interventions note that there is a knowledge gap with regard to researching burnout interventions (Bresó, Schaufeli, & Salanova, 2011; Gerber et al., 2013; Korczak, Wastian, & Schneider, 2012; Leiter & Maslach, 2014; Maslach & Leiter, 2014a). In particular they note that there is a need for randomized controlled trails with large, representative samples, which will generate evidence on which practice can be based. Within the studies on burnout interventions it stood out to me that very little is described on the effectiveness of the interventions. There are investigations on the effectiveness of interventions (Czabała, Charzyńska, & Mroziak, 2011; Le Blanc & Schaufeli, 2008), however reason for (in)effectiveness is not given. This is also reflected in guidelines of national mental health care organizations. The Dutch National Association of primary psychology (Landelijke Vereniging van Eerstelijnspsychologen) describe different types of interventions and their effects, but they do not give an account for how the interventions work (Verschuren et al., 2011). Also, the national mental health services in the Netherlands (GGZ) describe burnout interventions on their website and write that their methods are scientifically proven (GGZ Groep, 2015). On a request to provide information on effectiveness of their interventions they refer to principles and evidence of burnout interventions that can be found on internet. They could not give an explanation on the mechanisms within their intervention. Concluding, this means that the pathway as to why and how burnout interventions work is often unclear. This is emphasized by what Leiter, Bakker, and Maslach (2014) describe. They note that mindfulness can be effective in treating a burnout when relaxation techniques are used. Relaxation techniques could potentially reduce exhaustion, improve coping with distress and add to peoples sense of confidence, but investigation is needed to identify the actual mechanism (Leiter et al., 2014). This example shows that research can determine the effectiveness of an intervention while the underlying mechanisms are still unclear. Leiter et al. (2014) also mentioned that understanding change principles are at the base of effective interventions. Therefore, understanding the principles that caused change can be supportive to create evidence based interventions.

The absence of evidence based interventions and the lack of clarity about mechanisms that lead to positive change in burnout is also reflected in the working field. Interventions like the Vitaal Leiderschap by Vitaal aan het werk have been established based on education, experience and the intuitive idea of what is effective in treating a burnout. As previously described the intervention Vitaal 15

Leiderschap by Vitaal aan het werk applies coaching, exercise and relaxation techniques. Separately these three aspects are already researched in relation to stress. It is found that coaching can be effective in people facing high work stress (Gyllensten & Palmer, 2005, 2006). It is also found that people with an adverse childhood history can have an increased risk of adapting dysfunctional coping strategies in order to deal with stress later in life (Aldwin, Yancura, & Boeninger, 2010; Leitenberg, Gibson, & Novy, 2004). With regard to stress and exercise it is found that regular aerobic exercise reduces psychological stress and prevents stress-related diseases (De Geus & Stubbe, 2007). Another study found that intervention groups attending fitness workouts scored significantly lower on perceived stress and burnout (Baghurst & Kelley, 2014). It is also indicated that exercise and fitness result in less sick leaves and employees are better equipped to cope with chronic stress (Gerber, Kellmann, Hartmann, & Pühse, 2010). A scientific link is also made between stress and relaxation. It is found that several relaxation techniques result in good health and a decrease in stress (Varvogli & Darviri, 2011) .

Hence, looking at these studies it intuitively makes sense that coaching, exercise and relaxation could have a alleviating effect on burnout. However, a direct scientific explanation about the effect of coaching, exercise and relaxation in relation to burnout is still missing. Vitaal aan het werk asked their clients to rate how satisfied they were with the intervention and they gave a score of 8.8 out of ten. Thus, clients seem to be content with the intervention, but why and how does it work? Therefore, in this study it is assumed that coaching, exercise and relaxation have a alleviating effect on burnout, but it is questioned how coaching, exercise and relaxation induce a positive change in the feeling of stress and burnout.

Mediating mechanisms explaining how interventions work are usually investigated by the means of mediation analysis (Rochon, du Bois, & Lange, 2014). Figure 8 shows the mediation process (Rucker, Preacher, Tormala, & Petty, 2011).

Figure 8 Mediation analysis (Rucker et al., 2011)

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X represents the independent variable, which is in this case the burnout intervention. Y represents the dependent variable, which is the experienced outcome of the burnout intervention. The upper figure shows a direct effect from X on Y, and c represents the total effect. In the bottom figure a mediator (M) is introduced. In this figure c′ represents the direct effect from X on Y, after controlling for mediation. a is the effect from the independent variable on the mediator and b is the effect of the mediator on the dependent variable, controlling for the independent variable (Rucker et al., 2011).

Based on the theory of Rucker et al. (2011) Figure 9 is constructed. This is an example of implementation of mediation analysis applied to burnout interventions. Initially there is a person with a burnout. In this figure there is a line from burnout to burnout intervention. This connection applies when a person with a burnout participates in a burnout intervention. In this figure the burnout intervention is the independent variable. The outcome, for instance experienced level of stress and burnout, is the dependent variable since it depends on the burnout intervention. This relationship is probably supported by mediating mechanisms. These mediation mechanisms are currently unknown, but examples could be: body awareness, insight and acceptance.

Figure 9 Example of implementation mediation analysis

In Figure 10 (next page), the explanatory theory and the change theory to plan and eventuate health care programs, by Rimer and Glanz (2005), is used to display the way of thinking which is just explained. The explanatory theory describes the problem, in this case burnout. The theoretical background of this research can be seen as (part of) the explanatory theory of burnout. The change theory is about intervention programs that aim for alleviation of burnout. In the Figure 10 it is displayed that two ‘solutions’ are available for burnout issues. One option is to prevent burnout, the other is treatment of burnout. When prevention fails treatment can still be the next step. Following the line of treatment there are two types of treatment, organizational interventions and individual interventions. In this research focus is on individual interventions, since Vitaal aan het werk requested this research 17

and their intervention is focused on the individual. The example case is therefore also the Vitaal Leiderschap intervention by Vitaal aan het werk. The three elements, coaching, exercise and relaxation will be investigated. The thick closed lines denote the connections that already exist. The thin dotted lines denote the connections that are currently either unclear or unpresented, while these connections would be helpful to make practice more evidence based. The dotted lines with arrows, from individual intervention and the example case towards change theory, are the connections that are aimed to be developed by this study. By creating the connections of the dotted lines, the purpose is that connections of the thin lines will become more visible.

Figure 10 Connection of explanatory theory, change theory and interventions in relation to burnout

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In conventional research on health topics, evidence based practice is the widely accepted and applied. However, in this case practice developed the intervention and wants to know why and how it exactly works. Therefore, the research process is reversed into practice based evidence (Swisher, 2010; Tang, Ehsani, & McQueen, 2003). I will look at practice and investigate the elements that result in alleviation of burnout. By investigating this pathway this study will develop part of the change theory that explains why a certain intervention is potentially effective in treating burnout. This study will not be able to create a full picture of the change theory. Rather it will fill part of the knowledge gap, by building some of the change theory. The intervention Vitaal Leiderschap by Vitaal aan het werk will be the example case which will be investigated.

3.2 Aim and research questions The intervention by Vitaal aan het werk is a new type of intervention applying a more holistic approach towards burnout. To my understanding there is no intervention that corresponds to this holistic approach. Additionally, also no prior research has been done on the effects of this combination of therapeutic elements to treat burnout. Therefore the aim of this study is to create part of the change theory and explain what mechanisms are potentially effective in treating burnout. Therefore the general research question is: “From the point of view of the clients and practitioners, what are effective mechanisms in the burnout intervention Vitaal Leiderschap by Vitaal aan het werk and how does this relate to what is known in literature about effective mechanisms.” The sub questions to answer this general research question are: - What is known in literature about effective mechanisms in coaching, exercise and relaxation in relation to occupational stress and burnout? - Which mechanisms does the intervention Vitaal Leiderschap by Vitaal aan het werk contain? - What effects did the former clients experience after participating in the intervention Vitaal Leiderschap by Vitaal aan het werk? - What are effective mechanisms in the intervention Vitaal Leiderschap by Vitaal aan het werk according to the former clients of Vitaal aan het werk? - What are the observed and expected effects of the intervention Vitaal Leiderschap by Vitaal aan het werk according to the practitioners of Vitaal aan het werk? - What are effective mechanisms in the intervention Vitaal Leiderschap by Vitaal aan het werk according to the practitioners of Vitaal aan het werk?

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4. Methodology The methodology is separated into a literature study and a qualitative research including semistructured interviews. The latter is divided into interviews with former clients and practitioners. Both components were researched simultaneously, but are discussed separately. In the end the results of both components are aggregated and discussed together.

4.1 Literature study The aim of the literature study was to explore empirical evidence about effective mechanisms in stress and burnout interventions. The search only included burnout interventions applying coaching, exercise and relaxation techniques. Inclusion criteria -

Research studies published in English or Dutch;

-

Interventions implemented at the level of the individual;

-

Study population contains adults (>18 years);

-

Studies researching mediating mechanisms.

Exclusion criteria -

Studies including pharmacological interventions as treatment approach;

-

Interventions implemented at the level of the organization;

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Intervention focussing on prevention;

-

Studies only reporting the effect of an intervention.

The following databases were used for this search; PubMed, Scopus and Web of Science. Studies that were published between 2010 and 2015 were viewed. This time-frame was selected since the search resulted in 700 till 800 articles. In terms of context and time devoted to this study this was seen as feasible amount of articles to investigate. Also, references of the selected articles were screened, in that way also articles written before 2010 could be included.

The keywords have been established based on a consultation with a librarian from Wageningen University. Also the article “How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies” by Gu et al. (2015), served as a major source of information. Since this study also focused on mediating factors, a couple of keywords were adopted and other keywords were inspired on the article by Gu et al. (2015). The following combinations of specific keywords and combination of keywords were examined:

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Theme

Keywords

Issue:

burnout, stress

Intervention:

intervention, treatment, therapy

Focus intervention:

work-related, job-related, occupational, individual

Relationship:

mechanisms, mediation, predicting, process, causal, pathway, correlation, relationship, association

Types of treatment:

coaching, exercise, (physical) training, workout, relaxation, relief, loosening

Activities within the treatment:

family constellation, emotions, balance, breathing techniques, Ayurveda, mindfulness,

Possible aims or outcomes:

well-being, quality of life, work life balance

The search term was: (burnout OR stress) AND (intervention* OR treatment OR therapy) AND (“work related” OR “ job related” OR occupational OR individual) AND (mechanism* OR mediat* Or predict* OR process OR caus* OR path* OR correlat* OR relationship OR association) AND (coach* OR exercise OR training OR relaxation) AND (“family constellation” OR emotion* OR balance OR “breathing techniques” OR Ayurveda OR mindfulness) AND (wellbeing OR well-being OR “quality of life” OR “work life balance”). This search term proved to be ineffective. The results that emerged were not related to burnout interventions. Therefore the search was made more specific by splitting the keyword into three subgroups. The subgroups focused on (1) coaching, (2) exercise or (3) relaxation. The possible aims or outcomes were left out in this search to increase the number of potentially useful articles. The flowing search terms were used: 1. Coaching: (burnout OR stress) AND (intervention* OR treatment OR therapy) AND (“work related” OR “ job related” OR occupational OR individual) AND (mechanism* OR mediat* Or predict* OR process OR caus* OR path* OR correlat* OR relationship OR association) AND (coach* OR counselling) AND (“family constellation” OR emotion* OR balance OR mindfulness). 2. Exercise: (burnout OR stress) AND (intervention* OR treatment OR therapy) AND (“work related” OR “ job related” OR occupational OR individual) AND (mechanism* OR mediat* Or predict* OR process OR caus* OR path* OR correlat* OR relationship OR association) AND (exercise OR training OR workout) AND (balance OR Ayurveda OR mindfulness). 3. Relaxation: (burnout OR stress) AND (intervention* OR treatment OR therapy) AND (“work related” OR “ job related” OR occupational OR individual) AND (mechanism* OR mediat* Or predict* OR process OR caus* OR path* OR correlat* OR relationship OR association) AND (relax* OR relief OR loosening) AND (emotion* OR balance OR “breathing techniques” OR mindfulness) AND (wellbeing OR well-being OR “quality of life” OR “work life balance”). 21

To identify relevant publications that were not recognised by the database-search, a manual search through citations of the publications was performed as well. The titles and abstracts that were identified through the search were inspected for relevance. Articles were considered to be relevant when they provided information about effective mechanisms in stress and burnout interventions. Accordingly the full text was retrieved.

Review procedure and analyses First titles and abstracts of identified articles were examined on relevance. Each study that met the inclusion criteria was viewed. Subsequently the quality of the study was assessed. Guided by the following questions (Bowling & Ebrahim, 2005): 1. Do the findings of this article relate to the research question that is proposed? 2. Is the methodology appropriate? Meaning: “is the methodology sound, have the authors made reasonable assumptions, are there confounding factors they have failed to consider?“ (Bowling & Ebrahim, 2005). 3. Is there an explanation for who was and who was not included in the research? And do the researches give an account for dropouts? 4. What is the connection between the researchers and subjects of the study? Does this influence or bias the study? When the first three questions were answered positively and answer on the fourth question was negative, the review procedure continued. Not all articles described effective mechanism of an intervention straightforwardly. Therefore the selected articles were analysed guided by the Literature Survey Tally Matrix by Machi and McEvoy (2012). In appendix B a table with the Literature Survey Tally Matrix is displayed. All steps were documented (appendix C). First the collected data was assembled in four steps. 1. The key concepts was extracted from the text. 2. The external authors who were cited or referred to, and mentioned something about mediating mechanisms were listed. 3. The main ideas from the authors and external authors who were cited or referred to were clustered. The data was grouped into evidence patterns by various auteurs to get an insigth in the different mechanisms and patterns that are suggested. 4. Now the study was read more thoroughly the quality of the data was assessed again.

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In the following steps it is explained how the information was organized and claims were build. 5. The different mechanisms and patterns that were suggested were viewed again. Then a suitable reasoning pattern was applied to each different group. The optional reasoning patterns were: one-on-one reasoning, side-by-side reasoning, chain reasoning and joint reasoning. 6. The reasoning patterns (warranting schemes) were be documented. 7. Based upon the reasoning patterns (warranting schemes) conclusions were drawn. 8. The acceptability of the claim were revised. It was checked if the claims related to the augment, if the reasoning was strong, if the evidence supported the claim and whether the claim were understandable. In the last steps the data was analysed and patterns were sought. 9. The claims for step 8 were reorganized by using complex reasoning patterns. 10. The warrant scheme from step 9 were stated, by determining the reasoning pattern. 11. The complex statement for the discovery of the argument was stated. A more detailed description of each step can be found in the book by Machi and McEvoy (2012).

Study flow and characteristics Figure 11 depicts the flow of the literature search during the review process. The literature search identified 292 articles in the subgroup coaching, 307 in the subgroup exercise and 177 in the subgroup relaxation, which resulted in a total of 776 articles.

Figure 11 Diagram depicting the flow of literature search in review process

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Duplicates were not removed yet, since the three searches were done separately and overlap could not be monitored. 726 articles were excluded based on their title, 40 articles were excluded based on their abstract. The final number of individual articles meeting the inclusion criteria was ten. Eight articles were excluded because the study only focused on mindfulness, not on mediation factors (N=4), the study only focused on burnout interventions in general (N=2) and the study is not focused on stress reduction (N=2). The reference lists of the articles were assessed for further studies meeting the inclusion criteria. This resulted in one additional article. Finally three articles that met de inclusion criteria were included of analyses. Two articles related to coaching and one article was about mindfulness and mediation factors.

4.2 Qualitative research: semi-structured interviews with former clients and practitioners Study population & sampling method Five former clients who participated in the intervention were invited to participate in the research. One former client refused participation due to personal issues. Four former clients who participated in the intervention were interviewed to get an insight their perception on the intervention and on what they think effective are mechanisms in the burnout intervention Vitaal Leiderschap.. Besides the former clients also five practitioners providing the intervention were interviewed. The aim of these interviews was to get an insights in their ideas and philosophy with regard effective mechanisms of the intervention. The purpose was to distract the elements the former clients and practitioners think are supportive for the alleviating process of the client. The sample was composed by the means of convenient sampling. The aim of this research was to come to an understanding of the effective elements of the Vitaal Leiderschap intervention by Vitaal aan het werk. Therefore, only former clients and practitioners of this specific organization were included. Up to now there is no other organization offering a similar intervention, consequently research was restricted to Vitaal aan het werk.

Data collection The interviews were conducted in Dutch and were recorded by a voice recorder. The semi– structured questionnaire was guiding during the interviews. The questionnaire was established based on the research questions. An outline of guiding questions can be found in appendix D. The participants were encouraged to speak about the topics. Furthermore questions to clarify an answer and probing question were asked. The interviews lasted between 30 till 60 minutes. Especially the interviews with the former clients were rather personal, since these interviews were about the their personal experience in relation to burnout treatment. Therefore the interviews were conducted in a quiet environment where they could speak freely. At the start of the interview it was 24

explained what the purpose of the interview was and why the experiences of the former were an important asset for the research. Also, the interviewer introduced herself in order to create an atmosphere in which the former clients felt comfortable to speak about personal experiences. To ensure confidentiality the participants were asked to sign the informed consent. An example is displayed in appendix E.

Data analyses All interviews were transcribed to word level accuracy whereupon the transcripts were anonymised. To analyse the data retrieved from the interviews intensive manual coding was applied in order support systematic analyses of qualitative data. The data was analysed through a content descriptive analyses. This is a method that can be used for producing descriptions of qualitative data (Bowling & Ebrahim, 2005). First the interviews were transcribed. Than labels and codes were assigned to items in the text that related to (effective) mechanisms of the intervention. By coding the transcriptions the data was organized and the codes allowed for comparison between text units (Bowling & Ebrahim, 2005). During the content descriptive analyses the flowing steps, suggested by Hennie (2010), were used: (1) open coding, (2) axial coding, (3) selective coding. All steps are explained supported by examples.

1. Open coding is the process in which the interviews were examined, conceptualized and categorised. The collected data was read thoroughly and divided into fragments. Table 1 is an fragment of a transcript and the associated codes.

Table 1 Example of open coding process

Codes

Fragment of the transcript (translated from Dutch into English) Interviewee: How did it support you? Participant: The coaching, hmm, I thought, was

Confrontational

confrontational for me. [...]. The type of conversation and the family constellation or the advises, that combination is really

Confrontational and enlightening

confrontational, but also enlightening. And the good thing is that, is that practically, you come up

Solutions discussed but mainly translated into

with solutions. They are not discussed that much,

practise

however you kind of practise it by using a family constellation. Which is a great cognitive process,

Cognitive and behavioural process

but also a translation to behaviour is made. And

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to me some important issues came to the service

Awareness of important issues

and dealt with. These things were related to my burnout, direct or indirect.

2. Axial coding is the process in which the individual codes are connected and grouped into categories. It was decided whether the codes were sufficient to describe the data and when needed new codes were created. To create an overview a code tree was made. In this way the main head codes and sub-codes were distinguished and concepts were hierarchical combined. Initially the code tree was made in Dutch, but is it translated into English to continue further analysis in English. During the axial coding a distinction is made between the interviews with former clients and practitioners, since they both have another perspective. Table 2 is a fragment of the code tree of the former clients. In appendix F both complete code trees are displayed.

Table 2 Fragment of code tree

Intensity (therapy VS coaching + combination job and intervention) •

Experienced as it was therapy → caused ambivalence towards employer

•

Confronting → It has to be the right moment for you

•

Intense → difficult / impossible to combine with work

•

The transition back to work is challenging

3. Selective coding is selecting the core categories for refinement and structure. Emphasis is put on the integration and establishment of connections between the categories. While connecting categories focus was put on recurring themes and experiences, the main message with regard to the research question and exceptional items. This phase is described and displayed in chapter 5.2.3 (aggregated results semi-structured interviews).

Ethical considerations The conductance of the interviews and processing of the data was done in accordance to the Wageningen code of conduct for social science research. The participant of the study were informed about the purpose of the research. Engagement in the research was merely on voluntary basis. Although the participants were not anonymous, the information they provide was treated confidential and names are anonymised in the report.

Time of research The research was conducted between April 2015 and September 2015. This includes the full research period, including processing of data an writing the report.

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5. Results The literature study and the semi-structured interviews aim to answer the general research question: “From the point of view of the clients and practitioners, what are effective mechanisms in the burnout intervention Vitaal Leiderschap by Vitaal aan het werk and how does this relate to what is known in literature about effective mechanisms.” In the following chapter first the results of the literature study will be discussed, followed by a discussion of the results of the interviews. In the last subchapter the aggregated results of both studies will be discussed.

5.1 Literature study As shown in Figure 11 (page 24) the literature research identified three articles that met the inclusion criteria and that could contribute to answering the sub question: “What is known in literature about effective mechanisms in coaching, exercise and relaxation in relation to occupational stress burnout? “ Two of the articles that were found related to coaching and one article was about mindfulness and mediation factors. There were no articles on effective mechanisms related to exercise and relaxation.

5.1.1 Impact of coaching and mindfulness

Coaching The articles by Schneider, Kingsolver, and Rosdahl (2013) and Ro et al. (2010) met the inclusion criteria. The proposed mechanisms to enhance well-being and reduce burnout, retrieved from these articles, are presented in Table 3 (page 29). Schneider et al. (2013) researched physician coaching to enhance well-being. They found that coaching supported physicians to get a critical insight in boundary setting and prioritization, selfcompassion and self-care and increasing self-awareness. The respondents described focussing on boundary setting and prioritization as part of the coaching process and they experienced boundary setting as a method of self-care. It was reported that boundary setting clarified the difference between realistic and unrealistic expectations and it also involved awareness that the participants did have a choice in how to distribute their time. Some participants said that their confidence to “say no” increased. Coaching also increased the level of self-compassion and self-care. The participants reported that they took more time for self-care and wellness goals. Finally, also self-awareness increased. The physicians said that coaching supported them in taking back control in their lives, it decreased self-imposed pressure and perfectionism and they felt that they had more realistic expectations about themselves. The participants reported that coaching had a subtle effect on stress. Some said that they became more “mindful” and “more efficient and effective”, others said that coaching was “for preventing stress.”

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Ro et al. (2010) studied the relationships between coping, job stress and burnout after a counselling intervention for help-seeking physicians. They found that there is a sequential relationship indicating that the counselling intervention leads to a reduction in emotion focused coping and in job stress, which resulted in a reduction of emotional exhaustion. The effects of the counselling intervention were still maintained after three years. Ro et al. (2010) mention in their article that emotional exhaustion is often referred to as the primary dimension of burnout, which is in line with the definition of burnout by Maslach, Jackson, and Leiter (1997).

Table 3 Proposed mechanisms to enhance well-being and reduce burnout

Author Intervention Aim of the intervention Proposed mechanisms

(Ro et al., 2010) Counselling intervention Direct: Enhance well-being Indirect: Reduce level of stress and burnout Reduction in:  emotion focused coping  job stress

(Schneider et al., 2013) Physician well-being coaching Reduction of emotional exhaustion and therefore reduction or prevention of burnout among physicians Boundary setting and prioritization  applying boundary setting as a form of self-care  acknowledging the difference between realistic and unrealistic expectations  awareness that physicians had a choice in how to distribute their time  better prioritize personal health and well-being  increased personal efficiency and confidence to “say no” Self-compassion and self-care  increased self-permission to invest time in taking care of themselves and increased self-compassion  building in new time for self-care and setting personal wellness goals. Increasing self-awareness: a range of strategies that helped to take back some control over life  decreasing self-imposed pressure  letting go of perfectionism and perceptions of judgment  assuming more realistic expectations of themselves.  gain greater control: being more intentional about “taking an extra breath” when stress levels built, being more “mindful and calm during the busy day,” and noticing when they were “tired, frazzled, or stressed  more mindful and/or observant

Mindfulness Although the literature search did not result in information regarding exercise and relaxation, it resulted in articles addressing mindfulness in relation to stress. Most likely because mindfulness was one of the keywords.

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Gu et al. (2015) researched how mindfulness-based interventions lead to an improvement in mental health and wellbeing. In a systematic review and meta-analysis of mediation studies they found that there is a consistent body of evidence showing that mindfulness-based interventions lead to changes in cognitive and emotional reactivity, mindfulness, repetitive negative thinking, which resulted in changes in mental health outcomes. This is displayed in Table 4. Cognitive and emotional reactivity denote how stress activates negative thinking and emotional patterns, which increase the risk of a depressed mood. Mindfullness refers to worrying, rumination and psychological flexibility. Repetitive negative thinking are repeated negative thoughts which are difecult to disangege from. Concluding, mindfulness-based interventions result in a change in cognitive and emotional reactivity, mindfulness, repetitive negative thinking, which leads to improvement in mental health and wellbeing.

Table 4 Proposed mindfulness mechanisms

Author Type of intervention Proposed mechanisms

(Gu et al., 2015) Mindfulness-based intervention • Cognitive and emotional reactivity • Mindfulness • Repetitive negative thinking

5.1.2 Aggregated results literature study First, it has to be noted that the search resulted in a very limited number of articles providing information regarding coaching, exercise and relaxation in relation to stress and burnout. Only three articles provided information on coaching and mindfulness mechanisms in relation to stress and burnout. It was found that coaching can support clients to get a critical insight in boundary setting and prioritization, increased self-compassion, self-care and self-awareness. It was also found that counselling leads to a reduction in emotion focused coping and in job stress. Therefore effective mechanisms within coaching or counselling found in literature are; insight in boundary setting and prioritization, increased self-compassion, self-care and self-awareness and reduction in emotion focused coping and in job stress. It was also found that mindfulness interventions improved mental health and wellbeing. Mechanisms within a mindfulness intervention are cognitive and emotional reactivity, mindfulness and repetitive negative thinking. A change in these mechanims is shown to lead to a change in mental health and wellbeing.

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5.2 Results qualitative research: semi-structured interviews with former clients and practitioners In this sub chapter first the results of the interviews with former clients are discussed, then the results of the interviews with the practitioners of Vitaal aan het werk are described, and last the aggregated results of the analyses of the interviews will be discussed. Analysis of the results showed that the vision on stress, health, lifestyle and burnout of former clients and practitioners was constantly present when they described how they experience and envision the intervention. Although vision was initially not one of focal points of this research, discussing it is expected to create a context in which the experiences and ideas could be understood. This can be seen as an introduction to the results of the sub questions. The paragraphs answering sub questions will be introduced by the sub research question. For clarity and consistency, in the remaining part of this thesis there will be referred to the ‘former clients’ as ‘clients’. 5.2.1. Results semi-structured interviews clients

Vision All clients agreed that a holistic approach, like Vitaal Leadership, is powerful. This is illustrated by the following quote: “A part of the change process is mentally, another part of the change process is physical and related to breathing”. Also, some clients found that a holistic approach is necessary for a proper intervention. There was also a consensus with regard to events or patterns from the past. The clients found that it is, or can be, supportive to clarify patterns from the past. However there was a difference in the extent in which this should be done. Most clients appreciated this in-depth approach, but not all clients felt comfortable returning to, and analysing, issues from the past. This will be elaborated on later. According to the vision of one of the clients “emotions provide guidance and tell you which way to go”. Another client said that when you are calm, you can establish good things and you will be provided with things you need.

Outcome of the intervention What effects did participants experience after participating in the intervention Vitaal Leiderschap by Vitaal aan het werk? The outcome of the intervention forms a wide range of effects that the clients appointed to the intervention. The outcomes are divided into self-awareness and insight, self-management and coping skills, self-esteem, clarity and acceptance, reduced stress and increased relaxation, emotion regulation, and sense of direction. These overarching terms, written in bold, were applicable for the majority of

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the clients. The specific examples and quotes mentioned in the descriptions of the overarching terms were often only mention by one individual client.

Self-awareness and insight. The clients reported increased self-awareness and insights. This was mentioned in relation to personal behaviour, attitude, work and environment. One of the clients described: “you become aware of the processes within yourself [...] concerning collaboration with colleagues and your energy”. Overall the clients became more aware of their personal strengths, skills, interests and talents. One of the clients described: “I noticed what my interests, qualities and competence are”. Another client mentioned that personal qualities seemed to have faded away over the years. While working, only a limited amount of skills were required. Consequently authentic qualities vanished to the background. Another item that was commonly mentioned is ‘insight in patterns from the past’. When the clients talked about patterns from the past they referred to behavioral or mental patterns that originate from childhood. Sometimes these patterns were a blind spot, but sometimes these patterns were already known. Insight in patterns from the past also related to the insight that the clients had a choice in how to behave and how to act in a certain situation. Some realized they were not a victim of the situation, but that they had influence on their own future. A rather complex component that the clients mentioned in relation to self-awareness and insight was ‘energy’. In general, before the intervention started the energy level of the clients was quite low. One clients explained “I had the feeling that my energy disappeared, while I did not even realise where it was going.” The client explained that the intervention gave an insight in where energy was going.

Self-management and coping skills. The clients mentioned that intervention created the opportunity to ‘learn’ and ‘experience’. The clients noted that they learned to take breaks, to feel personal limits and how to anticipate on those limits. The clients described that their ability to deal with stressful situations increased, and some also experienced more control over situations. The intervention helped one of the clients to deal with conflicts: “I still find conflicts challenging, but I know what to do now.” For some clients self-management also related to being able to make personal choices, since some found that they knew better what they preferred. In some interviews self-management involved a more integrated way of functioning, meaning that the clients were able to recognize personal preferences which supported them in making congruent decisions. Some of the clients also mentioned that they realized that they were not a victim of the situation, but that they had influence on their own future, which made them able to act more securely.

Self-esteem. One of the clients described that the intervention resulted in more self-esteem. The increased self-esteem made it easier to be clear to others and supported boundary setting in social situations: “you are capable of standing firm on your own two feet.” 31

Clarity and acceptance. Clarity and acceptance mainly related to the past and patterns originating from the past. It was mentioned that the intervention resulted in a different attitude towards past, and some of the clients noted that they were able to understand and accept the past. One of the clients mentioned that the interventions changed the attitude towards parents.

Reduced stress and increased relaxation. In general the clients mentioned reduced stress and increased relaxation. It was noted that especially the relaxation sessions enabled the clients to experience relaxation of mind and body, including muscles. Some mentioned that they got more in touch with their body and in this way their energy level felt ‘recharged’. The following examples about reduced stress and increased relaxation were mentioned: “ I have less worries”, “less tired”, “more energy”, “calmer and more dynamic” and “physical less tired, less tense, less emotional, improved sleep and more relaxed during daytime.” Also a client mentioned to be more in balance and described to be “more clear, aware and alert.” Moreover a client said to experience an improvement in dealing with stress, which was related to reduced stress and selfmanagement.

Emotion regulation. The intervention helped the clients to open up for personal emotions, to recognise feelings and emotions and to regulate their emotions and/or to adept the way they coped with the emotion. This is demonstrated by the following example: “I can recognize my emotions, when necessary I can redirect my emotion and I know how to deal with my emotions.” Also one of the clients mentioned to be emotionally happier and another client felt emotionally more balanced. Another client explained that the intervention was supporting in recognizing and dealing with emotions, instead of hiding them.

Sense of direction. All clients mentioned an outcome in relation to clarity concerning future direction. Some experienced clarity in relation to work, clarity concerning personality and clarity about which direction to take in the future. Others pointed out that they found clearer focus points during the intervention: “possibilities in relation to passions and competences in the future were clarified”. Although the intervention increased clarity concerning future direction, one of the clients missed some direct guidelines. But it was also said that this could be elaborated on independently in the future.

Process What are effective mechanisms in the intervention Vitaal Leiderschap by Vitaal aan het werk according to the former clients of Vitaal aan het werk? Although the clients did not explicitly elaborate on the process and structure of the intervention, some of the clients mentioned the structure implicitly. 32

From awareness and insight towards a change in self-management and coping. As mentioned before, the clients noted that they were made aware of mental and/or behavioural patterns. Some of the clients said that patterns from the past related to the insight to have a choice in how to behave and how to act in a certain situation. One of the clients described that the intervention was enabling to get an insight in the patterns in the first place, and in the second place it was enabling to learn to let go of pathogenic patterns that could be obstructive for personal growth. Another client illustrated this by saying that he had learned in his upbringing that it is important to care for others, and to put in the first place. This pattern was still present in his work, where he cared more for others than for himself. He explained that when patterns from the past become clear, you have an option to change them. Although, he pointed out that it is quite a challenge to change these patterns, but he found it valuable to have in insight in this pattern. Thus, some of the clients noted an interactional process between raising awareness and insight, and change in self-management an coping.

Experiencing. Some clients mentioned that the intervention was quite practical. One client said that “Although solutions are discussed, mainly they are practiced [...] this fosters a translation towards different behaviour.“ Therefore, learning and change could be enhanced through experience.

Emotion regulation. It was also noted that the topic emotions was present during the whole process. One of the clients even said: “the whole process is actually an emotion, also the physical part”. Another client described: “Actually through some kind of physical entrance you were often working on emotional things. [...] I experienced this as pleasant and very informative.”

Intensity. From analysis of all interviews it can be concluded that the intervention process was experienced intense, and often also as confrontational. This is illustrated by the following example: “What I experienced as being confrontational is that it is painful to see how certain patterns arise. Or how imbedded it is and how difficult it is to let it go, that is confrontational. However, the good side from a confrontation is that it can also be a great relief to let go, when that is possible. “ Nevertheless, it must be noted that all clients experienced the intensity and confrontation at a different level. Not all clients found an in-depth confrontation needed: “Sometimes I was like, this has been an intense event in my life, let’s not go there. I've found my way to deal with it.” Therefore in-depth confrontations could not only be seen as a positive aspect of the intervention. Some clients wondered where the line is between coaching and therapy, and they noted that they experienced the intervention as therapy.

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Additional practical issues Combination intervention and therapy. Some of the clients mentioned that it is difficult or impossible to combine the intervention session with work. They experienced the intervention literally but mainly mentally as time-consuming. It was appointed that the sessions were often intense and therefore tiring. Also, additional exercises at home added to the intensity of the experience. Some clients questioned whether it was good to focus on the intervention only, and quit working for a while. The participant who did stop working mentioned that they found the transition back to work challenging. Some mentioned that the connection to work was missing and suggested that, when possible, it could be useful to continue working and participate in the intervention at the same time. When work and intervention would be combined it could be discussed in the sessions how clients could change and adjust things at work. However it was also said that this could decrease the intensity and therefore the and the strength of the intervention.

Coaching versus therapy. As mentioned before some clients wondered where the line is between coaching and therapy, since some experienced the intervention as therapy. As a result, one of the clients experienced some ambivalence towards the employer. This client mentioned that the intervention was therapeutic, especially by looking into family history and issues, an in-depth process is initiated. The client described: “ [...] I am grateful, but I found it strange that my employer funded this. Because this is just... such an intensive program. Which is not paid by my health insurer, but by my employer. And I do not think we are in a business sector that usually pays for this.” Hence, the therapeutic approach caused some ambivalence towards the employer regarding funding. It was also said that it needed to be the right timing, and clients needed to be open in order for this intervention to have a positive effect. It seemed like some clients wanted to point out that this intervention it is not suitable for every individual at every moment in time.

Coaching room. One client mention that the room where the coaching took place was not appropriate to fully express yourself, because the room was too noisy.

Practitioners. Though the sessions were not always experienced as being mentally or physically comfortable, the clients had a coherent positive view on the team of practitioners. The team was described as begin “very involved”, “professionals in their own area of expertise” and “beautiful group of honest people.” The clients had the impression that all practitioners were updated regularly on the process of the client: “so what you do in one session is continued in another session, without overlapping each other.” A client mentioned the feeling of safety, and another client noted the feeling of being taken seriously. It was also said that the aims were clear and that informative explanations were given if something was unclear. One of the clients also found that including

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multiple practitioners in an intervention increased chance of success, since everyone has his own area of expertise. This contributed to the confidence in the success of the intervention.

Sustainability. Although the sustainability of the effects from the intervention was not part of the research, a client noted that internal processes that were fuelled during the intervention continued, also after finishing the intervention. Other clients mentioned that the effects of the intervention seem to fade easily, but awareness of the 'dangers' of stress was enduring. It was said that personal discipline is important an important asset for sustainability of the effects. Some of the clients mentioned that they think it is up to them self to remain balanced in the long term. Since internal processes can continue while the intervention is finished, aftercare is essential according to one of the clients. It was mentioned that this was missing, which resulted in feelings of abandonment. 5.2.2. Results semi-structured interviews practitioners Following are the results of the analysis of the semi-structured interviews with the practitioners. The structure of the paragraphs are similar to the pervious subchapter.

Vision Holistic. All practitioners of Vitaal aan het werk have a holistic view on health, in which they value body and mind as equally important to sustain and improve health, as the following example demonstrates: “being healthy is a combination of an exchange in feeling physically and mentally well. It is the experience of feeling vital”. Therefore, the practitioners also had a strong preference for a holistic approach towards ill health, stress and burnout.

Balanced lifestyle. In the interviews the practitioners speak about a balance in effort and relaxation. It was mentioned that when people start to work more, often stress increases, then exercise and relaxation are needed as a counterbalance. Emotionally open. Some practitioners mentioned the importance of being ‘open’, referring to being open for personal emotions, for others and being open for possible change. It was described that through opening up energy can flow. One of the practitioners referred to being open to emotions as the following: “Usually people do not want to feel their emotions, they do not want to experience their vulnerability, anxieties, grief and sadness. But the greatest gift you can give yourself is to allow and accept those feelings.” Some practitioners mentioned the importance of a clear mind. They noted that a clear mind supports people to decide which way to go in life and to live a happy and passionate life.

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Patterns from the past. The practitioners devoted considerable attention to patterns from the past. The practitioners all share the believe that it is supportive for clients to get an insight in their patterns. These patterns are not only seen as constructs of mind, but some practitioners also find that these patterns and convictions are in a way stuck in the body. One of the practitioners described that therefore physical activity is needed.

Fundamental change. The analysis show that the practitioners share the opinion that a burnout intervention needs to result in a fundamental change within the participant. One of the practitioners stated: “after a burnout it is needed to take another direction in life.” In order to induce this change it was said that clients need to go to “the essence and the centre of the persons issues.” Other practitioners noted that the clients need to get out of their comfort zone in order to change the current situation.

Outcome of the intervention “What are the observed and expected effects of the intervention Vitaal Leiderschap by Vitaal aan het werk according to the practitioners of Vitaal aan het werk?” Self-awareness and insight. Some practitioners mentioned an increase in the self-awareness as an outcome of the intervention. Self-awareness and insight entails emotional awareness, physical Practitioners awareness and insight in personal patterns desires, needs, abilities, competences and behaviour. The practitioners extensively mentioned that the clients got insight in patterns resulting from the past. One of the practitioners described it as the following: “We look at your place in your family, and often you see that the patterns you currently have originate from the family situation in which you were raised”. An insight in patterns from the past was also linked to blind spots. These blind spots were described as unconscious issues, which were obstructing personal growth or happiness. Some practitioners mentioned that the clients got an insight in feelings of relaxation and tension. One of the practitioners said that clients were made aware that not only external factors cause stress, but also internal factors.

Self-management and coping skills. Self-management and coping skills were related to an increased ability to make personal and authentic choices, to deal with stress and to an increase in adaptive coping skills. Some practitioners mentioned that the clients were able to observe their thoughts, without identifying with those thoughts. In that way the clients were less bothered by preparative negative thoughts. Also one of the practitioners described how some clients felt with respect to their new skills: “[...] the feeling that I do matter, and that I can choose for myself , I can say no, I can indicate borders, I may approach, and I am allowed to make contact.” 36

Self-esteem. Some practitioners mentioned a change in self-esteem. They said that some clients had an increased confidence. Some practitioners noted that especially the physical exercises increased selfesteem: “[...] what we do with the body is a good instrument to create self-esteem.”

Clarity and acceptance. The practitioners described that an increase of awareness enabled the clients to get clarity and to accept situations from the past.

Sense of direction. Some practitioners mentioned that they experienced that the intervention supported people to come closer to who they truly are, and what they want in life. Most practitioners said that clarity about where to go, and what to do in the future is a considerable outcome. One practitioners illustrated this by saying: “One of the most imported reasons for why people do not get what they want is because they do not know what they want.” After the intervention it was noted that the clients knew better what they wanted.

Energy and vitality. The practitioners noted that the intervention resulted in an increase in energy and vitality. They also mentioned an increase in physical activity and an increased endurance.

Hormones. Some of the practitioners said that hormone levels changed due to exercise. They referred to articles they read about a change in hormones, a decrease of toxins in the body and an increased cortisol level.

Process What are effective mechanisms in the intervention Vitaal Leiderschap by Vitaal aan het werk according to the practitioners of Vitaal aan het werk? Interaction between self-awareness and insight, and (physical) experience. An interaction between self-awareness and insight, and (physical) experience was seen as an important asset of the intervention. This is displayed in Table 5 (page 39). In the first column of the table is about willingness. The practitioners noted the clients need to be willing and open to fully participate in order to change something. One of the practitioners stated: “it is a precondition that people are willing to really take a look at themselves.” When the clients are willing to engage in the intervention, the next step is awareness and insight. The practitioners explained that clients needed to increase their awareness, for example about relaxation and tension. Subsequently they should also experience and feel relaxation and tension. In the sessions the clients practice this guided by exercises. Some practitioners explained that experiencing the transition from tension towards relaxation support the clients to apply techniques that they learn also in everyday life situations.

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Table 5 Structure of Vitaal leadership self-awareness and insight interacting with (physical) experience

Willingness →

Self-awareness and insight

↔

(Physical) experience

Awareness of relaxation in

→

Experience mental and physical relaxation and tension

tension Insight in personal behaviour and

→

Experience self-regulation in relation to behaviour and thoughts

thoughts Emotional awareness

→

(Physical) experience emotion regulation

Physical awareness

→

Experience physical change

Insight in stress reduction

→

Reduces stress through experiencing exercise

One of the practitioners illustrated this process with the following statement: “When a person does not know how to relax, he/she can have an idea about how to do it and just give it a try, but if you do not actually know how to relax , then practical information is useless”. One of the practitioners also mentioned how coaching, exercise and relaxation enhanced each other in the process: “In the coaching they find out where it comes from, and how patterns were created. There they become aware. In relaxation therapy they learn how their body reacts. And they see where they across their personal limits. The personal trainer teaches them to really feel and use their body and to feel physical strength.” Thus the practitioners emphasize the interaction between self-awareness and insight, and (physical) experience.

Learning curve. Some of the practitioners mentioned the learning curve as being part of the process. This is illustrated by the following example: “there is a learning curve, you start with unconscious incompetent behaviour, then you get conscious competent behaviour. This is where the intervention usually ends. But the final stage is unconscious competent behaviour. “ Therefore the learning curve encompasses the process from unconscious incompetent behaviour to unconscious competent behaviour.

Intensity. With regard to the intensity of the intervention, some of the practitioners mentioned that the intervention aims to go into depth. It was mentioned that the different fields of expertise reinforce each other, which adds to the intensity of the intervention. Also some said that this structure of the intervention, approximately twenty sessions in two months, makes the intervention intensive. This was seen as a strength of the intervention. In order to be able to

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make a change in the lives of the clients, confrontation and a certain level of intensity was said to be needed. 5.2.3 Aggregated results semi-structured interviews With regard to the results of the interviews there were many similarities in how clients and practitioners viewed the intervention, but there were also some differences. First the differences will be appointed, then the similarities will be discussed.

With regard to the results of the interviews there were three considerable differences in how clients and practitioners viewed the intervention. First, the clients mainly focused on increasing selfawareness, self-management and the outcome of the intervention, the practitioners put an emphasis on the structure of the intervention, which makes sense, regarding their positions as client and practitioner. Second, there was difference in the way the clients and practitioners described the structure of the process. The clients noted a process from awareness and insight towards a change in self-management and coping. The practitioners focused more on the role of (physical) experience, which supports and intensifies the transition from self-awareness and insight towards a change in self-management and coping. Last the clients mentioned additional practical issues, which were not appointed by the practitioners. The clients mentioned the combination intervention and therapy, coaching versus therapy, the coaching room and sustainability as factors that influence the intervention process.

Besides these differences, also a major overlap was found in how clients and practitioners viewed the intervention. These findings are combined in Figure 12.

Figure 12 Vitaal Leiderschap intervention process and outcome

There is a direct connection from awareness and insight to self-management and coping, and there is a connection through (physical) experience. This process leads to the following effects; self-awareness 39

and insight, self-management and coping skills, , self-esteem, clarity and acceptance, reduced stress and increased relaxation, emotion regulation, sense of direction and, energy and vitality. Underneath is a chronologic line displayed, starting with unconscious incompetent behaviour towards unconscious competent behaviour.

5.3 Aggregated results literature study and qualitative research: semistructured interviews From the point of view of the clients and practitioners, what are effective mechanisms in the burnout intervention Vitaal Leiderschap by Vitaal aan het werk and how does this relate to what is known in literature about effective mechanisms. It must be noted that in the analysis of the interviews no distinction is made between coaching, exercise and relaxation. This is researched as a complete intervention. The results of the literature study are separated into mediating mechanisms resulting from a coaching, counselling and a mindfulness intervention separately. Though the context of the interventions is very different an attempt is made to compare the results.

According to the point of view of clients and practitioners the burnout intervention Vitaal Leiderschap first raises (self)awareness and insight. By raising (self)awareness and insight, self-management and coping could be adjusted. This process from (self)awareness and insight towards a change in selfmanagement and coping, is supported by (physical)experience. The outcomes of the intervention are self-awareness and insight, self-management and coping skills, self-esteem, clarity and acceptance, reduced stress and increased relaxation, emotion regulation, sense of direction and, energy and vitality. Analysis of literature shows that effective mechanism within coaching or counselling are; insight in boundary setting and prioritization, increased self-compassion, self-care and self-awareness and reduction in emotion focused coping and in job stress. Mechanisms within a mindfulness intervention are cognitive and emotional reactivity, mindfulness and repetitive negative thinking.

The results from the literature study show an improvement in insight in boundary setting and prioritization after the coaching intervention. This is similar to concepts self-management and coping resulting from the interviews. In both studies it was mentioned that clients experienced an increased confidence and increased relaxation. Literature also mentioned that clients got an insight in boundary setting and prioritization. This relates to concepts self-management and sense of direction, which were raised in the interviews. Also reparative negative thinking and a greater control over life is covered by the term self-management.

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Literature noted mindfulness and stress reduction as effective mediating mechanisms, which is similar to the concepts reduced stress and increased relaxation named in the interviews.

Concluding, the intervention Vitaal Leiderschap put emphasises on the process, in which (self)awareness and insight are raised in order to contribute to a change in self-management and coping. This process is supported by (physical)experience. In the literature study this process was not appointed. However the concepts self-awareness, insight and coping were mentioned.

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6. Discussion 6.1 Theoretical discussion Figure 13 displays the aggregated results of mechanisms in burnout interventions appointed by this study. On the left side is the box ‘burnout’. A person with a burnout can decide to participate in a burnout intervention, which is denoted in the middle box. This study found that there is a mediating process within the burnout intervention. This is the process from (self)awareness and insight to a change in self-management and coping, supported by (physical)activity. This process is supported by (physical)experience. Besides this process there are also ‘other influential factors’ that played a role in the burnout intervention. These factors are the intensity of the intervention, dedication of practitioners and vision of clients and practitioners. Intensity of the intervention was related to the in-depth approach of the intervention. The dedication of the practitioners was a factor that also added to the effect of the intervention, since the clients trusted the practitioners within their area of expertise. Vision of clients and practitioners also played a role in the interventions process. Both clients and practitioners hold a holistic vision, which allowed to address professional and private life, mind and body and the use coaching, exercise and relaxation techniques in the intervention.

Figure 13 Aggregated results mechanisms in burnout interventions

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In the right box the outcome of the intervention Vitaal Leiderschap is described. This study found the following outcomes: (self)awareness and insight, self-management and coping skill, self-esteem, clarity and acceptance, reduced stress and increased relaxation, emotion regulation, sense of direction and energy and vitality.

Looking back at the first part of the background at the definition of burnout, Maslach et al. (1997) described burnout as a syndrome of “emotional exhaustion, depersonalisation and reduction of personal accomplishment.” Vitaal Leiderschap pays attention to emotional exhaustion by relaxation exercises and by appointing emotional distress. The intervention also appoints depersonalisation, by the personal focus and by looking at patterns from the past. However, reduced personal accomplishment is not directly considered. This could be related to the personal orientated focus of the intervention. Also, looking at models describing burnout, all models note a connection between the employee, work and stress (Dewe et al., 2012; Dijk et al., 1990; Schaufeli & Bakker, 2004; Siegrist, 1996). These models indicate that stress is the result of personal and job characteristics, in which stress is seen as a result from disturbance in the interaction process between resources, efforts, characteristics versus demands, rewards, capacity. Also in the perspective of these burnout models it is noticed that the Vitaal Leiderschap intervention rather focusses on personal characteristics than on job characteristics. The model of the quality of working life, integrating the dominant theories of occupational stress by Kenny and McIntyre (2005), at page 12, displays how theories of occupational stress include aspects relation to the individual as well to the working environment. For example, coping repertoire and innate characteristics are present as well as organizational characteristics and quality of management. Looking at all these different aspects from the model of the quality of working life, and relating this to the Vitaal Leiderschap intervention it can be noted that the Vitaal Leiderschap intervention is mainly focused at the level of the individual. Moreover, relating the intervention Vitaal Leiderschap from Vitaal aan het werk to literature on burnout it is evident that Vitaal Leiderschap has a personal-orientated focus, while literature emphasises also on environmental characteristics. It can be questioned whether an inclusion of environmental aspects can improve the effectiveness of the intervention.

Processes of change As noted the main outcome denotes the process from (self)awareness and insight towards a change in self-management and coping. While studying effective mechanisms in burnout interventions, initially processes of change were not considered as a main aspect that would give insight in effectiveness of burnout interventions, rather there was a focus on individual aspects contributing to a change in experienced level of stress and burnout. However, after analysis of the interviews it occurred that processes of change were very informative in researching the effectiveness of burnout interventions. 43

Therefore, on the one hand it is unfortunate that this study did not look directly at processes of change, but on the other hand this study was needed to find out that process of change can be instructive while researching burnout interventions.

To show the usefulness of processes of changes, following are two studies that researched processes of change in relation to burnout. Also, a comparison is made with the outcome of these studies and the outcome of the current study.

Fjellman-Wiklund, Stenlund, Steinholtz, and Ahlgren (2010) studied patients' experiences during a burnout intervention containing cognitively-oriented behavioural rehabilitation and Qigong. Qigong is an holistic Chinese tradition to maintain improve physical and mental health. They found that patients learned to ‘take charge’, which denotes the beneficial process that supported the clients to increase control over their lives after a burnout. They also described that the following terms were mentioned by the patients as beneficial for the process of recovery: good encounters, affirmation, group cohesiveness, get to know myself (e.g. self-esteem, self-confidence and balancing between energy and relaxation), how can I be the one I want to be? (e.g. cognitive strategies, body and mind awareness and physical activity) and choice of track. Relating these outcomes to the intervention Vitaal Leiderschap there are some communalities, such as self-esteem, self-confidence, awareness of body and mind and physical activity. Also the process of taking control over their own life was mentioned by clients of the Vitaal Leiderschap intervention. Although there is a difference in the terminology and the sequence of the process, the experience of clients in both interventions seem to have a major overlap.

A study by Salminen, Mäkikangas, Hätinen, Kinnunen, and Pekkonen (2015) found that a multidisciplinary burnout rehabilitation intervention showed to be beneficial for the well-being of the clients. The results showed: “one overarching theme: my well-being in my own hands, and 4 categories: support, awareness, approval and regained joy. The accumulation of support, awareness and approval led to a revival of joy in life and greater perceived control over one’s well-being” (Salminen et al., 2015). Especially with regard to awareness and approval this intervention seem to have a major overlap with Vitaal Leiderschap intervention. Salminen et al. (2015) describe awareness as “increased knowledge and awareness of burnout and enhanced sensitivity towards one’s body and mind” and approval as “self-approval and self-mercy and recognition of one’s own needs and limits.” They explained that awareness was followed by approval. This process has similarities to the process awareness and insight to self-management and coping of Vitaal Leiderschap.

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Concluding, the studies by Fjellman-Wiklund et al. (2010) and Salminen et al. (2015) show to be instructive while researching effectiveness of burnout interventions. It is recommended to take processes of change into account in future research, this will be elaborated on in chapter 6.5 on future research (page 50).

6.2 Methodological discussion Since no known studies have investigated effective mechanisms in a holistic burnout intervention, the main strength of this study is the innovative character, by addressing this gap in literature. Although some studies addressed mechanisms in burnout interventions, none of them included exercise and relaxation as part of the intervention. The results can contribute to knowledge on burnout interventions, which can then be used to improve burnout interventions. Another strength is the information retrieved from the interviews with the clients and the practitioners. Through these personal interviews this study gave an exclusive insight in the experience and ideas of the clients and practitioners. A limitation of this explorative study was the limited amount of articles that were found in the literate search. Although an additional search was done by screening the references of the selected articles, only three articles could contribute to answering the research question. The studies that were included lacked active control conditions and might have been subject to the impact of publication bias (Turner, 2013). However, the studies that were included were published in peer-reviewed journals and were approved on their quality based on the assessment developed by Bowling and Ebrahim (2005).

Another limitation within the literature study were the different terms, such as coaching, counselling and therapy, used when speaking about a burnout intervention. In the literature study all of these terms were included. However, the differences between coaching, counselling or therapy was not appointed. Moreover, every type of coaching, counselling or therapy can be different, regarding the techniques that are used, the vision of the practitioner and the relationship between client and practitioner. Also, the specific term ‘coaching’ is a term covering a large range of methods, among others gestalt approach coaching, narrative coaching, developmental coaching and transpersonal coaching (Cox, Bachkirova, & Clutterbuck, 2014). Therefore, different types of coaching have different methods. It is a limitation that this study was not specific about the differences between the terms and types of couching, hence results cannot be generalized.

Although this study was an explorative study and generalizability was not an aim, this study might be affected by selection bias. One of the clients that was asked to participate, did not accept the invitation, and did not want to participate in the research. It is possible that this client had other experiences with the intervention, then the clients that accepted the invitation. Additional, the sample size was limited.

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Therefore, the results of the analysis of the interviews can only be attributed to the experience of a limited amount of interviewees.

There are many variables that could influence how the intervention was experienced, such as the type of burnout, personality characteristics, perceived job stress, coping strategies, demographic characteristics, working environment and working hours. This study did not take all these potentially influential variables into account, which is a limitation. However, this study was an explorative study in a field where there is little research done on describing effective mechanism in burnout interventions. Therefore, considering the explorative character of this study, this study can be seen as a starting step that was needed for more specific research in the future.

In this research it was found that clients described the practitioners as being dedicated and they trusted the practitioners in their area of expertise. Therefore an undefined amount of the effectiveness of the intervention could be a matter of trust and confidence in the practitioners. This study did not specifically address the effect that can be appointed to the relationship with the practitioners. Although, looking at literature on clients-therapist relationship, the impact of the this relationship should not be underestimated (Kivlighan Jr, Gelso, Ain, Hummel, & Markin, 2015; Lambert & Barley, 2001). These studies found that relationship between client and therapist have an influence on the outcome of therapeutic treatment (Kivlighan Jr et al., 2015; Lambert & Barley, 2001) . Hence, part of the effectiveness might be assigned to the client-practitioner relationship.

6.3 Discussion intervention Vitaal Leiderschap The intervention Vitaal Leiderschap includes coaching, exercise and relaxation sessions. As shown in the methodology no studies were found on exercise and relaxation in relation to stress and burnout interventions. Therefore, it can be questioned whether the exercise and relaxation are effective in treating burnout. However, the literature search did not generate results that provided an insight in exercise and relaxation in relation to stress and burnout interventions, the search led to information that showed effectiveness of interventions that included exercise and relaxation. Some articles also provided practical information that might be useful for providers of burnout intervention programs. Both are discussed here.

As noted, the search did not generate results that provide an insight in exercise and the relation to stress and burnout interventions. However, the positive effects from exercise on mental health do not have to be questioned (Lovallo, 2015). Gerber et al. (2015) found that people who were physically active at a moderate-to-vigorous level, experienced viewer symptoms of burnout. Schoenfeld, Rada, Pieruzzini, Hsueh, and Gould (2013) found that physical exercise restructures the brain. This

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restructuring enables the brain to respond better to stress and therefore stress has less influence on the functioning of the brain. Therefore it can be concluded that physical activity had a positive impact on stress and burnout. Moreover, Stults-Kolehmainen and Sinha (2014) did a literature study on the effects of stress on physical activity and exercise. They found that a majority of the literature suggests that experiencing stress impairs the effort to be physically active. Thus when people experience stress it might be helpful if physical activity is encouraged and supervised. This is in line with what is done in the Vitaal Leiderschap intervention.

Also the search on relaxation did not generated results that provide an insight in relaxation in relation to stress and burnout interventions. However, the results from the search showed two studies that were done using relaxation and breathing exercises among individuals with posttraumatic stress disorder (PTSD). A study by Blanaru et al. (2012) found that music relaxation and muscle relaxation techniques significantly increased the objective and subjective sleep efficiency in people with PTSD. Also feeling of depression significantly reduced. A research by Kim et al. (2013) showed that mindfulness-based stretching and deep breathing exercises reduce the prevalence of PTSD symptoms. Pal, Ganesh, Karthik, Nanda, and Pal (2014) researched the effects of short-term relaxation therapy on indices of heart rate variability and blood pressure in young adults. They found that relaxation therapy (shavasana with a soothing background music) reduced the heart rate and blood pressure. Which indicates that short-term relaxation therapy reduces stress. Concluding, relaxation interventions seem to have positive effects on sleep, PTSD symptoms, heart rate and blood pressure.

Additionally an article was found researching sick leave after a counselling intervention. Ro, Tyssen, Gude, and Aasland (2012) researched sick leave after a counselling intervention among Norwegian doctors. They found that sickness leave after a burnout intervention had a positive effect on emotional exhaustion at work 3 years later. “ Early return to work, by minimising full-time sick leave, increasing use of part-time sick leave, and going to work despite symptoms of illness (presenteeism), are often advocated to reduce the risk for negative health and economic consequences of mental health problems” (Ro et al., 2012, p. 283). Research also shows the beneficial effects of mindfulness based stress reduction (MBSR) interventions. MBSR is significantly associated with reduction in stress-related psychological distress (Chiesa & Serretti, 2009; Grossman, Niemann, Schmidt, & Walach, 2004; Martın-Asuero & GarcıaBanda, 2010) In summary, it can be concluded that interventions containing coaching, exercise, relaxation and mindfulness techniques showed to have positive effects on health. Although there are limited studies

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providing an insight in exercise and relaxation in relation to stress and burnout interventions, exercise and relaxation are potentially effective in stress reduction.

6.4 Recommendations for practice Following are recommendation for practice. Since this research specifically investigated the intervention Vitaal Leiderschap by Vitaal aan het werk the recommendations primary relate to Vitaal aan het werk.

For the practitioners it could be helpful to be aware of personal vision on stress, health, lifestyle and burnout, since this seems to influence the approach towards burnout. Vision influences the content of the sessions. It could be constructive to take into account the vision of the clients. When a client would have a different vision on stress, health, lifestyle and burnout it might lead to confusion or discord. In line with the vision of the practitioners the approach of the intervention was experienced as intense and confrontational. It is recommended to consider carefully, for each individual client, whether he or she is willing to engage in this confrontation.

Since the intervention seems to have a major impact on the life of the client, it is recommended to pay additional attention to after care. Processes initiated during the intervention may have a long-term impact. Some clients might need additional support, also after the intervention. There are three different types of burnout: frenetic, underchallenged and worn-out (Montero-Marín et al., 2009). This is also displayed in Figure 1 (page 3). To enhance further refinement of burnout interventions, it is recommended to take the different types of burnout and there features into account in the intervention sessions. Hence, burnout interventions can be more directed to individual situations and personal needs.

Some of the former clients suggested that it could be supportive to participate in the intervention while synchronously continue working. The advantages are that situations which occurred during work can serve as input for the session, and a challenging transition back to work can be avoided. However it is unclear how this will change the effectiveness of the intervention. When clients would continue their work and combine this with attending the sessions, a change in intensity could be the result. Therefore, it can be questioned what the impact of the combination of work and the intervention is on the effectiveness of the intervention. Moreover, some clients already stopped working when they started the intervention. It could be considered to recommend clients to go to work as well, when possible. It could also be considered to focus on the intervention only, during the first weeks. Then, after some weeks, the clients could combine the intervention with work.

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The intervention Vitaal Leiderschap has a personal- orientated focus. The intervention is mainly focused on the personal context and there is limited attention to the working environment of the clients. In literature burnout is also linked to the individual, however considerable attention is paid to the work environment (Kaschka et al., 2011; Kenny & McIntyre, 2005). The underlying idea of the practitioners of Vitaal aan het werk is that burnout is caused by patterns within clients, which can be dealt with in an intense intervention. One the one hand the intensity and personal-orientated focus are a strength, on the other hand it can be questioned whether role of the (working)environment is sufficient appointed in this burnout intervention. Therefore, it is recommended to consider if an increased attention to the work environment could enhance the quality of the intervention. It is also suggested to (re)consider whether the content of the intervention Vitaal Leiderschap is in line the aim of the intervention: sustainable employability.

With regard to the intensity of the intervention and the personal-orientated focus it was questioned whether the intervention could be considered as coaching. Especially with respect to coaching sessions it was questioned whether the sessions should be categorized as coaching or as therapy. This matter can also linked to financial aspect of the intervention. Usually the intervention in is financed by the employer. Therefore the personal-orientated focus could lead to ambiguity concerning the openness about the state of affairs between client and employer. It is recommended to be aware that this might cause friction and to be transparent towards clients and their employers.

6.5 Further research As noted in the theoretical background, the concept burnout started as a social problem and the first phase in which burnout was conceptualized had a non-empirical character. It seems that the same holds for burnout interventions. Interventions often have a non-empirical character. Now a more empirical phase has arrived (Schaufeli et al., 2009). In this phase not only the effectiveness of the interventions needs to be researched, but it would also be useful to research how the interventions facilitate change. When it is known how changes are facilitated in burnout interventions, interventions can be improved. Further research is needed to investigate in mediating mechanisms within different types of interventions. When these mechanisms are known, interventions could be more focused on these specific mechanisms, which enables the intervention to be directed more specifically towards the issues of the clients.

The outcome of this study indicated a process from (self)awareness and insight towards a change in self-management and coping. In the discussion an attempt is made to find a link between this process and change theory. Further research investigating burnout interventions could take processes of change as a focal point. It is recommended to research these processes of burnout recovery and to investigate 49

what can be learned from these models to improve burnout interventions. It is also recommended to investigate psychological models of change in general and relate these models to burnout interventions. Potentially relevant information can be found by researching theories of change and connect these theories to burnout interventions.

This study is an explorative study in which only a limited group of participants was interviewed. Further research could use the outcome of this study, and question other clients who participated in a similar intervention to research whether they have similar experiences. It is recommended to measure the long-term effect of the intervention.

The differences between coaching, counselling or therapy was not appointed in this study. In following studies it is recommended to define these terms, as these different terms probably mark a different accent within the intervention.

It is also recommend to research grey literature while studying burnout interventions. Although, reliability must be considered, grey literature seems to contain a great amount of information.

This study researched an intervention focused on the individual level. It would be useful for further studies to investigate interventions focused on induvial level and on environmental level, and compare the processes and outcomes. In this way the ideal balance in focus on individual and environment can be determined.

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7. Conclusions The exploration of mechanisms of change within burnout interventions is a complex yet crucial subject to investigate in order to improve the delivery, quality and effectiveness of burnout interventions. This study researched practice to create evidence based practice, and at the same time literature was studied to investigate how practice related to existing evidence.

The results show that the effective mechanism in the burnout intervention Vitaal Leiderschap is the process from (self)awareness and insight towards a change in self-management and coping, supported by (physical)experience. The studies that were found on effective mechanises in burnout interventions also mention self-awareness, insight and coping strategies.

The objective of this study was twofold. First, this study aimed to get an insight in effective mechanisms in the burnout intervention Vitaal Leiderschap by Vitaal aan het werk , according to clients and practitioners of Vitaal aan het werk: The effective mechanisms according to the clients and practitioners mainly related to the process of the Vitaal Leiderschap intervention. The clients and practitioners noted that (self)awareness and insight were raised, subsequently this enabled a change in self-management and coping. This process was enhanced by (physical)experience. Hence the effective mechanism is the process from (self)awareness and insight towards a change in self-management and coping, supported by (physical)experience. In addition to this process also the ‘intensity of the intervention’, ‘dedication of practitioners’ and ‘vision of clients and practitioners’ were found to have an influence on the effectiveness of the intervention. Second this study aimed to understand how the intervention Vitaal Leiderschap by Vitaal aan het werk relates to what is known in literature about effective mechanisms in burnout interventions: The intervention Vitaal Leiderschap had some similarities with the articles that were found on mediating factors in burnout interventions. The mediating factors self-awareness, insight and coping were appointed by clients and practitioners and were also mentioned in literature. However, the number of studies available on effective mechanisms in burnout interventions was very limited. Therefore, no strong conclusions can be drawn from the literature study.

It was noticed that the intervention Vitaal Leiderschap had a personal-orientated focus. Literature on burnout also refers to environmental factors as a major feature in burnout (interventions). Therefore, it is suggested to consider the work environment carefully in research, but also in practice. Also, it is recommended for further development of effective interventions to do comparison studies on

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interventions focused on an individual or environment and to study processes of change within burnout interventions .

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Appendix A. Vitaal aan het werk Introduction Vitaal aan het werk Vitaal aan het werk is an organisation specialised in interventions with regard to work related issues. In this thesis the focal point is their individual Vitaal Leiderschap program. In this program employees with stress related problems, such as burnout and overwrought, are offered an integrated intervention program. This program includes alternating sessions with a coach, a personal trainer and a relaxation therapist. The intervention starts with an intake. First the personal situation of the client is determined. Then the program is adjusted to the particular circumstances of each client. The treatment is executed with intermediate feedback on the progress of the client and the program. Vitaal aan het werk describes that stress and burnout have an effect on different levels, the physical level, the emotional level and the mental level. At the physical level there can be complains such as headache, burden in viscera (stomach, intestines) and pain in shoulders, muscles and back. On the emotional level often an imbalance in emotions is noticed and on the mental level there can be issues such as worrying, sleep deprivation and loss of concentration. When a person experiences prolonged stress they often have blockades which reduce the flow of energy. This often results in an imbalance on the different levels. Coaching, exercise and relaxation are deployed to create a new balance and to support sustainable employability by dealing with stressors at the different levels. Usually a complete treatment includes six coaching sessions of two hours, two coaching sessions focusing on passions and talents of one and a half hour, five relaxation-therapy sessions of one hour and also five exercise sessions of one hour. Besides the sessions the clients are also working on exercises and assignments at home. This ‘homework’ can put emphasis on the previous session, but it can also be a preparation for the following session. The sessions are executed by practitioners specialised in coaching, exercise and relaxation. They debrief the development of the client regularly to enhance the supportive process.

Intervention: Vitaal Leiderschap There was not yet a full description about content the of the Vitaal Leiderschap intervention. Therefore this information is obtained through a pre-research. A coach, a personal trainer and a relaxation therapist from Vitaal aan het werk were asked about the content of the intervention Vitaal Leiderschap through a semi structured telephone interview. The following questions were guiding during the interview: -

What is your specific method and/or technique to treat burnout?

-

Is there a specific format for this part of the intervention?

-

What is the aim of this specific part of the treatment?

The information provided by the coach, personal trainer and relaxation therapist was written down and afterwards structured in a consistent manner. The descriptions were sent back to the particular practitioner and they provided feedback on description of their intervention. This feedback is incorporated, and what is presented here is a comprehensive overview of the content of the intervention Vitaal Leiderschap according to the practitioners of Vitaal aan het werk. Coaching The aim of the coaching session is to make the client aware of his/her specific patterns, coping strategies, convictions and behaviour so that the client is able to make conscious choices with regard to behaviour in the future. In the first session the coach and client get acquainted to each other and a genogram is made. A genogram is a kind of family tree, in which the places of family members are depicted. The genogram forms the premise for the upcoming sessions, in which relationships, patterns and peculiarities within the family are discussed with the client. Within the coaching sessions there is attention for the personal issues of the client. One of the techniques that is used is the system theory. By using the system theory unconscious coping strategies, can be identified. When people experience stress they often use old coping strategies, that were effective in the past. These strategies result from the system of origin, usually the family situation. Coping strategies are usually applied automatically and unconsciously. When a person is not aware of this automatic behaviour it is also not a choice, but when people are more conscious about their behaviour, they have a choice. They can choose to try a different coping strategy and show a different type of behaviour. Especially when the behaviour is destructive it is useful to get an insight in the behaviour to be able to change it. When applicable, the design of a family constellation (mapping of family positions) is used to identify how the past influences the present. Hence emphasis is put on awareness of mental and emotional issues and on applying new coping strategies. Passion test and talent analysis The passion test and/or the talent analysis are often part of the Vitaal Leiderschap intervention. This are two or three session to aimed to identify a person’s passion and talents. The passion test is based on the book ‘The passion test’ by Attwood and Attwood (2007). A passion is seen as the something that is loved, that gives meaning and is important for a person. The passion test is a structured method by which the top five passions are identified. Limiting beliefs are addressed and it is discussed when to take action. The aim is to arrive at the heart of what a person is passionate about, which is seen as the key to a happy life. The talent analysis is based on the Talent Assignment Method by EHRM Vision in Utrecht. In the talent analysis an talent assessment is done with an online tool. This tool address a person’s talents in

the working environment. The result is a list with personal talents. By using this list it is discussed how the passions and talents fit together and how the talents can be applied to the passions. People will be more effective, successful and happy when talents are recognized and when passion is lived. Exercise The aim of the exercise sessions is to facilitate the transition towards balanced and health body and mind, in which the person experience embodiment of personal strengths. By offering exercises that confirm and/ or challenge personal characterises self-awareness and self-confidence will increase, and stress hormones will reduce. The first session is a consulting session. The issues of the client, lifestyle, diet and desires are discussed and an analyses on the sport background is made. Than the current mental and physical state and natural state of the client are identified through exercises. It is examined where the client is out of balance. For example when the client is stiff, focus of the intervention can be on increasing the flexibility or when a client has little power focus can be on increasing power. For each client some specific exercises are selected. These exercises form the basis of the training and return in the following sessions. In each session the level and types of exercises are extended. So there is a variation in exercises and the level of difficulty changes. In this way progress becomes visible. The ending point of one session is the starting point for the following session. When needed the lifestyle and diet of the client can be considered additionally. By also including lifestyle in the intervention the dis-balance can be addressed and the training can be directed more specific at the client needs and wishes. Relaxation The aim of the relaxation sessions is direct and long-term relaxation of body and mind, by teaching the client relaxation methods which can be applied in everyday life. When the body is relaxed the mind is relaxed. This is an continues interaction. Therefore, when the mind is relaxed the body will not feel stressed and vice versa. The relaxation therapy starts with an introduction. The effects from stress and burnout on the body are explained and breathing techniques and relaxation exercises are introduced. The following sessions are focused on physical, emotional and mental relaxation, by practising different types of breathing techniques and relaxation exercises . In these sessions the client practices with relaxation and contraction of separate body parts, with relaxation of the ‘emotional body’ guided by visualisations and learns observing one’s own thoughts. The clients also get a relaxation CD which is recorded by the relaxation therapist. Through relaxation people are more sensitive towards their emotions and feelings, which can help te reduce stress in body and mind.

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argument

major claim Author Text Periodical

C. Literature Survey Tally Matrix documentation A three-year cohort study of the relationships between coping, job stress and burnout after a counselling intervention for help-seeking physicians, by Karin E Isaksson Ro, Reidar Tyssen, Asle Hoffart, Harold Sexton, Olaf G Aasland and Tore Gude (2010). Assemblance collected data. 1. Key concept or descriptor “three-year follow-up study aimed to investigate the roles of coping strategies, job stress and personality traits in burnout reduction after a counselling intervention for distressed physicians. [...] A counselling intervention program offered to physicians at a Resource Centre for Health Personnel, Villa Sana in Norway, emphasized two main intervention areas. One was mapping and discussion of the physicians' current life situation, with an emphasis on job stress and its reduction - often job stress related to the work-home interface. The other was identifying and challenging the coping strategies being used by the physicians. [...] Follow-up of physicians who have participated in a counselling intervention showed that significantly reduced levels of emotional exhaustion, job stress, and emotion focused coping found at one-year, compared with baseline, were maintained at three-year follow-up.” 2. Citation or reference Not applicable 1. Main ideas Not applicable 2. Data quality Good, methodology is sound and assumptions are reasonable.

Organized information The study found that there is a sequential relationship that indicates that a counselling intervention leads to a reduction in emotion focused coping and in job stress, which resulted in a reduction of emotional exhaustion. As described in the background emotional exhaustion is one of the three dimensions of burnout (Maslach et al., 1997). In the article coping strategies are described as “ strategies used to reduce the possible harm of an event that is considered potentially dangerous to the person's psychological well-being, and they are usually grouped into (1) active, problem-focused and (2) emotion-focused or emotional ways of coping”. When the authors mention emotions focused coping they refer to unfavourable coping strategies

Analyses of patterns in the data The aim of the study was to research the roles of coping strategies, job stress and personality traits related to burnout reduction for physician who attended the counselling intervention. Therefore this study focused on the elements coping strategies, job stress and personality traits and the researches did not look for other factors in burnout reduction.

Physician Coaching to Enhance Well-being: A Qualitative Analysis of a Pilot Intervention by Suzanne Schneider, Karen Kingsolver and Jullia Rosdahl (2013) Assemblance collected data. 1. Key concept or descriptor

“The aim of this study is to evaluate the perceived impact of Physician Well-being Coaching on physician stress and resiliency, as implemented in a major medical center [...] The Physician Well-being Coaching model was adapted from Duke Integrative Medicine’s Integrative Health Coaching model, which draws on motivational interviewing and behavior change theories to support a process of self-discovery that builds internal motivation for behavior change [...] The Physician Well-being Coaching pilot program included physicians identified via talks on physician burnout and resilience given to several departments. [...] Physician Well-being Coaching helped participants increase resilience via skill and awareness development in the following three main areas: (1) boundary setting and prioritization, (2) selfcompassion and self-care, and (3) self-awareness. These insights often led to behavior changes and were perceived by physicians to have indirect but positive impact on patient care. [...] Devaluing selfcare while prioritizing the care of others may be a significant, but unnecessary, source of burnout. This study suggests that coaching can potentially help physicians alter this pattern.” 2. Citation or reference Not applicable 3. Main ideas Not applicable 4. Data quality Good, methodology is sound and assumptions are reasonable.

Organized information

Analyses of patterns in the data Coaching can be supportive for physicians to alter devaluation of self-care while prioritizing the care of others. The authors suggest that this could be a way to reduce prevalence of burnout in physicians. However it is still speculative if this coaching intervention actually has an effect on burnout. This explorative pilot study is tested on physician who were not specifically selected on the level of stress they experienced or on burnout. This is a relatively small pilot study, eleven participants were included. The results should be considered in this perspective.

How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies by Jenny Gu, Clara Strauss, Rod Bond and Kate Cavanagh (2015). Assemblance collected data. 1. Key concept or descriptor

“Given the extensive evidence base for the efficacy of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), researchers have started to explore the mechanisms underlying their therapeutic effects on psychological outcomes, using methods of mediation analysis. [...] The present study aimed to systematically review mediation studies in the literature on mindfulness-based interventions (MBIs), to identify potential psychological mechanisms underlying MBCT and MBSR's effects on psychological functioning and wellbeing, and evaluate the strength and consistency of evidence for each mechanism. [...] This paper's aims were threefold. First, it aimed to systematically review mediation studies in the literature on MBIs, in order to identify the mechanisms underlying MBCT and MBSR's effects on psychological functioning and wellbeing. Second, it aimed to evaluate and provide narrative summaries of the strength of evidence for each identified mechanism. Third, it aimed to conduct TSSEM analyses, to statistically synthesise evidence for mechanisms of the effects of MBIs on mental health outcomes which were supported by five or more mediation studies. [...] Most reviewed mediation studies have several key methodological shortcomings which preclude robust conclusions regarding mediation. However, they provide important groundwork on which future studies could build. “ 2. Citation or reference Not applicable

3. Main ideas Not applicable

4. Data quality Good, methodology is sound and assumptions are reasonable.

Organized information First this study showed the results from various studies focused on mindfulness-based interventions. Also the shortcomings of these studies are appointed, so the results need to be considered sensibly. The authors found that mindfulness-based interventions lead to changes in, cognitive and emotional reactivity, mindfulness, repetitive negative thinking

Analyses of patterns in the data According to study there is a consistent body of evidence that mindfulness-based interventions lead to changes in, cognitive and emotional reactivity, mindfulness, repetitive negative thinking, which then lead to changes in mental health outcomes. Although the research focusses on mindfulness-based stress reduction, an actual difference in the level of stress is not mentioned. Also burnout is not mentioned in this research.

D. Semi structured questionnaire Semi-structured questionnaire former clients Introduction information -

Introduction interviewee

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Explanation purpose of research

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Explanation about recording

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Singing informed consent

Questions: -

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You participated in the program Vital Leadership; 

How did you get in touch with the program?

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Did the program do something for you?

When you look back at the program, the coaching, exercise and relaxation; 

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How did you experience the coaching/ exercise / relaxation? 

How did you experience it?

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What were the results?

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Why was it (in)effective?

Often the program also contains a Passion test; 

Did you also do the Passion test? 

How did you experience it?

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What were the results?

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When you look back at the program as a whole;

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How or what did the program change you or your situation?

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What do you think contributed most to your process, coaching, exercises or relaxation?

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What was for the most important element in the program? 

Was the something unnecessary

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What do you think about the combination of coaching, exercises or relaxation?

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What change did your experience with regard to the burnout after participation in the Vitaal leadership intervention ? (change in work/ private life)

Semi-structured questionnaire practitioners Introduction information -

Introduction interviewee

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Explanation purpose of research

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Explanation about recording

Questions: -

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You provide the intervention Vital leadership; 

What do you think of this intervention?

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Why do you think it is effective?

If we look at the program, the coaching, exercise and relaxation; 

Can you explain of each element why you think it is effective?

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Is one element superior to another?

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Why do you think this specific combination of elements is effective for treating burnout?

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Why do you think the clients benefit from the intervention?

E. Informed consent Toestemmingsverklaring Onderzoek burn-out en werkstress interventies Beste deelnemer, U bent gevraagd om deel te nemen aan een onderzoek naar burn-out en werkstress interventies. Er is al veel bekend over burn-out en werkstress, maar met betrekking tot interventies is er nog veel te ontdekken. Vaak is wel bekend of behandelingen werkzaam zijn, maar het is niet bekend hoe het werkt en wat de werkzame aspecten zijn. Het doel van dit onderzoek is om inzichten te krijgen in de werkzame aspecten in een burn-out interventie. U wordt gevraagd deel te nemen aan een interview dat ongeveer een uur zal duren. Met uw toestemming wordt het interview opgenomen. Deze opname wordt gebruikt om het interview later uit te schrijven. Uw naam en/of andere informatie waardoor u te identificeren bent zal niet uitgeschreven worden. De informatie die u geeft tijdens het gehele onderzoek, wordt volledig anoniem verwerkt en alleen gebruikt voor dit onderzoek en bijbehorende publicaties. Aan het eind van het onderzoek worden de geluidsopnames gewist. Vitaal aan het werk heeft een student van Wageningen University gevraagd om onderzoek te doen naar de Vitaal Leiderschap interventie. Vitaal aan het werk zal alleen de verwerkte en geanonimiseerde gegevens kunnen inzien. Deelnamen aan dit onderzoek is vrijwillig. U mag op ieder moment beslissen om te stoppen of om een vraag niet te beantwoorden. Vragen stellen mag op elk moment voor, tijdens of na het onderzoek. __________________________________________________________________________________________

Ik, (naam) ______________________ heb alle informatie op deze pagina gelezen en heb de mogelijkheid gekregen om vragen te stellen. Ik begrijp het onderzoek en de rol die ik daarin speel.

Ik geef mijn toestemming om het interview op te nemen: Ja/Nee Ik geef mijn toestemming om anonieme citaten uit het interview op te nemen in het onderzoek: Ja/Nee

Datum:

Handtekening deelnemer:

Handtekening onderzoeker:

Dit document wordt twee maal ingevuld: een exemplaar is voor de deelnemer, het ander exemplaar voor de onderzoeker. Yvette Buist +31 6 30847481

[email protected]

F. Code tree: translated and unedited analysis Former clients Awareness and insights - You are put on hold to make you aware of processes within yourself - Awareness of o what happens to your energy o inner drive o signals coming from the body o personal strengths, skills, interests and talents o personal preferences o which choices to make o why things are difficult at work o why you exceed personal limits o personal behavior and attitude - Insight in o energy → how you use, lose and build up energy o past (understand and accept ) → discover blind spot → recognize patterns o pitfalls and fears o where patterns come from and how they are create o you have a choice → make personal choice o what you like in your work Learned and experienced - Getting in touch with body - Relaxation of muscles and mind - Leaned about tension and encouraged to relax - Rebuild energy → charge battery - Relaxing through physical exercises - Letting go of pathogenic patterns that can be obstructive for personal growth - Learn to take breaks - Learn to feel personal limits and how to anticipate on limits - Learn that physical exercises can be supportive for relaxation Solutions are discussed, but mainly they are practiced→ translation towards different behaviour - Alternative for behaviour is offered and directions are given to let go of issues Emotions / feelings - Open up for personal emotions - Giving attention to feelings and tension - Feel what is happening within the body - Expressing emotions (e.g. with boxing) - recognise feelings and emotions - Dealing with grief (outcome) Intensity (therapy VS coaching + combination job and intervention) - Experienced as it was therapy → caused ambivalence towards employer - Confronting → It has to be the right moment for you - Intense → difficult / impossible to combine with work - The transition back to work is challenging - Connection to work is missing→ it could be useful to keep on working and participate in the program at the same time, so it can be discussed how you change and adjust things at work - Some intense events of the past did not need to be dragged up

Outcome - You know better what you like→ make personal choices - You are able to be more awareness of yourself in relation to work and your environment - Understanding and accepting the past - Clarity about stagnation - Positive feeling - More energy - Less tension and less stress - Improvement in dealing with stress - More self-esteem - Understanding not to be responsible for feelings of others - Capable of standing firm on own two feet - Recognizing emotions → it is clear how you can deal with emotions - Different attitude towards parents and past - Calmer and more dynamic - Less rigid - More control over situations - Less worries - Less tired - More relaxed - Emotionally happier - Balance → more clear, aware and alert - For the employer: more motivated and productive employee

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Sense of direction Clearer about which direction to take and which direction not to take Clearer focus points→ clarity about what things are important for you so you can focus Clarity about what type of work suits your personality The direction you want to take in the future is more specific→ Although concrete tools were missing

Vision - When events from the past are clarified, you can change your view on the past - Holistic approach is good → Mind and body are one → therefore holistic approach necessary When you are calm, you can establish good things and you will be provided with things you need - Emotions provide guidance and tell you which way to go - Sports tell something about a person's mental state - It is good that the program is diverse - Change occurs not only in your mind, but also physically and includes breathing Practitioners - Very involved - Professionals in their own area - Including multiple therapists in intervention increases chance of success → everyone has his own area of expertise - Felt save - Taken seriously - The clarified the aims→ resulting in energy - Warm cooperation → warm bath of attention - Informative explanations if something was unclear - Beautiful group of honest people, who offered you tools to work with

Future and sustainability of effects of intervention - Effect intervention threatens to fade easily →but you are more aware of the 'dangers' - Personal discipline is important - Processes are continuing also after the finishing the intervention → feeling of abandonment when asked for additional support

Practitioners Awareness and insights ↔ - Learning what tension and relaxation is - Recognise passions - Awareness of o Personal behavior and thoughts o Patterns from the past o Strengths and pitfalls o Blind spot o Emotions o Personal physical movements -

Physical experience →Experience and feel tension and relaxation → Experience that types of behaviour are a choice → Letting go of emotions physically →Learn and experience how to change physical movements

Insights in o Personal desires, needs and abilities o Problems and origins of problems o Ways to reduce stress → reduce stress through exercises o Personal choices → person makes personal choices and is not a victim of the circumstances

Energy and vitality - Releasing energy through physical movement - Become physical active again - Increased endurance Intensity - Intense - Timespan, relatively short → makes the intervention intense and therefore effective - You touch a deeper layer - The different fields of expertise reinforce each other Outcome - More connected (to yourself) - Increased confidence - Positive attitude towards life - Good, satisfied, vital and fit feeling o o o o

Sense of direction Clarity about direction of life → enthusiasms Experiencing a positive idea about the future Having a goal Insight → in what you prefer in the future Hormones

o o o

Increased cortisol level Release of happiness hormone Decrease of toxins in body

Vision -

Vision on ill health, stress and health and healthy lifestyle o People experiencing stress mainly focus on the mind, which means that their energy is in their mind, they reason and analyse a lot o People developed patterns and convictions which are in a way stuck in there body, therefore one needs to become physical active o When people do not have a direction in their life they feel that they are stuck at the same place and they get depressed. People need a destination o The posture of the body can show what is wrong o Everyone experiences crisis’s in life, the question is how you dealt with it o People start working more, they experience more stress, but they do not exercise, but people need physical exercise (to be balanced) o Burnout is a physical and emotional problem o The body is in a need for relaxation o If you exercise your energy level will rise o Getting out of the comfort zone is needed to get out of the current situation o People have patterns that repeat o It is important to feel and express emotions o Usually people do not want to feel their emotions, they do not want to experience their vulnerability, anxieties, grief and sadness. But the greatest gift you can give yourself is to allow and accept those feelings. o When people experience physical how it is to release emotions, they feel powerful and at peace o When people open up energy can flow o After a burnout it is needed to take another direction in life o People can open up more in contact with others, when they can open up they feel more balance o Being healthy is a combination of an exchange in feeling physically and mentally well. It is the experience of feeling vital o In the program it is substantial to guide people from the head towards the heart o Important to get a positive view on life o Coaching supports to get to the essence and the centre of the persons issues o Feeling of connectedness with something bigger is important o When you start moving the physical body, energy is released again and the restorative capacity of the body is activated

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Vision on intervention o There is a learning curve, you start with unconscious incompetent behaviour, then you get conscious competent behaviour. This is where the intervention usually ends. But the final stage is unconscious competent behaviour. o During the program people come closer by who they truly are, and what they want in life. It is a deep process and they make a significant change. o It is supportive to work on physical, emotional and mental level o An intervention needs time, at least two months to integrate in the system o The intervention is focused on the individual but the individual is part of a system, and is influenced by people. Some influences are positive, some negative. o Clarity of mind is one of the most important thinks

Practitioners - Dedicated - Strong (internal) collaboration - Involved and devoted - Passionate - Strong network