Burnout: A Short Socio-Cultural History

Abstract

The work and organisational psychologist Wilmar Schaufeli explores the historical roots of burnout as well as the specific socio-cultural factors that led to its emergence. Addressing the question of whether the major symptoms of burnout are ubiquitous or context specific, he analyses how they relate to similar syndromes, such as neurasthenia and depression. Have burnout-like phenomena been observed in the past as well, and is it a typically Western phenomenon? Schaufeli’s chapter concludes with a discussion of differences in the ways the diagnosis is used and understood in North America and Europe.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

The term ‘burnout’ was first used in a clinical sense in the early 1970s by Herbert Freudenberger, a practicing American psychologist.¹ The concept was developed further by the academic researcher and social psychologist Christina Maslach, who subsequently developed the most widely used questionnaire for assessing burnout. From the beginning, two more or less independent streams of activities can be observed in the field of burnout studies: (1) a practice-based approach focused on burnout cures, which resulted in the emergence of a veritable ‘burnout industry’ offering workshops, training programmes, counselling, psychotherapy, organisational consultancy, and so on; and (2) academic research, which produced thousands of scientific publications (75,000 according to Google Scholar and 10,000 according to PsychInfo in March 2017).

Interestingly, there is not much interaction between these two fields. Very few practical burnout intervention measures, for example, have been scientifically evaluated; a systematic review of burnout prevention programmes identified only 25 studies, of which 14 were randomised controlled trials.² In a more recent study, Laurentiu Maricuţoiu, Florin Sava, and Oana Butta focus on all types of burnout intervention programmes, rather than restricting themselves to prevention programmes, in their meta-analyses.³ They found that a controlled intervention was performed in only 6% of the 913 intervention studies they originally identified, and eventually only 47 studies are included in their meta-analysis. The results of this meta-analysis show modest but lasting positive effects of interventions in reducing burnout.

This chapter seeks to explore the historical roots of burnout as well as the socio-cultural factors that led to its emergence. Significantly, burnout did not develop in a historical vacuum; in addition to a subjective experience, it is also a multi-faceted socio-cultural phenomenon. In the first part of this chapter, I discuss the academic discovery of burnout and why it emerged in the final decades of the twentieth century. Next, I address the question of how far the major symptoms of burnout are independent of time and place, and how they relate to other similar concepts. Have burnout-like phenomena been observed in earlier times, and is it a typically Western phenomenon? And how do the symptoms of burnout and those of depression relate to each other? In the final section, I discuss differences in the ways the diagnosis is used and understood in North America and Europe.

The Discovery of Burnout

The term burnout was first used as an informal, everyday term.⁴ Indeed, Freudenberger borrowed it from the illicit drug scene where it colloquially referred to the devastating effects of chronic drug abuse.⁵ He used the term to describe the gradual emotional depletion, loss of motivation, and reduced commitment among volunteers of the St Mark’s Free Clinic in New York’s East Village, whom he observed as a consulting psychologist. Such free clinics for drug addicts and homeless people had grown out of the counter-cultural movement, whose protagonists were dissatisfied with the establishment. Not unimportantly, Freudenberger himself fell victim to burnout twice, increasing his credibility when spreading the message of burnout. His writings on the subject were strongly autobiographical and his impact is illustrated by the fact that he received the Gold Medal Award of the American Psychological Association, for life achievement in the practice of psychology in 1999. Rather than a scholar, Freudenberger was a psychoanalytically trained practitioner who was primarily interested in preventing and combatting burnout, rather than in understanding and investigating its underpinnings.

Independently and simultaneously, Maslach and her colleagues came across the same term in California when interviewing a variety of human services workers. As a social psychology researcher at the University of California at Berkeley, Maslach was interested in how these workers coped with emotional arousal while performing their demanding jobs. As a result of these interviews, she learned that these workers often felt emotionally exhausted, that they developed negative perceptions and feelings about their clients or patients, and that they experienced crises in professional competence as a result of this emotional turmoil.⁶ Following the self-descriptions of workers’ symptoms, the practitioners referred to this psychological condition as ‘burnout’. Maslach and her colleagues subsequently developed an accessible and easy-to-use self-reporting questionnaire for assessing burnout, which became known as the Maslach Burnout Inventory (MBI).⁷ This went on to become the most widely used assessment tool for burnout.

Initially, the scientific community deemed burnout a ‘pseudoscientific’ or ‘fad’ concept and denounced it as ‘pop psychology’, but this soon changed after the introduction of the MBI, which triggered a wave of empirical burnout research.⁸ Cindy and Donald McGeary documented an exponential increase in burnout publications starting from the moment the MBI was introduced; from the 1980s to the 1990s, publications increased by 64%, and from the 1990s to the 2000s by 150%.⁹

Originally, burnout was described and discussed as a phenomenon that was specific to the human service sector, and especially in health care, education, social work, psychotherapy, legal services, and law enforcement. Indeed, the original version of the MBI could only be employed in these fields because of its content and the wording of its questions. Until the mid-1990s, when a general version was published, burnout was more or less a phenomenon restricted to the so-called caring professions.¹⁰ Yet why was this the case?

Why Did Burnout Emerge at the End of the Twentieth Century in the Human Services Sector?

It has been argued that the emergence of the burnout concept is related to several broader social, economic, and cultural developments of the 1960s in America.¹¹ Three specific developments may have contributed to the emergence of burnout in the human services sector. First, from the early 1960s onwards, the War on Poverty in the US led to a large influx of idealistically motivated young people into human services professions. However, after struggling to eradicate poverty for a decade or so, they found themselves increasingly disillusioned. Their frustrated idealism was a defining quality of the burnout experience, gradually turning into despair and cynicism.

Second, from the 1950s onwards, the human services underwent rapid professionalisation and bureaucratisation as a result of greater government and state influence. Small-scale traditional agencies, where work was considered a calling, transformed into large modern organisations with formalised job descriptions. Viewed from this perspective, burnout represents the price paid for professionalising the helping professions from callings into modern occupations. One may speculate that the frustration and disillusionment arising from a widespread institutionalised clash of utilitarian organisational values with the providers’ personal or professional values promoted burnout.

Third, the cultural revolution of the 1960s significantly weakened the professional authority of doctors, nurses, teachers, social workers, and police officers. The traditional prestige of these professionals was no longer accepted as a given, and ever more empowered and demanding recipients expected much more than in the past. As a consequence, recipients’ demands for care, service, empathy, and compassion intensified. From the perspective of social exchange, a discrepancy grew between the professionals’ efforts and the rewards they received in terms of recognition and gratitude. This ‘lack of reciprocity’ is known to foster burnout.¹²

These three factors are more or less specific to the human services sector, but there were also additional, more general socio-cultural developments that seem to have contributed to the emergence of burnout in the last quarter of the twentieth century. Since the Second World War the importance and roles of traditional social communities and networks such as the church, the neighbourhood, and the family have gradually been eroded. According to Richard Sennett, this is the result of the emergence of ‘flexible capitalism’, a system that replaced traditionally rigid, homogeneous, and predictable social institutions with more flexible, heteronymous, and continuously changing ones.¹³ This development encourages social fragmentation and what Sennett calls ‘the corrosion of character’, a notion akin to burnout.

Simultaneously, a ‘narcissistic culture’ developed, characterised by transient, unrewarding, and even combative social relationships that produced self-absorbed, manipulative individuals demanding the immediate gratification of their desires, but remaining perpetually unsatisfied.¹⁴ As Barry Farber noted, the combination of this more radical process of individualisation and narcissism produced ‘a perfect recipe for burnout’; the former generates stress and frustration, whereas the latter undermines people’s resources for coping.¹⁵

In conclusion, then, it seems that some specific socio-cultural conditions existed in the US in the final decades of the twentieth century that might have fostered the emergence of burnout as a social problem. However, as it is also a psychological phenomenon, it is highly unlikely that the experience of burnout exclusively occurred in this particular time window. Hence, in the following sections, the historical roots of burnout are discussed.

Is Burnout Specific to the Late Twentieth Century?

Although, as noted earlier, ‘burnout’ was first used in relation to work done in the last century, the term has a longer history that dates back to the end of the sixteenth century, when William Shakespeare wrote in the seventh poem of The Passionate Pilgrim (1599):¹⁶

She burn’d with love, as straw with fire flameth

She burn’d out love, as soon as straw outburneth

The phrase ‘burn’d out’ is used here, probably for the first time, in a psychological sense, that is, to describe a process of energy exhaustion in relation to love.¹⁷

There are numerous other examples of descriptions of burnout symptoms avant-la-lettre, in the sense that they document mental exhaustion and disengagement in people who used to be very dedicated and committed. Matthias Burisch argues that burnout cases can already be found in the Bible, such as with the prophet Elijah who, after winning several victories and performing miracles in the name of the Lord, breaks down in the face of an impending defeat, plunging into deep despair and falling into a deep sleep.¹⁸ This mental condition subsequently became known among priests as ‘Elijah’s fatigue’, and includes symptoms such as intense but exhausting commitment to a cause, disappointment, and social disengagement, all of which strongly resemble modern descriptions of burnout. Another example of a burnout case from the Bible is Moses, who at some point during the flight from Egypt becomes disillusioned because he has given so much, yet his people are still not satisfied and continue demanding more (including meat instead of manna).

Early examples of burnout symptoms can also be found in literary texts. For instance, it appears that Senator Thomas Buddenbrook, one of the protagonists in Thomas Mann’s novel Buddenbrooks (1901), suffers from burnout.¹⁹ Above all, he feels exhausted by his political work and business ventures in Lübeck, and the way Thomas Buddenbrook is portrayed by Mann is strongly reminiscent of a present-day case description of burnout, as it includes mental exhaustion, disillusionment, and the loss of interest and drive (i.e. the impoverishment and desolation of his inner life, the ‘Verarmung und Verödung seines Inneren’).

Probably, the best-known fictional example of a burnout-sufferer avant-la-lettre is the world-famous architect Querry, the main character in Graham Greene’s 1960 novel A Burnt-Out Case, who moves to Africa to live in a leper colony, with whom he identifies in various ways. Querry has gloom-filled thoughts, is disillusioned, and suffers from fatigue, apathy, and cynicism. The similarities to Freudenberger’s drug addicts are striking: Like drug addicts, lepers become emaciated by their illnesses. Both Freudenberger and Dr Collin, the character who diagnoses Querry as a burntout case in Greene’s novel, transpose a metaphor that is basically physical in nature (i.e. being literally consumed by narcotics or by a physical illness) into the mental domain. Greene’s novel appeared in 1960, before most of the developments commenced that are associated with the emergence of burnout in the 1970s, such as the influx of young human services professionals, the professionalisation of the human services, and the counter-cultural revolution. Hence, Querry can be considered a true burnout case avant-la-lettre.

The same applies to the much-cited case study of the psychiatric nurse Miss Jones, by Morris Schwarz and Gwen Will, which is considered to be the first publication on burnout in a professional journal.²⁰ Although the authors do not use the term burnout, their in-depth case description fits very well with the present-day notion of burnout. This case study not only describes the process of burning out that gradually takes place in Miss Jones but also documents the hospital staff’s low morale and its effects on patient care. By noting patients’ responses to Miss Jones’ cynicism and low morale, the key dynamic of burnout is aptly captured. The authors describe a vicious circle of Miss Jones’s alienation from her patients, leading to the patients’ alienation, and subsequently to the even greater alienation of Miss Jones. Seen from this perspective, burnout is a maladaptive strategy, an attempt to cope with the emotional demands of the job. This description resembles Maslach’s, who argues that increasing emotional demands are the root causes of burnout that lead to exhaustion.²¹ Depersonalisation – or mental distancing – aggravates this process, and is considered an inappropriate attempt to cope with these emotional demands.

Taken together, the examples above illustrate that the psychological condition that is characterised by loss of energy and motivation, and which has been branded as burnout in the mid-1970s, is not unique to that particular era. In addition, many other earlier cases have been described that fit the current descriptions of burnout, including loss of energy (i.e. feeling exhausted, weak, used-up, worn-out, and overburdened) and loss of motivation (in particular, disillusionment, poor morale, disengagement, withdrawal, cynicism, depersonalisation, and the loss of drive and interest). Moreover, the burnout metaphor itself has been used previously to denote the mental condition that is characterised by loss of energy and drive. In short, the experience of burnout symptoms is not specific to the late twentieth century. A compelling case that illustrates this point and deserves special attention is that of neurasthenia.

Neurasthenia: Nineteenth-Century Burnout?

The American neurologist George Miller Beard described a new illness in 1869 which he labelled neurasthenia, and which centred on the notion of a somatic depletion of nervous energy caused by a faster pace of life. The hallmark of this new illness – which literally means ‘nerve weakness’ – is severe debilitating mental and physical fatigue arising after even minimal effort. Beard was active in promoting neurasthenia through his publications, and soon his ideas took root in Europe, most notably in Germany, France, Britain, and the Netherlands, and after the First World War also in Japan and China.²²

Beard understood neurasthenia primarily as a disorder of modernity, caused by the fast pace of urban life. Accelerated modern life, he argued, puts excessive demands on peoples’ brains, which, in turn, weakens and depletes their nerve force, thus causing neurasthenic symptoms such as exhaustion, anxiety, despair, insomnia, indigestion, palpations, and migraines. In addition to mental overload resulting from an excessively demanding or pressured job, neurasthenia may also result from physical strain caused, for instance, by a prolonged viral infection. For this reason, Leone et al. not only see parallels between neurasthenia and burnout but also between neurasthenia and chronic fatigue syndrome:²³ ‘Beard’s neurasthenia combined features of both modern burnout and modern fatigue syndromes.’²⁴ What are the symptoms that are shared between neurasthenia and burnout?

First, mental exhaustion is considered the defining symptom of both conditions. This is exemplified by the fact that in the 1896 edition of his famous Textbook of Psychiatry, Emil Kraepelin classifies neurasthenia as a ‘disorder of exhaustion’.²⁵ Second, both neurasthenia and burnout have been considered maladies of their times. Freudenberger states that burnout is ‘a demon, born of the society and times we live in and our ongoing struggle to invest our lives with meaning’.²⁶ This statement could likewise apply to neurasthenia and Beard’s time. Neurasthenia was understood as the product of rapid social and technological changes, which resulted from the transformation of an agricultural into an industrial society. In a similar vein, burnout was seen as the product of the social and cultural changes that resulted from the transformation of an industrial society into a post-industrial service-oriented society.²⁷ This is exemplified by the fact that neurasthenia appeared first among the icons of the new industrial era – the dynamic businessmen – whereas analogously burnout appeared first among the icons of the new service era – the human services professionals.

Third, neurasthenia, like burnout, offered an explanation for an ordinary, rather than a pathological, trouble and affliction. In the nineteenth century, neurasthenia was clearly separated from mental disease and offered an alternative for the then popular diagnoses of hysteria and hypochondria.²⁸ In a similar vein, the popularity of burnout as a diagnosis has been explained by pointing to its ‘non-medical nature’.²⁹ Instead of as a mental disorder, burnout is usually considered a normal response to an abnormal situation; sometimes, it is even a diagnosis worn with pride, almost as a badge of honour (‘I’ve exhausted myself by going to the limit’).

Fourth, initially neurasthenia was very much an affliction of the educated elite rather than the labouring classes. However, ‘What started off as a more or less fashionable disease of the elites later on became to a certain extent “desocialized” and “democratized.”’³⁰ Burnout also started as a typical complaint of higher educated human services professionals. It took more than a decade after its discovery before it was acknowledged that burnout could also occur among the lower educated and those with less prestigious jobs, such as blue-collar workers.

Finally, the emergences of both the neurasthenia and the burnout diagnoses have brought in their wake attempts to exploit commercially these conditions. Marijke Gijswijt-Hofstra writes: ‘One could even speak of a “neurasthenia market”, a market where medical advice, technology, remedies and cures were advertised and sold, thus creating and playing on the demands from potential patients.’³¹ Currently, a similar burnout market seems to exist that produces training courses, e-health programmes, self-help books, prevention programmes, workshops, counselling, psychotherapy, organisational consultancy, and so on.

The neurasthenia diagnosis began to disappear after the First World War. Gradually, the diagnosis became out-dated, except in Japan and China, where it still enjoys popularity. The main reason for the disappearance of neurasthenia was that it came to encompass too many symptoms, which rendered it too baggy and unspecific as a diagnostic tool. Stephanie Leone et al. argue that CFS and burnout are the heirs of the physical and psychological symptoms of neurasthenia.³² Seen from this perspective, neurasthenia could, indeed, be considered the nineteenth-century forerunner of burnout. In spite of the fact that – at least initially – the notion of neurasthenia was firmly rooted in physiology, the parallels with burnout are striking, not only regarding their common core symptom (exhaustion) but also regarding their explanatory models, which blame external socio-cultural developments for the spread of the conditions.

On the Difference Between Depression and Burnout

A parallel exists between the pervasiveness of neurasthenia at the end of the nineteenth century and the omnipresence of depression at the end of the twentieth century. As Allan Horwitz and Jerome Wakefield argue, the apparent present-day epidemic of depression is primarily owing to how psychiatrists often understand and classify normal human sadness as an abnormal experience.³³ Since the publication of the DSM-III (the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association) in 1980, professionals began to diagnose depression based on such general symptoms as a depressed mood, loss of interest, and fatigue, all of which have to persist for at least two weeks.³⁴ According to Horwitz and Wakefield, this approach is fundamentally flawed because it fails to take into account the context in which the symptoms occur. This context may, for instance, be the work context and, as a consequence, considerable overlap might occur between burnout and depression because both share at least one core symptom, namely exhaustion.

Freudenberger already noted the close link between burnout and depression when he observed that, at least initially, the symptoms of burnout tend to be job related and situation specific rather than general and pervasive, as in the case of depression.³⁵ In his view, work-specific burnout symptoms could generalise across all situations and spheres of life, hence leading to a ‘real depression’. This theory is supported by a more recent three-wave study spanning seven years, which demonstrated that high levels of burnout constitute a risk factor for the development of future depressive symptoms.³⁶ Another study showed that burnout at the baseline predicted increased fatigue four years later, and the reverse was also observed.³⁷ This led the authors to conclude that burnout and prolonged fatigue seem to influence each other mutually over time in the manner of a ‘downward spiral’. Combining the results of both these studies, one may conclude that increased exhaustion is responsible for the generalisation of context-specific burnout into context-free depression.

Despite earlier claims of a distinction between burnout and depression, based on the results of a meta-analysis that involved 18 studies,³⁸ a more recent comprehensive review concludes that the empirical evidence for their distinction is somewhat inconsistent.³⁹ More specifically, and based on a set of 92 studies on burnout and depression, this review concludes that: (1) symptoms of burnout and depression overlap, and most burned-out workers also exhibit depressive symptoms; (2) burnout and depression levels are moderately to highly correlated, particularly so far as the exhaustion component of burnout is concerned; (3) results regarding the causal link between burnout and depression are heterogeneous; (4) somatic and biological levels of analysis seem to suggest some degree of distinctiveness; and (5) burnout and depression are found to differ in regard to their links to both job-specific (burnout), and to generic (depression), factors. Overall, the distinction between burnout and depression is partly supported by the empirical research. However, the authors also note that the comparison between depression and burnout is hampered by the heterogeneity of the spectrum of depressive disorders and by a lack of consensual diagnostic criteria for burnout. Therefore, a final conclusion regarding the overlap between burnout and depression cannot be given, although it seems that exhaustion constitutes the primary link.

Is Burnout a Western Phenomenon?

After its emergence in the US in the 1970s, in the 1980s the concept of burnout spread to Western Europe, particularly to the UK, Germany, the Low Countries (Holland and Belgium), and the Nordic countries (Scandinavia and Finland), as well as to Israel. From the mid-1990s onwards, burnout was also observed in the rest of Western, Middle-, and Eastern Europe, Asia, the Middle East, Latin America, Australia, and New Zealand. After the turn of the last century, research on burnout also spread to Africa, China, and to the Indian subcontinent. It is interesting to note that, very generally speaking, the order in which the interest in burnout seems to have spread corresponds to the socio-economic development of the countries involved.

It has been suggested that globalisation, privatisation, and liberalisation cause rapid changes in modern working life, such as the necessity to acquire new skills, the need to adopt new types of work, the imperative to achieve ever higher productivity, general acceleration, and increased temporal pressures, which, in their turn, may produce burnout.⁴⁰ In addition, as discussed above, socio-cultural developments such as social fragmentation, individualisation, and the rise of the ‘me culture’ are pervasive not only in the US and Europe but also in other countries. Although the notion of burnout seems to have spread around the globe, it yet remains to be seen whether or not it is essentially a Western phenomenon.

Most studies on burnout that have been conducted in non-Western countries use similar conceptualisations of burnout; burnout is predominantly assessed with the MBI. Further, the specific cultural contexts tend not to be taken into account in these non-Western studies. Basically, non-Western burnout studies are replications of those that have been conducted in Western countries. Only a small number of studies have compared the prevalence of burnout across two or more countries. But even these comparative studies have lacked a truly cross-cultural perspective, because the differences in prevalence of burnout are merely described, and not explained in terms of socio-cultural differences.

In her review of cross-cultural and anthropological studies on burnout, Ina Rösing only found four exceptions to the weakness described above.⁴¹ The most notable one is Victor Savicki’s study, which investigated burnout among child and youth-care workers across 13 different countries.⁴² He found that the prevalence of burnout symptoms seems, indeed, to be dependent on cultural factors. More specifically, burnout levels of child and youth-care workers were higher in countries where people feel uncomfortable with uncertainty and ambiguity, and where they accept and expect that power is distributed unequally, as well as in countries that value career success over quality of life. In addition, across all countries burnout was correlated to high job demands and coping styles driven by avoidance.

Rösing also criticises the concept of burnout as such on a more fundamental level as being ethnocentric.⁴³ Burnout, she argues, is inherently linked to a job or profession. Indeed, the public discourse surrounding and almost all research are about job or professional burnout, rather than about burnout as a universal experience. However, the very notions of ‘job’ and ‘profession’ are culture-specific constructs and exist only in modern industrialised societies and not in traditional, rural, agricultural communities. Therefore, job/occupational burnout is intrinsically intertwined with the former and not with the latter.

As far as the various components of the MBI burnout questionnaire are concerned, Rösing also argues that depersonalisation and reduced personal accomplishment are ethnocentric concepts. Depersonalisation presupposes a Western personality conception, which emphasises a sharp distinction between ‘me’ and ‘you’, who then enter both – as separate entities – into a ‘personal’ relationship. In a similar vein, personal accomplishment presupposes a Western conception of achievement, that is, one that links achievement to the ‘self’; achievement is seen as personal achievement. This is typical for Western, individualised cultures, whereas in collectivistic cultures achievement is considered to result from group efforts.

By contrast, the core symptom of burnout – emotional exhaustion – seems to occur universally. For example, Rösing describes ‘burnout’ among the Quechua and Aymarai Indians from the Andes (Bolivia) and among the Ladakhs in the Himalaya (Tibet), calling it a ‘loss of soul’, in which exhaustion plays an important role, together with feelings of meaninglessness and emptiness.

To sum up, despite the fact that the concept of burnout has spread around the globe, virtually no investigation has been carried out that takes cultural differences between countries into account. There is only one study so far to show that such differences matter. At a more basic level, it seems that at least two of the three burnout components (depersonalisation and reduced personal accomplishment) are ethnocentric Western concepts that cannot be applied in traditional societies. This can also be said to apply to the entire concept of job and occupational burnout. In contrast, context-free emotional exhaustion is likely to be a universal experience. Hence, for the time being, it seems that the concept of burnout is restricted to modern, industrialised, and urbanised societies.

The Global Reception of Burnout

As noted above, the concept of burnout originated in the US in the 1970s, before rapidly spreading to other countries around the world. Its quickly growing popularity in the US has been explained by its non-medical nature.⁴⁴ Initially, the term burnout was not used as a medical diagnosis. Rather, it was considered an almost inevitable process that would occur among highly motivated human services workers (i.e. a normal response to an abnormal situation). However, burnout was also considered as a particular negative psychological state manifest in various symptoms, described as the ‘burnout syndrome’. Wilmar Schaufeli and Dirk Enzmann demonstrated that, from the outset, academic authors used both process-oriented and state-oriented definitions of burnout.⁴⁵

In crossing the Atlantic Ocean the meaning of burnout changed, and gradually expanded from a psychological phenomenon into a medical diagnosis. This happened, particularly, in European countries such as Sweden and the Netherlands, and has to do with the way their social security systems operate; in these countries social security systems cover sickness and work incapacity pensions for employees who suffer from burnout.⁴⁶ This means that the gatekeepers of these systems need assessment tools for identifying those who suffer from burnout. In this sense, these social security systems reflect commonly held social values about job stress and compensation for psychosocial risks at work. In contrast to the US (and also many other European countries), Sweden and the Netherlands have a long tradition of being sensitive to employees’ stress at work, and in compensating for its adverse effects.

Yet a burned-out employee in Sweden or the Netherlands is only eligible for financial compensation (in the form of sick leave or disability payments) when officially diagnosed by a medical professional. The medical professional thus acts as a gatekeeper, using officially sanctioned diagnostic criteria. The problem in the case of burnout is precisely the lack of such criteria. Burnout is not included in the DSM-V. In the ICD-10 (the World Health Organization’s International Classification of Diseases), burnout (code Z73.0) is placed in the ‘problems related to life management difficulty’ category and loosely described as ‘a state of vital exhaustion’, without further elaboration. This leaves much room for interpretation by medical professionals. It thus follows that, if burnout is to be considered a mental condition that renders sufferers eligible for financial compensation, specific diagnostic criteria should be developed.

For this reason in 2005 the Swedish National Board of Health and Welfare added ‘exhaustion disorder’ (utmattningssyndrom) to the national version of the ICD-10.⁴⁷ In a similar vein, in the Netherlands the Royal Dutch Medical Association in 2000 issued guidelines for assessing and treating stress-related disorders in occupational and primary health care.⁴⁸ The diagnostic classification in these guidelines distinguished between three levels of stress-related disorders at work: (1) mild distress (relatively minor symptoms that lead to minimal or only partly impaired occupational functioning); (2) serious distress (major distress symptoms which cause temporal loss of the entire occupational role); and (3) burnout (work-related neurasthenia and long-term loss of the occupational role).⁴⁹

In essence, then, the degree to which a professional role can be fulfilled is the defining characteristic that differentiates between these three types of stress-related disorders. ‘Burnout’ is defined as the final stage of a chronic exhaustion process that prevents employees from fulfilling their occupational roles. It is treated as a serious medical diagnosis that generates access to financial compensation, treatment, and rehabilitation. The very fact that burnout as a medical diagnosis is associated with these benefits has increased its social acceptance in the Netherlands.

The reason why the understanding of burnout in the Netherlands differs from its original meaning in the US has to do with the fact that an alternative term already existed when ‘burnout’ entered the scene in the 1980s. For decades, both the lay public and professionals had used the notion of overspannenheid (literally, ‘overstrain’) to denote a psychological state that is similar to what was known as ‘burnout’ in the US. Since the 1950s Dutch physicians had been using ‘overstrain’ (or its French equivalent surmenage) as an official diagnostic label, albeit one that was not restricted to the work context. When ‘burnout’ was introduced, it was used to indicate a severe psychological disorder rather than a mild form of distress; more precisely, the final stage of a long-term process of exhaustion from which it is very difficult to recover.

The popularity of ‘burnout’ in North America can be explained by the fact that ‘burnout’ is a non-medical, socially accepted label that carries very little stigma. Paradoxically, the reverse seems to be true in some countries in Europe: burnout is very popular because it is an official medical diagnosis that opens the gates of the welfare state, with its compensation claims and treatment programmes.

Conclusion

Two types of conclusions can be drawn regarding the historical and socio-cultural context of burnout. First, the core symptom of burnout – exhaustion – is a context-free, universal, psychological experience, which neither seems restricted to a particular historical era nor to a particular culture. The importance of the exhaustion symptom further seems to link burnout with depression, which also counts exhaustion among its core symptoms. The most telling historical example of burnout avant-la-lettre is nineteenth-century neurasthenia, but burnout-like phenomena have also been observed in non-Western cultures among indigenous peoples from the Andes and the Himalaya.

Second, burnout, as it has been ‘discovered’ in the US in the 1970s, seems to be rather specific to modern, advanced societies that are characterised by social fragmentation and individualisation. Moreover, burnout is equated with occupational burnout (i.e. a work-related and context-bound condition), and therefore is a culture-specific notion. This means that it occurs by definition exclusively in those cultures in which ‘jobs’, ‘occupations’, and ‘professions’ exist. Yet even within Western culture ‘burnout’ can mean different things in different countries, ranging from mild psychological distress to a medically diagnosed incapacity to work.

It can be argued that the specificity of burnout, which lies in the combination of exhaustion with other symptoms such as mental distancing (depersonalisation, cynicism) and reduced personal accomplishment, is lost when it is reduced to mere exhaustion. This would lead to the final conclusion that, indeed, burnout is a psychological condition that is rooted in a specific historical and socio-cultural context.