Journal of Occupational Health Psychology 2004, Vol. 9, No.

3, 220 237

Copyright 2004 by the Educational Publishing Foundation 1076-8998/04/$12.00 DOI: 10.1037/1076-8998.9.3.220

Burnout Patterns in Rehabilitation: Short-Term Changes in Job Conditions, Personal Resources, and Health
Marja Hatinen, Ulla Kinnunen, Mika Pekkonen, and Antti Aro
University of Jyvaskyla
This longitudinal study reports the patterning of the burnout symptoms and the changes in employees job conditions, personal resources, and psychological health 4 months after a rehabilitation intervention. The data were gathered by means of questionnaires before and after a rehabilitation period. Four patterns were identied: not burned out (n 55), exhausted and cynical (n 36), burned out (n 26), and low professional efcacy (n 18). These patterns differed in terms of job resources, personal resources, and depression. There were both positive and negative changes detected in participants psychological health and job resources at the follow-up. The study shows the importance of identifying different burnout patterns in order to focus rehabilitation activities more effectively.

There has been ample empirical evidence to show that burnout is a serious threat to employees psychological health and working ability (Schaufeli & Enzmann, 1998; Schaufeli, Maslach, & Marek, 1993). In addition, research has shown that burnout is not only related to negative outcomes for the individual but also to negative outcomes for the organization (for reviews, see Burke & Richardsen, 2001; Cooper, Dewe, & ODriscoll, 2001; Cordes & Dougherty, 1993; Maslach, Schaufeli, & Leiter, 2001). It is therefore understandable that burnout intervention programs have been on the increase and that many recent studies have focused on nding the best ways to prevent and reduce burnout (e.g., Cooley & Yovanoff, 1996; Rowe, 2000; Schaufeli, 1995; van Dierendonck, Schaufeli, & Buunk, 1998). One way to intervene in the progression of burnout is employee rehabilitation, which is dened as a tertiary preventive intervention (Cooper & Cartwright, 1997; Reynolds, 1997). In general, the main reason for rehabilitation is to maintain and improve employees working ability, to prevent disability, and, thus, to ensure the supply of skilled and capable individuals in the workforce. The present study was

targeted at employees who had sought and been referred to rehabilitation courses aiming at reducing job-related psychological health problems, such as burnout, but also maintaining and promoting personal resources and working ability. Previous studies on burnout have been criticized for healthy worker effect, which means that relatively healthy individuals (i.e., only mild burnout symptoms) have mainly been investigated (Schaufeli, Bakker, Hoogduin, Schaap, & Kladler, 2001). In this study this effect was partly avoided as we investigated a group of individuals who had sought treatment specically because of burnout. The primary objective of the study was to examine the short-term changes in employees job- and individual-related variables after a rehabilitation intervention.

A Person-Oriented Approach to Burnout

Most of the empirical work on burnout has been variable oriented. This approach focuses on statistical relations between variables across individuals at group level (Magnusson, 1998). Following this approach, each burnout symptom in isolation and their relations to antecedents and outcomes have been the main object of interest. In contrast, we used a personoriented approach, the aim being to discover the distinctive congurations of factors that characterize each individuals functioning (Magnusson, 1998). Applied to the study of burnout, the person-oriented approach posits that several burnout symptoms operating simultaneously best capture the burnout phenomenon; that is, we paid attention to covariations in multiple burnout symptoms. Compared with the variable-oriented approach, our focus here is on the pro-

Marja Hatinen, Ulla Kinnunen, Mika Pekkonen, and Antti Aro, Department of Psychology, University of Jyvas kyla, Jyvaskyla, Finland. The research project Job Burnout: Evaluation, Development and Effectiveness of Intervention (Grant No 100118) was nancially supported by the Finnish Work Environment Fund. Correspondence concerning this article should be addressed to Marja Hatinen, Department of Psychology, Uni versity of Jyvaskyla, P.O. Box 35, FIN 40014, Jyvaskyla, Finland. E-mail: marja.hatinen@psyka.jyu.

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le of variable values, not the variables in themselves (Bergman & Magnusson, 1998). The person-oriented approach to burnout (see Bergman & Magnusson, 1997, 1998; Magnusson, 1998) was applied because we wanted to explore the patterning of the burnout symptoms within an individual, instead of studying one symptom at a time interindividually. By examining the possible burnout patterns and differences in antecedents and outcome variables between these patterns, we expected to be able to provide some practical implications for professionals working in the burnout rehabilitation eld. As Farber (2000) stated, it is important to identify different manifestations of burnout to be able to treat burnout successfully. Overall, we aimed at contributing to an understanding of the burnout phenomenon itself in the rehabilitation context, as this is a context in which the syndrome has rarely been studied.

Burnout and Interventions

Burnout develops as a reaction to prolonged exposure to job stressors (Maslach, 2000), and it is characterized by exhaustion, cynicism, and reduced professional efcacy (Maslach, Jackson, & Leiter, 1996). The Maslach Burnout InventoryGeneral Survey (MBIGS) is a measure of burnout that can be used in any occupational context. Therefore, its items are generic, making no reference to people or personal relationships at work, contrary to the items of earlier versions of the MBI (Maslach & Jackson, 1981, 1986). The items representing exhaustion in the MBIGS describe the core component of the syndrome, that is, the depletion or draining of emotional resources in doing ones work (Maslach et al., 1996). The cynicism component reects indifference, or a negative or distant attitude toward ones work in general, and it can be characterized as dysfunctional coping, in which employees develop cynicism about their work to distance themselves from it (Leiter & Schaufeli, 1996). The third burnout dimension, reduced professional efcacy, represents a decline in ones feelings of competence and effectiveness in regard to both the social and nonsocial aspects of occupational accomplishments. The previous intervention studies and meta-analyses (e.g., Bond & Bunce, 2000; Reynolds, 1997; van der Klink, Blonk, Schene, & van Dijk, 2001) have tried to establish what kinds of interventions are effective from the perspective of psychological health. To sum up, interventions using cognitive behavioral strategies and focusing on an individual rather than on an organizational level were found to

be successful for reducing work-related stress, burnout, and mental health. The rehabilitation intervention in this study was individual oriented in a sense that it did not try to directly change employees working conditions. Instead, the intervention used primarily cognitive behavioral techniques by modifying employees appraisals of stressful situations and helping employees to deal with their stress. More specically, the three burnout symptoms have reacted differently to activities aiming at their alleviation. Basically, the various interventions have resulted in a lower level of emotional exhaustion (e.g., Cooley & Yovanoff, 1996; Higgins, 1986; Rowe, 2000; Schaufeli, 1995; van Dierendonck et al., 1998), whereas the components of cynicism and professional efcacy have turned out to be more difcult to change by interventions. For example, van Dierendonck et al. (1998) found that no changes occurred in the level of cynicism, whereas feelings of reduced personal accomplishment initially increased rather than decreased after 6 months of a 5-week groupbased intervention program. This intervention program aimed at the cognitive restoration of equity perceptions on the interpersonal and organizational levels. Also, shorter follow-ups than 6 months have resulted in positive changes in job stress and burnout. After a 3-month follow-up, Bunce and West (1996) found that an intervention designed to create innovative responses to job stressors resulted in improvements in work-related stress. Schaufeli (1995) reported a decrease in emotional exhaustion one month after a 3-day burnout workshop. Additionally, Rowe (2000) found that emotional exhaustion decreased and personal accomplishment increased at a 2-month follow-up after a coping skills training program.

Burnout Development and Patterning of the Symptoms

The different manifestations of burnout, that is, patterning of burnout symptoms within an individual, may be due to the particular phase or developmental cycle of burnout an individual is going through. According to the different burnout development theories, the three dimensions of burnout develop either partially simultaneously (Leiter, 1991, 1993) or independently over time (Golembiewski & Munzenrider, 1984, 1988; Leiter & Maslach, 1988; van Dierendonck, Schaufeli, & Buunk, 2001). In fact, there are three contrasting views of this developmental progress. As the rst symptom, Leiter and Maslach

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(1988) proposed emotional exhaustion, Golembiewski and Munzenrider (1984, 1988) depersonalization, and van Dierendonck et al. (2001) reduced personal accomplishment. In addition, the burnout patterns may relate to the fact that individuals react to certain sources of stress in ways that are natural to them, stemming from their personal history, including personality, available resources, and life experiences (Friedman, 1996). We assumed that this might lead to different developmental pathways, which in turn may appear as various burnout patterns. On the basis of the developmental theories of burnout, we expected to nd such a pattern in which rehabilitation clients would suffer from all burnout symptoms, but also a pattern in which participants would have relatively low scores on all three symptoms. Furthermore, in Leiters (1991, 1993) developmental model, emotional exhaustion arises rst in response to demanding work environment, which in turn brings about depersonalization as a way of coping with increased strain (see also Lee & Ashforth, 1993; Leiter & Maslach, 1988). This implies that exhaustion may occur alone, but the pattering of the two symptoms emotional exhaustion and depersonalizationmay also be possible. Additionally, because diminished personal accomplishment develops independently, depending on available job and individual resources (Leiter, 1991, 1993), we expected that this dimension would occur alone.

The COR Theory, Job Conditions, and Personal Resources

Many studies have shown differential relationships between the three symptoms of burnout, job demands, resources, and psychological health. The conservation of resources (COR) theory provides a useful framework within which to examine these connections. By emphasizing that interventions aimed at reducing burnout must focus on enhancing employees resources and, thus, eliminating vulnerability to resource loss (Hobfoll & Freedy, 1993), it is also in line with the aims of the rehabilitation intervention examined in the present study. The basic idea of the COR theory is that individuals strive to obtain and maintain what they value, that is, resources. Burnout may ensue if these resources are threatened, lost, or when an individual invests in resources but does not get back what he or she expects. According to the COR theory, prolonged exposure to demands will eventually lead to physical and emotional exhaustion, which is the core component of burnout

(Hobfoll & Freedy, 1993). On the other hand, resources help to overcome the need for defensive coping, that is, depersonalization, which may occur as the consequence of resource loss (in this case depletion of emotional resources). Furthermore, resources help to promote self-efcacy, which represents the dimension of personal accomplishment in the burnout syndrome. The theory denes four basic categories of resources: objects, conditions, personal characteristics, and energies. In this study we focused on job conditions and personal characteristics. The two main categories of job conditions demands and resourcesare differently related to the three burnout dimensions. Job demands and absence of job resources are commonly seen as antecedents of burnout (for reviews, see Cordes & Dougherty, 1993; Schaufeli & Enzmann, 1998). High job demands (e.g., work overload, time pressure, unfavorable environmental conditions, interpersonal conicts) have been primarily found to be associated with high emotional exhaustion (Demerouti, Bakker, Nachreiner, & Schaufeli, 2000, 2001; Greenglass & Burke, 2000; Janssen, Schaufeli, & Houkes, 1999; Lee & Ashforth, 1996; Leiter, 1991, 1993; Rafferty, Friend, & Landsbergis, 2001; Taris, Schreurs, & Schaufeli, 1999), whereas lack of job resources (e.g., social support, supervisor support, job control, workplace climate) have been related to either increased cynicism or reduced personal accomplishment (Demerouti et al., 2001; Janssen et al., 1999; Landsbergis, 1988; Lee & Ashforth, 1996). Specically, of the job demands, we concentrated on time pressures at work, and of the job resources, we concentrated on job control, workplace climate, and supervisor satisfaction. Coping strategies and sense of coherence (SOC) can be dened as important personal resources that play a signicant role in employees psychological health. Lack of these resources can be seen as antecedents of burnout, because they may predispose employees to stress or burnout (see Antonovsky, 1979, 1987; Schaufeli & Enzmann, 1998). There is also evidence that coping strategies (Stewart & Schwarzer, 1996) and SOC (Feldt, Kinnunen, & Mauno, 2000; Feldt, Leskinen, Kinnunen, & Ruoppila, 2003) are only moderately stable over time, which may indicate that they can change, for example, along with burnout development and, thus, be considered as outcomes of burnout. Promoting these resources was an important goal in the rehabilitation process under examination. Emotion-oriented coping (e.g., self-preoccupation and fantasizing to reduce stress; Sears, Urizar, & Evans, 2000) and avoidance-oriented or escape cop-

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ing (e.g., activities and cognitive changes aimed at avoiding a stressful situation) have been associated with a high level of burnout (Chan & Hui, 1995; Leiter, 1991), whereas task-oriented or control coping (e.g., purposeful efforts aimed at solving or cognitively restructuring the problem) has been related to a decreased level of burnout in the form of decreased exhaustion and increased personal accomplishment (Leiter, 1991). More specically, task-oriented coping has accounted for the greatest proportion of the variance in personal accomplishment (Sears et al., 2000). This result is consistent with ndings showing that control coping is strongly related to personal accomplishment (Greenglass & Burke, 2000; Lee & Ashforth, 1996; Leiter, 1991) but weakly related to emotional exhaustion and depersonalization (Lee & Ashforth, 1996). Sense of coherence, or SOC, is dened as the global orientation of an individual in terms of comprehensibility, manageability, and meaningfulness (Antonovsky, 1979, 1987). Comprehensibility refers to the cognitive controllability of ones environment, manageability to the extent to which an individual considers coping resources to be available, and meaningfulness to the motivational component that determines whether a situation is appraised as challenging and justies making commitments. Strong SOC has been negatively related to emotional exhaustion (Feldt, 1997; Feldt, Kinnunen, & Mauno, 2000; Gilbar, 1998) as well as to the whole burnout syndrome (Soderfeldt, Soderfeldt, Ohlson, Theorell, & Jones, 2000).

1996; Cooper et al., 2001; Glass, McKnight, & Valdimarsdottir, 1993; Leiter & Durup, 1994; Schaufeli & Enzmann, 1998). Empirical research has established that although all burnout symptoms are positively related to depression (Glass et al., 1993; Landsbergis, 1988; McKnight & Glass, 1995), emotional exhaustion is closest to depression (Boles, Dean, Ricks, Short, & Wang, 2000; Glass & McKnight, 1996; Leiter & Durup, 1994; Schaufeli & Enzmann, 1998).

The Present Study

The present study examines the short-term changes in employees job conditions, personal resources, and psychological health after an employee rehabilitation intervention. Burnout was approached from a personoriented perspective; that is, the proles of burnout components are at focus, not the burnout components themselves. Specically, we addressed the following research questions. First, we examined whether it would be possible to identify homogeneous and meaningful burnout patterns among the rehabilitation clients. After identifying burnout patterns, we studied whether there would be changes in the various burnout patterns at a follow-up 4 months later, rst, in the levels of burnout (exhaustion, cynicism, and professional efcacy); second, in perceived job demands (time pressures at work), job resources (job control, workplace climate, supervisor satisfaction), and personal resources (coping strategies and SOC); and, third, in the level of depression. Because burnout has not been previously studied from a person-oriented viewpoint, our hypotheses, posited on the basis of the ndings of variable-oriented studies, were tentative only. First, we expected to nd various burnout patterns, because it is probable that individuals burn out in different ways over time or they react differently to job stressors resulting in different burnout symptoms. On the basis of the developmental models of burnout (e.g., Leiter, 1991, 1993), we expected to nd one pattern in which participants would suffer from all burnout symptoms and one in which the participants burnout levels would be low or nonexistent. Besides, we assumed that there would be a pattern in which exhaustion might occur alone or together with cynicism and one in which low professional efcacy would occur alone. Second, on the basis of previous intervention studies that have resulted in reducing burnout at short intervals (1 to 6 months; e.g., Cooley & Yovanoff, 1996; Schaufeli, 1995; van Dierendonck et al., 1998),

Depression and Burnout

Prolonged exposure to burnout and to other life stressors can be manifested in depressive symptomatology. The COR theory suggests that symptoms of depression may emerge in an advanced stage of burnout because of the escalating spiral of losses (Hobfoll & Shirom, 2001, p. 68). Depression is characterized by a range of general negative self-evaluations, such as guilt, sense of failure, and eating and sleep disturbances (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Some researchers suggest that burnout is actually a form of depression (Hallsten, 1993); that is, clinically exhaustion and depression share partly similar symptoms (e.g., fatigue, loss of energy) and statistically they share an appreciable amount of variance (Brenninkmeyer, van Yperen, & Buunk, 2001; Glass & McKnight, 1996). However, depression is more often considered to be a negative health consequence of burnout (Burke, Greenglass, & Schwarzer,

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we hypothesized that the level of exhaustion, in particular, would decrease in the burnout patterns during the 4 months after the employee rehabilitation intervention. It was assumed that decrease in exhaustion would be most prominent in the pattern in which this symptom might dominate. Third, because emotional exhaustion has been related to high job demands in previous studies (Demerouti et al., 2000, 2001; Greenglass & Burke, 2000; Janssen et al., 1999; Lee & Ashforth, 1996; Leiter, 1991, 1993; Rafferty et al., 2001; Taris et al., 1999), we expected that in the burnout pattern in which the exhaustion component (either alone or combined with cynicism) might dominate, sufferers would experience higher job demands compared with the pattern in which reduced professional efcacy component might dominate. Individuals characterized by the reduced professional efcacy would be likely to experience a lower level of job resources than those in whose burnout pattern exhaustion might dominate (Demerouti et al., 2001; Janssen et al., 1999; Landsbergis, 1988; Lee & Ashforth, 1996). Furthermore, because the primary purpose of the rehabilitation intervention applied in this study was to improve employees resources by teaching the skills to cope with stress and cognitive reevaluations of stressful situations, we expected that especially personal resources would improve during the rehabilitation period. Treatment strategies that are based on cognitive behavioral strategies have turned out to be effective in previous studies (e.g., Bond & Bunce, 2000; van Dierendonck et al., 1998). Thus, of personal resources, task-oriented coping and SOC would increase, and emotion-oriented and avoidance-oriented coping would decrease in all burnout patterns during the postintervention follow-up. However, we did not expect major changes in job demands or job resources during the short follow-up due to the fact that aiming at changing job conditions in the workplaces was not the target of the intervention. Fourth, we hypothesized that in the burnout pattern in which exhaustion (alone or combined with cynicism) might dominate, individuals would experience a higher level of depression compared with those patterns dominated by reduced professional efcacy (see Boles et al., 2000; Glass & McKnight, 1996; Leiter & Durup, 1994; Schaufeli & Enzmann, 1998). We also expected that as in previous studies after a short-term follow-up (e.g., Bond & Bunce, 2000), the level of depression in every pattern would decrease during the 4-month follow-up period.

Method Participants and Procedure

The participants consisted of 135 clients from a rehabilitation center situated in central Finland. The mean age of the clients was 51.2 years (SD 5.5). Most were women (60%) and living with a partner (married or cohabiting, 74%). The majority of them had completed either a vocational school (31%) or a vocational college (30%) education. Occupationally, 35% were blue-collar employees (e.g., postmen, bus drivers), 44% lower white-collar employees (e.g., nurses, clerical workers), and 21% higher white-collar employees (e.g., teachers, managers). Average hours worked weekly were 44.3 (SD 11.2) per week. The participants were recruited from two rehabilitation programs on the rst day of their arrival after a brief introduction to the study. In this introduction, the voluntary basis, condentiality, and anonymity of the participants were emphasized. Eight clients out of 143 were unwilling to participate in the study, and during the 4-month follow-up period, there were 7 dropouts. Thus, of the 135 clients who participated in the rst measurement (Time 1), 128 were still in the study 4 months later (Time 2). Both the employee rehabilitation programs, Vitality and Energy for Working Life (Vitality) and Maintaining and Promoting Working Ability (Working Ability), from which the participants were recruited during the years 2000 2001, have been set up in accordance with the Finnish rehabilitation legislation by the Social Insurance Institution of Finland. The former program is aimed at individuals suffering from job-related psychological health problems. Of the 135 participants, 65 were on this program, which lasts for a whole year and consists of two rehabilitation periods (12 5 days) conducted at the rehabilitation center. The latter program is directed at individuals whose working ability is substantially threatened or diminished because of disease, disability, or disorder. Of the 135 participants, 70 were from this program. This rehabilitation program lasts for 112 years and includes three or four rehabilitation periods (13 12 5 5 days) conducted at the rehabilitation center. The present study focused on the rst rehabilitation period only (lasting about 2 weeks) and included a 4-month follow-up. The participants lled out a set of questionnaires before the intervention actually started (on the 2nd day after their arrival at the rehabilitation center, baseline measurement) and again 4 months after the rst rehabilitation period (short-term follow-up measurement). This rst period lasted for 12 days in the Vitality program and 13 days in the Working Ability program. In the former rehabilitation program, the follow-up questionnaires were lled out at the rehabilitation center when the clients started their second rehabilitation period (on the day of their arrival) approximately 4 months after the rst period (M 105 days, SD 24 days). In the latter program, the follow-up questionnaires were mailed to the clients approximately 4 months after the rst rehabilitation period (M 109 days, SD 2 days), because the second rehabilitation period of this program was not scheduled as the Working Ability program. All questionnaires were code-numbered in the rehabilitation center and sent to the researchers for statistical recording.

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Description of the Employee Rehabilitation Intervention

The aims and contents of the two intervention programsVitality and Working Abilitywere basically similar during the rst rehabilitation period, the focus in the present study. Both programs aimed at maintaining and improving the participants working ability and prerequisites for continuing working. In addition, both interventions are based on a multidisciplinary and holistic approach; that is, the interventions include a comprehensive evaluation of participants physical, psychological, and social conditions. On the basis of these evaluations, all of the participants receive a personal rehabilitation plan, which they follow throughout the rehabilitation process and, it is hoped, after the rehabilitation process has ended. Individuals suffering from physical or psychological problems participated in both programs. Although, in particular, the Vitality program is aimed at burned-out individuals, the Working Ability program may also include clients with burnout symptoms. Employees are referred to a specic rehabilitation program on the basis of their primary diagnosis. Both programs consist mostly of a xed set of programmatic activities, but some activities based on individual needs, such as physical exercise, are also available. The focus in both programs is primarily on the individual and partly on the individual organizational interface (see Le Blanc, de Jonge, & Schaufeli, 2000; Schaufeli & Enzmann, 1998). Generally, individual-level interventions aim at increasing the individuals awareness and ability to cope with stress, whereas interventions aiming at the individual organizational interface focus on increasing the employees resistance to specic job stressors in the context of his or her working environment. The Vitality program is aimed at employees who are under 50 years of age and have become exhausted by their work. They may suffer from one or more of various jobrelated psychological health problems, such as work stress, burnout, and decreased self-esteem. The participants send their medical report and rehabilitation application to the local ofce of the Social Insurance Institution of Finland, from where the papers are delivered to a rehabilitation center. The selection of the participants to the Vitality intervention program is made by the physicians of the rehabilitation center. Participants go through the rehabilitation process in groups of 8 to 10 clients. The purpose of this intervention is to restore, maintain, and improve individuals physical, psychological, and social resources by nding practical solutions to the problems of coping in working life. The idea of this intervention is that the employee nds ways in which to recognize and evaluate his or her own resources and working situation to be able to monitor and recognize the warning signs of impending psychological health problems or to nd ways of helping himself or herself in the recovery process. During the rst period of this program (12 days), various individual (e.g., physical exercises) and group-based activities (e.g., discussions on work-related issues) are engaged in, which mainly focus on improving the individuals coping resources. In this program the rehabilitation activities are more group-based and the participants psychosocial functioning is usually at a lower level than that of the participants in the Working Ability program (Pekkonen, Mannikko, Sorensen, & Alen, 2002). The con

tent of this rehabilitation program is shown in more detail in Table 1. The Working Ability rehabilitation intervention is targeted at employees who are 40 to 60 years of age and whose working ability has generally been reduced or threatened by disease, disability, or other disorder. The participants usually seek rehabilitation when the actions taken by their employer and by occupational health care services to improve their situation have failed. When the client has received sickness allowance at least for 60 days, the Social Institution of Finland is under law required to assess a clients need of rehabilitation. Based on this fact and the clients medical report and rehabilitation application, the decision of the selection to the Working Ability intervention is made by medical experts in the local ofces of the Social Insurance Institution of Finland. The fact that the participants working ability has already diminished or is threatened for one reason or another is the most distinctive difference between the two employee rehabilitation intervention programs. The main purpose of the Working Ability program is to help the participants to nd ways of supporting their possibility to continue in their work. Also in this program rehabilitation occurs in groups, in this case comprising from four to six clients, and includes individual (e.g., physical exercises) and group-based activities (e.g., discussions on work-related issues). However, the activities during the rst period of this program (13 days) are more individual-centered and multidisciplinary-oriented than in the Vitality program, and the participants physical functioning is at a lower level compared with the participants in the Vitality program (Pekkonen et al., 2002; see Table 1 for more details).

Measures
Job burnout. The MBIGS was used to assess occupational burnout (Maslach et al., 1996). The MBIGS consists of 16 statements and three subscales: exhaustion, cynicism, and professional efcacy. High scores on exhaustion (5 items; Time 1 .95, Time 2 .94) and cynicism (5 items; Time 1 .86, Time 2 .83) and low scores on professional efcacy (6 items; Time 1 .80, Time 2 .85) are indicative for burnout. The items were rated on a 7-point frequency-based scale (0 never, 6 every day). Job conditions. For the subjective evaluation of working conditions, one job demand factor (time pressures at work) and three job resources factors (job control, workplace climate, and supervisor satisfaction) were measured. Time pressures at work were assessed with four items (Time 1 .74, Time 2 .66). Job control was measured by nine items in which respondents were asked to evaluate their possibility to control certain aspects of their work (e.g., workload, quality of work, and working pace; Time 1 .89, Time 2 .89). The quality of the workplace climate was measured with ve items, which described the atmosphere in the workplace (Time 1 .84, Time 2 .88). These three measures have been widely used in Finnish occupational studies and validated by the Finnish Institute of Occupational Health (Bergstrom et al., 1997; Elo, Lep panen, Lindstrom, & Roponen, 1990). Supervisor satisfac tion was assessed using three items (Time 1 .87, Time 2 .89) from the Finnish version of the Job Diagnostic Survey (Vartiainen, 1989). All of the working conditions

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Table 1 Focus and Contents of the Two Employee Rehabilitation Intervention Programs
Employee rehabilitation intervention Vitality and energy for working life (Vitality) Target group and duration of the rst intervention period Employees under 50 years of age with jobrelated psychological problems Duration: 12 days Focus on individualorganizational interface Group discussions on work-related issues Individual counseling session with psychologist (2 60 min) (e.g., stress management, work and private life interface, time management) 3 content according to individual needs

Focus on individual Tests and examinations by physician and physiotherapist (e.g., ECG, medical and physiotherapy examinations, physical capacity tests) Group discussions and lectures by physician (e.g., medical treatment), psychologist (e.g., stress management; burnout), psychiatrist (e.g., depression, psychotherapies), and physiotherapist (e.g., ergonomics, physical exercise) Physiological and occupational therapy Physical exercise activities and relaxation Tests and examinations by physician and physiotherapist (e.g., ECG, medical and physiotherapy examinations, physical capacity tests) Social evaluation (112 hr) by a social worker Group discussions and lectures by physician (e.g., medical treatment), psychologist (e.g., workload), physiotherapist (e.g., ergonomics, workload) and physical education instructor (e.g., physical exercise) Physical exercise activities and relaxation Physiotherapeutic training

Maintaining and promoting working ability (Working ability)

Employees about 4060 years of age whose working ability is threatened or has already decreased Duration: 13 days

Group discussions on work-related issues Individual counseling session with psychologist (112 hr) (e.g., stress management, psychosocial factors at work) 3 content according to individual needs

items were rated by using a 5-point Likert-type response scale (1 strongly agree, 5 strongly disagree). Personal resources. The 21-item shortened version of the Coping Inventory for Stressful Situation (Endler &

Parker, 1990) was used to measure task-oriented coping (7 items; Time 1 .83, Time 2 .86), emotion-oriented coping (7 items; Time 1 .83, Time 2 .82), and avoidance-oriented coping (7 items; Time 1 .72, Time

BURNOUT PATTERNS IN REHABILITATION 2 .68). The extent to which each strategy has been used in a stressful situation at work was rated on a 5-point Likert-type scale (1 not at all, 5 very much). SOC was operationalized by the shortened 13-item Orientation to Life Questionnaire (Antonovsky, 1987). Participants were asked to select a response on a 7-point semantic differential scale with two anchoring phrases. The SOC scale includes 5 items about comprehensibility (1 very often, 7 very seldom or never), 4 about manageability (1 never happened, 7 always happened), and 4 about meaningfulness (1 very seldom or never, 7 very often). The three intercorrelated components form the composite measure of the strong SOC (Time 1 .88, Time 2 .88). Depression. The Beck Depression Inventory (BDI; Beck et al., 1961) was used to measure depression. The BDI is a 21-item questionnaire asking about the degree to which the respondent is experiencing negative thoughts, feelings, and behavior. The items cover a range of general self-evaluations unrestricted to ones work or work environment. Specically, the inventory was composed of 21 symptom-attitude categories: mood, pessimism, sense of failure, lack of satisfaction, feeling of guilt, sense of punishment, self-hate, self-accusations, self-punitive wishes, crying spells, irritability, social withdrawal, indecisiveness, body image, work inhibition, sleep disturbance, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss of libido. In each category the respondent had to choose one statement (from four to six statements), which was scored from 0 to 3. The higher the BDI score (range from 0 to 63) the more severe the level of depression (Time 1 .89, Time 2 .90). The means, standard deviations, and intercorrelations for all the measures at Time 1 and Time 2 are presented in Table 2.

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Statistical Analysis
We used cluster analysis to identify natural groupings or patterns of burnout within the rehabilitation clients. This multivariate technique is a statistically sound means by which to form homogeneous groups that contain highly similar entities (Aldenderfer & Blasheld, 1984). This cluster procedure is especially useful when we do not have nation-specic and clinically validated cutoff points indicating levels of burnout, as is the case at present in Finland. Using other countries cutoff points is not recommended because burnout levels vary across countries (Maslach et al., 1996). Thus, the three standardized burnout variables at Time 1 were used as clustering variables in a hierarchical, agglomerative cluster analysis. This cluster approach begins with the same number of clusters as there are potential burnout patterns (i.e., number of individuals). At each step, clusters are joined together on the basis of their similarities, or individuals are added into existing clusters, until nally there is only one cluster. We used Wards method as a linkage method, whereby the clusters are chosen in which the variance among the cases is as small as possible (Aldenderfer & Blasheld, 1984), and squared Euclidean distance as a similarity method, which takes both the form and the level of the proles into account (Bergman & Magnusson, 1991).

According to Bergman and Magnusson (1991), the most optimal cluster solution can be obtained by starting with Wards method and then subjecting the solution to a Kmeans cluster analysis. This procedure is useful because once agglomerative hierarchical clustering starts joining the cases together, the cases cannot be moved from one cluster to another, even where another cluster would nally be a better t. K-means clustering can correct the initial cluster solution by relocating a mist case into the cluster the center of which is closest to the case. After identifying the meaningful burnout patterns, we tested the cluster solution by performing multivariate analysis of variance (MANOVA) with the three burnout dimensions at Time 1 as dependent variables (see Aldenderfer & Blasheld, 1984). Evidence for the validity of the burnout patterns was sought in the differences in the background factors (rehabilitation program, gender, age, living with a partner, vocational education, socioeconomic status, hours worked per week) by using either chi-square test or one-way analysis of variance (ANOVA). The post hoc group comparisons were performed either with Scheffes (equal variances assumed) or with Tamhanes (equal variances not assumed) test. A repeated measures MANOVA was conducted to examine whether there would be any changes in burnout symptoms between the burnout patterns after the worker rehabilitation intervention. This analysis used the group of burnout pattern as a between-groups variable and time as a repeated measure, enabling us to examine between-groups differences in burnout symptoms at both measurement times. The same procedure was used to search for changes in job conditions, personal resources, and depression between the burnout patterns. Using these external variables (i.e., variables that were not included in the original clustering) to examine the differences between the burnout patterns served also as a validation method for the nal cluster solution (Aldenderfer & Blasheld, 1984). In those instances in which two or more than one dependent variable within a domain correlated with each other, we analyzed the variables with the same MANOVA. Univariate ANOVAs were followed. Where signicant main effects occurred, post hoc comparisons were performed on the dependent variables using Bonferronis test. Additionally, the effect sizes measured with eta-square ( 2) are reported. According to Cohen (1988), the effect sizes can be classied as small (0.01 to 0.04), medium (0.05 to 0.11), and large (0.12 to 1.0). Missing data in the cluster and MANOVA analyses were treated by listwise deletion.

Results Cluster Identication and Denition

The burnout patterns were explored by cluster analysis, using the three baseline measures (exhaustion, cynicism, and professional efcacy) as the clustering variables. The number of clusters that most accurately reected the hierarchical structure of the data was decided on the basis of the dendrogram. A dendrogram is a visual representa-

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Table 2 Intercorrelations of the Study Variables at Time 1 and Time 2

Variable Time 1 1. Exhaustion 2. Cynicism 3. Reduced professional efcacy 4. Time pressures at work 5. Job control 6. Workplace climate, good 7. Supervisor satisfaction 8. Task-oriented coping 9. Emotion-oriented coping 10. Avoidance-oriented coping 11. Sense of coherence 12. Depression Time 2 13. Exhaustion 14. Cynicism 15. Reduced professional efcacy 16. Time pressures at work 17. Job control 18. Workplace climate, good 19. Supervisor satisfaction 20. Task-oriented coping 21. Emotion-oriented coping 22. Avoidance-oriented coping 23. Sense of coherence 24. Depression Note. r .18 , p .05. r .24 , p M 2.80 2.06 1.94 3.29 2.88 3.13 2.93 3.61 2.80 2.15 4.60 12.66 2.12 1.82 1.97 3.19 3.01 3.11 2.93 3.42 2.54 2.03 4.61 9.50 .01. r SD 1.71 1.50 1.24 0.78 0.86 0.88 0.97 0.76 0.82 0.70 1.11 8.89 1.46 1.40 1.32 0.57 0.76 0.90 0.92 0.81 0.74 0.60 1.06 8.78 1 .71 .36 .29 .19 .28 .38 .28 .32 .10 .57 .70 .68 .55 .35 .30 .15 .19 .26 .18 .52 .27 .48 .53 2 3 4 5 6 7 8 9

.42 .06 .27 .40 .44 .31 .43 .09 .58 .57 .50 .68 .43 .13 .24 .24 .27 .15 .50 .17 .47 .45 .001.

.00 .18 .21 .20 .43 .21 .04 .36 .45 .19 .40 .69 .08 .22 .20 .15 .44 .22 .11 .38 .28

.21 .04 .11 .00 .15 .08 .22 .29 .35 .12 .06 .69 .14 .07 .12 .02 .17 .07 .20 .07

.37 .34 .01 .14 .08 .31 .22 .14 .21 .35 .22 .75 .30 .20 .02 .19 .04 .27 .25

.47 .16 .25 .09 .44 .24 .19 .25 .21 .13 .29 .65 .33 .04 .19 .21 .30 .30

.10 .16 .07 .40 .37 .30 .27 .17 .20 .22 .37 .61 .01 .16 .17 .25 .34

.09 .13 .41 .29 .23 .30 .41 .08 .01 .15 .07 .72 .14 .02 .42 .28

.14 .42 .39 .19 .25 .23 .10 .24 .13 .11 .14 .54 .05 .34 .36

.31 , p

tion of the steps in a hierarchical clustering solution, and it identies not only the clusters being combined at each step but also the distances at which they are joined. In this study, the fourcluster solution produced clusters that contained an adequate number of individuals in interesting and interpretable ways (see Figure 1). In the threecluster solution Groups 2 and 3 clustered in one group (excluding a meaningful group, Group 2), and in the ve-cluster solution Group 1 divided into two clusters, both of which comprised individuals with rather low burnout scores and therefore did not differ in terms of conceptual clarity. Because of this, these two-cluster solutions were rejected, and the four-cluster solution was considered the best. To dene the four clusters, we performed a MANOVA with the three burnout dimensions (at Time 1) as dependent variables and the four burnout patterns as an independent variable. Due to the fact that cluster analysis is designed to nd groups that express high intracluster homogeneity and high extracluster heterogeneity, it is not surprising that the

result showed a signicant multivariate effect for the burnout pattern, F(9, 314) 71.07, p .001, 2 .59, indicating that the level of burnout symptoms differed signicantly between the four burnout patterns and the effect size was large. Univariate analyses with each burnout dimension as a dependent variable showed that these differences occurred in all three burnout symptoms: exhaustion, F(3, 135) 144.63, p .001, 2 .77; cynicism, F(3, 135) 96.00, p .001, 2 .69; and reduced professional efcacy, F(3, 134) 71.38, p .001, 2 .62. The post hoc comparisons indicated that Group 3 experienced more exhaustion than Groups 1, 2, and 4 (p .001). Furthermore, Group 2 reported more exhaustion than Groups 1 and 4 (p .001). Besides, Group 3 experienced more cynicism compared with Groups 1, 2, and 4 (p .001), and Group 2 more than Group 1 (p .001) and Group 4 (p .01). In other words, the two burnout groups that did not differ from each other in either the exhaustion or cynicism dimension were Groups 1 and 4, both of which had low scores on exhaustion and cynicism. Finally, Groups 3 and 4 reported lower professional

BURNOUT PATTERNS IN REHABILITATION

229

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

.04 .01 .09 .03 .02 .13 .01 .06 .08 .10 .01 .56 .06 .11

.67 .43 .51 .45 .28 .27 .30 .24 .25 .43 .12 .73 .56

.54 .53 .44 .29 .23 .19 .33 .22 .52 .20 .64 .70 .71 .32 .37 .08 .26 .35 .25 .43 .23 .51 .68 .47 .20 .24 .34 .32 .30 .47 .12 .57 .60

.06 .38 .30 .23 .51 .20 .01 .54 .43

.14 .12 .23 .06 .09 .14 .21 .10

.43 .30 .19 .17 .06 .30 .17

.59 .14 .12 .17 .30 .26

.04 .12 .16 .23 .23

.04 .02 .43 .26

.26 .49 .55

.05 .12

.69

efcacy than Groups 1 and 2 (p .001), of which Group 2 scored higher on reduced professional efcacy than Group 1 (p .01). The only two groups that did not differ in the reduced professional efcacy dimension were Groups 3 and 4, both of which had high scores on reduced professional efcacy. The four burnout patterns were dened on the basis of the above-described MANOVA results as follows (see Figure 1): (a) Participants who did not feel the various burnout symptoms were named as not burned out (n 55). (b) The exhausted-and-cynical pattern (n 36) comprised those who felt exhaustion and cynicism more often than on the average. (c) The pattern of burned out (n 26) comprised those suffering from all three burnout symptoms more often than on the average. (d) Those who suffered mainly from a decline in feelings of competence were named as low professional efcacy (n 18); this symptom was experienced more often than on the average. We validated the cluster solution with regard to the background variables. Only the rehabilitation pro-

gram and the burnout pattern were signicantly related to each other, 2(3, N 135) 23.80, p .001. Those belonging to the burned-out pattern participated more often in the Vitality intervention program than the Working Ability program (89% vs.11%), whereas the participants who were labeled as not burned out participated more often in the Working Ability intervention program than Vitality program (67% vs. 33%). This provides further support for the cluster solution because the Vitality intervention program was especially targeted at employees suffering from job-related psychological health problems, such as work stress and burnout. In the further analyses, the rehabilitation program was used as a covariate. Besides this, because the two interventions are targeted at the workers of different ages and health problems, we added age (in years) and self-reported prolonged illnesses (asked by a single question How many prolonged illnesses diagnosed by the physician do you have at the moment? at the baseline) as continuous variables into the analyses as covariates. The three covariates did not correlate with each other.

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Figure 1. Mean z scores of the three burnout dimensions (Time 1) within the four burnout patterns. Ex exhaustion; Cy cynicism; Pe professional efcacy.

Short-Term Changes in Perceptions of Burnout Symptoms, Job Conditions, Personal Resources, and Depression Within the Burnout Patterns
We performed 4 (burnout pattern) 2 (time) multivariate analyses of covariance (MANCOVAs) using the type of rehabilitation program, age, and prolonged illnesses as covariates to analyze the shortterm changes in burnout symptoms, job conditions, personal resources, and depression after employee rehabilitation. In those instances in which the variables in a domain correlated with each other, we analyzed them simultaneously. The results of these analyses are shown in Table 3. Burnout symptoms. The three burnout symptoms served simultaneously as dependent variables in the MANCOVA analysis. After adjusting for covariates, a signicant Group Time interaction effect was identied for the burnout dimensions, F(9, 263) 5.34, p .001, 2 .13. Thus, the burnout symptoms differentiated between the burnout pattern groups over time. There was also a signicant multivariate main effect found for burnout pattern, F(9, 263) 30.19, p .001, 2 .44, as the denition of the patterns already showed. At the univariate level there was a signicant Group Time effect identied for each burnout symptom: exhaustion, F(3, 110) 10.74, p .001, 2 .23; cynicism, F(3, 110) 4.85, p .01, 2 .12; and professional efcacy, F(3, 110) 4.26, p .01, 2 .10. These

interactions meant (see Table 3) that, rst, exhaustion showed a decreasing trend especially in the burnedout and exhausted-and-cynical patterns compared with the two other patterns. Second, there was a decreasing trend in cynicism in the burned-out pattern. Finally, reduced professional efcacy showed an increasing trend in the exhausted-and-cynical group, whereas in the low-professional-efcacy pattern the trend was decreasing. Job conditions. After adjusting for the three covariates, the MANCOVA for time pressures at work showed neither a signicant interaction nor main effects (see Table 3 for means). All job resources (job control, workplace climate, supervisor satisfaction) correlated with each other, and thus they all served simultaneously as dependent variables in the analysis, in which the effects of the three covariates were also controlled. The Burnout Pattern Time interaction effect was not signicant. However, signicant multivariate main effect for burnout pattern, F(9, 248) 1.93, p .05, 2 .05, was observed. At the univariate level there was a main burnout pattern effect for job control, F(3, 104) 2.97, p .05, 2 .08; workplace climate, F(3, 104) 3.31, p . 05, 2 .09; and supervisor satisfaction, F(3, 104) 2.98, p .05, 2 .08. In the pairwise comparisons any differences between job control and supervisor satisfaction were not detected, but those who were burned out reported worse quality of workplace climate (p .05) compared with those who

Table 3 Short-Term Changes in Psychological Health, Job Conditions, and Personal Resources According to the Four Burnout Patterns
(2) Exhausted and cynical (n 36) F value Group effecta 4.03* 0.31 Time effect Group Time 10.74*** 4.85** Time 1 M 3.90 2.47 2.25 4.48 3.42 1.54 1.68 2.92 4.53 3.06 1.81 1.50 Time 2 M Time 1 M Time 2 M Time 1 M Time 2 M (3) Burned out (n 26) (4) Low professional efcacy (n 18)

(1) Not burned out (n 55) Time 2 M 1.53 1.14

Outcome variable

Time 1 M

Psychological health Exhaustion (n 117) 41.26*** 2, 3 1, 4 45.12*** 2, 3 1, 4 3 2

1.46

Cynicism (n

117)

0.95

Reduced professional efcacy (n 117) 1.12 5.93 3.13 3.14 3.23 3.10 3.69 2.34 1.94 5.02 2.22 4.22 2.20 4.48 2.15 3.72 2.91 2.72 3.32 3.59 3.40 3.48 3.25 3.16 2.24 3.80 2.59 2.75 2.60 2.49 2.93 2.87 2.58 2.67 3.19 3.04 3.17 2.57 1.95 4.63 3.37 2.57 3.32 2.89 3.35 2.58 3.24 2.62 3.08 2.72 3.21 2.83 3.33 3.15 2.91 2.29 1.89 4.62 15.39 12.63 19.01 12.43 10.68 9.30 1.66 2.20 3.44 3.16 3.34 2.92

0.98

1.00 10.49**

4.26** 2.23

Depression (n

98)

7.31

52.83*** 3, 4 1, 2 2 1 9.66*** 2, 3 1 0.53 2.97*

Job conditions Time pressures (n 120) Job control (n 111) Workplace climate, good (n 111)

3.25 3.07

0.14 3.97* 0.58 0.10 6.09** 1 4 7.12*** 3 1, 4 1.15 10.51*** 4 3 1 2, 3 0.30 1.93 0.15 2.45

0.87 1.33 0.65 0.73 0.05 0.08 0.79 1.83

3.35

BURNOUT PATTERNS IN REHABILITATION

Supervisor satisfaction (n 111) Personal resources Task-oriented coping (n 117)

3.18

3.31* 1 3 2.98*

3.90

Emotion-oriented coping (n 117)

2.55

Avoidance-oriented coping (n 117) Sense of coherence (n 123)

2.11 5.18

Note. Rehabilitation program, age, and number of prolonged illnesses served as covariates in all analyses. a Pairwise comparisons with Bonferronis test. * p .05. ** p .01. *** p .001.

231

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HATINEN, KINNUNEN, PEKKONEN, AND ARO

were not burned out. Finally, a main time effect at the univariate level was found for job control, F(1, 104) 3.97, p .05, 2 .04. Participants in every pattern experienced that their job control increased during the 4-month follow-up. Personal resources. All individual resources (three coping strategies and SOC) were analyzed in separate MANCOVAs. After adjusting for the covariates, no signicant Burnout Pattern Time interaction effect was identied for any of the coping strategies (task-oriented, emotion-oriented, or avoidance-oriented coping). However, a signicant multivariate main effect for burnout pattern, F(3, 110) 6.09, p .01, 2 .14, was observed for taskoriented coping. Participants who were not burned out used more task-oriented coping than those who experienced low professional efcacy (p .01). For emotion-oriented coping, a signicant multivariate main effect was also observed for burnout pattern, F(3, 110) 7.12, p .001, 2 .16. In the pairwise comparisons, burned-out participants used more emotion-oriented coping compared with those who belonged to the patterns of low professional efcacy (p .01) and not burned out (p .001). No significant effects were observed for avoidance-oriented coping. For SOC, neither a signicant Group Time interaction effect nor multivariate main effect for time was identied. Instead, a signicant main effect for burnout pattern was observed, F(3, 116) 10.51, p .001, 2 .21. The pairwise comparisons revealed that the not-burned-out group experienced stronger SOC compared with the exhausted-and-cynical (p .01) and burned-out (p .001) groups. In addition, participants who reported low professional efcacy had a stronger SOC than the participants who were burned out (p .05). Depression. No signicant Burnout Pattern Group Time interaction effect was obtained for depression. Instead, signicant main effects for time, F(1, 91) 10.49, p .01, 2 .10, and burnout pattern, F(3, 91) 9.66, p .001, 2 .24, were identied. The level of depression declined at a follow-up 4 months later in every pattern. According to the pairwise comparisons, those belonging to the exhausted-and-cynical (p .001) or burned-out pattern (p .001) experienced more depression than those who were not burned out.

Discussion
The results showed that the employees in the two rehabilitation programs manifested burnout symptoms in different ways. We identied four homoge-

neous and meaningful burnout patterns: not burned out, exhausted and cynical, burned out, and low professional efcacy. These burnout patterns differed in terms of job and personal resources, as well as depression. Additionally, after adjusting for the covariates (type of rehabilitation program, age, and number of prolonged illnesses), the changes observed in the rehabilitation clients burnout during the 4-month period depended on the burnout pattern membership. The levels of exhaustion and cynicism showed a decreasing trend in the burned-out pattern, whereas the levels of exhaustion and professional efcacy showed a decreasing trend in the exhausted-and-cynical pattern. Professional efcacy showed in turn an increasing trend in the low-professional-efcacy pattern. Furthermore, depression decreased and job control increased during the 4 months after the employee rehabilitation. One burnout pattern was characterized by high levels in all the burnout symptoms (i.e., the burnedout pattern) and one by low levels in all the burnout symptoms (i.e., the not-burned-out pattern). However, no burnout patterns were identied in which the participants would have experienced only exhaustion or cynicism. Instead, we identied two further burnout patterns, which can be interpreted in the light of the developmental models of burnout. Leiters (1993) process model suggests that emotional exhaustion is the rst reaction to demanding work. Consequently, when other coping strategies have failed to reduce stress, one tries to cope with the situation by depersonalization. These two symptoms may, therefore, have clustered in these data as the exhausted-andcynical pattern, describing the situation in which people have resorted to defensive coping (depersonalization) as a consequence of the depletion of their emotional resources. In addition, Leiter proposed that personal accomplishment develops rather independently of the two other burnout symptoms depending on the available resources, and this may explain the existence of the pattern of low professional efcacy. Altogether, the burnout patterns found in our study were in line with our hypotheses. Our cluster solution can also be interpreted in the light of the phase model of burnout development (Golembiewski & Munzenrider, 1988). Applying this model to the four burnout patterns found in this study, not burned out (Phase I) and low professional efcacy (Phase III) represent the early phases of burnout development, whereas exhausted and cynical (Phase VI) and burned out (Phase VIII) represent progressed phases of burnout. Parallel to the phase model, the COR theory contributes to the understand-

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233

ing of burnout development by suggesting that when resource loss occurs and if resources cannot be replenished, cycles of losses may follow and this, in turn, eventually leads to burnout (Hobfoll & Shirom, 2001). The implication for the development of burnout is that only one type of burnout symptom may appear at rst, expanding over time nally to include all the symptoms of burnout (Taris et al., 1999). In other words, the more the burnout symptoms, the later the phase in burnout development and the more severe the burnout condition. The four-cluster solution was also supported by differences in one background factor. Burned-out individuals participated more often in the Vitality intervention program, whereas the respondents who were not burned out participated more often in the Working Ability intervention program. Because the Vitality intervention program is designed especially for those employees who suffer from job-related psychological health problems, such as burnout, the cluster analysis succeeded in placing the rehabilitation clients in the correct groups. Additionally, the four burnout patterns differed in terms of job resources, personal resources, and depression, indicating the validity of the cluster solution (see Aldenderfer & Blasheld, 1984). This study conrmed the previous ndings that exhaustion could be the easiest symptom to alleviate by interventions (e.g., Cooley & Yovanoff, 1996; Schaufeli, 1995; van Dierendonck et al., 1998). Exhaustion decreased in both the burned-out and exhausted-and-cynical patterns. Also, the level of cynicism seemed to decrease in the burned-out pattern, and professional efcacy showed an increasing trend in the low-professional-efcacy pattern. However, contrary to our expectations one negative trend was detected: Professional efcacy was reduced in the exhausted-and-cynical pattern 4 months after the postintervention. This negative tendency in burnout development may nevertheless indicate that diminishing professional efcacy is, as a matter of fact, one part of the recovery process. In the intervention study of van Dierendonck et al. (1998), personal accomplishment diminished 6 months after a 5-week groupbased burnout intervention program, returning, however, to the baseline level after 1 year. The authors suggested that this temporary decrease in personal accomplishment might actually be a positive effect, because the intervention program may have sensitized the participants to a greater awareness of their professional situation, leading to a critical perception of their personal accomplishments. This awareness can be regarded as a positive outcome, because peo-

ple who suffer from burnout may not acknowledge their own situation (Freudenberger, 1974). Unfortunately, we still cannot rule out the fact that the reduced professional efcacy in the exhausted-andcynical pattern may also imply that these individuals are on their way to becoming totally burned out. Finally, the question remains as to whether the two burnout symptoms that decreased after rehabilitation would in any case have decreased without treatment. However, as such, untreated burnout symptoms have turned out to be quite stable across time (Schaufeli & Enzmann, 1998), and therefore they are not likely to disappear without any treatment. Our expectations in relation to differences between the various burnout patterns in job conditions and personal resources over time were partly met and consistent with the ideas of the COR theory. However, contrary to our hypothesis, there were no differences in the perceptions of job demands between the four patterns over time, as main effects either for group or for time. This implies that time pressures at work operated as a work stressor to some extent for all the rehabilitation clients. Furthermore, as the COR theory suggests, burned-out individuals have experienced major losses in their lives and therefore have few resources left (Hobfoll & Freedy, 1993; Hobfoll & Shirom, 2001). In this study, resource losses were indeed apparent in those burnout groups in which two or three symptoms dominated. As we hypothesized, burned-out participants had fewer job resources (lower supervisor satisfaction) and fewer personal resources (lower SOC) than not-burned-out participants; however, the exhausted-and-cynical participants also experienced a lower level of personal resources (SOC) compared with the not-burned-out participants. More specically, when studying the relationships between burnout and coping strategies, employees who suffered from low professional efcacy reported less use of task-oriented coping than employees who were not burned out. The relationship between taskoriented coping and personal accomplishment has been found in other studies as well (Greenglass & Burke, 2000; Lee & Ashforth, 1996; Leiter, 1991; Sears et al., 2000). According to Lee and Ashforth (1996), a problem-focused, active response to problems and a positive evaluation of the self may reinforce each other. Following this line of thought, participants who experienced low professional efcacy may have felt that they were incompetent and inefcient in handling problems proactively, and therefore did not engage in task-oriented coping. Furthermore, previous studies have proposed that

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emotion-focused coping has been associated with high levels of burnout (Sears et al., 2000), which was also conrmed in this study: Burned-out clients reported more use of emotion-oriented coping than clients in the low-professional-efcacy and notburned-out patterns. Previous studies have also demonstrated the associations between low SOC and burnout (Soderfeldt et al., 2000). A person with a high SOC can handle stressors better than one with a low SOC (Antonovsky, 1987; Feldt, 1997; Soderfeldt et al., 2000). It is not surprising therefore that the not-burned-out participants experienced a stronger SOC than the exhausted-and-cynical and burned-out participants, or that participants in the low-professional-efcacy pattern experienced a stronger SOC than those who were burned out. Although Antonovsky (1987) assumed that SOC is a relatively stable characteristic in adults, there are research results to show that the level of SOC can change in adulthood (Feldt, Leskinen, Kinnunen, & Mauno, 2000). For example, Feldt et al. indicated that alterations in the work environment may change individuals SOC. Therefore, it would be important to target rehabilitation activities on improving working conditions to promote SOC, which in turn can promote the recovery from burnout. We hypothesized that especially personal resources would increase in the 4 months following rehabilitation. However, there were no changes identied in these outcome variables. Contrary to our expectations, of job resources, job control did increase to some extent during the 4-month follow-up, suggesting that the rehabilitation succeeded in promoting clients abilities to control certain job characteristics. No improvements in workplace climate and supervisor satisfaction were identied after the rehabilitation programs. The reason for this may be due to the short follow-up but may also be due to the nature of the rst rehabilitation period, which was carried out in the rehabilitation center away from the employees workplace, and which did not focus on changing actual jobs or job conditions. It must be remembered that the total rehabilitation process is far longer, including three to four rehabilitation periods, and that later on, as the rehabilitation process proceeds, the focus of intervention will be shifted more onto the organizational level. According to the COR theory, depression appears at an advanced stage in the burnout process (Hobfoll & Shirom, 2001), which was evident in the fact that the burned-out pattern had the highest scores for depression. The relationship between burnout and depression has been found in previous studies as well

(Glass et al., 1993; Landsbergis, 1988; McKnight & Glass, 1995). Because depression is considered to be a consequence of burnout (Burke et al., 1996; Cooper et al., 2001; Glass et al., 1993; Leiter & Durup, 1994), alleviating depressive symptoms in burnedout individuals would be a sensible rst step when starting the rehabilitation process. The employee rehabilitation interventions in this study seemed to be successful in this regard. Four months after the employee rehabilitation intervention, both positive and negative changes were detected in the participants psychological health. To be able to affect burnout and the underlying causes of burnout more efciently, intervention programs should focus more on changing the situational and organizational factors that may have had a greater role in the development of burnout than the individual ones (Maslach, 2000; Maslach et al., 2001). The COR theory also suggests that interventions should place greater emphasis on the objective job factors that more permanently shape individuals perception of job stressors (Hobfoll & Freedy, 1993). Metaanalyses and reviews on work stress and burnout interventions have also stressed that individually oriented interventions do not include sufcient actions to take care of the causes that underlie burnout development (Ganster & Murphy, 2000; Murphy, 1996; van der Klink et al., 2001). This does not mean that interventions should concern themselves solely with changing job or job conditions, but instead that interventions that combine both an individual and organizational level focus could be the most benecial solution in reducing and preventing burnout (Maslach, 2000; Maslach et al., 2001). Nevertheless, in this study, burnout symptoms decreased regardless of the fact that no actions were thus far taken in clients workplaces during the follow-up. From the practical point of view, the most important implication in this study relates to the four patterns of burnout, which occupied different positions during the rehabilitation process, that is, patterns characterizing people who are differently burned out in terms of job resources, personal resources, and psychological health. Recognizing the different patterns of burnout and knowing how these patterns are related to various job- and individual-related outcomes will enable rehabilitation professionals to focus their intervention activities more effectively. Although there were no positive changes detected during the follow-up in the job resources (except for job control) or personal resources, we consider that it is very important to study whether this treatment strategywhich is costly for the society, employers,

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235

as well as employeesis actually successful. This study revealed that to some extent the rehabilitation intervention (which lasted for 2 weeks) was already efcient; this concerned especially the burned-out clients. As mentioned before, these interventions will continue, and we shall be able to study their longterm effects in the future. Employees may need longer treatment period to regain their resources and working ability. Besides, burnout usually develops gradually, over many years; therefore, it is natural to expect that the recovery process also requires several years. The employee rehabilitation intervention seemed to be most useful for the burned-out clients, who had the greatest lack of personal resources and suffered most from psychological health problems compared with the other patterns. For burned-out clients the rst step in rehabilitation is to alleviate burnout symptoms and depression. After that the target of the intervention should also focus on the organizational level due to the fact that the burned-out employees reported worse interpersonal relations (poor workplace climate and dissatisfaction with supervision), a situation that can only be remedied by organizational-oriented intervention activities. Furthermore, for individuals who suffer from reduced professional efcacy, supporting and guiding them in proactive ways of handling problems at work could be the most useful rehabilitation strategy. There are a number of limitations concerning the present study. First, the sample size was small and the grouping of rehabilitation clients was based on cluster analysis. To test whether the same cluster solution has any generalizability, one should replicate the solution repeatedly across other samples in the same general population (Aldenderfer & Blasheld, 1984). The second limitation concerns the fact that there was no control group. We cannot be sure whether the differences in outcome variables that occurred during the 4 months are due to the intervention programs, although at least burnout and depressive symptoms have turned out to be stable without treatment. Third, because the sample for this study consisted of employees whose need for rehabilitation services had been established by a physician, the results of this study can only be generalized to the working rehabilitation population. On the other hand, this study is valuable, particularly on account of the nature of this sample, which comprised a group of individuals who had sought rehabilitation particularly because of burnout; therefore, the healthy worker effect was partly avoided. In addition, those differences between the burnout patterns and the changes

over time found in our study can be considered reliable, because we were able to control for confounding factors in our analyses.

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Received February 28, 2003 Revision received June 11, 2003 Accepted October 1, 2003 y