Received 11/16/19

Revised 05/02/20
Accepted 05/04/20
DOI: 10.1002/jcad.12376

Cost Borne by the Counselor:

Comparing Burnout Between
Dialectical Behavior Therapy (DBT)
Counselors and Non-DBT Counselors
Craig A. Warlick, Nicole M. Farmer, Bruce B. Frey, Kaylee Vigil,
Abigail Armstrong, Thomas S. Krieshok, and Juliet Nelson
Although counseling in itself can be a stressful task, counseling complex clients can exacerbate this stress and can
lead to burnout. Burnout negatively affects the counselor’s personal life, client care, and the health care system.
Dialectical behavior therapy (DBT) is a multimodal treatment designed specifically for treating complex clients.
The treatment contains counselor supports to protect against burnout. This study used a national sample of 209
counselors to assess whether DBT counselors (n = 87) possess higher levels of burnout than non-DBT counselors
(n = 122). The results suggest that despite literature stating that working with complex clients increases counselor
burnout, there was no difference in client-related burnout between DBT counselors and non-DBT counselors.
However, DBT counselors had higher levels of personal burnout and work-related burnout compared with non-DBT
counselors, even after controlling for known covariates. Implications for future research and practice regarding
mitigating counselor burnout are discussed.

Keywords: counselor burnout, Copenhagen Burnout Inventory, dialectical behavior therapy, public-domain instruments,
mindfulness

Although counseling in itself can be a stressful task, coun-
seling complex clients (e.g., those with complex trauma or
personality disorders) increases the likelihood of experienc-
ing stress and can lead to burnout (Perseius et al., 2007).
Burnout leads to negative consequences for the provider, for
the client, for therapeutic outcomes, and for the entire health
care system (Garcia et al., 2014). It is widely acknowledged
in the health care community that clients with a diagnosis of
borderline personality disorder (BPD) can be challenging and
difficult to treat (Linehan et al., 2000). Dialectical behavior
therapy (DBT), a multimodality treatment, is often used to
treat these complex clients (Linehan, 1993). DBT has shown
positive effects in the treatment of other complex clients, such
as individuals with binge eating disorder (Safer et al., 2010),
individuals with treatment-resistant depression (Harley et
al., 2008), and veterans who are at high risk for suicide (M.
Goodman et al., 2016), among other populations. Many mental
health professionals have begun modifying DBT to assimilate
it into their practice (DiGiorgio et al., 2010). Developed with
an awareness of complex client characteristics, DBT is embed-
ded with counselor supports to protect against client burnout,
which suggests that counselor burnout can be mitigated (e.g.,
consultation team, specific treatment roles for counselors,
multiple team members facilitating client treatment; Linehan,
1993). However, no known literature has compared burnout
between counselors who practice DBT and counselors who
practice other treatment orientations. The present study exam-
ined this gap using a national sample of counselors.
Burnout
Burnout remains a common experience for mental health
providers, with about 67% of counselors experiencing it
(Morse et al., 2012). Burnout is characterized by emotional
exhaustion, depersonalization, and reduced feelings regarding
personal accomplishment (Maslach et al., 1996). The cost

Craig A. Warlick and Abigail Armstrong, School of Psychology, University of Southern Mississippi; Nicole M. Farmer, Department
of Veterans Affairs, Tucson, Arizona; Bruce B. Frey and Thomas S. Krieshok, Department of Educational Psychology, University
of Kansas; Kaylee Vigil, Federal Bureau of Prisons, Englewood, Colorado; Juliet Nelson, DBT Center of Lawrence, Lawrence,
Kansas. We extend our gratitude to the many counselors who contributed to this study. Correspondence concerning this article
should be addressed to Craig A. Warlick, School of Psychology, University of Southern Mississippi, Owings-McQuagge Hall 213B,
Hattiesburg, MS 39401 (email: craig.warlick@usm.edu).

© 2021 by the American Counseling Association. All rights reserved.

302 Journal of Counseling & Development ■ July 2021 ■ Volume 99
Comparing Burnout Between DBT Counselors and Non-DBT Counselors
of this common experience often affects multiple domains
(Schaufeli et al., 2009).
Kristensen et al. (2005) focused their investigation of burn-
out on those who work in the fields of human service (e.g., home
health care service, psychiatric hospitals). They illustrated how
fatigue and exhaustion influence one’s life in three specific
spheres: (a) personal burnout, (b) work-related burnout, and (c)
client-related burnout. Personal burnout refers to fatigue and
exhaustion felt by the provider even outside of the workplace.
Work-related burnout refers to exhaustion from work factors
excluding clients, such as feeling that every hour of work is
tiring. Client-related burnout emphasizes fatigue and exhaus-
tion associated with work tasks specifically involving clients.
Counselor burnout affects clients. It has a negative impact
on quality of care (Leiter et al., 1998), counselor outcomes
(Delgadillo et al., 2018), client dropout (McCarthy & Frieze,
1999), client satisfaction (Garman et al., 2002), and feelings
about client recovery (Salyers et al., 2013). Counselors report
that burnout negatively affects the quality of care they provide
to clients (Salyers et al., 2015). In short, burned-out work is
impaired work (Maslach & Leiter, 2016).
Burnout also affects the counselor and is negatively associated
with years of experience (Farber, 1990). Among medical provid-
ers, burnout is positively related to substance misuse (Jackson
et al., 2016), declines in physical health (Lheureux et al., 2016),
and even increases in suicidal risk (Kuhn & Flanagan, 2017).
Burnout extends beyond the client and the counselor to
the larger organization. In organizational systems, burnout is
associated with the amount of time allocated only for client
care (Garcia et al., 2014). Burnout also spreads among teams
(Bakker et al., 2005) and negatively affects staff outcomes
(Lasalvia et al., 2009), absenteeism (Maslach, 1978),
productivity (Dewa et al., 2014), retention (AbuAlRub &
Al-Zaru, 2008), and professionalism (Holmqvist & Jeanneau,
2006). Burnout incurs financial costs in terms of productivity,
turnover, and the training of new hires (Stoller et al., 2001).
In mental health care, burnout is common (Morse et al.,
2012), and issues related to absenteeism, productivity, and
professionalism will also negatively affect client care.
An absent counselor cannot see clients, a counselor with
production issues is not providing care to as many clients
as needed, and an unprofessional counselor should not be
seeing clients. Even work-related burnout affects client care.
As Schaufeli et al. (2009) stated, “Burnout is an end stage”
(p. 204) with a process, rather than being a sudden random
occurrence. Mitigating counselor burnout improves client care
(Kim et al., 2018). Better detecting who is at risk for burnout
remains crucial for counselors, clients, and the system.
Burnout and DBT
For DBT clients, counseling “is like climbing out of hell
on a red-hot aluminum ladder with no gloves or shoes”
Journal of Counseling & Development ■ July 2021 ■ Volume 99
(Linehan, 1993, p. 210). This vivid metaphor reminds
counselors that counseling this clientele is not always
easy. Also, in the counselor-client dyad, there are costs
borne by the counselor who provides counseling to DBT
clients. These clients often have problems managing affect
(Conklin et al., 2006), are more likely to use self-harm
and drugs as regulation strategies (J. Paris, 2002), and are
more likely to attempt suicide (Blasco-Fontecilla et al.,
2009). Clients with this level of dysregulation often make
demands of their mental health practitioners (Linehan,
1993). Sciberras and Pilkington (2018) provided qualitative
data from psychologists who worked with clients with severe
pathology and described these clients as “the hardest clients”
(p. 153). One psychologist, who felt not properly trained for
this level of complex pathology, remarked “I suffered a lot”
(p. 153). As a result, mental health professionals who work
with this population may develop hopelessness (Linehan et al.,
2000). These factors may lead to counselors feeling burned
out (Federici & Wisniewski, 2013). Acker and Lawrence
(2009) suggested that treating severe mental illness is
associated with a lower sense of competence and a higher level
of burnout among counselors. Additionally, counselors may
encounter legal and professional consequences with high-risk
clients (Swenson, 2016). In short, clients with BPD traits are
recognized as stressful for counselors to treat (Perseius et al.,
2007). However, DBT has become a treatment modality not
solely for those with BPD but for many “hard to treat” clients
(Federici & Wisniewski, 2013, p. 323; see also Harley et al.,
2008). While diagnostically diverse, clients who are enrolled
in DBT are assumed to demonstrate behaviors that warrant
their inclusion in this intensive program.
DBT was designed to treat clients with behaviors
that may contribute to burnout. Linehan (1993) outlined
the protective mechanisms of this treatment, including
specific treatment roles for counselors, multiple team
members facilitating the treatment of a client, an insis-
tence on counselors’ practicing skills, and a consultation
team’s accountability. Despite a small sample size, quan-
titative evidence in Carmel et al.’s (2014) study showed
that merely training counselors in DBT can mitigate
burnout. And Perseius et al.’s (2007) study to verify that
DBT helps with burnout has been supported qualitatively
among experienced psychiatric hospital providers who
were implementing DBT. There is additional physiologi-
cal evidence as well. Among counselors-in-training who
were treating suicidal clients who exhibited BPD traits,
the counselor trainees who used DBT had lower salivary
cortisol biomarker levels over time compared with those
who used a psychodynamic approach (Miller et al., 2011).
Furthermore, among DBT counselors, greater DBT skill
usage is also associated with lower levels of burnout
(Jergensen, 2018), suggesting that DBT treatment is as-
sociated with some protections against burnout.
303

Mindfulness and Burnout
One skill that has been found to mitigate burnout is mindful-
ness, defined as “a way of paying attention in a particular way:
on purpose, in the present moment, and nonjudgmentally”
(Kabat-Zinn, 1994, p. 4). Mindfulness is a core behavioral
skill module of DBT (Linehan, 1993). Perseius et al. (2007)
provided qualitative evidence that mindfulness practice was
viewed as particularly helpful for hospital providers imple-
menting DBT for burnout. Among DBT counselors, mind-
fulness skills were found to be the most used and the most
helpful at mitigating work stress (Jergensen, 2018).
However, mindfulness and its benefits are not unique to
DBT. Surguladze et al. (2018) found evidence suggesting
that trait mindfulness is a protective factor against burnout
among mental health providers. Trait mindfulness is also
malleable, with research suggesting that repeated increases
in state mindfulness are associated with increases in trait
mindfulness (Kiken et al., 2015). This malleability has led
to decreased burnout levels after mindfulness training in
physicians (Fortney et al., 2013; Krasner et al., 2009); nurses
(Bazarko et al., 2013); and a sample of health care providers,
including physicians, nurses, psychologists, and social workers
(M. J. Goodman & Schorling, 2012). A meta-analysis study
suggested that mindfulness training is effective at reducing job
burnout among health care professionals and teachers (Luken
& Sammons, 2016).
Self-care mitigates burnout (Rupert & Kent, 2007). As
part of a counselor’s professional responsibility, self-care is
embedded in the ACA Code of Ethics (American Counseling
Association [ACA], 2014, Section C: Professional Responsi-
bility). Within DBT, self-care is characterized as an element
of adherent treatment. This characterization is done through
mandating integration of mindfulness and other DBT skills
into a counselor’s own practice and the counselor consulta-
tion team, which serves as a continuous form of support and
supervision (Linehan, 1993). Nevertheless, counselor burnout
remains an issue. The impairment associated with burnout
leads one to question the effectiveness of such treatment.
DBT counselors remain integral to the treatment of many
individuals, but the effects of burnout may negatively affect
their work with clients.
To improve client outcomes, one must examine counselor
burnout (Carmel et al., 2014; Kim et al., 2018). Previous re-
search examining the association between DBT counselors and
burnout has been hampered by small sample sizes (N = 30 in
Linehan et al., 2000; N = 22 in Perseius et al., 2007; N = 6 in
Miller et al., 2011; and N = 9 in Carmel et al., 2014) and has
focused on how clients, too, can be burned out from counseling
and how that affects counselors (Linehan et al., 2000), imple-
mentation of DBT among psychiatric professionals (Perseius
et al., 2007), counselors’ cortisol levels (Miller et al., 2011),
or the training of new counselors who work with BPD clients
304 Journal of Counseling & Development
Warlick et al.
(Carmel et al., 2014). Although Jergensen’s (2018) study had
a larger sample (N = 135) compared with the other studies, the
study focused solely on DBT counselors and did not have a
comparison group. Therefore, to date, there are still no studies
examining burnout and DBT orientation in a large sample.
Additionally, there are no known factor-analytic studies of
the Copenhagen Burnout Inventory (CBI; Kristensen et al.,
2005) with a counselor population. Kristensen et al. (2005)
reported that the rationale for the three distinct burnout do-
mains (personal, work-related, and client-related burnout) was
theoretical and methodological but was “not statistical” (p.
205). Currently, psychometric evidence for the CBI focuses
on Cronbach’s alpha. Although Cronbach’s alpha provides
estimates of internal reliability, model fit provides evidence
of dimensionality (DeVellis, 2016).
Also, despite the presence in the literature related to burn-
out in counselors who work with clients with BPD, and despite
the protections against burnout provided by DBT, no known
research exists comparing whether DBT counselors indeed
possess greater or fewer symptoms of burnout than counselors
who subscribe to other treatment orientations. Last, although
DBT mandates mindfulness practice as a self-care strategy,
there has been no known research comparing mindfulness
levels in DBT counselors and non-DBT counselors.
The Present Study
To address the above-mentioned gaps, we used a national
sample of counselors who practice DBT and counselors who
use other treatment orientations to accomplish the following:
(a) assess the psychometrics of the CBI and its subscales; (b)
use the CBI to compare total burnout between DBT coun-
selors and non-DBT counselors; (c) use the CBI to compare
the three specific domains of burnout (workplace burnout,
personal burnout, and client burnout) between counselors
who practice DBT and counselors who use other treatment
orientations; (d) examine the relationship between mindful-
ness and burnout; and (e) compare the five facets of mindful-
ness between DBT counselors and non-DBT counselors. Our
corresponding hypotheses were as follows:
Hypothesis 1: The CBI would have appropriate model fit
and reliability.
Hypothesis 2: DBT counselors would have lower levels
of overall burnout than non-DBT counselors.
Hypothesis 3: Counselors who practiced DBT would have
higher levels of client burnout and lower levels of per-
sonal burnout and workplace burnout compared with
counselors who used other treatment orientations.
Hypothesis 4: There would be negative relationships
among mindfulness and burnout measures.
Hypothesis 5: Counselors who practiced DBT would
have higher levels of mindfulness than non-DBT
counselors.
■ July 2021 ■ Volume 99
Comparing Burnout Between DBT Counselors and Non-DBT Counselors
Participants
This study was reviewed and approved by the institutional
review board of the University of Kansas, Lawrence Campus.
A Qualtrics (https://www.qualtrics.com) survey was dis-
seminated to national and regional electronic mailing lists,
including a DBT-specific email list, inviting counselors to
complete a brief series of surveys. There was no incentive
provided to counselors who participated. This study follows
ACA guidelines regarding the term “counselor.” This noun is
used unless that label is not accurate (e.g., psychiatric hospital
staff as opposed to psychiatric hospital counselors).
We conducted multiple power analyses to determine the
required sample size for the analyses. Regarding the confirma-
tory factor analysis, a power analysis indicated a minimum
total of 200 participants to detect a medium effect size. A
power analysis was also conducted for the t tests and indicated
a minimum total sample size of 176 to detect a medium effect
size with 88 participants in each group (Erdfelder et al., 2004).
A final power analysis was conducted to determine how many
participants would be needed for the analysis of covariance
(ANCOVA). The power analysis indicated a minimum total
sample size of 210 to detect a medium effect size (Erdfelder
et al., 2004).
In this study, we divided participants (N = 209) who saw
at least one client weekly into two groups—a DBT group
(n = 87) and a non-DBT group (n = 122)—based on their
identified primary and secondary orientation. Sixty-five
counselors reported DBT as their primary orientation, and 23
counselors reported DBT as their secondary orientation (one
of these counselors identified DBT as both their primary and
secondary orientation). Overall, 17 theoretical orientations
were represented across 22 types of vocational settings. To
address the first and second research aims, we included these
counselors in the DBT group (n = 87). All other orientations
were included in the non-DBT group (n = 122). To confirm
consistency across counselors who reported DBT as their
primary orientation and their secondary orientation, we re-
peated analyses with the DBT primary group (n = 65), which
excluded counselors who reported DBT as their secondary
orientation. Group demographics, mean scores, and standard
deviations are detailed in Table 1 and Table 2.
Measures
The survey included demographic items, the CBI (Kristensen
et al., 2005), and the Five Facet Mindfulness Question-
naire (FFMQ; Baer et al., 2006). The CBI allows for the
identification of specific domains in which counselors may
be experiencing burnout. As such, this study used the CBI
because it may allow for targeted interventions to prevent
and reduce burnout.
The CBI (Kristensen et al., 2005) consists of 19 items us-
ing the scoring of 0, 25, 50, 75, and 100. Eighteen of the 19
items are reverse scored. The CBI has been shown to have
Journal of Counseling & Development ■ July 2021 ■ Volume 99
high internal consistency (αs = .85 to .87). The CBI has also
been shown to have adequate to high convergent validity, as
evidenced by the negative correlations (rs = –.46 to –.75)
between the CBI subscales and the subscales on the 36-item
Short Form Health Survey (Ware et al., 1993). The highest
correlation is among personal burnout and vitality, whereas
the lowest correlation is among general health and client-
related burnout. After reverse scoring, higher scores indicate
greater levels of burnout. The CBI yields a total score and
subscale scores for the following: Personal Burnout (PB;
e.g., “How often are you emotionally exhausted?”), Work-
Related Burnout (WB; e.g., “Do you feel that every working
hour is tiring for you?”), and Client-Related Burnout (CB;
e.g., “Do you feel that you give more than you get back when
you work with clients?”). Scores are calculated by averaging
the score of the items for a given subscale.
Given the noted relationship between mindfulness and
burnout as well as the prominent role of mindfulness in DBT,
we included the FFMQ (Baer et al., 2006) as a measure of
trait mindfulness. This instrument consists of 39 items that
are scored using a 5-point Likert-type scale of responses
ranging from 1 = never or very rarely true to 5 = very often
or always true. The FFMQ yields a total score and subscale
scores for the following subscales: Observe, Describe, Acting
With Awareness (AA), Nonjudgment of Inner Experience
(NJ), and Nonreactivity of Inner Experience (NR). Example
items include “I’m good at finding words to describe my
feelings” (Describe) and “I pay attention to how my emotions
affect my thoughts and behavior” (Observe). After reverse
scoring, higher scores indicate greater levels of mindfulness.
The FFMQ has been shown to have adequate to high internal
consistency (αs = .75 to .91). Support for the validity of the
FFMQ has included positive correlations with related con-
structs (i.e., openness to experience, emotional intelligence,
and self-compassion; rs = .42 to .60) and negative correlations
with unrelated constructs (rs = –.49 to –.68).
We operationalized three variables collected alongside
demographic items as possible covariates for our analyses.
We calculated workload through the average weekly num-
ber of individual client sessions (individual workload) and
average weekly number of group sessions (group workload)
conducted. Counselors self-reported years of counseling
experience (years of experience).
Analyses
To assess the first aim, investigating the psychometrics of the
CBI, we conducted confirmatory factor analysis on responses
to the CBI to assess appropriateness of model interpretation.
Results were analyzed using the statistical package Lavaan
(Rosseel, 2012) for the open-source R software using the
methodology proposed by Garrard et al. (2016). Cohen’s d
was calculated using the Social Science Statistics calculator
(https://www.socscistatistics.com). To assess the second and
305
 Warlick et al.

TABLE 1
Counselor Characteristics by Orientation Status
Total (N = 209) DBT (n = 87) Non-DBT (n = 122)
Variable n % M SD n % M SD n % M SD
Demographics
Age (in years) 39.58 13.32 40.55 10.56 38.90 14.97
Female 167 79.9 81 93.1 86 70.5
White/Caucasian 186 89.0 77 88.5 109 89.3
Degree program
Counseling psychology
MS 11 16.2 0 0.0 11 20.8
PhD 18 26.5 1 0.1 17 32.1
School psychology
EDS 1 1.5 1 0.1 0 0.0
PhD 18 26.5 5 0.3 13 24.5
Other 20 29.4 8 53.3 12 22.6
Level of licensure
Graduate student 59 28.2 8 9.2 51 41.8
Social worker
BSW/LMSW 12 5.7 8 9.2 4 3.3
LSCSW 29 13.9 18 20.7 11 9.0
Licensed professional 9 18.7 23 26.4 16 13.1
counselor/licensed
master’s-level
psychologist
Clinical nurse (LPN/RN) 1 0.5 0 0.0 1 0.8
Psychiatric nurse 3 1.4 1 1.1 2 1.6
Licensed psychologist 55 26.3 20 23.0 35 28.7
MD psychiatry 2 1.0 2 2.3 0 0.0
Other 9 4.3 7 8.0 2 1.6
Most frequent psychological
orientationa
Primary-DBT(CBT) 65 31.1 65 74.7 (38) (31.1)
Secondary-DBT(CBT) (42) (20.1) 23 26.4 (26) (21.3)
Years of clinical experience
Less than 1 year 16 7.7 1 1.1 15 12.3
1–5 years 62 32.7 22 25.2 40 32.8
6–10 years 43 20.6 25 28.7 18 14.8
11–15 years 21 10.0 8 9.2 13 10.7
16–20 years 18 8.6 7 8.0 11 9.0
Primary setting
Community mental health center 62 29.7 32 36.8 30 24.6
University counseling center 22 10.5 3 3.4 19 15.6
VA hospital/VA setting 10 4.8 2 2.3 8 6.6
Medical hospital 16 7.7 6 6.9 10 8.2
Forensic setting 3 1.4 1 1.1 2 1.6
Private practice 42 20.1 14 16.1 28 23.0
Faculty member who sees clients 7 3.3 3 3.4 4 3.3
Other 47 22.5 26 29.9 21 17.2
Average weekly individual clients
0 4 1.9 0 0.0 4 3.3
1–5 51 24.4 21 24.1 30 24.6
6–10 54 25.8 17 19.5 37 30.3
11–16 33 15.8 18 20.7 15 12.3
17–19 21 10.0 10 11.5 11 9.0
20–25 29 13.9 13 14.9 16 13.1
25 or more 17 8.1 8 9.2 9 7.4
Average weekly group sessions
0 91 43.5 19 21.8 72 59.0
1–2 75 35.9 43 49.4 32 26.2
3–4 29 13.9 16 18.4 13 10.7
5–6 7 3.3 5 5.7 2 1.6
7–10 4 1.9 2 2.3 2 1.6
11–13 2 1.0 1 1.1 1 0.8
14 or more 1 0.5 1 1.1 0 0.0
Note. Percentages may not total 100 because of rounding. Six counselors declined to provide age, and only those who identified as graduate
student or other for level of licensure were asked about their graduate program (n = 68). DBT = dialectical behavior therapy; BSW = bachelor’s of
social work; LMSW = licensed master’s of social work; LSCSW = licensed specialist clinical social worker; LPN = licensed practical nurse; RN =
registered nurse; MD = medical doctor; CBT = cognitive behavior therapy; VA = Veterans Affairs.
a
For primary and secondary orientation, values in parentheses indicate CBT orientation. One counselor identified DBT as both their primary and
secondary orientation.

306 Journal of Counseling & Development ■ July 2021 ■ Volume 99

Comparing Burnout Between DBT Counselors and Non-DBT Counselors

TABLE 2
Mean Scores by Orientation Status
Total (N = 209) DBT (n = 87) Non-DBT (n = 122)
Scale and Subscale M SD M SD M SD
CBI total 38.03 15.18 40.88 17.09 35.99 13.36
Personal Burnout 44.88 16.14 49.19 18.19 41.80 13.77
Work-Related Burnout 41.03 18.23 45.16 20.66 38.09 15.73
Client-Related Burnout 27.67 17.42 27.59 19.28 27.73 16.04
FFMQ total 143.62 18.89 147.86 18.73 140.60 18.48
Observe 28.34 5.14 30.00* 4.42 27.16* 5.31
Describe 31.74 5.18 32.36 5.15 31.30 5.18
Acting With Awareness 26.74 5.01 26.95 5.14 26.59 4.93
Nonjudging of Inner Experience 31.93 6.03 32.62 6.46 31.43 5.68
Nonreactivity to Inner Experience 24.87 4.22 25.93* 3.97 24.11* 4.24

Note. Higher scores indicate higher levels of burnout and mindfulness. DBT = dialectical behavior therapy; CBI = Copenhagen Burnout
Inventory; FFMQ = Five Facet Mindfulness Questionnaire.
*p < .01, controlling for years of experience.

third aims, we compared the DBT and non-DBT groups using
independent t tests, with the total score (second aim) and the
subscale scores of the CBI as dependent variables (third aim).
Following that, we completed additional comparisons using
analysis of variance (ANOVA) with covariates. Workload
and years of experience were included in the ANCOVA to
further investigate any differences in burnout between the
two counseling orientations. We used confirmatory factor
analysis and multivariate analysis of variance (MANOVA) and
ANOVA to conservatively investigate whether differences in
FFMQ scores may have explained the differences in burnout.
To confirm these results, we repeated these analyses with the
non-DBT group and the DBT primary group.
Results
CBI Psychometrics
For our first aim, investigating the CBI’s psychometrics, we
conducted two confirmatory factor analyses and reliability
analyses. Model fit was assessed using Hu and Bentler’s
TABLE 3
Measurement Psychometrics for All Participants
(1999) standards. Reliability was assessed using DeVellis’s
(2016) guidelines. Table 3 presents measurement psychomet-
rics for all participants.
The first set of psychometrics analyses focused on the
one-factor model of the CBI. The one-factor model achieved
excellent reliability (α = .93), but the global model fit indices
did not reach acceptable limits (Hu & Bentler, 1999). Al-
though the standardized root-mean-square residual (SRMR)
reached acceptable levels (.08), the root-mean-square error of
approximation (RMSEA) was .12 (95% confidence interval
[CI] [.11, .13]), which is higher than the acceptable limit
of .08. Also, the comparative fit index (CFI; .80) and the
Tucker-Lewis index (TLI; .77) failed to reach the acceptable
level of .90. Given these psychometrics, our second research
aim, comparing total burnout between DBT and non-DBT
counselors, was not completed.
The second set of psychometric analyses focused on the
three-factor model of the CBI. The three-factor model of the
CBI achieved good reliability (αs = .85–.89) and appropriate
model fit (CFI = .92, TLI = .91, RMSEA = .07, 95% CI

Scale and Subscale Cronbach’s a CFI TLI RMSEA 95% CI SRMR

CBIa .93 .80 .77 .12 [.11, .13] .08
Personal Burnout .86 .92 .91 .07 [.06, .08] .06
Work-Related Burnout .89 .92 .91 .07 [.06, .08] .06
Client-Related Burnout .85 .92 .91 .07 [.06, .08] .06
FFMQa .95 .53 .50 .12 [.12, .13] .12
Observe .84 .88 .88 .06 [.05, .07] .07
Describe .89 .88 .88 .06 [.05, .07] .07
Acting With Awareness .89 .88 .88 .06 [.05, .07] .07
Nonjudging of Inner Experience .93 .88 .88 .06 [.05, .07] .07
Nonreactivity to Inner Experience .87 .88 .88 .06 [.05, .07] .07

Note. CFI = Comparative fit index; TLI = Tucker-Lewis index; RMSEA = root-mean-square error of approximation; CI = confidence interval;
SRMR = standardized root-mean-square residual; CBI = Copenhagen Burnout Inventory; FFMQ = Five Facet Mindfulness Questionnaire.
a
One-factor model.

Journal of Counseling & Development ■ July 2021 ■ Volume 99 307


[.06, .08], SRMR = .06). These psychometrics allowed us to
complete our third research aim, comparing the three specific
burnout domains between DBT and non-DBT counselors.
Burnout and Orientation
For our third research aim, we investigated the three specific
burnout domains between the DBT and non-DBT counselor
groups. Because Levene’s test for equality of variances sug-
gested unequal variances, we used t-test methods, which
do not require equal variances between groups (Green &
Salkind, 2014). The two groups differed significantly on
personal burnout, t(152.54) = 3.19, p = .002, d = 0.46, and
work-related burnout, t(153.19) = 2.69, p = .008, d = 0.39, but
not client-related burnout, t(163.57) = 0.06, p = .95, d = 0.01.
In both cases where differences were found, DBT counselors
reported greater burnout, and the group differences were small
to moderate (Cohen, 1988). This was in direct opposition to
our second hypothesis.
To examine whether workload and years of experience af-
fected our results, we first considered whether these variables
might be useful covariates. The workload factors—number
of clients and number of groups—were not found to cor-
relate with our two burnout measures, so they were rejected
as worthwhile covariates. Years of experience, however, did
correlate significantly with work-related burnout (r = –.19,
p = .007, N = 209) and was nearly correlated significantly
with personal burnout (r = –.13, p = .07, N = 209). Given
the exploratory nature of this inquiry, years of experience
was deemed potentially informative and was inserted as
a covariate. Consequently, we conducted a new round of
comparisons between groups on work-related burnout and
personal burnout, but this time using ANCOVAs with years
of experience as the covariate. We conducted a preliminary
analysis to test for homogeneity of slopes. The analysis in-
dicated that the relationship between the covariate years of
experience and the dependent variable did not differ between
groups significantly as a function of the independent variable
for both personal burnout, F(1, 205) = 0.71, MSE = 171.87, p
= .4, η2 = .003, and work-related burnout, F(1, 205) = 0.27,
MSE = 308.41, p = .6, η2 = .001. As such, we conducted the
respective ANCOVAs. The difference between counseling
orientation remained, with slightly greater but still moderate
effect sizes. The results were as follows: for personal burnout,
F(1, 206) = 13.91, p < .001, η2 = .06; and for work-related
burnout, F(1, 206) = 11.34, p = .001, η2 = .05.
Given these results, one explanation hypothesized was that
there may be a difference in treatment adherence between
counselors who reported DBT as their primary orientation and
counselors who reported DBT as their secondary orientation,
and that counselors who identified stronger with DBT would
have less burnout. To test this hypothesis, we repeated these
analyses. First, we removed all counselors who listed DBT as
their secondary orientation (n = 22). Counselors who indicated
308 Journal of Counseling & Development
Warlick et al.
DBT as their primary orientation (DBT primary group; n =
65) and counselors who did not report DBT as their primary
or as their secondary orientation (n = 122) were included in
these analyses.
We then repeated the psychometric analyses. (Supple-
mental material illustrating full psychometrics is available
from the first author.) As in the first analyses, the CBI’s three-
factor model fit well (CFI = .92, TLI = .91, RMSEA = .07,
95% CI [.06, –.09], SRMR = .06), but the CBI’s one-factor
model did not fit well (CFI = .80, TLI = .78, RMSEA = .11,
95% CI [.10, .12], SRMR = .08). Thus, we included only
the three-factor model for testing. Because Levene’s test for
equality of variances again suggested unequal variances, we
used t tests to examine whether differences in burnout were
present between the DBT primary group and the non-DBT
group. As with the first set of analyses, the two groups dif-
fered significantly on personal burnout, t(105.45) = 3.13, p
= .002, d = 0.5, and work-related burnout, t(104.68) = 2.91,
p = .004, d = 0.46, but not client-related burnout, t(107.14)
= 0.45, p = .66, d = 0.07. In both cases where differences
were found, DBT counselors reported greater burnout and
the group differences were greater in size, but these group
differences were still classified as small to moderate.
To assess whether workload and years of experience
affected the results, we again investigated their potential as
covariates. Years of experience did correlate significantly with
work-related burnout (r = –.17, p = .025, N = 187) and was
nearly significant with personal burnout (r = –.13, p = .08, N =
187). In contrast to the first analyses, individual workload also
correlated significantly with work-related burnout (r = –.16,
p = .034, N = 187) and was nearly significant with personal
burnout (r = –.14, p = .06, N = 187). Given the exploratory
nature of these analyses, both were deemed potentially
informative and inserted as covariates.
Before conducting the next round of comparisons
between the DBT primary group and the non-DBT group
on work-related burnout and personal burnout with years of
experiences and individual workload as covariates, we again
performed two preliminary analyses to test for homogeneity
of slopes. The first analysis indicated that the relationship
between years of experience and the dependent variable did
not differ significantly between groups as a function of the
independent variable for both personal burnout, F(1, 183)
= 0.11, MSE = 229.67, p = .75, η2 = .001, and work-related
burnout, F(1, 183) = 0.08, MSE = 23.87, p = .78, η2 < .001.
The second analysis indicated that the relationship between
individual workload and the dependent variable did not differ
significantly between groups as a function of the independent
variable for both personal burnout, F(1, 183) = 0.97, MSE
= 228.32, p = .33, η2 = .005, and work-related burnout, F(1,
183) = 0.001, MSE = 298.20, p = .97, η2 < .001. As such, we
conducted the respective ANCOVAs. The difference between
counseling orientations remained, with slightly greater but
■ July 2021 ■ Volume 99
Comparing Burnout Between DBT Counselors and Non-DBT Counselors
still moderate effect sizes. The results were as follows: for
personal burnout, F(1, 183) = 14.69, p < .001, η2 = .07; for
work-related burnout, F(1, 183) = 13.74, p < .001, η2 = .07.
This provides additional evidence that DBT counselors scored
higher on personal burnout and work-related burnout, and
there was no difference regarding client-related burnout.
Burnout and Mindfulness
Because meta-analysis has shown that mindfulness helps
mitigate burnout (Luken & Sammons, 2016), and because
mindfulness practice is mandated for DBT counselors
(Linehan, 1993), our fourth research aim was to examine
whether mindfulness was related to burnout in our sample.
Our fifth research aim was to assess whether there would
be a difference in mindfulness between the two groups. As
repeated increases in self-reported state mindfulness can
lead to increases in self-reported trait mindfulness (Kiken et
al., 2015), a difference between the two groups may be one
indicator of treatment adherence for DBT counselors.
To examine these aims, we conducted another confirmatory
factor analysis on the FFMQ to assess the appropriateness of
the model for interpretation. We used the statistical package
Lavaan (Rosseel, 2012) and followed the methodology
proposed by Garrard et al. (2016). Because the FFMQ is
intended to produce five subscale scores in addition to a
total score, a five-factor model was tested and found to have
acceptable fit using Hu and Bentler’s (1999) guidelines.
Although the CFI and TLI were slightly below the guidelines
(CFI = .88, TLI = .88), the RMSEA and SRMR indicated
close fit (RMSEA = .06, 95% CI [.05, .07], SRMR = .07).
A one-factor model of the FFMQ did not fit well (CFI =
.53, TLI = .50, RMSEA = .12, 95% CI [.12, .13], SRMR =
.12). Therefore, correlations and group comparisons were
conducted only on the five FFMQ subscales and not on the
FFMQ total score.
To assess our fourth research aim, examining the rela-
tionships between mindfulness and burnout in this sample,
we computed correlation coefficients among the subscales
of the FFMQ and the CBI. After a Bonferroni correction
(0.05/15 = .003), 13 of the 15 negative correlations were
statistically significant. The relationships among the CBI
subscales and the FFMQ subscales were all significant. Us-
ing Cohen’s (1988) guidelines, effect sizes for the subscales
ranged from small (–0.21 for Observe, –0.23 for Describe,
and –0.27 for AA) to moderate (–0.33 for NJ and –0.36 for
NR). The PB subscale’s relationship was not significant with
Observe (p = .43), but its relationship with all other subscales
was significant. Effect sizes ranged from small (–0.21 for
Describe) to moderate (–0.34 for NR, –0.35 for AA, and
–0.37 for NJ). The WB subscale’s relationship with Observe
(p = .16) was not statistically significant, but its relationship
with all other subscales was significant. Effect sizes ranged
from small (–0.28 for Describe) to moderate (–0.33 for AA,
Journal of Counseling & Development ■ July 2021 ■ Volume 99
–0.36 for NR, and –0.39 for NJ). This provides support for
the fourth hypothesis.
Given these relationships among the mindfulness and
burnout measures, we proceeded to our fifth research aim.
We conducted a one-way MANOVA to compare the types of
mindfulness scores for the DBT group and non-DBT group.
Significant differences were found among the five types of
mindfulness for the two groups, Wilks’s Λ = 0.9, F(5, 203)
= 4.52, p = .001, η2 = .10. The DBT group had higher mean
scores than the non-DBT group on all five facets of mind-
fulness. (Supplemental material containing the means and
standard deviations of the dependent variables for the two
groups is available from the first author.)
As follow-up tests to the MANOVA, we conducted
ANOVAs on the dependent variables to determine whether
these differences were significant. After the Bonferroni cor-
rection, the alphas were set at .01 (.05/5 = .01). The ANOVA
on the Observe subscale score was significant at the .01 level
with a moderate effect size, F(1, 207) = 16.6, p < .0001, η2 =
.07. Also, the ANOVA on the NR subscale score was signifi-
cant at the .01 level with a moderate effect size, F(1, 207) =
9.89, p = .002, η2 = 0.5. None of the other variables reached
significance at the .01 level. Although treatment fidelity can-
not be wholly judged with a self-report measure, this finding
is one indicator of potential treatment adherence.
When these analyses were repeated with the DBT primary
group and the non-DBT group, the results were similar but
not identical. Again, we conducted a confirmatory factor
analysis on the FFMQ responses to assess its appropriateness
for interpretation. The FFMQ’s five-factor model possessed
appropriate psychometrics (CFI = .87, TLI = .86, RMSEA =
.06, 95% CI [.06, .07], SRMR = 0.07), but the FFMQ’s one-
factor model did not fit well (CFI = .52, TLI = .50, RMSEA
= 0.12, 95% CI [.12, .13], SRMR = .12).
After the same Bonferroni correction (.05/15 = .003),
11 of the 15 negative correlations were statistically sig-
nificant. The CB subscale’s relationship with Describe
was no longer significant (p = .006), but its relationships
with the other subscales retained significance. Effect sizes
ranged from small (–0.22 for Observe and –0.27 for AA)
to moderate (–0.30 for NJ and –0.37 for NR). The PB
subscale’s relationship was not significant with Observe
(p = .43) or Describe (p = .013) but was significant with
all other subscales. The effect size of the relationship with
AA decreased from moderate to small (–0.29), but the
relationship with NJ (–0.32) and NR (–0.31) remained
moderate in effect size. The WB subscale’s relationship
was not statistically significant with Observe (p = .28),
but it was significant with all other subscales. Effect sizes
ranged from small (–0.27 for Describe and –0.28 for AA)
to moderate (–0.31 for NJ and –0.32 for NR). This provides
additional support for our fourth hypothesis that mindful-
ness and burnout would have a negative relationship.
309

Given the aforementioned relationships between mindful-
ness and burnout, we again conducted a MANOVA. Signifi-
cant differences were found between the DBT primary group
and the non-DBT group on the five categories of mindful-
ness, Wilks’s Λ = 0.86, F(5, 181) = 5.69, p < .001, η2 = .14.
The DBT primary group had higher mean scores on all five
mindfulness categories. The Bonferroni correction set alpha
levels to .01. The ANOVA on the Observe subscale score was
again significant at the .01 level with a moderate effect size,
F(1, 185) = 20.22, p < .0001, η2 = .10. Also, the ANOVA on
the NR subscale score was significant at the .01 level with a
moderate effect size, F(1, 185) = 11.51, p = .001, η2 = .06.
None of the other variables reached significance at the .01
level. This provides additional evidence that the DBT group
scored higher than the non-DBT group on this one indicator
of treatment adherence.
Discussion
The findings in this study are notable. Regarding our first
research aim, the CBI psychometrics provide model fit evi-
dence for the three-factor instrument. Reliability results in
this American counselor sample are similar to those found
in a Danish counselor sample (Kristensen et al., 2005). The
former remains especially notable as Kristensen and col-
leagues intentionally focused scale design from theoretical
and methodological standpoints. Although the one-factor
instrument did not possess appropriate psychometrics, our
findings illustrate statistical support for the use and applica-
bility of the CBI as developed to be a three-factor instrument
for studying counselor burnout. For practicing counselors, the
CBI may be helpful as a brief, public-domain quantitative tool
to help monitor their own level of burnout.
Our second research aim was not completed, given the
poor model fit statistics exhibited by the one-factor model
of the CBI. Our third research aim investigated the three
burnout domains among DBT and non-DBT counselors. For
this research aim, we posited that DBT counselors would
score higher on client-related burnout than would non-DBT
counselors. This hypothesis was not supported. We found no
difference in client-related burnout among DBT counselors
and non-DBT counselors. This was surprising, because DBT
was initially created for individuals with BPD, and previous
research has suggested that DBT counselors are more likely
to see clients with more complex diagnoses (e.g., Harley et
al., 2008). One interpretation could be that there may be ele-
ments within DBT that protect counselors from client-related
burnout. However, the use of DBT has also spread widely
since the earlier trials. There is a need to further examine
the diagnoses and concerns of those clients seen by DBT
counselors to investigate if they are similar to clients seen in
previous clinical trials. In our study, we followed the assump-
tion that DBT counselors would treat clients whose symptoms
310 Journal of Counseling & Development
Warlick et al.
warranted this intensive treatment. As such, information about
clientele was not collected. Future studies should collect this
information to test the assumption that DBT counselors see
more complex clients than counselors not practicing DBT.
This could be completed by asking counselors about the
acuity levels of their clients (e.g., Stage 1 of DBT vs. Stage
4 of DBT) and soliciting information associated with client
difficulty (e.g., disordered personality).
Additionally, DBT counselors had significantly higher lev-
els of burnout with regard to their personal lives and their non-
client work-related domains, even after controlling for years
of experience. These results were consistent when we included
counselors who endorsed DBT as their primary orientation,
even after controlling for years of experience and individual
workload. This finding also contradicts our third hypothesis
that DBT counselors would have lower work-related burnout
and personal burnout. For DBT counselors, the mean scores
for DBT on personal burnout (49.19) and work-related burn-
out (45.16) both approached the “burned out” classification
score of 50 proposed by Borritz and Kristensen (2004). When
we included only counselors who endorsed DBT as their
primary orientation, these mean scores rose slightly for both
personal burnout (49.74) and work-related burnout (46.59). In
comparison with non-DBT counselors, these DBT counselors
still endorsed significantly higher levels of burnout in their
personal lives and their nonclient work-related domains. This
finding is notable as DBT assumes that protections built into
the treatment help mitigate burnout (Linehan, 1993).
Our fourth research aim found significant negative rela-
tionships among mindfulness and burnout measure. Thirteen
of the 15 negative correlations were statistically significant,
and effect sizes ranged from small to moderate. When these
analyses were repeated omitting the counselors who endorsed
DBT as their secondary orientation, 11 of the 15 negative cor-
relations were statistically significant, and effect sizes ranged
from small to moderate. These findings support our fourth
hypothesis and align with previous literature that mindfulness
is negatively related to burnout (Luken & Sammons, 2016).
Our fifth research aim found significant differences in
mindfulness among DBT and non-DBT counselors. DBT
counselors had significantly higher scores than did non-DBT
counselors on the Observe and NR subscales with a medium
effect size. When these analyses were repeated omitting the
counselors who endorsed DBT as their secondary orientation,
these findings were similar. Although the FFMQ is a trait
mindfulness measure, evidence suggests that with repeated
behavioral practice, as is mandated within DBT, trait mind-
fulness scores will increase. This is one indicator of possible
treatment adherence for DBT counselors.
Burned-out work is impaired work (Maslach & Leiter,
2016). This is problematic because burnout affects client
care (e.g., Salyers et al., 2015), and mitigating burnout
improves client care (Kim et al., 2018). As such, burnout is
■ July 2021 ■ Volume 99
Comparing Burnout Between DBT Counselors and Non-DBT Counselors
a counseling-interfering behavior on the part of the counselor
and the system that employs the counselor. The finding that
DBT counselors experienced higher levels of work-related
burnout and personal burnout suggests the need for greater
assessment, prevention, and treatment of personal burnout
and work-related burnout among DBT counselors. Additional
research needs to focus on DBT counselors regarding self-care
practices, clientele treated, and adherence. DBT counselors
self-report following a stricter adherence to DBT protocol
when treating clients with BPD traits than when treating
clients with a different diagnosis, which indicates intentional
drift from DBT principles (DiGiorgio et al., 2010). Counselors
working toward adherence, as well as researchers studying
counselors, may benefit from using the free DBT Therapist
Rating and Feedback Form (Fruzzetti, 2012), which provides
supervisors with a structured tool to assess supervisees on
their DBT adherence. For counselors, Rupert et al. (2015)
suggested being proactive toward work-life balance. Given
previous research and the present findings regarding its
negative relationship with burnout, practicing mindfulness
may be a useful strategy. Both DBT and non-DBT counselors
reported lower levels of client-related burnout relative to other
areas of burnout. As such, focusing on client-related work may
serve as a burnout coping strategy (Sciberras & Pilkington,
2018). For those who manage counselors, Sodeke-Gregson
et al. (2013) found that perceived support from management
led to less burnout. Therefore, investigating perceived support
of not just management, but also supervisors, trainers, and
consultation team members who practice DBT, could be
helpful regarding work-related burnout. These investigations
may be especially beneficial for more junior counselors, as
Farber (1990) and the present study found years of experience
was negatively associated with burnout.
Limitations
The primary limitation of our study was that our sample was
a convenience-based sample. Additionally, a counselor’s self-
report of their own orientation was accepted without fidelity.
Although we added the FFMQ as one indicator of possible
adherence, additional indicators of orientation would improve
research in this study. One study of over 200 counselors
found no differences in cognitive behavior therapy (CBT)
skill competency among counselors who proclaimed CBT
as their orientation and counselors who did not (Creed et
al., 2016). This indicates that although a counselor may be
intending to practice a certain orientation, they may not be
actually practicing that orientation. In addition to self-reported
orientation, training and experience within that orientation
could serve as markers (Carmel et al., 2014). Within DBT,
drift is a counselor-interfering behavior (Linehan, 1993). Two
separate studies have shown that counselors with more DBT
training and DBT experience were less likely to drift from
Journal of Counseling & Development ■ July 2021 ■ Volume 99
DBT principles than counselors with lesser levels of training
(DiGiorgio et al., 2010; Wisniewski et al., 2018). Brosan et al.
(2007) found that greater adherence for counselors with more
advanced training extended to CBT counselors. Additionally,
DiGiorgio et al. (2010) calculated a DBT adherence score
from counselors’ self-report regarding the differences between
the techniques used with modification and the techniques
used without modification. Modifying their method could be
useful in assessing self-reported drift in counselors endorsing
other orientations. It is likely that nonadherent behaviors will
still occur during session. Thompson-Brenner and Westen
(2005) reported that drift is often nonadherent—dynamic
counselors use behavioral techniques, and CBT counselors
use dynamic techniques. Even using a single-item question
asking counselors how much they drift from their orientation
during an average session would provide additional insight
into orientation adherence. To minimize this concern, one
option would be to investigate counselors for treatment adher-
ence (e.g., Linehan Board Certification [https://dbt-lbc.org/]).
Even though certified counselors can perform under accepted
adherence levels (Brosan et al., 2007), this investigation would
provide additional information about counselors of specific
orientations with recognized competencies and training. Ad-
ditionally, the CBI and the FFMQ are self-report measures.
Despite these limitations, this is the first known study to use
both an adequate sample and a comparison group to investi-
gate burnout among counselors.
Conclusion
Burnout exists in counselors’ lives. According to M. Paris
and Hoge (2010), “a primary challenge for the mental health
field is to . . . build a more robust knowledge base about the
prevalence, causes, and effects of burnout in this field” (p. 526).
The results of the present study indicate that a DBT orientation
is associated with significantly more burnout in personal and
work-related domains, even after accounting for covariates.
Additionally, the evidence suggests that DBT counselors do
not differ in their levels of client-related burnout. This study
provides evidence that DBT may help protect against client-
related burnout but fails to protect against work-related and
personal burnout. Burnout is a process—a process that can
be mitigated before the impact becomes too large (Swenson,
2016). A DBT consultation team is tasked with monitoring each
other regarding client-related burnout; it may be beneficial to
expand this guideline to monitoring specific signs of burnout
related to work and to one’s personal life. One of the main
DBT assumptions is that while we are all doing the best we
can, we all also need to do better (Linehan, 1993). Although
this assumption may have been directed at clients receiving
DBT, we assert that this assumption applies equally well to all
counselors and all staff. Burnout interferes with counseling and
affects client outcomes; this variable is one over which we as
311

counselors possess some influence. In examining counseling ef-
fectiveness and outcomes, we must monitor our own resources
and support our fellow counselors in monitoring their own.
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