Mediating Role of Professional Quality of Life Between Emotional Regulation and Psychological Well-Being among Mental Health Professionals
Sehrish Amjad*, Saadiya Abbasi, Usmana Altaf and Farrukh Ijaz
Department of Psychology, Foundation University, Pakistan
Submission: December 30, 2019; Published: February 13, 2020
*Corresponding author: Sehrish Amjad, Department of Psychology, Foundation University, Islamabad, Pakistan
How to cite this article:Sehrish A, Saadiya A, Usmana A, Farrukh I. Mediating Role of Professional Quality of Life Between Emotional Regulation and Psychological Well-Being among Mental Health Professionals. Psychol Behav Sci Int J. 2020; 14(3): 555888. DOI:10.19080/PBSIJ.2020.14.555888.
Abstract
Mental health professionals which include clinical psychologists and psychiatrists in the course of their professional duty report being either burdened or exhilarated. The present study investigated the role of emotional regulation and professional quality of life in predicting psychological well-being among mental health professionals. It was also intended to determine the mediating role of professional quality of life in the relationship between emotional regulation and psychological well-being. Professional quality of life was defined on the basis of three components; Compassion satisfaction, Compassion fatigue/Secondary traumatic stress, and Burnout, whereas, cognitive reappraisal and expressive suppression constitute emotional regulation. A sample of 185 mental health professionals including both males and females (age range of 21-62 years; M = 29.03, SD = 7.73) was acquired through purposive/convenient sampling technique. Emotional Regulation Questionnaire [1], Professional Quality of Life Scale, Stamm (2005), and Ryff’s Psychological Well-Being Scale [2] were used to measure the study variables. Step-wise regression showed that cognitive reappraisal, compassion satisfaction, secondary traumatic stress, and burnout were significant predictors of psychological well-being, while mediation analysis indicated that compassion satisfaction and burnout mediated the relationship between cognitive reappraisal and psychological well-being. The knowledge generated from the present study provides a relevant basis for enhancing psychological wellbeing in this sample.
Keywords: Emotional regulation; Professional quality of life; Psychological well-being; Mental health professionals
Abbrevations: PWB: Psychological Wellbeing; ProQOL: Professional Quality of Life; CS: Compassion satisfaction; STS: Secondary Traumatic Stress; ER: Emotional self-regulation; RPWS: Ryff’s Psychological Well-being Scale
Introduction
The well-being of professionals in mental health settings has attracted considerable interest recently. Professional quality of life as a matter of subject has also gained a lot of importance in different work settings due to its connection with the personal characteristics of people working in the organizations and their repetitive exposure to challenging situations at their workplace [3]. Caring for patients by professional mental health staff in psychiatric settings can be traumatic. In present study, mental health professionals were studied to explore their psychological wellbeing (PWB) and professional quality of life (ProQOL), and how they manage to maintain these two by regulating their emotions.
Psychological wellbeing is the amalgamation of feeling good and functioning effectively in our daily lives. Psychological well-being is a state characterized by health, happiness, and prosperity [4]. Recently, WHO defined positive mental health as a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community, WHO (2001). Higher psychological well-being can be associated with many physical and mental health benefits, including healthier immune system, improved sleep patterns, lower blood pressure, and even longevity [5]. Ryff [2] established the model of PWB on the basis of six dimensions which are inter-related, these includes Self-acceptance, Positive relation, Environmental mastery, Personal growth, Autonomy, and Meaning of life [6]. In the present study, psychological wellbeing is been studied as a unified construct. Emotional self-regulation or regulation of emotions is the ability to respond to the daily life experiences with a balanced manner of the emotions i.e. spiritually healthy and supportive. Regulating one’s emotions reduce the behaviors that can be harmful for the individuals. It is directly related to the competence and coherence of the individual. Emotion regulation refers individuals attempting to how and when to express and experience the emotions. This can be automatic or can be controlled. Emotion regulation is basically how someone manages to regulate the ups and downs of the negative and positive aspects of emotions [7].
Individuals regulate their emotions in numerous ways [8-10]. This study focuses on two emotion regulation strategies: Reappraisal and Suppression. Reappraisal is a cognitive based strategy in which individuals regulate their emotions through thinking about the situation, this stage appears before the expression stage. While in suppression, individuals regulate their emotions by preventing them from expressing through behaviors. Recent literature shows that reappraisal is an adaptive strategy as compared to suppression and leads to different health related outcomes [1]. Professional Quality of Life (ProQOL) refers how individuals feel while working as a helper, it has both positive and negative aspects [3]. Together, compassion satisfaction and the two components - secondary traumatic stress and burnout, generate professional quality of life. Compassion satisfaction (CS) is the satisfaction of having the ability to help other people [3,11]. Compassion fatigue is also known as Secondary Traumatic Stress (STS) [3,13-15]. Figley [16] argued that STS is not only experienced by working with the traumatic clients, but also may be caused by the non-supportive families and surroundings which may lead to intrusive thoughts and sleep disturbances, forgetting, and inability to separate their personal and professional lives [3,15].
Burnout refers to the emotional exhaustion of having the insufficiency of fulfilling the duties and responsibilities of the personal and professional life, it is caused by the stressful environment in work and can result in lack of self-esteem [17-20]. Burnout was seen to be high when individuals spend more time at their work places [21]. Burnout has also been shown to lead to lower organizational commitment, which is related to higher staff turnover and lower productivity [22], and potentially decreased effectiveness in work with clients [23].
Literature has a detailed account of relationship between all three variables along with their sub components. Emotion regulation can be positively as well as negatively associated with psychological well-being because of the different nature of its sub constituents. Studies show that cognitive reappraisal shares a positive relationship with psychological well-being, and it is also related to higher self-esteem, life satisfaction, and positive emotions [1,24,25]. Expressive suppression was found to be negatively related with well-being [26]. The studies conducted in past years indicate that psychological well-being is often associated with the quality of work life [27,28]. There is a positive relationship between compassion satisfaction and psychological well-being. When professionals help the people suffering from trauma, they feel accomplished and their quality of work life is enhanced [29]. On the other hand, secondary traumatic stress and burnout both have negative relationships with psychological well-being. When therapists listen to the traumatized clients, they may feel same emotions as their clients which can affect their quality of life [30,31]. Previous researches identified by studying different samples that increased levels of burnout decrease psychological well-being, Lareson (1991), Ryff (1989), [32].
Numerous studies were done which showed that cognitive reappraisal is more adaptive than suppression [33]. One study indicated that as cognitive reappraisal is the reinterpretation and reconstruction of the situations, therefore, it is an effective coping strategy which helps to reduce the levels of burnout [34]. Another study proved that secondary traumatic stress negatively correlated with cognitive reappraisal. The study explained that reappraisal changes the perception of the stressful situation which helps to decrease its impact of stress [35-37]. Literature also showed that positive strategies within emotion regulation such as cognitive reappraisal, are associated with increased levels of satisfaction with the job; compassion satisfaction which is defined as when a professional is satisfied with his duties regarding his work [38]. The study demonstrated that as reappraisal is the reinterpretation of the situations and emotional events, it leads to the satisfaction with the job, whereas, suppression is when the person controls his emotions and do not express them which increase the interpersonal relations with colleagues and clients that also results in increased levels of satisfaction with their job [39]. Current study extends emotion regulation, professional quality of life and psychological wellbeing literatures by examining their relationship to gain a clearer understanding of how professional quality of life mediates the relationship between emotion regulation and psychological well-being.
There were numerous studies done in past decades across multiple disciplines on the effects of trauma on mental health professionals who work with challenging clients directly [3,11,40,41]. It is very vital to understand those factors which influence the professional quality of life in order to help the professionals [42]. The main focus of present study was to assess how psychological well-being (PWB) of mental health professionals is affected by both positive and negative aspects of Professional Quality of Life (ProQOL) and Emotional self-regulation (ER), and the role of ER in dealing with stressful situations. The above literature shows that psychological wellbeing is related with emotional regulation and professional quality of life. Previous literature also suggests that limited researches were conducted to study expressive suppression (ES) as a method of emotional regulation, and its relationship with professional quality of life and psychological wellbeing. Therefore, present study aimed to explore role of this variable in predicting different outcomes. Also, expressive suppression was found to show inconsistent results in different settings. Sometimes this particular technique of emotional regulation is found to be adaptive, whereas, in other instances it was found to predict negative outcomes. Thus present study intends to explore role of expressive suppression as a technique of emotion regulation in work setting where professionals use to experience emotionally challenging situations on daily basis. New forms of evidence will give a triangulated understanding about the promotion of well-being in mental health professionals.
Hypotheses
i. Mental health professionals who score high on cognitive reappraisal will score high on psychological well-being.
ii. Mental health professionals who score high on expressive suppression will score low on psychological well-being.
iii. Mental health professionals who score high on compassion satisfaction will score high on psychological well-being.
iv. Mental health professionals who score high on secondary traumatic stress will score low on psychological well-being.
v. Mental health professionals who score high on burnout will score low on psychological well-being.
vi. Compassion satisfaction will mediate the relationship between cognitive reappraisal and psychological well-being among mental health professionals.
vii. Secondary traumatic stress will mediate the relationship between cognitive reappraisal and psychological well-being among mental health professionals.
viii. Burnout will mediate the relationship between cognitive reappraisal and psychological well-being among mental health professionals.
Method
Sample
The sample consisted of 185 mental health professionals including both males and females of public and private sectors from Islamabad, Rawalpindi, Bhawalpur, Kharian Lahore, Karachi, Sialkot, and Peshawar (age range of 21-62 years; M = 29.03, SD = 7.73) was acquired through purposive/convenient sampling technique. The respondents of the study included Psychologists, Psychiatrists, Speech and Language Pathologists, Counselors, and Special school teachers. Minimum experience of 1 year criterion was adopted. This tenure gave respondents a better understanding of their work related experiences. The respondents would also have undertaken challenging duties, which give them sufficient experience required for eliciting responses to the questionnaires administered.
Measures
Ryff’s psychological well-being scale (RPWS)
Ryff’s Psychological Well-being Scale (RPWS), Ryff (1989) was used to assess psychological well-being of mental health professionals. The scale comprised of 42-items. A 6-point Likert type rating scale was used for scoring from Strongly Disagree (1) to Strongly Agree (6). Items 3, 8, 10, 13, 14, 15, 16, 17, 18, 19, 23, 26, 27, 30, 31, 32, 34, 36 and 39 were reversed scored. To obtain an overall psychological well-being score, scores on individual scales can be combined into a composite score, which could be interpreted following the above guidelines. The test-retest reliability coefficient of RPWS was .82 (Bayani, Koocheky, & Bayani, 2008).
Emotional regulation questionnaire (ERQ)
The Emotional Regulation Questionnaire (ERQ) [1] is a 10-item scale that was used to assess two kinds of emotional regulation techniques i.e., cognitive reappraisal and expressive suppression. It is a self-report measure of habitual expressive suppression (four items) and reappraisal (six items). Reappraisal Items includes 1, 3, 5, 7, 8 and 10, whereas Suppression Items includes 2, 4, 6 and 9. ERQ uses a 7-points Likert scale ranging from Strongly Disagree (1) to Strongly Agree (7). The alpha reliabilities averaged .79 for reappraisal and .73 for suppression (Gross and John, 2003) Test–retest reliability was .69 for both scales [1].
Professional quality of life (ProQOL)
Professional Quality of Life (ProQOL) was developed by Stamm in 2005. The scale comprised of 30-items. It is a self-report measure including 3 subscales: Compassion satisfaction, Secondary traumatic stress, and Burnout. Each subscale consists of 10 items. Compassion satisfaction scale includes the following item numbers (3, 6, 12, 16, 18, 20, 22, 24, 27, and 30). Burnout scale includes the following item numbers (1, 4, 8, 10, 15, 17, 19, 21, 6, and 29). This scale also includes some negative items and are “reverse scored” which includes item number (1, 4, 15, 17, and 29). Secondary Trauma scale includes the following items ( 2, 5, 7, 9, 11, 13, 14, 23, 25, 28). A 5-point Likert type rating scale was used for scoring from Never (1) to Very often (5). The alpha reliability coefficient for compassion satisfaction was .88, for secondary traumatic stress was .81, and for burnout, it was .75 [43].
Procedure
Researchers sought official permission from the administrative heads of the special schools, universities, clinics, hospitals and rehabilitation centres to carry out this study. Participants were assured that the data collected would be used for research purpose only and that all personal details asked through demographic sheet would be kept confidential. Researchers introduced themselves to the participants and explained the purpose of the study. All the questionnaires were presented in random order so as to counterbalance the effects of scale administration. Written instructions and verbal explanations were provided to the respondents.
Results
In order to assess reliabilities and descriptive statistics, alpha reliability coefficients and descriptive statistics of all study variables were computed.
![Click here to view Large Table 1](images/PBSIJ.MS.ID.555888.T001.png)
Table 1 shows that alpha reliability coefficients of all scales and subscales were found to be in acceptable range except subscale burnout of professional quality of life which shows moderate level of alpha reliability coefficient, but still was found to be in acceptable range. The mean values show that distribution of test scores of majority of the study variables were found to be average. However, test scores obtained on psychological well-being and compassion satisfaction was found to be higher. The values of skewness and kurtosis show that the scores across the study variables were found to be normally distributed.
![Click here to view Large Table 2](images/PBSIJ.MS.ID.555888.T002.png)
Note: PWB = Psychological Wellbeing , CR = Cognitive Reappraisal , ES = Expressive Suppression, CS = Compassion Satisfaction, STS = Secondary Traumatic Stress, B0 = Burnout.
**p < .01.
Table 2 shows that psychological wellbeing is significantly related with cognitive reappraisal, compassion satisfaction, secondary traumatic stress, and burnout (p<.01). Cognitive reappraisal and compassion satisfaction were found to be positively related with psychological wellbeing, whereas, psychological wellbeing was found to be negatively related with secondary traumatic stress and burnout. Furthermore, expressive suppression was found to be negatively related with psychological wellbeing, but this relationship was found to be non-significant. Results also reveal that cognitive reappraisal was found to be significantly related with expressive suppression and compassion satisfaction in positive direction. Whereas, a significant negative association was found between cognitive reappraisal and burnout (p<.05). Next, expressive suppression was found to be positively related with secondary traumatic stress and burnout and this relationship was found to be significant (p<.01). Lastly, burnout was found to be negatively associated with compassion satisfaction, whereas, significant positive relationship was found between burnout and secondary traumatic stress (p<.01). Stepwise regression was performed to study the role of cognitive reappraisal, compassion satisfaction, secondary traumatic stress, and burnout in predicting psychological wellbeing.
![Click here to view Large Table 3](images/PBSIJ.MS.ID.555888.T003.png)
Note: *p < .05, ***p <.001.
Table 3 shows the results of prediction in psychological wellbeing accounted for cognitive reappraisal, compassion satisfaction, secondary traumatic stress, and burnout. Findings indicate that 28%, 8%, 5%, and 2% of variance was caused by burnout, cognitive reappraisal, compassion satisfaction, and secondary traumatic stress respectively. Burnout and secondary traumatic stress predict psychological wellbeing in negative direction which shows that mental health professionals who experience high burnout and secondary traumatic stress show lower psychological wellbeing. Whereas, cognitive reappraisal and compassion satisfaction positively predict psychological wellbeing which indicates that individuals showing higher cognitive reappraisal and compassion satisfaction have better psychological wellbeing.
![Click here to view Large Table 4](images/PBSIJ.MS.ID.555888.T004.png)
Findings in Table 4 indicate that cognitive reappraisal came out to be a significant predictor of compassion satisfaction as well as burnout, accounting for 6% variance in compassion satisfaction and 3% variance in burnout respectively. Cognitive reappraisal predicts compassion satisfaction in positive direction, whereas, direction of the predictive relationship between cognitive reappraisal and burnout was found to be negative. In order to study the mediatory role of compassion satisfaction and burnout between cognitive reappraisal and psychological wellbeing, hierarchical regression analysis was performed.
Table 5 indicates significant prediction accounting for total 33% of variance in psychological wellbeing by cognitive reappraisal and compassion satisfaction (See Model 1, Table 5). Findings show that both cognitive reappraisal and compassion satisfaction are significant positive predictors of psychological wellbeing accounting for 14% and 19% of variance respectively. Findings also indicate the mediating role of compassion satisfaction between cognitive reappraisal (predictor) and psychological wellbeing (criterion). Results reveal that the value of regression coefficient for cognitive reappraisal was significantly higher in Step 1 (β = .37, p < .001). Whereas, this value of coefficient gets lowered in Step 2 (β = .26, p < .001), when compassion satisfaction entered in the model. The significance of this relationship i.e., cognitive reappraisal and psychological wellbeing also dropped, but it remains significant. This phenomenon is termed as partial mediation, Baron & Kenny (1986). Finally, this mediatory role was confirmed through sobel-t test. The value of sobel-t test was significant, thus confirming the mediatory role of compassion satisfaction between cognitive reappraisal and psychological wellbeing.
Model 2 in Table 5 indicates significant prediction accounting for total 36% of variance in psychological wellbeing by cognitive reappraisal and burnout. Findings show that cognitive reappraisal predicts psychological wellbeing in positive direction accounting for 14% of variance in it, whereas, burnout predicts psychological wellbeing in negative direction and accounts for 22% of variance respectively. Findings also indicate the mediating role of burnout between cognitive reappraisal (predictor) and psychological wellbeing (criterion). Results reveal that the value of regression coefficient for cognitive reappraisal was significantly higher in Step 1 (β = .37, p < .001). Whereas, this value of coefficient gets lowered in Step 2 (β = .29, p < .001), when burnout entered in the model. The significance of the relationship between burnout and psychological wellbeing drops, but it remains significant, thus showing partial mediation. Finally, this mediatory role was confirmed through sobel-t test. The value of sobel-t test was significant, thus confirming the mediatory role of burnout between cognitive reappraisal and psychological wellbeing.
![Click here to view Large Table 5](images/PBSIJ.MS.ID.555888.T005.png)
For Model 1: Step 1: F = 28.74. ***p < .001; For Step 2: F = 43.96. *** p < .001.
For Model 2: Step 1: F = 28.74. ***p < .001; For Step 2: F = 52.02. ***p < .001.
Discussion
Present study was conducted on a sample of 185 mental health professionals working in different rehabilitation centres, hospitals, clinics, and special schools. The instruments used in this study showed good range of reliability coefficients except subscale burnout of professional quality of life which showed relatively lower value of alpha reliability, but even then it was found to be in acceptable range. The finding was consistent with studies which also reported subscale burnout shows relatively low reliability than other subscales of the scale [43].
First hypothesis of this study is when cognitive reappraisal increases, it leads to enhanced psychological wellbeing. These variables showed significant positive relationship in present study, also cognitive reappraisal was found to predict psychological wellbeing in positive direction thus confirming this hypothesis. This is because when individuals reinterpret their stressful situation in a way that help them to cope up with that stress result in increased PWB. Second hypothesis stated that increase in expressive suppression results in reducing individual’s psychological wellbeing. Present study also confirmed a negative relationship between these two variables, but this relationship was found to be non-significant. This explained that when individuals face stressful situations and instead of sharing their feelings or reinterpreting the situation they simply suppress them; it results in poor wellbeing. According to a study expressive suppression causes a psychological difficulties in an individual’s life [44-47]. Earlier, researchers also found inconsistent findings across expressive suppression, thus present study also confirmed that expressive suppression is not a significant factor contributing in psychological wellbeing of mental health professionals.
Next, compassion satisfaction was found to be positively related with psychological wellbeing. This finding thus conformed third hypothesis. Results suggest that mental health professionals who are satisfied with their job and helping clients with their problems result in their increased psychological wellbeing. The finding was in line with previous literature which indicate that individual’s satisfaction with their work contributes in overall wellbeing. Fourth hypothesis of present study stated negative relationship between secondary traumatic stress and psychological wellbeing. Present findings confirmed this association where secondary traumatic stress also called as compassion fatigue was found to negatively predict psychological wellbeing among mental health professionals. This is because after listening to clients sharing their experiences, mental health professionals are affected by their problems which leads to low psychological wellbeing. Finding was consistent with previous literature which also revealed negative association between these two variables. Next, burnout was found to be negatively related with psychological wellbeing and come out to be a strong predictor of psychological wellbeing in negative direction, thus approving fifth hypothesis. This finding was in accordance with previous literature which also showed burnout negatively influencing individual’s wellbeing. Results suggest that mental health professionals who face emotional exhaustion and feel that they are not able to meet the demands of their jobs result in poor wellbeing.
Sixth hypothesis of present study was approved as compassion satisfaction was found to mediate the relationship between cognitive reappraisal and psychological wellbeing. Finding suggests that as an individual reinterpret the stressful situation in a way that it becomes less threatening, it will lead to the increase in compassion satisfaction i.e. they will be satisfied with their work [39] which will ultimately results in increased level of psychological wellbeing [29]. Seventh hypothesis of the study stated that secondary traumatic stress mediates When the individuals get direct contact with the people who are suffering from serious traumatic issues that affect the thought patterns which results in STS so to reduce this CR is an effective coping mechanism that helps to reinterpret or change the conceptualizing of the situation which helps to reduce traumatic stress [35-37], when STS decreases PWB increases [31]. But the data did not provided support to our eighth hypothesis as Table 3 shows that STS is the lowest predictor of the PWB so there was no mediating relationship of STS found between CR and PWB which is proved in Table 5. The reason of no mediating relationship of STS found could be because it is the duty of the mental health professionals to deal with the traumatic clients on the daily basis it’s part of their job and they are used to it so they know how to deal with the stresses as a result it doesn’t affect their PWB. When the individuals feel committed to their work and helping people, they don’t get effected by their clients stresses.
Seventh hypothesis of this study was BO will mediate the relationship between CR and PWB. As the individuals will re construct their thoughts on the respective event the emotional exhaustion regarding their work will decrease and they will feel satisfied with their work and will have good interpersonal relations with the colleagues that will help in the satisfaction of their work life [34], so as the BO will decrease this will result in the increased levels of PWB, Veer (1995). This hypothesis was also supported by Table 5 which predicts that there was a negative direction between BO and CR and there was a positive direction between CR and PWB, whereas findings also prove the mediating role of BO between CR (Predictor) and PWB (criterion). Lastly our study proves that it is not the STS which effects the PWB of the individual it’s the BO which effects mostly, when the individuals starts feeling that he is not able to fulfil the demand of his work or is unable to help their clients that effects their Psychological well-being and self-esteem, so this is reduced with the help of emotional coping strategy i.e. Cognitive reappraisal. It’s essential for a mental health professional to regulate their cognitions in order to have good psychological wellbeing which is useful in helping their clients and give their best to their work [48,49].
Limitations and Suggestion
This study was conducted in short period of time that created difficulty in finding sample, literature review, applying methodology and interpretation of result. Secondly, for effective results and generalization there should be average percentage of male and female in sample but in this study male participants are less than female participants. Moreover, sample size is small therefore it was difficult to find significant relationships from data as statistical tests normally require a larger sample size to ensure representative distribution of population. The study should be replicated with more sample and equally distributed sample from all over Pakistan in order to get effective and more generalized results. Moreover, comparative study could also be done to see the difference among the both male and female about their stresses of working with the traumatic clients.
Implications
As the study emphasizes on mental health professionals and its relations to the psychological wellbeing, emotional self-regulation and professional quality of life, therefore the people working with specifically issues regarding to mental health which includes clinical psychologists, psychiatrists and special school teachers. This study would help to understand how the mental health professionals cope up with the stresses, which they get by working with the traumatic clients. This study includes both positive and negative aspects of their profession and describe that emotion regulation is very essential for a mental health professional for their high levels of psychological well-being and their better professional quality of life. Moreover, the mental health professionals should be given counselling for their mental stability.
Conclusion
Psychological well-being among mental health professionals is an essential requirement for their professional life. In conclusion, the present study contributes to our growing understanding of the connections between Professional quality of life, Emotional Regulation which have both negative and positive aspects that can affect psychological wellbeing among mental health professionals in the unique cultural context of Pakistan. Further the study demonstrated that the professionals who are satisfied with their working life in helping others and their levels of burnout and secondary traumatic stress works as a mediator between the cognitive reappraisal and psychological wellbeing.
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