Welcome back to the Healing Pain Podcast with Jason Cherry, PT, DPT, EdD

Stress and burnout have been recognized in many health professions. Specifically, researchers have reported that many Doctor of Physical Therapy (DPT) students are actively experiencing moderate to high levels of stress each and every day. Joining Dr. Joe Tatta to discuss the topic in depth is Jason Cherry, PT, DPT, EdD. Dr. Cherry is an Assistant Professor in the Division of Physical Therapy at Binghamton University. In this episode, he shares the results of his study on the relationship between psychological flexibility, perceived stress and academic burnout in DPT students, along with practical applications on how professors in the field can model healthier behaviors as preventive measures. Tune in for more valuable insights as Dr. Cherry defines these concepts.

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Reducing Stress And Burnout In Doctor Of Physical Therapy Students With Psychological Flexibility With Jason Cherry, PT, DPT, EdD

In this episode, we’re talking about stress and burnout in the student physical therapist. Over the years, the prevalence of psychological distress, depression and even anxiety related to the lived experience of being a college student has skyrocketed. COVID certainly has intensified it. Stress and burnout have been recognized in many health professions but specifically, researchers have reported that many DPT students or Doctor of Physical Therapy students are actively experiencing moderate to high levels of stress every day.

Academic burnout, which is a form of psychological distress, is also high in DPT students. The consequences of unaddressed stress or academic burnout include things like decreased academic performance, reduced empathy, decreased professionalism, physical and mental health problems and even things like substance use and suicidal ideation.

Burnout in physical therapy school doesn’t necessarily stop there. Professionals can carry over this burnout into the professional phase of their careers. DPT students are at risk of burning out even before they enter into the profession. The sad thing about this is that it’s been associated with an intent to leave the profession or what many of you might identify as turnover in a physical therapist.

In my opinion, many of you reading this episode believe this to be true as well. Academic burnout and professional burnout throughout the entire professional physical therapy is a top priority. We can’t support people with chronic health and mental health problems if we are overly stressed and burned out. We know this to be a profession-wide problem. It means that everyone from the Commission of Accreditation of Physical Therapy Education programs to DPT program directors and faculty to everyday clinicians and employers should take steps to reduce or mitigate burnout in physical therapy professionals.

Many of you know I conducted some research with Annette Willgens and Kerstin Palombaro, who are physical therapists professors in DPT programs. We demonstrated that ACT training for chronic pain significantly reduced burnout, secondary traumatic stress and compassion fatigue in DPTs with 0 to 2 years of experience. You can read that article called The ACT Trained Physical Therapist in the Journal of Contextual Behavioral Science, which is where it was published.

However, I’m even more excited to bring you my guest, Dr. Jason Cherry, who is a Physical Therapy Professor and is working inside DPT education programs to research and develop ways we can help DPT students cope with stress and burnout. This includes identifying the relationship between psychological flexibility, stress and academic burnout in DPT students

Jason is an Assistant Professor in the division of Physical Therapy at Binghamton University. He’s a board-certified Orthopedic Clinical Specialist and has over twenty years of clinical experience in pain management orthopedic sports medicine and the acute care setting. His area of research is related to the relationship between psychological flexibility and the management of perceived stress and academic burnout.

In this episode, we discuss the important relationship between stress, burnout and psychological flexibility in the DPT student and some of the research that Jason has already conducted on the importance of this topic for physical therapy students, educators and clinicians. Without further ado, let’s begin, meet Dr. Jason Cherry and learn about the relationship between stress, burnout and psychological flexibility in the DPT student.

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Jason, it’s great to have you here.

Thanks, Joe. It’s great to be here. I’m a big fan of your work and your show. It’s my pleasure.

Thank you. I’m excited to speak with you because I know a lot of the things that you’re working on build on some of the work that my other colleagues and I have worked on. It’s great to see like minds coming together and discussing these topics for DPT students and later on, physical therapy clinicians and the whole profession. We’re all starting to look at burnout and stress and how it impacts our personal, mental health and physical health, our relationships and everything. How did you become interested in burnout as a topic?

As a physical therapist and healthcare practitioner, I’ve certainly experienced my share of feeling like I was burnout. I’ve worked with colleagues who went through those types of feelings and sensations. Now that I’m in academia, I certainly notice it with students. One thing that happens is professional burnout may start with student burnout or academic burnout. I’m particularly interested in solving the problem at the DPT level so that we can hopefully prevent it from occurring once our students go out into the profession.

Getting to the root of the problem means that we may be starting to smolder a little bit in PT school even before we get into our internships, our residencies or fellowships and onto our career path and trajectory.

People write about two different ways to look at the burnout problem. One is to address the environment and the second is to address the individuals. The answer is and, not or, we certainly can do some things to improve the academic environment. My concern is that these students are going to go from a stressful academic environment to a potentially even more stressful professional environment. If our job as PT educators is to prepare our students for careers and physical therapy, we need to prepare them to be able to cope with what they’re going to be experiencing as professionals.

I’m sure there are DPT students reading who resonate. It resonates with maybe even new physical therapists who are graduating and realizing how to deal with the stress of school and the boards. Some of that stress is carried over into their professional life. How do you define stress and academic burnout? There are maybe two distinct things that we need to piece apart for people.

In the study that I performed, we defined stress as perceived stress. Perceived stress is the way that somebody appraises a stressful or difficult situation. A stressful situation means different things to different people. You can measure that based on the individual’s response. You have perceived stress. The thought is that as perceived stress increases, it eventually leads to academic burnout. The way that progresses is it starts with perceived stress. The more stressed people are, the more they’re having to cope and the more they’re using their resources to cope with that stress so they start to get exhausted. One piece of the definition of burnout is exhaustion.

As they become exhausted, they need some way of dealing with that exhaustion. Sometimes they start to become cynical in the academic environment. They start to question what they’re learning. They question the importance of what they’re learning and that can progress in lower academic efficacy. They’re questioning what they’re learning so they don’t perform as well. They start to question their ability. That’s important to mention.

The true definition of burnout according to Maslach is the combination of exhaustion and cynicism. There’s been some debate lately about the efficacy piece. Some people say that the efficacy piece isn’t quite as important. You need the exhaustion piece and the cynicism piece. For the full definition, also the efficacy.

I like that I can see a downward spiral almost as you’re talking because we’re all going to experience some type of burnout. If we can intervene and how people cope before it moves on to that emotional exhaustion and then look at that efficacy piece, it’s important. You’ve started to go much deeper into this and look at the construct of psychological flexibility, which mostly is from the ACT world, it is a common construct in many mindfulness-based approaches. It’s something that I’ve been very interested in and have done some research on. How’d you become interested in that particular construct? Having talked about this for years, it’s always helpful for people to redefine what psychological flexibility is and maybe why that’s important in the context of burnout.

I came across psychological flexibility through my experience. As a human, especially as a healthcare provider, I’ve come up against difficult situations. I’ve tended to have more of what we would call negative coping strategies. I would tend to try to avoid those difficult situations, change the situation or distract myself by drinking beer, eating ice cream or binge-watching Netflix shows, which would help in the short-term but ultimately, it didn’t do me very much good in the long-term.

A while back, I had a particularly stressful situation occur. I went to those strategies and it didn’t work. I saw psychological counseling. I had a high deductible and couldn’t afford it, which says something about our current healthcare system. 1) I couldn’t afford it. 2) I couldn’t find a provider that could see me in a relatively quick period.

I came across a book and I can’t remember how I found the book but it’s called The Happiness Trap by Russ Harris. The more you talk to people who are exposed to ACT and psychological flexibility, the more you hear that book come up as an entry point. The title is what grabbed me. I was trying to be happy and I couldn’t find a way to be happy. The book is based on acceptance commitment therapy and psychological flexibility. What I learned from the book was that I was trying too hard to be happy and that I needed to go in a different direction. That brings us to the definition of psychological flexibility. First, we have to understand that pursuing a meaningful life is going to be difficult. There are going to be challenges and tribulations.

The first part of psychological flexibility is being open to experiencing difficult situations, thoughts and feelings and noticing when we are getting derailed by those thoughts and feelings and then shifting our focus to the present moment and our behavior so that it’s in alignment with our values. Number one, you have to know what your values are to pursue them. The hardest part is noticing. You have to be able to notice when you are getting distracted by your thoughts and your emotions and then pivot that focus towards the present moment. You may be worrying about the past or the future but psychological flexibility involves being able to pivot, focus more on the present moment and be in alignment with the values

The idea that doctoral-trained licensed health professionals can’t access counseling mental health services when needed says so much about our country and society. Thanks for sharing with us that because it’s important. Patients expect that we have these skills somewhat instilled in us from school. Sometimes we do or sometimes we have them from previous life circumstances. Sometimes the things that we face as professionals or even people extend beyond our skills, even beyond our doctoral skills.

I have friends who are mental health professionals who see counselors regularly and they’ve gone to school for eight years to be clinical psychologists and they’re still supporting their mental well-being. I appreciate you bringing that to the physical therapy profession because it’s a conversation we need to have more in the open about how are we training PTs with regard to cognitive and psychologically based skills and taking a moment to notice, “How are you as an individual in academia?”

“How are you doing? How are you as an individual in clinical practice? How are you feeling working in that environment? How is it impacting your health?” This is the work that you do. How are we starting to open the eyes of early PTs in school to the idea that you might have to not only track your patient’s health but you might have to track your health as you’re going through your career?

It starts with letting the students know that it’s normal. Stress and difficult situations are normal. We all feel these ways sometimes. I tell my stories to my students. There are times after a lecture when I wonder if I might have shared a little too much. It’s important to share that because Imposter syndrome is real. They feel like they’re not supposed to feel stressed. They’re supposed to be confident. They look up to us as professors. When they hear that we go through similar feelings and thoughts helps them realize that what they’re going through is normal. I hope that also bleeds into them wanting to help patients with these things as well because then they realize that it is a normal part of the healing process that they need to address.

As professionals, we gravitate to the idea of physical resilience. However, we also have to start to recognize there is a mental psychological resilience that is by direction on working off each other. It’s great to hear that. Tell us about the study you went through. It’s an EdD program and this was a lot of your work. You spent a lot of time and here’s researching. Tell us about your study and what you found.

The title of my study was The Relationship Between Psychological Flexibility, Perceived Stress and Academic Burnout in DPT Students. The reason why I conducted the study was that I ultimately want to teach psychological flexibility or acceptance commitment therapy skills so that students can work on their psychological flexibility. Before I did that, I wanted to see if psychological flexibility was relevant in the DPT population. I had a pretty good idea that it was because it’s relevant in so many other populations but I thought a good first step was to see to what degree psychological flexibility correlates with perceived stress and academic burnout.

Did you look at a certain population of students over a course of a certain amount of time? How’d you measure it?

We looked at students from four different campuses after midterms. We wanted it to be a relatively stressful time but we didn’t want to do it at the end of the semester when they probably wouldn’t fill out our surveys. We used the compact questionnaire to measure psychological flexibility. We used the perceived stress scale, which is the most commonly used scale for perceived stress. We use the Maslach Burnout Inventory to measure academic burnout.

Did you find significance in all three of those?

What we found was that psychological flexibility was a predictor of lower perceived stress. That’s what you would expect. It was an inverse correlation. Not only through linear regression or correlation but also through predicted perceived stress. This was cool because it aligned with the theory. Also, psychological flexibility was a predictor of academic burnout.

When you look at the different dimensions, we looked at the three broad components of psychological flexibility as six processes can be organized into three basic components. You have openness to experience, which is the ability to be present in difficult situations. You have behavioral awareness, which is also the ability to be present and be aware of how you are behaving in a specific situation. You have valued action, which is the ability to move towards your values.

Openness to experience was the biggest predictor out of those three areas. It was the biggest predictor of perceived stress. It was also the biggest predictor of exhaustion, which makes sense from a theoretical perspective. We think that the higher the perceived stress translates into higher exhaustion. With the other two components of burnout, different parts of psychological flexibility influenced each part of burnout. It was the behavioral awareness component of psychological flexibility that was the biggest predictor of cynicism and it was the valued action component that was the biggest predictor of academic efficacy.

What that means to us is that interventions to help students learn the skills to become more psychologically flexible can help with stress and burnout. That maybe different parts of psychological flexibility can be emphasized depending on what’s going on with the students. Measuring the students as a group, what degree of perceived stress are they under and how much exhaustion are they experiencing? If those are looking high, you can perform intervention as a group. You don’t want to separate the different components of psychological exploitation but you can emphasize certain components. With those types of groups, you may get better results if you emphasize the openness to experience component of psychological flexibility.

It’s nice to see those three pillars map onto what you did, right?

Yes. It’s comforting to see that my results matched up with the theory.

Let’s talk about the openness to experience pillar, which if you’re looking at a traditional ACT model, that’s diffusion and diffusion is a big part of it there. Acceptance is the other part of it. Through your lens, as you’re looking at that pillar, the diffusion and acceptance part, you’re saying, “This pillar needs to be trained in physical therapy students.”

Take me back a little bit maybe into your study. The opposite of acceptance is avoidance and the opposite of diffusion is fusion. They fuse with their thoughts and they’re avoiding things that are uncomfortable or unpleasant, which could be physical sensations in their body. It could be the yearnings and cravings that we all experience as humans. There are so many facets to that. When you do research, you’re looking for the statistical significance piece of it but through your perspective, how do you see that show up in a lived experience of a student?

That’s a good way to look at it is from the student’s perspective. This goes to the idea that you cannot separate the different components you may be able to emphasize but it goes back to values. Having conversations with students about what their values are and what their ultimate goal is going through physical therapy school.

I have the benefit of teaching the first class in the program so I can talk to students about this a little bit. On day one, we talk about what is it you want to become eventually. Physical therapy school can be a bit of a drag. People go into it thinking, “I want to get through physical therapy school.” We all do that. It’s that hedonistic treadmill of, “I just want to pass this exam. I just want to pass my practical. I just want to get through this semester. I just want to get through physical therapy school.”

With that mindset, there’s a lost opportunity because we can start developing expertise during physical therapy school. On day one, we talk about what that means. What does expertise mean to you? The question is, what type of physical therapist do you want to be? How will you be as a physical therapist? How will you interact with patients and your colleagues?

Number one, getting those values open out front first, then bringing up what might you experience as you pursue those values. What difficulties might you experience? What thoughts might you have? What doubts might you have? Even bringing that back to previous experience because they’ve all overcome things to get to physical therapy school and they’ve had to experience difficult situations. They’ve had to experience difficult thoughts and feelings.

Framing it from that perspective, what thoughts might you have? What things might you try to avoid that you know you shouldn’t? If you do avoid them, you’re moving away from your goal versus towards your goal. That’s a big part of it. The other part is talking about thoughts with students. We have this tendency to believe our thoughts and let our thoughts push us around and dictate what we do. That’s part of the cognitive fusion but we don’t necessarily have to do that.

We do some exercises that are on to help students realize that thoughts aren’t necessarily true or false. They’re the story that your mind is telling you and it’s up to you whether you follow that story or not. Ultimately what can help you decide if this story or thought helping you move towards the person you want to be in the classroom or is it helping you move towards the person you want to be in the clinic?

Two things come up for me here. The first is more of a research perspective. Was there any qualitative data that you collected on their experience?

No. That’s the next step. Not only that but this is a correlational study. We can’t say that this is causative. We can’t say that low psychological flexibility causes stress, burnout or vice versa. The next step is to do more experimental studies and do interventions with the students to see if it does improve their stress and equipment burnout. That is also a good place to do the qualitative piece as to how did they feel as they were going through it. Was it helpful? What did they think about this idea of not necessarily following your thoughts and feelings?

In our study, we had that qualitative piece. Annette Willgens, who’s a physical therapy professor and she teaches at Nova Southeastern, I believe Tampa campus, is an excellent qualitative researcher. What showed up in our study was that psychological flexibility is an essential skill for physical therapists to manage the types of conditions that we see. It’s interesting to look at people’s experiences here in their words and how they impacted their health.

The second thing is if people have studied ACT or taken my courses, they know that there’s a big part of becoming ACT informed. Let’s say I’m a physical therapist and I become trained in ACT for pain. It’s not so much that I’m doing something or providing an intervention but it’s that I’m modeling psychological flexibility in myself for the patient.

As I’m listening to you talking about that, we need to help students reflect on where they’re going in life, what they want to be and how they want to act and be in life. Do physical therapy educators need to model psychological flexibility for the students? What are your thoughts on that? There’s a bit of vulnerability wrapped up in that. A part of psychological flexibility at times is saying, “I’m struggling with this one thing and here it is. Here’s what I’m thinking and feeling. Here are the images that are passing through my mind.” I’m not sure. I can’t think of an experience like that happened in physical therapy school where the professors were modeling it on the level that you and I are discussing here.

Every professor has to decide that on their own. My feeling is that we do need to model these things and be a bit more explicit about our thought process even in the classroom. The good professors that I know change as the semester goes on, as far as how they deliver the material based on what they’re experiencing. The more we verbalize that, we noticed. That’s the big thing.

We noticed that something didn’t go very well. For instance, I’ve had classes where the previous class didn’t go well and I wasn’t happy with it. In the next class, I mentioned that to the students. I said, “I didn’t feel very good about the last class because this happened. That’s not in alignment with how I want this class to go and how I want to be as a professor. Here’s what we need to change going forward.”

When I’ve done that, I’ve gotten positive feedback from students. I share some silly things with students. Sometimes after class, I wonder if I should have shared those things because it’s uncomfortable but I value sharing those things so that students can learn from me, my experiences and the mistakes I’ve made. If I’m going to be psychologically flexible, I need to be willing to experience that discomfort of putting myself out there in service of my value of helping students realize that these things are normal and that they can build these skills.

What’s the risk when students don’t have these?

The risk can be drastic. The risk can lead to severe clinical diagnoses. There’s even the ideation. That does occur among physical therapy students. We have literature that documents that. The risk and the consequences are high for the students themselves and also for their future patients. The healthcare system. We know that academic burnout can lead to professional burnout and professional burnout leads to errors and increased cost of care. It’s a big drain on our healthcare system.

It’s important to bring all that up. We didn’t talk about it in the beginning but sometimes there’s a perception like, “You’re burnt out. You need a week off. Go on vacation, de-stress, kick back, have a beer or a glass of wine and a nice meal and then go to the gym.” When people don’t have these skills, especially professionals, these are pathways to clinical depression and extreme amounts of anxiety. Secondary traumatic stress is aligned with post-traumatic stress disorder, which we’re seeing in post-COVID in many different health professionals.

The one that doesn’t come up a lot is in many ways, this could be an intent to leave the profession. We train excellent therapists, go through school and sit on the boards. They start and last for 1 year or 18 months and then they’re like, “I need to transition to something else.” They can’t tolerate or manage their burnout. With mental and physical health also, people don’t reconnect that. Burnout is a physical health problem as well. Your physical health will change when you are burnt out.

You cannot separate the mind from the body as much as you would like to. We have these discussions with students where we talk about psychosocial aspects. They get a little bit scared when we start talking about the psychological components because they think that’s outside their scope of practice and they get worried about that. As I tell them all the time, “You cannot separate the mind and the body.” They feed on each other. The body feeds on the mind and the mind feeds on the body. You cannot treat one without the other.

In any licensed health professional space, it’s very difficult to treat one without the other. This is your work. You’ve been presented at the Academy of Education Leadership, I believe. People are starting to become aware of your work. How would you like to see your work adopted maybe in other schools or throughout the profession to serve and help physical therapy students?

This study has shown that psychological flexibility is correlated with stress and burnout. One of the reasons why I grab it towards acceptance and commitment training, as we call it when it’s non-clinical and psychological flexibility, is it’s a tool set. We know of resilience and mindset issues. We have good intentions but what we tend to say to students is, “You need to be more resilient and have a growth mindset.” When students hear that, they hear that there’s more wrong with them, that they don’t know what to do with that or how to fix it.

The reason why I like psychological flexibility is it gives the tools to help students become more resilient and develop a growth mindset. That’s why there was an impact. That’s my biggest hope. There’s more research to do and more to show. I hope that physical therapy programs will start to integrate the education of these tools. It doesn’t have to be acceptance commitment training but something to work on the cognitive behavioral aspects for students to give them the tools to be more resilient.

I was at a conference years ago where I sat in on a lecture. There was a woman, a physical therapy professor, presenting a model of how to help students learn better. At the very top of the model was metacognition, which is the idea of being able to observe your thinking. That was at the top. She spent a lot of time on the bottom, explaining all the pieces on the bottom.

I said to her, “What do you do to work on the top part there, metacognition?” It is a mindfulness, a psychological flexibility type approach. She said, “We don’t do that. We’re going to work on that.” Telling students, “You need to be more flexible, have a growth mindset and be more open-minded,” is a very different conversation than, “As part of our program, we nurture you in how to be more behaviorally flexible, psychologically flexible, mindful as a clinician,” which we know spills over into life. It impacts us on a personal level. Jason, it’s been great speaking with you. I know a lot of people are going to want to learn more about your work and follow things that you’re doing in the academic environment and DPT programs. How can they follow you and learn more about you?

I am at Binghamton University. If you want to get in touch with me, the best way is by email. My email is [email protected]. I’m not a big social media guy because, for me, it can lead to avoidance of what I need to be doing.

I am big on social media so I’m there a lot. I love Instagram. If you’re on Instagram, tag me and say, “This is a great episode. Jason’s work is great and it’s great that you guys are talking on this level about mental health in physical therapy.” That’s what we’re talking about in some way. How to improve the mental well-being of the profession of physical therapy and other professionals as well, looking at similar challenges. It’s been a pleasure being here with you. We’ll see you next time.

Important Links

• The ACT Trained Physical Therapist
• Binghamton University
• The Happiness Trap
• [email protected]
• Instagram – Dr. Joe Tatta
• https://Members.IntegrativePainScienceInstitute.com/courses/Act-For-Chronic-Pain

About Jason Cherry

Jason Cherry is an Assistant Professor in the Division of Physical Therapy at Binghamton University.

Dr. Cherry is a board-certified Orthopedic Clinical Specialist through the American Board of Physical Therapy Specialties. He has over 20 years of clinical experience in pain management, general orthopedics, sports medicine, and acute care settings. Dr. Cherry also serves as a Faculty Mentor for the Cayuga Medical Center Orthopedic Physical Therapy Residency and Spine Fellowship programs.

Dr. Cherry’s area of research is related to the relationship between psychological flexibility and the management of perceived stress and academic burnout. He is also interested in the development of strategies to enhance the characteristics of the master adaptive learner and adaptive expertise.