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Burnout

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Full-Text Articles in Clinical Psychology

The Psychological Effects Of Restraints On Mental Health Workers, Jessica Baroni Jan 2018

The Psychological Effects Of Restraints On Mental Health Workers, Jessica Baroni

Antioch University Dissertations & Theses

This dissertation describes an empirical study of the psychological effects of restraints on mental health workers that perform this duty. To date, there is little research on the long-term, detrimental, and potentially traumatizing effects of restraints on an individual’s personal and professional life. Five self-report measures assessed the frequency that participants performed restraints, use of support after a restraint incident provided by their employer, perceived social support within their work environment, intention to leave their job, absenteeism, levels of job burnout, and post-traumatic stress symptoms. The study investigated the relationship between exposure to restraints and adverse stress effects and the …


Burnout Syndrome And Depression, Renzo Bianchi, Irvin Sam Schonfeld, Eric Laurent Jan 2018

Burnout Syndrome And Depression, Renzo Bianchi, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

In this chapter, we proposed an overview of burnout, from the introduction of the construct in the mid-1970s to the growing realization that the syndrome was better conceived of as a depressive condition. Recent studies have shown that the distinction between burnout and depression is problematic, both theoretically and empirically. The history of burnout research suggests that transdisciplinary communication and methodological standards should be strengthened to avoid the proliferation of constructs that, in fact, refer to the same phenomena. Construct proliferation, a transgression of the scientific canon of parsimony, is considered a major problem today because it undermines theory building …


What Is The Difference Between Depression And Burnout? An Ongoing Debate, Irvin Sam Schonfeld, Renzo Bianchi, Stefano Palazzi Jan 2018

What Is The Difference Between Depression And Burnout? An Ongoing Debate, Irvin Sam Schonfeld, Renzo Bianchi, Stefano Palazzi

Publications and Research

Il burnout è concepito come una sindrome che si sviluppa in risposta a condizioni di lavoro cronicamente avverse. Si ritiene che il burnout comporti esaurimento emotivo, depersonalizzazione e riduzione della realizzazione personale. Storicamente, tuttavia, il burnout è stato difficile da separare dalla depressione. In effetti, i sintomi del burnout coincidono con i sintomi della depressione. L'evidenza della validità discriminante del burnout nei confronti della depressione è debole, sia a livello empirico sia a livello teorico. L'esaurimento emotivo, il nucleo del burnout, riflette una combinazione di umore depresso e affaticamento / perdita di energia e si correla molto bene con altri …


Burnout And Depressive Symptoms Are Not Primarily Linked To Perceived Organizational Problems, Renzo Bianchi, Eric Mayor, Irvin Sam Schonfeld, Eric Laurent Jan 2018

Burnout And Depressive Symptoms Are Not Primarily Linked To Perceived Organizational Problems, Renzo Bianchi, Eric Mayor, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

In this 257-participant study (76% female; mean age: 44.84), we examined two ideas that are widespread among burnout researchers: (a) the idea that burnout is primarily related to occupational-level factors; and (b) the idea that burnout should be considered a sentinel indicator in research on negative occupational outcomes. We investigated the links between burnout and a series of generic and work-related variables, namely, depressive symptoms, neuroticism, extraversion, effort-reward imbalance in the job (ERI), social support at work (SSW), and turnover intention. Burnout was assessed with the Shirom-Melamed Burnout Measure, depressive symptoms with the PHQ-9, neuroticism and extraversion with the NEO-Five …


Interpretation Bias Toward Ambiguous Information In Burnout And Depression, Renzo Bianchi, Eric Laurent, Irvin Sam Schonfeld, Jay Verkuilen, Chantal Berna Jan 2018

Interpretation Bias Toward Ambiguous Information In Burnout And Depression, Renzo Bianchi, Eric Laurent, Irvin Sam Schonfeld, Jay Verkuilen, Chantal Berna

Publications and Research

Burnout has been defined as a job-related syndrome combining pervasive fatigue and loss of motivation. In recent years, evidence has mounted that burnout may reflect a depressive condition. In this study, we expanded on past investigations of burnout-depression overlap by focusing on interpretation biases toward ambiguous information among the two entities. We conducted a web-based study involving 1056 participants (83% female; mean age: 42.87). Burnout symptoms were assessed with the Shirom-Melamed Burnout Measure and depressive symptoms with the PHQ-9. The Ambiguous Scenarios Test (AST), a measure of interpretation bias validated among dysphoric individuals, was the outcome of interest. The AST …


Revisiting The Compassion Fatigue, Burnout, Compassion Satisfaction, And Resilience Connection Among Cism Responders, Harvey J. Burnett Jr. Jul 2017

Revisiting The Compassion Fatigue, Burnout, Compassion Satisfaction, And Resilience Connection Among Cism Responders, Harvey J. Burnett Jr.

Faculty Publications

Previous research by Burnett and Wahl found that resilience moderately mediated the association between compassion fatigue (CF) and burnout (BO) among trauma responders. No studies have attempted to replicate and verify the research results of Burnett and Wahl. This study examined whether similar patterns of resilience, CF, BO, and compassion satisfaction (CS) would be found among a convenience sample of disaster behavioral health (DBH) responders (N = 70) attending an annual Critical Incident Stress Management training conference in Michigan. Measures included the 30-item Professional Quality of Life Scale, the 14-Item Resilience Scale, the Response to Stressful Events Scale, and a …


Burnout Or Depression: Both Individual And Social Issue, Renzo Bianchi, Irvin Sam Schonfeld, Éric Laurent Jan 2017

Burnout Or Depression: Both Individual And Social Issue, Renzo Bianchi, Irvin Sam Schonfeld, Éric Laurent

Publications and Research

In view of the profound problems attached to the construct of burnout, we recommended in our that occupational health specialists focus on (job-related) depression rather than burnout to help workers more effectively. The phenomena of interest (burnout or depression) should not be confused with the perspectives (individual or social) adopted to elucidate those phenomena. Both burnout and depression are best explained through the interaction of social or external conditions with individual or internal dispositions.


Vital Exhaustion, Burnout, And Other Avatars Of Depression, Bianchi Renzo, Irvin Sam Schonfeld, Eric Laurent Jan 2017

Vital Exhaustion, Burnout, And Other Avatars Of Depression, Bianchi Renzo, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

In our view, there is a worrying tendency in psychology and medicine to let proliferate “depression-like” constructs—a transgression of the scientific canon of parsimony. The problem is not limited to vital exhaustion (VE). Burnout, a condition akin to VE, has been shown to problematically overlap with depression. Compassion fatigue, a condition that shows particularly blurred definitional contours, is also uncomfortably close to depressive symptomatology. The construct of neurasthenia may be part of this confusing trend as well, although neurasthenia has been elevated to the status of nosological category in the ICD. Construct proliferation jeopardizes knowledge growth by undermining theory building …


On Parsimony And Tautology In The Study Of Acute Coronary Syndrome, Bianchi Renzo, Irvin Sam Schonfeld, Eric Laurent Jan 2017

On Parsimony And Tautology In The Study Of Acute Coronary Syndrome, Bianchi Renzo, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

In a recent study, Zhang et al. concluded that burnout was associated with poor physical function and low quality of life after acute coronary syndrome (ACS). In our estimation, the authors' study has at least two unnoticed, though major, methodological limitations: not controlling for depression and using a burnout scale that is a questionable choice.


On The Depressive Nature Of The “Burnout Syndrome”: A Clarification, Renzo Bianchi, Irvin Sam Schonfeld, Pierre Vandel, Eric Laurent Jan 2017

On The Depressive Nature Of The “Burnout Syndrome”: A Clarification, Renzo Bianchi, Irvin Sam Schonfeld, Pierre Vandel, Eric Laurent

Publications and Research

Key theoretical arguments and empirical findings converge to suggest that the burnout construct captures a depressive phenomenon. The reluctance to consider burnout a depressive condition may be due to (a) a neglect of the stress–depression relationship and (b) a difficulty coordinating dimensional and categorical approaches to psychopathology in burnout research. The dimensions and categories constitute two ways of describing (psychopathological) phenomena. Thus, dimensions and categories should be heuristically combined rather than opposed: burnout and depression can be studied both as ‘‘processes’’ or ‘‘end-states’’. Clarifying what burnout actually is matters in terms of conceptual parsimony, theoretical integration, nosological consistency, interventional effectiveness, …


Burnout And The Hypothalamic-Pituitary-Thyroid Axis: A Methodological Comment, Renzo Bianchi, Irvin Sam Schonfeld, Eric Laurent Jan 2017

Burnout And The Hypothalamic-Pituitary-Thyroid Axis: A Methodological Comment, Renzo Bianchi, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

Because (a) burnout overlaps with depression and (b) depression has been associated with altered functioning of the hypothalamic-pituitary-thyroid axis changes in the activity of the HPT axis can be expected in burnout. Most probably, Guo et al.’s (2017) results are flawed by a severe form of the “healthy worker effect.”


Consequences Of Job Stress For The Psychological Well-Being Of Teachers, Irvin Sam Schonfeld, Renzo Bianchi, Peter Luehring-Jones Jan 2017

Consequences Of Job Stress For The Psychological Well-Being Of Teachers, Irvin Sam Schonfeld, Renzo Bianchi, Peter Luehring-Jones

Publications and Research

This chapter examines research on the relationship between job stressors and mental health (depressive symptoms, burnout, and mental disorders such as depression) in teachers. Teachers are exposed daily to job stressors (e.g., student disruptiveness) that have been linked to adverse mental health effects. Epidemiologic research indicates that when compared to members of other groups, teachers experience higher rates of mental disorder, although some studies question that conclusion. Large-scale studies indicate when compared to members of other occupational groups, teachers are at higher risk for exposure to workplace violence, with its adverse mental health consequences. Longitudinal research has linked teaching-related stressors …


The Big Five As Predictors Of Behavioral Health Professional Burnout, Alicia Mae Greene Jan 2017

The Big Five As Predictors Of Behavioral Health Professional Burnout, Alicia Mae Greene

Walden Dissertations and Doctoral Studies

While the majority of studies appeared to focus on health service workers and job satisfaction, there was a substantial lack of literature that explored the relationship of personality traits and burnout specific to behavioral health professionals. Research has indicated that behavioral health professional burnout is a mediating factor in early job exodus primarily due to highly interactive work with people. The purpose of this study was to consider the relationship between behavioral health professional burnout, as measured by the Maslach Burnout Inventory for Health and Human Service workers, and the big five personality traits, as measured by the NEO Five …


Predictors Of Vicarious Traumatization Among Trauma Clinicians And General Mental Health Providers: A Comparison, Shaina Gulin Jan 2017

Predictors Of Vicarious Traumatization Among Trauma Clinicians And General Mental Health Providers: A Comparison, Shaina Gulin

Theses and Dissertations

Vicarious traumatization (VT) describes the gradual, transformative shifts in internal experience that occur as a result of cumulative exposure to clients’ trauma material. VT is thought to develop in the therapist due to empathic engagement with clients, resulting in profound disruptions in frame of reference. Because VT is conceptualized as a condition that develops due to frequent exposure to clients’ traumatic material, a rapidly emerging body of theoretical literature suggests that clinicians can safeguard against VT by maintaining a more balanced workload (i.e., a caseload of clients with a variety of presenting problems) and limiting the number of trauma cases. …


Can Wearable Devices Reduce Burnout By Making People Aware Of Stress?, Rohit Mundayaliyath Mundayadan Dec 2016

Can Wearable Devices Reduce Burnout By Making People Aware Of Stress?, Rohit Mundayaliyath Mundayadan

Open Access Theses

Wearable fitness technology is advancing in its capabilities. Every new sensor collects new health data, and it becomes important to study how effectively this data can be utilized to help people lead healthier lives. The American Psychological Association found that Americans live with stress levels higher than what is considered healthy. Poorly managed stress can lead to burnout, which leads to unproductive workers. Burnout is known to cost businesses considerable money. The goal of this research study was to determine if burnout could be reduced through the use of a consumer wearable device along with smartphone apps that alerted wearers …


Burnout Et Dépression, Entre Normal Et Pathologique? Histoire D’Une Différenciation Hasardeuse, Bianchi Renzo, Irvin Sam Schonfeld, Eric Laurent Oct 2016

Burnout Et Dépression, Entre Normal Et Pathologique? Histoire D’Une Différenciation Hasardeuse, Bianchi Renzo, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

Initial described in the 1970s, the burnout syndrome has been difficult to characterize. It has been difficult to distinguish it from both clinical and subclinical depressive syndromes. In this chapter, we present a logical analysis of the distinction between burnout and depression. We synthesize the results of studies that bear on that distinction. We find that methodological and the historical separation of two lines of research as well as the lack of articulation between dimensional and categorical approaches to psychopathology.


Providing Care For Many In The Context Of Few Resources: Secondary Traumatic Stress, Burnout And Moral Distress Experienced By Healthcare Providers In Rural Uganda, Lauren Michelle Dewey Sep 2016

Providing Care For Many In The Context Of Few Resources: Secondary Traumatic Stress, Burnout And Moral Distress Experienced By Healthcare Providers In Rural Uganda, Lauren Michelle Dewey

Dissertations, Theses, and Capstone Projects

In the context of the global nursing shortage, and particularly in low-resource settings, nurses are at an increased risk for work-related stress problems like secondary traumatic stress (STS), burnout, and moral distress. These three work-related mental health consequences, sometimes associated with absenteeism and intent to leave the profession, could potentially contribute further to the shortage of nurses. This two-part study is a longitudinal examination of the work-related mental health consequences experienced by healthcare providers in rural Uganda. In Study 1, participants (n=208; 159 students and 49 experienced health workers) completed self-report, psychosocial measures at baseline and 134 of the students …


Burnout Is Associated With A Depressive Cognitive Style, Renzo Bianchi, Irvin Sam Schonfeld Jan 2016

Burnout Is Associated With A Depressive Cognitive Style, Renzo Bianchi, Irvin Sam Schonfeld

Publications and Research

We examined whether burnout is associated with a depressive cognitive style, understood as a combination of dysfunctional attitudes, ruminative responses, and pessimistic attributions. A total of 1386 U.S. public school teachers were included—1063 women (M_age: 42.73, SD_age = 11.36) and 323 men (M_age: 44.60, SD_age = 11.42). Burnout was assessed with the Shirom–Melamed Burnout Measure (SMBM). Dysfunctional attitudes were measured with the Dysfunctional Attitude Scale Short Form, ruminative responses with the Ruminative Responses Scale, and pessimistic attributions with the Depressive Attributions Questionnaire. For comparative purposes, depression was assessed using the 9-item depression module of the …


Burnout-Depression Overlap: A Study Of New Zealand Schoolteachers, Renzo Bianchi, Irvin Sam Schonfeld, Eric Mayor, Eric Laurent Jan 2016

Burnout-Depression Overlap: A Study Of New Zealand Schoolteachers, Renzo Bianchi, Irvin Sam Schonfeld, Eric Mayor, Eric Laurent

Publications and Research

We examined the overlap of burnout with depression in a sample of 184 New Zealand schoolteachers. Burnout and depressive symptoms were strongly correlated with each other (r = .73; disattenuated correlation: .82) and moderately correlated with dysfunctional attitudes, ruminative responses, and pessimistic attributions. All the participants with high frequencies of burnout symptoms were identified as clinically depressed. Suicidal ideation was reported by 36% of those participants. Three groups of teachers emerged from a two-step cluster analysis: “low burnout-depression,” “medium burnout-depression,” and “high burnout-depression.” The correlation between the affective-cognitive and somatic symptoms of depression was similar in strength to the burnout-depression …


Burnout And Depression: Label-Related Stigma, Help-Seeking, And Syndrome Overlap, Renzo Bianchi, Jay Verkuilen, Romain Brisson, Irvin Sam Schonfeld, Eric Laurent Jan 2016

Burnout And Depression: Label-Related Stigma, Help-Seeking, And Syndrome Overlap, Renzo Bianchi, Jay Verkuilen, Romain Brisson, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

We investigated whether burnout and depression differed in terms of public stigma and help-seeking attitudes and behaviors. Secondarily, we examined the overlap of burnout and depressive symptoms. A total of 1046 French schoolteachers responded to an Internet survey in November–December 2015. The survey included measures of public stigma, help-seeking attitudes and behaviors, burnout and depressive symptoms, self-rated health, neuroticism, extraversion, history of anxiety or depressive disorder, social desirability, and sociodemographic variables.The burnout label appeared to be less stigmatizing than the depression label. In either case, however, fewer than 1% of the participants exhibited stigma scores signaling agreement with the proposed …


Distress Among Psychologists: Prevalence, Barriers, And Remedies For Accessing Mental Health Care, Kimberly Patterson-Hyatt Jan 2016

Distress Among Psychologists: Prevalence, Barriers, And Remedies For Accessing Mental Health Care, Kimberly Patterson-Hyatt

Antioch University Dissertations & Theses

This study completed a critical review of psychologists’ mental health by developing a conceptual analysis based on the current empirical literature of the mental health needs of clinical psychologists. Distress among psychologists was explored by examining the following domains: (a) examining the prevalence of mental illness and psychological distress that exist among them, (b) examining the barriers they encounter to seeking treatment when experiencing this distress, and (c) reviewing current interventions and integrating remedies for access to mental health care that best meets psychologists’ needs. Results included several themes within each domain shaping a contextual picture of some of the …


Burnout In Firefighters: A Word On Methodology, Irvin Sam Schonfeld, Renzo Bianchi Jan 2016

Burnout In Firefighters: A Word On Methodology, Irvin Sam Schonfeld, Renzo Bianchi

Publications and Research

At least three methodological problems affect the study by Katsavouni et al. (2016). First, there are currently no diagnostic criteria for burnout, neither in the DSM-5, nor in the ICD-10. Second, one extremely important variable was omitted from this study of firefighters, namely, depression. Third, the authors did not control for relevant nonoccupational factors such as stressors occurring outside of work.


Gender And Self-Care Behaviors In The Burnout Of Mental Health Professionals, Kafy-Ann Martin-Johnson Jan 2016

Gender And Self-Care Behaviors In The Burnout Of Mental Health Professionals, Kafy-Ann Martin-Johnson

Walden Dissertations and Doctoral Studies

Difficulties experienced at work can cause feelings of burnout that become prolonged and intensified without acts of self-care. The intense nature of mental health workers' jobs may make them, more vulnerable to burnout than other professionals. Because mental health professionals' mental and emotional wellness can significantly affect their work, adequate self-care is critical to both their well-being and that of their clients. Previous researchers have investigated the self-care behaviors of mental health professionals, but little was known about how gender affected the use of these behaviors in burnout prevention among mental health professionals. The purpose of this quantitative study was …


Burnout And Depression In Psychiatric Residents, Irvin Sam Schonfeld, Eric Laurent, Pierre Vandel, Renzo Bianchi Jan 2016

Burnout And Depression In Psychiatric Residents, Irvin Sam Schonfeld, Eric Laurent, Pierre Vandel, Renzo Bianchi

Publications and Research

Kealy et al. (2016) found that 21% of psychiatric residents were suffering symptoms of burnout. A number of problems call that finding into question. First, the writers used a one-item measure to assess burnout. Second, mounting evidence suggests that burnout is a depressive syndrome. Third, unresolvable job stress is related to depression. Given burnout's overlap with depression and the diagnostic blur around burnout, research on the impact of job stress should connect with depression, which is nosologically well characterized and diagnosable using clinically validated instruments.


Burnout And Depression: Label-Related Stigma, Help-Seeking, And Syndrome Overlap, Renzo Bianchi, Jay Verkuilen, Romain Brisson, Irvin Sam Schonfeld, Eric Laurent Jan 2016

Burnout And Depression: Label-Related Stigma, Help-Seeking, And Syndrome Overlap, Renzo Bianchi, Jay Verkuilen, Romain Brisson, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

We investigated whether burnout and depression differed in terms of public stigma and help-seeking attitudes and behaviors. Secondarily, we examined the overlap of burnout and depressive symptoms. A total of 1046 French schoolteachers responded to an Internet survey in November–December 2015. The survey included measures of public stigma, help-seeking attitudes and behaviors, burnout and depressive symptoms, self-rated health, neuroticism, extraversion, history of anxiety or depressive disorder, social desirability, and socio-demographic variables. The burnout label appeared to be less stigmatizing than the depression label. In either case, however, fewer than 1% of the participants exhibited …


Is Burnout Separable From Depression In Cluster Analysis? A Longitudinal Study, Renzo Bianchi, Irvin Sam Schonfeld, Eric Laurent Jan 2015

Is Burnout Separable From Depression In Cluster Analysis? A Longitudinal Study, Renzo Bianchi, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

Purpose: Whether burnout and depression represent distinct pathologies is unclear. The aim of this study was to examine whether burnout and depressive symptoms manifest themselves separately from each other or are so closely intertwined as to reflect the same phenomenon.

Methods: A two-wave longitudinal study involving 627 French schoolteachers (73 % female) was conducted. Burnout was assessed with the Maslach Burnout Inventory and depression with the 9-item depression module of the Patient Health Questionnaire.

Results: Burnout and depressive symptoms clustered both at baseline and follow-up. Cluster membership at time 1 (T1) predicted cases of burnout and depression at time 2 …


Burnout-Depression Overlap: A Review, Renzo Bianchi, Irvin Sam Schonfeld, Eric Laurent Jan 2015

Burnout-Depression Overlap: A Review, Renzo Bianchi, Irvin Sam Schonfeld, Eric Laurent

Publications and Research

Whether burnout is a form of depression or a distinct phenomenon is an object of controversy. The aim of the present article was to provide an up-to-date review of the literature dedicated to the question of burnout–depression overlap. A systematic literature search was carried out in PubMed, PsycINFO, and IngentaConnect. A total of 92 studies were identified as informing the issue of burnout–depression overlap. The current state of the art suggests that the distinction between burnout and depression is conceptually fragile. It is notably unclear how the state of burnout (i.e., the end stage …


Rural Clinicians’ Perceived Ethical Dilemmas: Relationships With Clinician Well-Being And Burnout, Amithea M. Love Jan 2015

Rural Clinicians’ Perceived Ethical Dilemmas: Relationships With Clinician Well-Being And Burnout, Amithea M. Love

Antioch University Dissertations & Theses

Mental health clinicians are bound by professional ethics codes that are intended to ensure beneficence toward clients. When clinicians reside in rural areas, ethical dilemmas result from the distinct nature of rural life and clinical practice. Despite extant literature on the ethical dilemmas of rural practice, little research has examined the effect of ethical dilemmas on the social-emotional functioning of clinicians. In response to this need, the study investigated the relationships of frequency of and discomfort from ethical dilemmas on clinician social-emotional functioning. Participants were rural and small town clinicians (N = 60) between ages 24-65 and primarily Caucasian (83.3%), …


Health Behaviors, Hardiness, And Burnout In Mental Health Workers, Jeremiah Brian Schimp Jan 2015

Health Behaviors, Hardiness, And Burnout In Mental Health Workers, Jeremiah Brian Schimp

Walden Dissertations and Doctoral Studies

Burnout has emerged as a significant and costly issue in the modern workforce. Researchers have not fully explored the role of individual health behaviors and personality in burnout among mental health workers. The knowledge gap addressed in this study was the connection between health behaviors, what mental health workers do to take care of themselves, and hardiness, the characteristic way they perceive and interpret environmental challenges. The purpose of this study was to examine the influence of health behaviors and hardiness among mental health workers on the 3 dimensions of burnout as measured by the MBI-HSS: emotional exhaustion, depersonalization, and …


Is There A Relationship Between Alcohol/Drug Counselor's Strength Of Belief In The Disease Concept Of Addiction And Burnout?, Dan D. Dodd Jan 2015

Is There A Relationship Between Alcohol/Drug Counselor's Strength Of Belief In The Disease Concept Of Addiction And Burnout?, Dan D. Dodd

Antioch University Dissertations & Theses

This study examined the association between substance abuse counselors’ (a) level of burnout and strength of belief in the disease concept of addiction, (b) level of burnout and recovery status, and (c) recovery status and strength of belief in the disease concept. Participants were recruited via a purposive convenience survey sampling method of counselors who were certified Chemical Dependency Professionals (CDPs) or Chemical Dependency Professional Trainees (CDPTs) who were employed in substance use disorder outpatient treatment facilities. A total of 130 surveys were distributed of which 72 were returned giving a 55% response rate. Six surveys were removed due to …