Burnout in Mental Health Occupations: A Trans-Occupational Review
The College of New Jersey
Although those who work at different occupational levels within the mental health field are highly prone to burnout, relatively little empirical research has been conducted on this subject and the body of research that does exist focuses more on graduate level practitioners than on nurses and paraprofessionals. The goals of this paper are to present an overview of this research and to explore the ways in which its causes, treatment, and prevention might have similar application across occupational boundaries. Further empirical research is needed, especially that which examines burnout as it effects mental health workers at all levels and which recommends interventions that might be applicable, in some degree, to all mental health occupations.
The sources used were articles from various professional publications within the counseling and nursing professions.
Burnout in Mental Health Occupations: A Trans-Occupational Review
High levels of stress and burnout have long been associated with occupations that have significant, daily involvement with people in need, and this includes mental health occupations ranging from psychiatrists and psychologists to entry-level human services workers and psychiatric nursing aides (Coffey & Coleman, 2001). While literature on burnout among mental health personnel is relatively scarce compared to similar studies of other stressful occupations (Kilfedder, Power & Wells, 2001), within this milieu the bulk of research has focused on burnout among psychiatrists and psychologists rather than on nurses, counselors, or paraprofessional staff (Donat & Neal, 1991).
Here, then, is an overview of this literature, which includes terms and symptoms related to burnout, how it has been shown to manifest itself within different mental health occupations, and what preventions and interventions are currently available.
Background on Burnout
Definitions of Terms
The term burnout has been widely defined by various researchers and scholars. Thornton (1991) describes it simply as any negative reaction to stress within the work environment, noting that there is a positive relationship between workplace stress and occurrences of burnout. Pines and Maslach (as cited in Emerson and Markos, 1996, Burnout section, para 2) describe burnout as “a condition of physical exhaustion, involving the development of negative self-concept, negative job attitudes, and loss of concern and feeling for clients.”
Maslach (as cited in Thornton, 1991) describes burnout as a syndrome consisting of emotional exhaustion, depersonalization, and reduced personal accomplishment, whereas Pines and Anderson (as cited in Emerson & Markos, 1996, Burnout section, para 2) define it as “physical and emotional exhaustion brought on by involvement over long periods with emotionally demanding situations and weakness.” Schaufeli, Maslach & Marek (as cited in Emerson & Markos, 1996) view burnout as more of a process than an endpoint, which if uncorrected can lead to serious depression, substance abuse, and eventually to “critical impairment.” In the long run, burnout can result in catastrophic consequences including heart attack, stroke, cancer, and suicide (Kesler, 1990).
In summarizing these various definitions of burnout, Thornton (1991) notes that most researchers agree on several key features: burnout occurs at the individual level; it is an internal psychological experience involving feelings, attitudes, motivations, and expectations; and it is a negative experience for the individual, involving problems, distress, discomfort, dysfunction, and/or negative consequences.
Professional impairment is the term used to describe the latter stage of burnout, when patient care becomes compromised. The American Medical Association (as cited in Emerson and Markos, 1996, Definitions section, para 1) defines professional impairment as “the inability to deliver competent patient care resulting from alcoholism, chemical dependency, or mental illness, including burnout or the sense of emotional depletion which comes from stress.” Emerson and Markos note that professional impairment may be outwardly subtle, leaving coworkers and supervisors puzzled and unsure of what interventions, if any, they should take on behalf of an afflicted colleague.
Depression is characterized by the following symptoms: a) withdrawal from interactions with others; b) lack of cheerfulness; c) unwillingness to talk; d) feeling un-needed and useless; e) experiencing disabling anxiety, loneliness, lack of interest in work, and unpredictable moods; and f) an irrational self-schema that “no one cares.” (Emerson & Markos, 1996).
Another term germane to the discussion of burnout is emotional exhaustion, defined as “feelings of helplessness, hopelessness, and entrapment [that lead to] negative attitudes toward self, work, and life itself” (Emerson & Markos, 1996, Burnout section, para 2). Its outward manifestations, Emerson and Markos note, include anger, boredom, cynicism, loss of confidence, impatience, irritability, sense of omnipotence, paranoia, denial of feelings, perceptual rigidity, and even physical ailments (Emerson & Markos, 1996).
SYMPTOMS OF BURNOUT
The process of burnout has its own symptomology as well. Edelwich and Brodsky (as cited in Kesler, 1990) describe a progressive, four-stage burnout model: a) Enthusiasm–a tendency to become overly available and to over-identify with clients; b) Stagnation–when the mental health professional’s or paraprofessional’s expectations shrink from high to normal to discontentment; c) Frustration–when difficulties seem to multiply and boredom, intolerance, lack of sympathy, avoidance, and withdrawal begin to set in; and d) Apathy–which is marked by depression and listlessness. Other symptoms include a reluctance to discuss one’s work with friends or family, not returning clients’ messages, inappropriate delight in missed client appointments, and displaying inappropriate humor (Emerson & Markos, 1996). Increased anxiety, interpersonal conflicts and strained relationships, low morale, low productivity, physical complaints, and a tendency toward substance abuse are also described (Kesler, 1990).
Who Gets Burned Out
As previously acknowledged, Coffey and Coleman note that mental health work produces high levels of stress and burnout that cut across occupational, educational, and experiential boundaries. Kilfedder et al. (2001) state that the bulk of research on this problem focuses on doctoral-level practitioners. The limited research available on impaired counselors tends to be anecdotal rather than empirical and much of that dates from the 1970s and 1980s (Olsheski & Leech, 1996). Studies focusing on stress and burnout among licensed practical nurses (LPN), psychiatric aides, and other mental health workers are generally rarer than similar studies of psychiatric registered nurses (RN) (Kilfedder et al., 2001).
One empirical study of counselors, cited by Emerson & Markos (1996) revealed that 32% of counseling faculty (those teaching in graduate-level counselor training programs) and practicing counselors admitted to having felt burned out at some point in their careers, and 63% said they knew colleagues whose work was affected by burnout. These respondents also gave fear of retaliation as the most common reason why they chose not to intervene on behalf of an impaired colleague.
Boy & Pine (1980) state that agency counselors are prone to burnout because they are often under constant pressure to expand their roles beyond that of actual counseling (i.e., administrative duties) yet still must carry heavy caseloads. The authors add that the quality of good counseling is directly related to the counselor’s ability to assimilate and identify with certain professional goals, and to have a clear sense of who she or he is professionally. Too many non-counseling responsibilities can cause a counselor to lose this perspective and sense of commitment.
Lack of initiatives to prevent and treat counselor burnout is another problem. Witmer and Young (1996) make the case that while other professions such as medicine, nursing, and psychology have conducted research and developed interventions and programs dealing with impairment, few if any exist for counselors per se. They further note several studies that suggest counselors, counseling students, and counseling faculty may have higher levels of psychological disturbance than does the general public. Ironically, counselors are trained in helping their clients deal with the stresses of daily life, yet they receive little training or support in helping themselves avoid burnout (Emerson & Markos, 1996).
Those new to the counseling profession may be especially vulnerable. Graduate counseling students begin their studies filled with idealism that soon turns to disillusionment when they move from the altruistic and humanistic rhetoric of their textbooks into the realities of agency counseling, with its emphasis on short-term treatment and maximizing billable hours (Warnath & Shelton, 1976; Warnath 1979). Warnath (1979, page 327) contends that many graduate counseling programs indoctrinate their students “as if they were going to have the freedoms of a private practitioner, working with affluent clients who have no restrictions on their time or financial resources.” Such programs, Warnath contends, place the focus almost exclusively on counselor-client relationships, rather than on addressing the realities of working as an employee of an agency.
Consequently, the newly-hired agency counselor, struggling with a heavy caseload and under pressure to see as many clients in one day as possible, may begin to feel isolated and lacking control over his or her job, and “have the sense of being on an endless treadmill.” (Warnath & Shelton, 1976, page 174).
COUNSELORS IN OTHER SETTINGS
Specialized counselors face similar stressors to those of their agency counterparts. Rehabilitation counselors burnout from excessive client contact, caseload responsibilities, and positive or negative outcomes (Payne, 1989), while youth counselors succumb to “overexposure to the complicated, confused lives of ‘unruly’, runaway, truant, or delinquent children and their families” (Van Auken, 1989, page 143). Likewise, Kesler (1990) describes school guidance counselors as being particularly susceptible to burnout because of the stresses they face as a result of their role expectations and responsibilities. Kesler adds that school counselors often must contend with ill-defined job duties, unrealistic expectations and lack of understanding on the part of school administrators, teachers, and students and their families.
The National Association of Social Workers (NASW) (as cited in Olsheski & Leech, 1996) acknowledged in 1979 that its members are especially prone to alcohol and drug abuse. So widespread is the problem that NASW now offers an Impaired Social Worker Resource Book as a tool for state associations to use in assisting impaired members.
PSYCH NURSES AND OTHER MENTAL HEALTH PARAPROFESSIONALS
Mental health workers dealing in direct patient care (e.g., RNs, LPNs, and psych aides) face chronic stress—and a particularly high risk of burnout—as a result of “the numerous, prolonged, and intensive nature of the interpersonal interactions between these helpers and the recipients of their services” (Donat & Neal, 1991, para 2). Ironically, those with the least status, pay, or training (not including RNs, who are generally better educated and better paid) are typically the most heavily involved in direct patient care (Willetts & Leff, 1997; Field & Gatewood, 1976). This discrepancy, according to Donat and Neal, and its accompanying stress, affects caregivers’ emotional stability to the extent that it directly impacts patients’ recovery. Thus LPNs, aides and mental health assistants often see little chance for advancement or career growth. And because many of these workers may live in the same impoverished environments as the clients they serve, they may over-identify with their clients to the point where their objectivity is compromised. Furthermore, lack of sufficient education as to the structure and function of the institutions in which they serve can foster frustration and suspicion in these workers and hinder their ability to adhere to and enforce rules and regulations (Field & Gatewood, 1976).
Quintal (2002, page 49) asserts that lack of adequate indoctrination, education, and training causes many lower-echelon mental health workers to operate with a “high incidence of authoritarian and inflexible styles of working with people who are mentally ill, which increases the likelihood of provocation because of style of personality.” In particular, such staff are likely to experience emotional exhaustion and to depersonalize the patients under their care (Willetts & Leff, 1997).
Willetts & Leff add that a similar situation exists in residential settings, where lower-echelon paraprofessionals frequently live and work with mentally ill clients. In these places, expressed emotion on the part of staff—making critical comments and acting hostile toward clients—is often a problem. This behavior typically arises when poorly trained staff become over-involved with clients, feeling frustrated at what they perceive to be clients’ lack of immediate and discernable progress, and being unwilling or unable to see things from the clients’ perspectives. The authors note that under such circumstances, increased assaults on staff, as well greater likelihood of client relapse–particularly among those afflicted with schizophrenia–can result.
The high risk of patient assault confronts RNs on inpatient psychiatric units as well. A 1996 survey of public sector psychiatric facilities, conducted by Love and Hunter (as cited in Quintal, 2002), reveals injury rates from patient assaults ranging from 146 to 32 per thousand. In addition, 38% of all nonfatal workplace assaults occurred in healthcare settings, and of those, some 41% were against nurses (75% of which occurred on psych units). The survey also found that approximately 75% of all psychiatric nurses reported having been assaulted at least once in their careers. Other stressors endemic to psych nurses include high job demand-low job satisfaction, lack of job clarity and management feedback (Walsh & Walsh, 2002).
Additional stress factors for psych nurses and their paraprofessional coworkers include work schedules, work overload, understaffing, lack of autonomy and power, deficient positive reinforcement, maladaptive coping strategies, to name a few. Kilfedder et al. (2001), however, note that healthcare workers outside psychiatry face similar stressors yet have lower burnout rates. The difference, according to the authors, may be that psychiatric staff face the additional pressure of working closely, often on a long-term basis, with a disturbed patient population.
Interventions and Prevention
COGNITIVE-PHENOMENOLOGICAL THEORY OF STRESS
Much of the research cited herein describes stress—both personal and work-related—as a vital ingredient in the burnout process. Lazarus and Colleagues (as cited in Thornton, 1991) have developed the Cognitive-Phenomenological Theory of Stress, in order to provide a conceptual foundation for the study of stress and its relationship to burnout. This theory identifies two processes that are essential to the appraisal of stress and the ability to cope with it. Cognitive appraisal is the process by which an individual evaluates whether a particular encounter with the environment relates to his well-being. Cognitive appraisal is further broken down into two types: primary appraisal determines whether the encounter is irrelevant, benign-positive, or stressful; in secondary appraisal the individual identifies which coping options and resources are available and what degree of control he has over the stressful situation.
The second process, coping, requires the individual to constantly change his cognitive-behavioral efforts in order to help manage certain external or internal demands which he finds to be particularly taxing (Lazarus and Folkman, as cited in Thornton, 1991). This process is achieved by either problem-focused coping (doing something to change the distress-producing problem) or emotion-focused coping (regulating one’s distressing emotions when the situation cannot be changed).
Thornton implies that training in cognitive appraisal and coping skills may help mental health workers to improve their locus of control over stressful events and their reactions to them, thus reducing the chances of potential burnout.
MULTIDIMENSIONAL APPROACH TO IMPAIRMENT PREVENTION IN FACULTY, STUDENTS, AND PRACTITIONERS
Witmer and Young (1996) have constructed a multidimensional approach to preventing burnout in counseling faculty and students as well as those in practice, and which is drawn from the body of wellness, stress management, and coping literature. Regarding the selection and retention of faculty and students, the authors recommend the following: a) require statements of personal wellness and adjustment on all faculty employment and graduate counseling student applications; b) assess personal adjustment and self-development in prospective students, along with skill competencies; c) discuss with students any observed attitudes or behaviors that may put them at risk; d) conduct joint evaluation procedures between a select faculty committee and either students who have potential to become impaired or other faculty members who have potential to become impaired; e) provide conditional retention, including periodic progress, consultation, or time off, for any faculty member or student exhibiting burnout symptoms; f) conditionally dismiss any faculty member or student not in active treatment for burnout, and not allow them back to work or study until specific conditions are met.
Witmer and Young also stress that a graduate counseling curriculum should reflect a wellness philosophy and require all students to agree, in writing, to utilize holistic wellness strategies in order to ensure their personal growth and professional competence. And they suggest that graduate counseling programs themselves develop curricula around a wellness model that encompasses spiritual, intellectual, emotional, and physical health.
For counseling agencies and mental health facilities, Witmer and Young advocate: a) encouraging their staff to use employee assistance programs (EAPs); b) providing staff with workplace childcare, flextime options, and ergonomically sensitive environments; and c) spreading caseloads and most difficult cases more equitably among counseling staff.
OTHER INITIATIVES FOR NEW COUNSELORS
On the subject of counselor training, Warnath and Shelton (1976) suggest various initiatives to narrow the discrepancy between the idealism of counselor studies and the realities of counseling work. Faculty, they argue, should be required to work one term per every two to three years as a full-time counselor, and while teaching they should continue to carry a small, ongoing caseload. Students should be required to serve one semester (three to four months) in their second year of studies doing full-time, supervised counseling.
The original goal of the Thorne Initiative, as described by Willetts and Leff (1997), was to help psychiatric nurses improve their skill in approaching situations with patients from the patients’ viewpoints. Using this approach would ideally reduce the nurses’ propensity toward expressed emotion and thus diminish the accompanying risk of patient assault. Willetts and Leff argue that the Thorne Initiative has wider application for other paraprofessional staff, namely LPNs, aides, and mental health assistants.
In practice, the Thorne Initiative consists of nine two-hour sessions held once a week. Teaching components include formal instruction, role-playing, group work, feedback and discussion, and evaluation. Session topics follow this schedule: a) Introduction to Mental Illness, b) Problem Solving, c) Improving Communication, d) Specific Problem Behaviors (i.e., negative symptoms, delusions and hallucinations, irritability, and violence), and e) Effective Staff Coping Strategies. Within this framework, the trainer uses a non-critical instructional approach and covertly models a low expressed emotion level for participants.
Willetts and Leff note that while testing of the Thorne Initiative with paraprofessional staff has been preliminary and inconclusive, those who have completed the program demonstrate slightly lower expressed emotion levels and rate the program either useful or very useful.
HELP STAFF MANAGE WHAT THEY CAN AND CANNOT CHANGE
Research shows that level of support and degree of job discretion (the extent to which workers have control over what they do and how they do it) can serve to buffer the negative effects of workplace stress (Walsh and Walsh, 2002). On this topic, Donat and Neal (1991) conducted a study of 100 LPNs and psych aides conducted at a public residential facility in Virginia. Some 39 worksite situations involving eight stress factors were identified using several self-reporting tools. Some of the situations described were potentially changeable by staff members and others were beyond their immediate control. Based on the results, the authors recommend that mental health institutions and organizations: a) build competencies to enable their staff to better manage certain problem behaviors of clients; b) train staff to more accurately gauge the impact they can as well as cannot have on patient outcomes; c) help staff develop effective coping strategies that enable them to accept the realities of what they cannot change; d) educate staff as to possible avenues through which they might have a voice in affecting change within the workplace; e) improve social support among staff by teaching assertiveness and communications skills, which can enable them to achieve greater cohesiveness and collegiality among themselves.
PREVENTIVE MEASURES FOR GUIDANCE COUNSELORS
Kesler (1990) recommends that school systems provide guidance counselors with shared authority in making guidance decisions, do a better job of informing teachers, students and their parents about the role of guidance counselors, and create working environments for guidance counselors that are more varied, self-actualizing and creative.
NURSES AND PARAPROFESSIONAL STAFF
Quintal (2002) argues that reducing the risk of patient assault is a critical factor in lowering levels of burnout among direct care staff. She suggests that hospitals and psychiatric facilities must do a better job of educating staff in empathetic limit setting, therapeutic communications, and non-violent de-escalation techniques. She also recommends these facilities perform complete assessments of patients as to their propensity for violent behavior, establish strict “zero tolerance” policies on patient violence, and clearly communicate these policies to patients during intake. For those staff who have already experienced patient assault, Quintal advocates that employers provide them with effective counseling and emotional support resources.
WHAT PROFESSIONAL ORGANIZATIONS AND ASSOCIATIONS CAN DO
Hazler and Kottler (1996) contend that organizations and associations, such as the American Counseling Association (ACA), have a significant role to play in promoting wellness. Among their recommendations: a) advance research and fund grants to study burnout, with a view toward developing more effective methods of prevention and treatment; b) establish specific committees to identify tasks and establish timelines for program development in this area; and c) create social and emotional support for members, via peer support groups, workshops, conferences, publications, and other means.
BASIC I.D., as reported by Kesler (1990) is a conceptual device to clarify symptoms and consequences of burnout among counselors and provide interventions. The acronym stands for Behavior-Affect-Sensation-Imagery-Cognition-Interpersonal relationships-Drugs/diet. BASIC I.D. operates under the premise that people have multi-dimensional life experiences and that they function on many overlapping levels (e.g., emotions affect thought; images affect behavior, sensations affect physical health, etc.).
Applying BASIC I.D. to burnout prevention involves the following:
Interventions include: a) defining goals by keeping a daily log of stresses, manner of coping, and the success or failure of those strategies; b) educating the service population about what the counselor can and cannot do; c) periodically assessing and modifying role obligations; d) prioritizing counseling duties while limiting non-counseling duties; and e) planning leisure time.
Find an outlet to release stress and to help guard against stress buildup. Humor and tears are two self-directed examples, and others include participating in group therapy and support groups.
Counteract the physical “fight or flight” reaction induced by stress, by attending relaxation training, getting a neuromuscular massage, or participating in music, art, dance, or yoga.
Keep the boundary between work and home life distinct by using imagination, perspective, and intuition to correct faulty schemas and develop a degree of balanced detachment toward work.
Minimize self-criticism and pessimism by acknowledging personal limits, clarifying values, setting goals, and finding the time to self-regulate (cognitive restructuring). Spiritual and philosophical development are part of this process.
Learn to receive help as well as give it, and develop mature, reciprocal, supportive relationships with others.
Drugs and Diet
Maintain a regular, healthy diet, get adequate rest, exercise non-competitively, and avoid misuse of alcohol or drugs.
The literature reviewed herein documents the fact that high risk of burnout exists for virtually all who work in the mental health field, from doctoral level practitioners to entry-level, direct caregivers. Causal factors may differ somewhat from one occupation to the next—for the psychologist a major stressor may be heavy caseload, while for a psych nurse it may be the constant risk of patient assault. However, there is much common ground as well. For example, the idealistic new counselor may feel the same frustration over a client’s perceived lack of progress, as does the mental health aide who has become over-identified and thus over-critical of the client. Also, maladaptive coping strategies and pre-existing psychological problems can lead to impairment for anyone at any level. On this point, Thornton (1991) points out that in order to understand the relationship between burnout, work stress, and the characteristics of those who suffer burnout, one must look to how people differ in the ways they cope with stress.
A significant fact, emerging from the body of literature reviewed herein, is that there is a lack of comprehensive, empirical research on burnout that covers the full gamut of mental health occupations (Kilfedder, et al., 2001; Donat & Deal, 1991; Olsheski & Leech, 1996). Because so much existing research has been linear—focusing on specific occupations or occupational groups—there lacks any definitive answer as to whether some of the prevention and intervention strategies also presented herein might have application across some, most, or even all occupational lines.
Another question is: might some of the stressors ascribed to certain mental health occupations also be experienced, to some degree at least, by people employed in other mental health occupations? To illustrate this point, Quintal (2002) notes the high rate of patient assaults that occur against psychiatric nurses, while Donat & Neal (1991)—as noted earlier—blame burnout in paraprofessional mental health workers on these workers’ long-term, intensive involvement with mentally disturbed patients. Might counselors and psychologists working in certain settings—for example, a high-security forensic psych unit—face these same risks and stresses? Moreover, would a survey of doctoral level practitioners who work in such settings reveal similar, or near-similar rates of patient assaults as those reported for psych nurses?
Clearly, trans-occupational research, in which burnout would be examined within the context of mental health occupations on the whole, would add interesting perspective and, ideally, result in more holistic approaches to minimizing burnout and promoting wellness across the mental health spectrum.
Boy, A., & Pine, G. (1980). Avoiding Counselor Burnout Through Role Renewal. Personnel and Guidance Journal, 56, 161 – 163.
Donat, D., & Neal, B. (1991). Situational Sources of Stress for Direct Care Staff in a Public Psychiatric Hospital. Psychosocial Rehabilitation Journal, 14, 76 – 79.
Emerson, S., & Markos, P. (1996). Signs and Symptoms of the Impaired Counselor. Journal of Humanistic Education and Development, 34, 108 – 117.
Field, H., & Gatewood, R. (1976). The Paraprofessional and the Organization: Some Problems of Mutual Adjustment. Personnel and Guidance Journal, 55, 181 – 185.
Hazler, R., & Kottler, J. (1996). Following Through on the Best of Intentions: Helping Impaired Professionals. Journal of Humanistic Education and Development, 34, 156 – 158.
Kesler, K. (1990). Burnout: A Multimodal Approach to Assessment and Resolution. Elementary School Guidance and Counseling, 24, 303 – 311.
Kilfedder, C., Power, K., & Wells, T. (2001). Burnout in Psychiatric Nursing. Journal of Advanced Nursing, 34, 383 – 396.
Olsheski, J., & Leech, L. (1996). Programmatic Interventions and Treatment of Impaired Professionals. Journal of Humanistic Education and Development, 34, 128 – 140.
Payne, L. (1989). Preventing Rehabilitation Counselor Burnout by Balancing the Caseload. Journal of Rehabilitation, 1989, 20 – 24.
Quintal, S. (2002). Violence Against Psychiatric Nurses. Journal of Psychosocial Nursing, 40, 46 – 52.
Thornton, P. (1991). The Relation of Coping, Appraisal, and Burnout in Mental Health Workers. The Journal of Psychology, 126, 261 – 271.
Van Auken, S. (1979). Youth Counselor Burnout. Personnel and Guidance Journal, 66, 143 – 144.
Walsh, B., & Walsh, S. (2002). Caseload Factors and the Psychological Well-Being of Community Mental Health Staff. Journal of Mental Health, 11, 67 – 78.
Warnath, C. (1979). Counselor Burnout: Existential Crisis or a Problem for the Profession? Personnel and Guidance Journal, 66, 325 – 328.
Warnath, C., & Shelton, J. (1976). The Ultimate Disappointment: The Burned-Out Counselor. Personnel and Guidance Journal, 55, 172 – 175.
Willetts, L & Leff, J. (1997). Expressed Emotion and Schizophrenia: The Efficacy of a Staff Training Programme. Journal of Advanced Nursing, 26, 1125 – 1133.
Witmer, J., & Young, M (1996). Preventing Counselor Impairment: A Wellness Approach. Journal of Humanistic Education and Development, 34, 141 – 155.
James Genovese, Department of Counselor Education, The College of New Jersey.
All correspondence regarding this article should be sent to James Genovese, 123 Elmwood Avenue, Atlantic Highlands, NJ, 07116-2020. Email: firstname.lastname@example.org.