Discussion

Building upon the theoretical framework presented earlier, this study focused on exploring how sociodemographic factors, alexithymia, and mentalizing capacity are associated with various dimensions of burnout among physicians in Montenegro, as well as on assessing their independent contributions after controlling for relevant factors. The findings underscore the significant contribution of psychological factors, particularly mentalizing capacity, in understanding burnout among physicians. These findings should be interpreted in a broader international context, as burnout among physicians is reported to be high in Western European and American countries, while additional structural and organizational challenges characteristic of healthcare systems in transition countries may further contribute to this burden [27]. In line with findings from regional studies conducted in healthcare settings in the Balkans, where mentalizing capacity was also identified as an important factor associated with burnout among healthcare workers, the results of this study further support the relevance of psychological resources in shaping the outcome of work-related stress [28].

The healthcare system in Montenegro is characterized by limited resources, chronic labor shortages, high administrative burden, and frequent shift work, all of which may contribute to increased work-related stress and burnout risk [22]. Consistent with contemporary models that conceptualize burnout as the result of an interaction between individual psychological characteristics and work-related conditions [29] and which highlight the role of mentalizing processes in emotional regulation and interpersonal functioning [30], the present findings indicate that different dimensions of burnout are differentially associated with the examined factors.

The findings of the present study are consistent with previous research, as reported by Safiye et al., indicating that hypomentalizing is associated with higher levels of emotional exhaustion and depersonalization, as well as lower levels of personal accomplishment [28]. Similarly, in our study, hypomentalizing emerged as a significant positive predictor of emotional exhaustion and depersonalization, whereas higher RFQ-C scores were associated with lower levels of emotional exhaustion and depersonalization. These findings may be interpreted in light of contemporary mentalizing theory, which emphasizes the importance of understanding one's own and others' mental states for emotional regulation and adaptive interpersonal functioning, particularly in demanding clinical settings [30]. Reduced mentalizing capacity may be associated with difficulties in interpreting emotional experiences, which may in turn be associated with greater interpersonal strain, professional frustration, and emotional burden [30]. In contrast, greater certainty in understanding mental states may be associated with more effective emotional regulation and adaptive coping with occupational stress [31].

However, the interpretation of RFQ-C requires particular caution. Although higher RFQ-C scores are frequently interpreted as reflecting hypermentalizing, hypermentalizing itself is generally conceptualized as a biased or maladaptive form of mentalizing rather than a protective characteristic [20]. In non-clinical occupational samples such as the present one, higher RFQ-C scores may instead reflect greater certainty in understanding mental states or more adaptive reflective functioning, rather than pathological overmentalizing. Therefore, the observed inverse association between RFQ-C scores and burnout should not be interpreted as evidence that hypermentalizing is protective. Rather, it may reflect greater confidence in understanding one's own and others' mental states, which in this non-clinical occupational sample was associated with lower burnout among physicians. Given the ongoing conceptual debate regarding the interpretation of RFQ-C and the recognized limitations of the RFQ-8 in distinguishing adaptive certainty from maladaptive overconfidence, these findings should be interpreted with caution and require further investigation [20]. Accordingly, the present findings should be interpreted in terms of RFQ-C scores rather than as evidence for beneficial effects of hypermentalizing itself. Importantly, the use of the RFQ in a non-clinical sample of healthcare professionals represents an innovative approach, suggesting that mentalizing may be understood not only as a psychopathological construct but also as a psychological characteristic relevant to professional functioning in clinical practice [20].

An additional important finding is the association between alexithymia and mentalizing. Specifically, hypomentalizing showed a strong positive association with alexithymia, whereas higher RFQ-C scores were negatively associated with this construct. These findings are consistent with previous research suggesting that difficulties in identifying and describing emotions directly impair mentalizing capacity [32, 33, 34].

In the univariate analysis, alexithymia was not significantly associated with any dimension of burnout. However, in the multivariate model, it emerged as a significant predictor of emotional exhaustion, while no significant associations were observed with depersonalization or personal accomplishment. In contrast to previous evidence, which has consistently demonstrated that alexithymia is associated with increased emotional exhaustion and depersonalization, together with reduced personal accomplishment, the present findings only partially correspond to these established patterns [11, 35]. Furthermore, alexithymia has been linked to a broader spectrum of psychological difficulties, including increased stress, anxiety, and depressive symptoms, which may further elevate the risk of burnout among healthcare professionals [36]. Additional sequential regression analyses showed that the regression coefficient for alexithymia changed progressively after the inclusion of hypomentalizing and hypermentalizing variables, shifting from a small positive, non-significant association to a significant negative association with emotional exhaustion. This pattern is consistent with a possible suppression effect, suggesting that the shared variance between alexithymia and mentalizing capacity dimensions may have obscured the unique association between alexithymia and emotional exhaustion in the univariate analysis [37]. However, because suppression was not formally tested using dedicated statistical procedures, this interpretation should be considered exploratory. Overall, these findings suggest that the relationship between alexithymia, mentalizing capacity, and burnout is likely to be more complex than a simple direct association, and future studies employing formal suppression, mediation, or path analyses are needed to clarify these underlying mechanisms.

When considering sociodemographic and occupational variables, the results highlight age and gender as relevant determinants of specific burnout dimensions. In particular, higher levels of emotional exhaustion and depersonalization were observed among older participants. This finding contrasts with studies reporting higher burnout among younger individuals, often attributed to less developed coping mechanisms and lower emotional resilience [38]. A possible explanation for this pattern is that, within the medical profession, prolonged exposure to occupational stress, high demands, and responsibility may be associated with a cumulative burden of professional strain over time [39]. This finding may also be interpreted within the framework of compassion fatigue, in which long-term exposure to emotionally demanding clinical environments has been associated with gradual depletion of emotional resources and reduced empathic engagement [39].

This finding may also reflect the fact that senior physicians in Montenegro often assume greater clinical, supervisory, and administrative responsibilities than their younger colleagues, which could further increase their cumulative occupational burden. Differences in healthcare organization, resource availability, cultural expectations, and cohort characteristics may also partly explain why our findings differ from studies reporting higher burnout among younger physicians. Nevertheless, because of the cross-sectional design, these explanations remain hypothetical and should be interpreted with caution.

With regard to gender, male participants reported higher levels of emotional exhaustion and depersonalization, whereas female participants demonstrated higher levels of personal accomplishment.

One possible explanation is that male physicians in Montenegro may be more frequently employed in certain hospital-based specialties that involve greater clinical responsibility, emergency work, and physically or emotionally demanding tasks, whereas female physicians may be relatively more represented in primary care and other less acutely demanding settings. If such differences in specialty distribution indeed exist, they could partly contribute to the observed gender differences. However, because specialty-specific analyses were not performed in the present study, this explanation should be considered speculative and warrants further investigation.

This finding is not entirely consistent with previous research suggesting that women are more prone to emotional exhaustion, often attributed to greater role strain and challenges in achieving work-life balance [40].

Finally, personal accomplishment was not significantly explained by the examined variables, suggesting that this dimension of burnout may have a distinct psychological basis and may be more strongly related to intrinsic factors such as motivation and professional identity, which reflect individuals’ sense of competence, purpose, and personal investment in their professional role [29].

Limitations and future directions

The present study has several important strengths. To the best of our knowledge, this is the first study to examine the associations between mentalizing capacity, alexithymia, and burnout among physicians in Montenegro. Furthermore, the inclusion of physicians from primary, secondary, and tertiary healthcare settings, together with the use of validated psychometric instruments, provides a comprehensive assessment of psychological factors associated with burnout.

Several limitations need to be taken into account when interpreting the findings. In particular, the cross-sectional design restricts the ability to establish causal relationships. Accordingly, the observed associations should not be interpreted as indicating causal relationships, and reverse or bidirectional associations between burnout and mentalizing capacity cannot be excluded. Second, the use of self-report measures introduces the possibility of response bias. Third, the sample was limited to physicians in Montenegro, which may restrict the generalizability of the findings to other healthcare systems and cultural contexts. Additionally, due to multicollinearity, age and years of work experience could not be included simultaneously in the multivariate models, which may limit the ability to fully disentangle their individual contributions to burnout. Additionally, the study did not include other relevant psychological variables, such as depression, anxiety, or stress, which may be associated with both burnout and emotional processing constructs. Additionally, certain statistical limitations should be acknowledged. Additionally, the internal consistency of the Personal Accomplishment subscale was slightly below the conventional threshold (Cronbach's α = 0.68), which should be considered when interpreting findings related to this burnout dimension. The pronounced skewness observed in depersonalization scores may reflect potential social desirability bias, whereby physicians may be reluctant to report cynical or detached attitudes toward patients. Furthermore, the relatively strong intercorrelations among psychological variables, particularly between alexithymia and mentalization capacity dimensions, may complicate the isolation of their independent effects and should therefore be considered when interpreting the regression findings.

Future studies should employ more advanced analytical approaches, such as structural equation modeling or path analysis, to further elucidate the complex direct and indirect relationships among mentalizing capacity, alexithymia, and burnout dimensions, including potential suppression and mediation mechanisms. Moreover, studies involving larger and more diverse samples across different healthcare systems are warranted.

From a practical perspective, the findings suggest that interventions aimed at enhancing mentalizing capacity and emotional regulation may be worthy of further investigation as potential approaches for addressing burnout among physicians [16]. Such interventions may include Balint groups, which are structured peer discussion groups in which physicians reflect on emotionally challenging clinical encounters and the doctor-patient relationship, as well as peer supervision programs and communication training grounded in mentalization-based treatment principles, which emphasize understanding one's own and others' mental states, strengthening reflective functioning, emotional regulation, and enhancing interpersonal understanding in clinical settings. These findings may have broader implications for staff support programs, undergraduate and postgraduate medical education, and continuing professional development by promoting the integration of mentalizing-informed approaches into training and clinical practice. At the same time, it is important to emphasize that strengthening individual psychological resources should not replace the responsibility of healthcare institutions to address structural and organizational factors contributing to burnout. Efforts to reduce burnout should therefore involve both individual-level interventions and systemic changes, including workload management, organizational support, and improvement of working conditions.