When I took on the initiative to write this blog on burnout in the mental health field, I decided to google some articles to see what’s said about the topic. Prominently landing on the top of the Google search results was a “helpful guide” with recommendations on how to avoid burnout. While I won’t say the name of the mental health provider offering the guide, out of respect for their privacy, I will say that I was offered a job by said company and their compensation structure perpetuates the likelihood of clinician burnout with its tiered plan which “rewards” clinicians with bonuses and increased income by carrying a larger caseload and “graduating” clients. Add to that a dismal base salary, and it nearly guarantees that therapists will need to accept more clients than they can comfortably serve in order to yield a sustainable revenue, especially given the ever-increasing costs of living we face. Ironic, no?

Heavy caseloads lead to compassion fatigue and clinician burnout. And I won’t even take on the massive ethical concern of bonusing clinicians for the number of clients who complete the program. We are serving people and their mental health – not selling cars!

For the sake of staying in my lane with the topic of burnout at hand, I’ll redirect my focus back to that. In doing so, I decided to reach out to the REAL experts: the clinicians on the front lines. So, I consulted some of the best, most seasoned therapists in the field. Here’s what they had to say when identifying the key issues and some potential solutions:

Unanimously, they cited low compensation, especially in comparison to other roles in the healthcare industry, matched with unreasonable caseload expectations as the main factors contributing to a high rate of burnout in the mental health field. Other key elements include: high risk clients, carrying a huge liability, frequent case turnover, high volume of documentation, a schedule that is not conducive to work/life balance (nor having a family), and an overall sense of being unappreciated and undervalued.

Let’s start with low compensation: Unfortunately, after graduating with my Master’s degree, completing two years of clinical supervision (which most of us pay for by the way), and passing the clinical licensure exam to become a licensed clinical social worker in Florida, I was hired to work at a community-based agency serving children and families with the glorious salary of $45k!! And, when I say “glorious” I hope you can detect the sarcasm and deep eye roll to indicate how atrocious that salary was – especially in South Florida where the cost of living resulted in me having to supplement my income with several other jobs or agree to take on other roles in the agency to decrease the required number of billable hours. This resulted in me wearing the following hats: intake specialist, therapist, trainer, marketing liaison, and insurance consultant. I can vividly recall many nights spent at the office completing my documentation at 3am! Yes, really. And I consider myself to be someone with excellent organizational and time management skills.

High Caseload: This is a key contributing factor leading to compassion fatigue and, in turn, burnout. It is customary for clinicians to be required to provide face to face therapeutic support to an average of 25-32 clients per week (sometimes more!). Now, that might not sound like a full-time job but add to those direct care hours insurmountable amounts of documentation, administrative work, supervision, billing, and copious other job requirements and it generally equals MORE than a 40-hour work week! Hence, why I was at the office at 3am. Additionally, imagine listening to and advising 25-32 people with various levels of need (everything from life transitions to panic attack to addiction to trauma to suicidality) to gain an understanding of the emotional and mental toll it would have on you. And, if you’re working with children, you get the entire family as “bonus” clients which means ONE case might actually include multiple people.

Compassion Fatigue: Being a mental health provider means that you literally have peoples’ lives in your hands. And, far too often, we have too many lives in our hands. It’s a very emotionally and mentally draining profession. Don’t get me wrong – it’s also very rewarding! That’s generally what keeps us motivated. But, it can also feel like we make no traction due to a breakdown in the system that is already stretched beyond capacity. This looks like clients cycling through treatment options (i.e hospital EDs, rehab facilities, psych wards, as well as a host of other short-term solutions). It’s heart-breaking to witness chronic clients go through a revolving door. And this makes the clinician feel hopeless and defeated – like there is really no win in the effort to help people. One of my sources explained it perfectly: “emotional bandwidth is limited for anyone but especially therapists who deal with trauma, crisis, and exist in a heightened emotional state all day”.

Invisible Work: That same source referred to the misconception that all a therapist does is show up to see clients when, in reality, there are so many other tasks being managed behind the scenes, which she called “invisible work”. A huge portion of the “invisible work” is documentation, which comprises about 50% of the clinician’s workload. There is a popular saying in mental health: “if it’s not documented, it didn’t happen.” And, if it didn’t happen on paper, providers will not get paid for their services. For this reason, there is a hyperfocus on documentation, and the ever-increasing requirements to be in compliance with payors and accrediting bodies often results in the clinician feeling overwhelmed by paperwork, having their job merit based solely on the quality of their documentation, and taking paperwork home with them, which decreases the likelihood of having work/life balance.

Low Compensation: Again, my first job post license in South Florida paid $45,000!! I would have been better off to drive for Uber or deliver with Amazon – and with far less stress, I’m fairly certain. Fast forward 10+ years, a wealth of experience and knowledge, and THREE clinical licenses and I’ve finally established a lucrative income between contract work and my private practice clients. But, as you can see I’m continuing to work multiple jobs and log about 55 hours a week – often working late or on weekends – in exchange for the financial stability I’ve achieved. How much longer can I maintain this pace? I have no idea.

Unreasonable Hours: One of my sources who has a young child highlighted that our field is not conducive to work/life balance nor having a family due to long and late hours. And weekends are often required. Fortunately, the advent of telehealth has helped shift from the more traditional hours of evenings and weekends as clients can more easily access sessions during the day, logging on from the comfort of work or home and avoiding the commute to an office space. But the typical therapist schedule still looks very different than a 9-5.

Poor Training/Supervision: Another source identified supervision and training limitations as a factor contributing to burnout. She stated that clinicians are often not provided with enough or quality training which leaves them to figure out various components of the job on their own. Unfortunately, supervisors are stretched so thin operationally and clinically between managing administrative needs and doing their best to provide oversight on high-risk cases that they are often not able to provide more or better training and supervision. Plus, to beat the compensation horse dead, supervisors are not well-compensated for their jobs. Back in the day when I was working the job that paid $45k, I was asked to apply and interview for the Regional Director position. When I found out that the salary was a mere $55k per year, I declined. I’m supposed to take on the liability of the ENTIRE region’s clinicians as well as the stress of managing those clinical obligations along with billing, administrative duties, etc. for only $10k more?! No thanks!

This leads me to my last point: burnout is often the result of clinicians overextending themselves. Aside from low pay leading to the necessity of working more than one job, therapists might overextend themselves for the following reasons:  unpredictable or irregular pay (i.e. billing Medicaid and having your pay frozen during an audit or being in private practice and dealing with delayed reimbursement from insurance panels), or clinicians having difficulty with setting boundaries, or the common perception that mental health workers are something akin to Mother Theresa or Ghandi and should just donate our time and energy to save the world, as if we have no expenses (insert another eye roll here and maybe a crying emoji as well).

Put succinctly, unrealistic expectations + low compensation = higher risk of burnout and even the possibility of completely leaving the field.

So, why stay in the field? It might seem cliché but it’s the reward of making a difference in people’s lives. It is gratifying to be a catalyst in someone’s well-being. Seeing the progress is a huge part of the payoff. That being said, the field needs A LOT of restructuring in order to prevent burnout so therapists can continue to show up for the challenge.

What would that restructuring look like? I don’t have all the answers. But I do know it starts with addressing the issues identified in this article. Let’s get started!