Some people wonder why we become therapists. This study discovered that people become therapists and stay in the field - despite the challenges in a lot of different ways - because they want to help people improve, simple as that. It is a great reward to see people feel better.
It’s no secret to anybody in our field that this is a tough time to be a therapist. In public agencies, we’re underpaid, overworked, and held to unattainable “productivity standards” (24 to 28 client hours a week; 30 to 34 scheduled appointment hours to make up for cancellations and no-shows). We’re subjected to a continual onslaught of paperwork to secure payments, and frequently face cutbacks and layoff threats. While some of us still thrive in private practice, most of us make far less than we did during the “golden age” of fee-for-service insurance reimbursement. Furthermore, the nature of clinical work often is frustrating, even anxiety-provoking, exposing us to high levels of human suffering.
Adding insult to injury, the culture at large doesn’t seem to admire therapists particularly, or understand what we do. This point is clear if you take a moment to think about the portrayals of therapists by Dr. Marvin Monroe of The Simpsons or Jack Nicholson in Anger Management or Barbra Streisand in Meet the Fockers. Sure, good examples of competent clinicians exist, but they’re far outweighed by those that cast us as self-indulgent crackpots endlessly mouthing psychobabble. So, why would anybody choose to enter such a field?
To be sure, most of us didn’t choose this work because we thought we’d acquire the lifestyles of the rich and famous. A massive, 20-year, multinational study of 11,000 therapists conducted by researchers David Orlinsky of the University of Chicago and Michael Helge Rønnestad of the University of Oslo not only has the answers, but captures the heart of our aspirations and perhaps the soul of our professional identity.
For their book published in 2005, How Psychotherapists Develop, they collected and analyzed detailed reports from nearly 5,000 psychotherapists about the way they experienced their work and professional development. Since then, 6,000 more therapists have participated in the study. Therapists stay in the profession, they found, not because of material rewards or the prospect of professional advancement, but because—above all—they value connecting deeply with clients and helping them to improve. On top of that, the clinicians interviewed consistently reported a strong desire to continue learning about their profession, regardless of how long they’d been practicing. Professional growth was cited as a strong incentive and a major buffer for burnout across the board.
Orlinksy and Rønnestad termed both what therapists seek in their professional careers and the satisfaction they receive from the work they do healing involvement. This concept describes therapists’ reported experiences of being personally engaged, communicating a high level of empathy, and feeling effective and able to deal constructively with difficulties. Healing involvement represents us at our best—those times when we’re attuned to our clients and the path required for positive change becomes clearly visible; those times when we can almost feel the “texture” of our therapeutic connection and know that something powerful is happening. But what causes this, and more important, how can we make it happen more often?
We all know that healing involvement isn’t simply an inevitable outcome of sitting in an office with troubled and unhappy people for many years. According to Orlinsky and Rønnestad, it emerges from therapists’ cumulative career development, as they improve their clinical skills, increase their mastery, gradually surpass limitations, and gain a positive sense of their clinical development through the course of their careers.
But an even more powerful factor promoting healing involvement is what the authors call therapists’ sense of currently experienced growth—the feeling that we’re learning from our day-to-day clinical work, deepening and enhancing our understanding in every session. Orlinsky and Rønnestad suggest that this enlivening experience of current growth is fundamental to maintaining our positive work morale and clinical passion.
According to their study, the path to currently experienced growth is clear. It’s intimately connected to therapists’ experiences with clients and what they learn from them, and is unrelated to workshops and books trumpeting the latest and greatest advances in our field. Almost 97 percent of the therapists studied reported that learning from clients was a significant influence on their sense of development, with 84 percent rating the influence as “high.” It appears therapists genuinely believe that clients are the best teachers. But the finding that most impressed Orlinsky and Rønnestad was therapists’ inextinguishable passion to get better at what they do. Some 86 percent of the therapists in the study reported they were “highly motivated” to pursue professional development. It appears that no matter how long they’ve been in the business, therapists still want to learn more and get better.
To the question, “Why is our growth so important to us?” Orlinksky and Rønnestad posited a close link between healing involvement and currently experienced growth. The ongoing sense that we’re learning and developing in every session gives a sense of engagement, optimism, and openness to the daily grind of seeing clients. It fosters continual professional reflection, which, in turn, motivates us to seek out training, supervision, personal therapy, or whatever it takes to be able to feel that the developmental process is continuing. Borrowing a term from the late Johns Hopkins psychiatrist and common-factors theorist Jerome Frank, having a sense of currently experienced growth “remoralizes” therapists, repairing the abrasions and stressors of the work and minimizing the danger of falling into a routine and becoming disillusioned. “[It] is the balm that keeps our psychological skin permeable,” said Orlinsky. “Many believe that constantly hearing problems makes one emotionally callused and causes one to develop a ‘thick skin.’ But not therapists. We need ‘thin skin’—open, sensitive, and responsive—to connect with clients.” Currently experienced growth, then, is our greatest ally for sending the grim reaper of burnout packing—we need to feel we’re growing to fend off disenchantment.
The Importance of Measuring Outcomes
Achieving a sense of healing involvement requires a continual evaluation of where we are compared to where we’ve been. We must keep examining our clinical experiences, looking for evidence of our therapeutic mastery and mining our sessions for the golden moments that replenish us. But if our sense of healing involvement with clients is tied to our ongoing sense of making a difference, how do we know we’re truly helping? You know when a roof is tarred or a tank drained, but how do you know when psychotherapy is beneficial? Therapeutic outcomes are hard to define and harder to measure.
The research literature offers strong evidence that therapists aren’t good judges of their own performance. Consider a study by Vanderbilt University researcher Leonard Bickman and associates reported in 2005 in the Journal of Clinical Psychology: In Session in which clinicians of all types were asked to rate their job performance from A+ to F. About 66 percent ranked themselves A or better. Not one therapist rated him- or herself as being below average! If you remember how the Bell Curve works, you know that this isn’t logically possible.
It’s not that we’re naïve; it’s simply hard, if not impossible, to accurately assess your effectiveness on a client-by-client basis. For this, you need some quantitative standard as a reference point—you need to measure outcomes. I can hear you groan, but I’m not talking about outcome measurement for the sake of bureaucratic “accountability” to funding sources or for justifying your existence by demonstrating your “proof of value” or “return on investment.” Rather, measuring outcomes allows you to cut through the ambiguity of therapy, using objective evidence from your practice to help you discern your clinical development without falling prey to that perennial bugaboo of the therapeutic endeavor: wishful thinking. Taking the time to measure outcomes relates directly to both having an awareness of our mastery over time and experiencing a sense of current growth.
How does outcome measurement further cumulative career development and currently experienced growth—the two keys to greater healing involvement with clients? First, cumulative career development is another way of saying that we’re “getting better all the time.” The routine collection of outcome data allows you to determine your effectiveness over time, and gives you a base for trying out and accurately evaluating new strategies. Begin simply by entering your outcome scores into a database, and keeping track of them on an ongoing basis: intake and final session scores, average change score (the difference between average intake and final session scores), and, ultimately, the percent of your clients who benefit. If you can review and assess your clinical work through the years, you can actually learn from your experience, rather than simply repeating it and hoping for the best.
Of course, finding out how effective you really are can be risky business. What if you find out that you’re not so good? What if you discover that you’re—say it isn’t so!—just average? Measuring outcomes takes courage, but so did walking into a consulting room for the first time to counsel someone in distress—and so does doing it day in and day out.
The Orlinsky and Rønnestad study contains important information about who we are and what we have to do to remain a vital force in our clients’ lives. It shows that our professional growth is a necessary part of our identity, as is our need to harvest the experiences that replenish us. It’s not enough to be soft-hearted and empathetic. Therapists need to have a keen sense of reality-testing to keep their heads above water in this field and make sure their work continues to be fulfilling.
I saw some relevant news from MedPage Today regarding the impact of the pandemic on mental health, psychiatric practitioners, and the way we do therapy as a result. I still see at least 50% of my patients virtually now.
I'll put all the articles here for convenience:
More and more psychiatrists are facing burnout amid the pandemic-related mental health crisis. (Business Insider)
According to a study including a representative sample of the U.S. adult population ages 20 and older, telehealth was utilized by more than half of patients for a behavioral health condition during the early months of the COVID-19 pandemic. (Journal of General Internal Medicine)
This is important for both mental health employees and employers to read and be made aware, if they haven't already considered it and the potential aftermath.
Mental Health Workers: The Other First Responders in this Pandemic
Why mental health workers need safeguarding and protection more than ever
In response to the COVID-19 outbreak, there has been a lot of talk in the media about the importance of preventing overload to our health care system. What we are only starting to hear about is its (anticipated) overwhelming impact on mental health services… and its providers.
Mental health workers are just as prone to burnout as any other care providers. Given the predicted impact of this pandemic on the well-being of virtually everyone, we need these service providers to be stronger than ever. Mental health workers need protection now, to ensure that they are available and prepared for the coming mental health crisis.
Nobody is immune to the pandemic’s negative mental health effects.
Social distancing measures keep loved ones apart, businesses and schools closed, people without steady work or income, and other services overloaded. The stress to essential workers and their families is obvious. We are living in a time of great uncertainty, with no end in sight.
Psychiatrists Dr. Andrew L. Smith of The Ottawa Hospital and Dr. Neil de Laplante of the University of Ottawa support that while social distancing measures are necessary, they could “lead many of us to feelings of isolation and powerlessness”, which are both linked to anxiety, depression, and possibly suicide.
The pandemic could be detrimental for those already facing complex mental health challenges: chronic anxiety, trauma, delusional paranoia, and addictions to name a few. There are people without the cognitive ability to understand the situation. Some are without a working memory. And others could be further subjected to daily abuse.
Health care workers and first responders are also high-risk groups for mental health challenges during this pandemic. They face prolonged exposure to high-stress work environments, in addition to the personal struggles we all face waiting out COVID-19. Post-trauma effects are a real threat to this group. Positively, there are mental health resources specific to first responders, but I wonder how accessible or effective these services will be long-term.
With the anticipation of a mental-health crisis secondary to this pandemic, mental health services could be more important than ever. Undoubtedly, we will need a strong system to help those most at-risk to the consequences of this pandemic, and to continue caring for our most vulnerable persons. To maintain a strong mental health system, we must protect and safeguard its most important resource: its workers.
Without its workers, the mental health system will breakdown, and this is already starting to happen.
As a mental health worker, I can tell you that many of us will be or are on the verge of burnout, the longer this situation continues as is or worsens. The state of the world is pushing people into survival mode; those who feel powerless and unprotected will resort to fighting for themselves. In survival mode, one can hardly help his or herself let alone others. In my field, workers are already walking off the job for self-preservation.
I am a front-line mental health worker supporting persons who require 24-hour care. I work in a home in close proximity to about 8–11 people (workers and residents) during my shift, where social distancing is near impossible, and PPE availability is extremely limited.
Last week, I was informed for a second time that someone in the home would be tested for COVID-19. I was left to wonder what will happen if the results are positive. How will we manage a potential outbreak at work? Will I be put off work to isolate? Have I exposed the elderly person I live with to the virus? What will I tell my family if the result comes back positive?
For confidentiality reasons, I cannot give specific details. I can tell you that at this time, there is no confirmed case of COVID-19 at my place of work. But this is a possibility that I need to be prepared for, and yet, there is very little certainty on what will happen if there is an outbreak.
Not knowing what to expect leads me to feel powerless and anxious. Still, I try to remain strong and composed for the people I support, who depend on my care.
I support people who have a very limited understanding of what this pandemic means. For them, it means a lot of changes to regular routine, a lack of contact with the outside world, and a lot of waiting and boredom. Without structure and purpose, their risk of self-destructive behaviour increases. It cannot simply be explained to them what might happen if there is an outbreak in the home. This could create further anxiety, paranoia, and undue stress.
To the best of our ability, my front-line team tries to keep routine in the home, offer alternative activities, and practice a lot of supportive counselling and patience. Most importantly, we try to keep individuals safe and healthy, not only from the virus, but from mental health crisis.
This means that we as essential workers need to keep ourselves safe and healthy. We must be so careful not to come in contact with the virus and bring it to work. Conversely, we are trying not to bring the virus home to our loved ones should there be an outbreak at work.
Just as important, we must look after ourselves mentally, so that we can continue to work effectively for those who need us. This is easier said than done, given the circumstances.
We have limits, and a lot of us will be prone to burn out the longer this situation continues to negatively impact us both personally and professionally.
We are human, not super heroes.
I think I speak for most mental health professionals during this time. I have helpers and healers in my own life who I know are struggling personally in this pandemic. One even said she is cutting back on work to look after herself and her family.
I know front-line workers who are thinking about a leave of absence or extended holiday at some point, knowing that they cannot sustain working under stressful conditions long-term without hitting “reset”. Some have even opted for early retirement to protect their health and their loves ones. Meanwhile, many of us are currently working overtime, and this field was facing a staffing crisis even prior to the pandemic.
We are only in the beginning stages of this pandemic, and essential care workers are already walking away.
If mental health workers all burnout, what replaces us? When mental health crisis reaches its peak in response to the pandemic and overloads mental health services, what happens then?
As Dr. Andrew L. Smith and Dr. Neil de Laplante note, the mental health system is already “chronically under-resourced”, and vulnerable persons face the greatest consequences if the system breaks-down in response the pandemic crisis.
Funding is necessary to keep mental health resources in place or develop new services as the effects of the pandemic evolve. Additional funding is required to implement health and safety measures to protect people living and working in group-homes, institutions, and long-term care facilities. But money is not the only important resource.
In addition to funding, mental health workers need safeguarding and protection. The most important resource in the mental health system is its workers. Without anyone available to provide the service, funding loses its purpose.
Eventually, COVID-19 will no longer be a significant health threat. However, we can expect a long-term impact on society. Loved ones will be lost. People will struggle to recover financially. Some might be traumatized. Vulnerable persons could face significant abuse in isolated situations. Addictions could surge. Not everyone will come out of this pandemic being able to continue on their previous life.
Mental health workers are not miracle workers, but they are necessary when people are in crisis, which will be an inevitable result of the current situation.
So, how can we protect and safeguard the most important resource in the mental health system? Really, how can we better protect all essential workers right now?
Protecting Rights
In emergency situations, employers are allowed (under government Acts) to override collective agreements to “protect” the safety of its workers or clients. For example, employers might be allowed to temporarily change an employee’s job classification or location to provide support where needed. Unfortunately, this gives employers a lot of free reign, rendering unions who protect employees almost powerless.
Employers should still be held responsible for their decisions. Yes, temporary changes may need to be implemented under extraordinary circumstances. But as much as possible, employers need to consider the mental well-being of their employees. This means listening to employee concerns and respecting their right to refuse unsafe work. If we are facing a pandemic that will impact us for months to a year, employers need to ensure that they do not make decisions that cause undue long-term stress to their employees. Otherwise, they risk being left short of those essential persons.
Compensating According to Risk
Appropriate compensation to me means that employers consider unforeseen risks associated with jobs and what that means for their employees. While I do agree that wage increases should be implemented in some cases (kudos to these companies), there are other ways in which essential workers can be compensated or supported during this pandemic.
Increased paid “personal days” for full and part-time employees will allow essential workers to take time off to care for themselves and their families. Extra sick days should also be provided if a worker comes into contact with COVID-19 on the job. Expectations that employees use their vacation time or go without pay are unreasonable when workers are coming into contact with an unforeseen risk associated with the job.
Protecting Health
Government and employers need to take more responsibility in ensuring that essential workers have what they need to stay healthy right now. Sourcing products like disinfectants, gloves, and hand sanitizer, and ensuring that essential workers have these items will reduce at least one stress associated with this pandemic. I support that everyone needs access to these items, but front-line workers especially need them to keep themselves and the people they live and work with safe.
Additionally, initiatives could be set forth to ensure that essential workers have the means of obtaining nutritious foods for themselves and their families. Employers can only benefit from keeping their workers strong during these times.
Providing Solutions
We are in a time of great uncertainty, and I can respect that experts in health and government are dealing with a situation that they have never handled on this scale before. I do believe that there should be honesty and transparency regarding the pandemic and its predicted course.
What is concerning is the presentation of scary problems without action or solution. Advising everyone to “get used to this way of life” (i.e., social distancing) for months to a year or longer is not practical or helpful. This is not sustainable. We all know this, and it will become increasingly difficult to support people through this pandemic without long-term solutions.
Mental health workers can help people manage and cope with the situation they face, but that only goes so far. Until people start to feel hope and control, until they can re-establish some normalcy in their lives, the looming mental health crisis will grow.
— — —The only way to prevent or minimize this crisis is to come up with alternatives to just “staying home.” -- -- --
Nothing about this pandemic is simple. There are no easy answers. I respect that most advisors and decision-makers, at all levels, are doing their best.
We need to work together to see the situation from all angles, to prevent further crisis.
The people who make up health care services are the most essential resource to safeguard. In the coming weeks, it is imperative to everyone’s well-being that action plans are implemented to keep workers safe and healthy.
Now is the time to help and protect these workers, so that they are available and strong when they are needed.
