Where Have All the Mental Health Workers Gone?

Despite rising rates of suicide and substance abuse, nearly 117 million Americans live in what is known as “health professional shortage areas.”

Put another way, only 27% of mental health needs in those areas are being met, according to the Health Resources and Services Administration (HRSA). More than 6,300 additional providers would be needed to erase the gap.

“This has been a problem that’s been building over decades and decades, and now we’re at a crisis point,” said Angela Beck, Director of the Behavioral Health Workforce Research Center at the University of Michigan, in Ann Arbor. “We’ve got demand going up,” Beck said, “but we don’t have a pipeline or a supply that’s expanding to keep pace.”

America’s youth may be bearing the brunt of the shortfall. A 2019 report in the journal JAMA Pediatrics examined disparities in mental health care. Among children with a mental health disorder, nearly half (49.4%) did not receive the necessary treatment or counseling from a mental health professional.

Almost 60% of young adults aged 18 to 25 with a severe mental illness reported an unmet need for mental health care in the past year, according to a 2018 national survey. The average for all adults was just over 45%. And the continued shortages in practicing school psychologists are expected to continue through the year 2025.

The Consequences of Burnout

Job burnout among school psychologists is nothing new, but it is becoming a potentially severe issue, given this widespread shortage of practitioners. Some recent studies estimate up to 90% of school psychologists experience occasional feelings of burnout in their working lives.

In 2018, when the American Psychological Association analyzed several studies that looked at burnout among mental health services providers, its researchers found that “anywhere between 21% and 61% of mental health practitioners experience signs of burnout“. A 2018 research review paper published in the Journal of Clinical Psychology analyzed 30 years of research on this topic, involving 9,000 psychotherapists. Over half of the therapists they sampled reported “moderate-high levels of stress and burnout.”

The problem is that job burnout becomes the catalyst of a vicious cycle. As more school psychologists leave the field, the workload increases for those therapists left behind. Increased workloads increase the vulnerability of those still working to suffer from burnout themselves, which leads to more school psychologists leaving the field, and so on.

You get the picture.

What Is Job Burnout?

In his book Burnout: The High Cost of High Achievement, the term “burnout” is relatively new, first coined in 1974 by Herbert Freudenberger. Freudenberger originally defined burnout as “the extinction of motivation or incentive, especially where one’s devotion to a cause or relationship fails to produce the desired results.”

In essence, job burnout is a reaction to prolonged or chronic job stress that morphs into a psychological syndrome in response to those chronic interpersonal stressors. Decades of research regarding the construct of job burnout conceptualize this response as including three distinct dimensions: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.

Emotional Exhaustion

Emotional exhaustion refers to feeling tired or fatigued within the context of one’s work. It includes feelings of being overextended and drained of one’s emotional and physical resources within the work environment.

Feelings of Depersonalization

Feelings of depersonalization are characterized by a general sense of detachment from one’s job. They can include the adoption of insensitive, uncaring, or even hostile/negative attitudes toward others (i.e., colleagues and clients).

Reduced Sense of Personal Accomplishment

Finally, a reduced sense of personal accomplishment is defined by feelings that one is not accomplishing anything worthwhile at work and, thus, experiencing a lack of motivation to perform one’s job.

Common Signs and Symptoms of Burnout

Alienation from work-related activities: Individuals experiencing burnout view their jobs as increasingly stressful and frustrating. They may grow cynical about their working conditions and the people with whom they work. They may also emotionally distance themselves and begin to feel numb about their work. These are some of the common signs and symptoms associated with burnout.

Physical symptoms

Chronic stress may lead to physical symptoms, like headaches and stomachaches or intestinal issues.

Emotional exhaustion

Burnout causes people to feel drained, unable to cope, and tired. They often lack the energy to get their work done.

Reduced performance

Burnout mainly affects everyday tasks at work—or in the home when someone’s main job involves caring for family members. Individuals with burnout feel cynical about tasks. They have difficulty concentrating and often lack creativity.

Causes of Burnout

According to a 2018 report by Gallup, employee burnout has five main causes.

Unreasonable Time Pressure

Employees who say they have enough time to do their work are 70 percent less likely to experience high burnout. Individuals who cannot gain more time, such as paramedics and firefighters, are at a higher risk of burnout.

Lack of Communication and Support from a Manager

Manager support offers a psychological buffer against stress. Employees who feel strongly supported by their managers are 70 percent less likely to experience burnout regularly.

Lack of Role Clarity

Only 60 percent of workers know what is expected of them. When expectations are like moving targets, employees may become exhausted by merely trying to figure out what they are supposed to be doing.

Unmanageable Workload

When a workload feels unmanageable, even the most optimistic employees will feel hopeless. Feeling overwhelmed can quickly lead to burnout.

Unfair Treatment

Employees who feel they are mistreated at work are 2.3 times more likely to experience a high level of burnout. Unfair treatment may include things such as favoritism, unfair compensation, and mistreatment from a co-worker.

Compassion Fatigue

While any job is prone to burnout, there is a particular concern regarding those in the mental health professions — compassion fatigue. Psychologist Heidi Allespach, Ph.D., of the University of Miami’s Miller School of Medicine, knows that the big hearts that propel people into psychology and other caregiving careers also put them at risk of developing compassion fatigue.

Ironically, she explains, caregivers can become so over-empathic that they find themselves growing numb to their patients’ suffering. That’s why she urges the medical residents she teaches to develop what she calls a “semi-permeable membrane” around their hearts. “Without enough of a shield, everything just comes in,” says Allespach. “And being overwhelmed with the feelings of others can feel like drowning.”

Now Allespach and other psychologists are worried that psychologists are facing increased risks of compassion fatigue as the COVID-19 pandemic stretches on.

Compassion fatigue occurs when psychologists or others take on the suffering of patients who have experienced extreme stress or trauma, explains Charles R. Figley, Ph.D., founder of the Traumatology Institute at Tulane University.

It is an occupational hazard of “any professionals who use their emotions, their heart,” he says, and represents the psychological cost of healing others. “It’s like a dark cloud that hangs over your head, goes wherever you go and invades your thoughts.”

Compassion fatigue doesn’t just make it difficult to feel empathy for your patients, says Kerry A. Schwanz, Ph.D., of Coastal Carolina University. One component of the condition is burnout, which is associated with too much work and insufficient resources to do that work well. “I sometimes refer to this component as ’empathy overload,'” says Schwanz, adding that symptoms include anxiety, intrusive thoughts, hypervigilance, numbness, or feelings of having nothing left to give.

Relieving Burnout

Make Self-Care Part of a Routine

Psychologists should adopt the mantra of flight attendants: “Put your own oxygen mask on before helping others,” says psychologist Amy M. Williams, Ph.D., of the Henry Ford Health System. Good self-care means developing a routine that makes each day predictable. That includes what Williams calls the big five of self-care: adequate sleep, healthy nutrition, physical activity, relaxation, and socializing.

Practice Self-Compassion

Psychologists are having a hard time along with everyone else, says Allespach, and that’s unusual. Most psychologists are now experiencing the same problems their patients are experiencing—worries about safety, uncertainty, financial concerns, and disrupted routines.

“Psychologists are usually the rocks in the river of life’s uncertainty for our patients, but right now, we’re in that river with them. For those of us in the helping professions, we’re trying to help our patients make sense of this strange new reality while doing that ourselves.”

That unusual situation can increase psychologists’ stress, says Allespach. But so can psychologists’ tendencies, says psychologist Anna Baranowsky, Ph.D., founder of Toronto’s Traumatology Institute, who says psychologists tend to be “over-copers.” “They are capable of working really hard and delivering great results,” says Baranowsky. “But they are very self-demanding and very focused on the perfection of what they’re delivering, until the point of total exhaustion.”

Psychologists need to take time to reflect—alone, with a trusted colleague, spiritual leader, or therapist—on any surfacing wounds during this uncertain time. “You want to really respect the fact that you’re human, too,” she says. “Bearing witness to another person’s suffering ignites things within ourselves.”

Create a Community

Connecting with like-minded others is another strategy that can help prevent compassion fatigue. “It may not sound fancy or sophisticated, but building community is the most powerful thing you can do,” says Geoffry White, Ph.D., a private practitioner in Los Angeles who has worked to prevent compassion fatigue in mental health practitioners responding after terrorism and war.

“Compared with other societies, the United States has a very mind-your-own business culture, prizing independence and self-reliance over community,” says White. “But anything that takes away from that isolation—peer support—will help.”

Help Colleagues

The pandemic exacerbates what was already a crisis of burnout for healthcare providers, say researchers and medical professionals at Texas A&M University and Houston Methodist Hospital. They found that intensive care unit workers face longer shifts, increased patient deaths, lack of personal protective equipment, and financial fears, among other stressors (Sasangohar, F. et al., Anesthesia and Analgesia, published online ahead of publication, 2020).

“Those stressors can also lead to compassion fatigue. If psychologists see signs that a colleague, whether another psychologist or a healthcare professional, is developing compassion fatigue, they should check-in, says Schwanz. Psychologists and trusted colleagues can give each other permission to point out potential problems and keep at it despite attempts to deflect or deny”, says Schwanz.

Focus on Compassion Satisfaction

Psychologists should celebrate the positives of helping others. “There can be terrible things going on, but focus on the wins,” suggests Schwanz, citing the celebrations healthcare providers hold when patients come off ventilators. Focusing on gratitude can also help, she says.

Be Aware, Be Honest, and Be Proactive

Burnout can have severe consequences. However, although the term “burnout” suggests it may be a permanent condition, the good news is that it’s reversible. An individual who feels burned out has many options as to how to engage it, and heal from experience. The key is to engage the burnout. Please do it for yourself, do it for your family, and do it for all of those precious children who so desperately need you!