This is the second in a five-part series on how alumni of Antioch’s Graduate School of Leadership and Change are advancing healthcare in service of the common good.
It wasn’t just another name on a long list when William Keating’s colleague stepped down from their role as a mental health clinician. They held their position for nearly two decades and cared deeply about the work. “I was floored by the fact that this person was leaving after close to 20 years. And the reason why wasn’t their caseload,” Keating says.” It wasn’t all burnout, either. It was because of how this highly effective and experienced provider was being treated.”
It was a sign to Keating that there was something deeply flawed in the system they worked in. Clinical Mental Health Centers, or CMHCs, in his home state of New Hampshire, have high staff turnover rates. It’s an issue that leaves the state’s most vulnerable communities at risk of losing the services they need to have full and connected lives.
These centers have an extensive intake process to receive service. Adults have to show that their mental health is impacting their daily lives or have a diagnosis like schizophrenia, post-traumatic stress disorder, or obsessive-compulsive disorder to be eligible. Clinicians often work with people who are at risk for hospitalization or incarceration or facing homelessness.
“It’s really important that these CMHCs exist because they provide such an essential service to the community. Private practice is not going to be able to provide the necessary services at this level of care,” Keating explains. “It’s not going to be able to have first-episode psychosis programs or provide that continuous level of care that helps people stay out of the hospital and live better lives.”
Like many nonprofits, these clinics are trying to recruit and retain staff while competing with the private sector. In mental healthcare, this is especially difficult. Private practices offer much higher pay, more autonomy to choose which clients the person wants to work with and control over the number of clients they take on.
It’s a wonder why anyone wouldn’t move to a private practice. And that’s exactly what Keating studied at Antioch’s Graduate School of Leadership and Change – not why people were leaving, but what would make them stay. Without looking at remedies for turnover and changing systems that lead to burnout, people across the state will lose the care they deserve.
Personal Experience with the Impacts of Turnover Inspire Studies
Keating worked in CMHCs for nearly ten years before returning to school to work on his dissertation, A Case Study on Factors Influencing Retention of Mental Health Clinicians in a New Hampshire Community Mental Health Center. What inspired him to keep working in these settings for so long, even with the promise of a more balanced workload that private practice offered, was a combination of purpose and the people.
“I have made some really, really close friends in the system, and I still maintain those friendships,” he says. It’s been almost two years since he left community mental health, but it wasn’t an easy decision. “I miss working with the people, because that passion is still there, even though there’s burnout,” Keating shares. “There is that positive, there’s a sense of community.”
His passion for the work helped him see the problem of turnover as an opportunity to help make the systemic changes that could have supported his own staying in the community mental health system. Experiences both as a clinician and as a member of leadership in different CMHCs meant he came to his research with multiple vantage points to inform his work.
As a clinician, when someone left, Keating and others on his team would have to pick up their caseload. He experienced a prevailing attitude that this was an expectation of the job. Not only were there no pay increases, there was rarely even recognition of the additional labor.
As a supervisor, he was faced with a different set of challenges, like shifting caseloads and communicating with his team. Additionally, it was his responsibility to find and hire a new provider, which included training them in the policies, procedures, and administrative responsibilities of that center.
One estimate in Keating’s dissertation puts the cost of hiring and training a new clinician close to $4,000 annually. But the drain on funds at these under-resourced centers isn’t the biggest impact – that’s felt by the person who loses the relationship with their care provider.
There are many layers to working in these centers that coalesce into a recipe for widespread burnout. Again and again, Keating saw systemic flaws force passionate individuals to reconsider their commitment to working in these centers.
This is what inspired him to write his dissertation, to create a tool that could be used to reflect on what would support people working in CMHCs. “I wanted it to be meaningful. I wanted it to be usable,” Keating says of his dissertation. He didn’t want it to be another dusty book on a shelf, but a guide to build better working conditions for mental health professionals and support the healing of the communities they serve.
Higher Expectations without Support Lead to Exhaustion
In the early years of the pandemic, mental health issues were reported at higher levels than ever before. According to Keating’s dissertation, 4 in 10 adults reported symptoms of anxiety or depression, four times the number of pre-pandemic statistics. As the need for mental health services rose, so did the pressure on the frontline workers in CHMCs.
Keating witnessed a distressing trend – employees were being assigned nearly impossible workloads. Seeing patients means more than just the time spent in direct service; there are often travel hours if providers are meeting people in their communities, and there is time needed for notes, paperwork, and other administrative tasks.
Because each clinic operates under its own rules, some recognize the time needed for this work when balancing caseloads better than others. This, combined with the emotional toll and stress of providing care for people in crisis, exacerbated an already distressing number of workers reporting burnout.
Burnout has become a catch-all term for exhaustion but was developed in the ’70s specifically for people working in healthcare. It’s commonly considered to have three dimensions that boil down to an employee’s inability to continue working in the field. But that fails to recognize the personal toll someone experiences in the midst of it.
Indicators of burnout include emotional exhaustion, which can lead to the person becoming detached from their work and then often left feeling like nothing they do will make a difference. This is compounded in therapeutic work. Clinicians are likely to also experience “compassion fatigue” as they continually help others work through traumatic events. This is shown to directly impact the practitioner’s emotional state as well.
Keating had his own experience with burnout when he wanted to expand his leadership skills to support the team he supervised. “I felt like I was being boxed in,” he explains. “I kept saying, ‘I want to learn, I want to grow, I want to be a leader that’s more advanced.’” Instead of being met with support, he was repeatedly told that the clinic didn’t have the capacity to invest in him.
Keating is understanding of the limited resources centers have, but he also knows there are ways to support people in the midst of challenging work. It’s the solution Keating could have used in his own time at CMHCs, one he heard often in his research, and it was what might have kept his colleague in the field another twenty years.
Beyond Burnout: Solutions in Relationships
Keating underscores that strong working relationships between supervisors and clinicians are one of the top reasons people stay in their positions at CHMCs. When his colleague was faced with a toxic manager, they felt they had no other recourse but to leave. If that manager had more training in leadership, relationship building, and accountability from their supervisor, it could have been a different story.
Although there are many other examples of what helps retention – competitive salaries, incentives, opportunities for professional growth, and funding for increased staffing are all crucial elements – positive working relationships with supervisors and leadership were a crucial indicator for retention.
A difficult relationship is one reason clinicians might leave, but on the flip side, losing a well-established relationship is another factor that can contribute to turnover. One theme that surfaced in Keating’s interviews for his research was that if their supervisor left an agency, the person would strongly consider leaving as well. They cited how difficult building trust with a new person would be. This is a clear example of how important these relationships are. But how can someone build this necessary trust?
Regularly scheduled supervisions are the best way, in Keating’s opinion. The consistent connection can help build a working relationship, making a person feel invested in, and give a sense of reliability. Keating says a level of openness is needed as well, “Your supervisor needs to be approachable. And it can’t all be business; you have to be able to have a balance. I need to be able to talk with my supervisor about work and about personal things that can potentially impact the work they are doing.”
This recognizes the need for a holistic perspective that’s necessary for supporting a workforce under intense emotional strain. The effects of high and ever-increasing rates of turnover in mental healthcare institutions is an erosion of their goal to help people who need those services most. Keating’s research provides an inroad to what’s needed to build a better system, supporting both the people who provide care and those who receive it.
