The world seems to be in the midst of a pandemic of burnout, spread across all age groups, genders, professions, and cultures. Research specific to mental health providers finds that between 21 and 67 percent may be experiencing high levels.  Other related “conditions” have been identified, including compassion fatigue (CF), vicarious traumatization (VT), and secondary traumatic stress (STS), all aimed at describing the negative impact that working in human services can have on mental and physical health.

An entire industry of authors, coaches, and trainers has sprung up to address the problem, providing books, videos, presentations, retreats, and organizational consultation. There’s only one problem: currently fashionable approaches to burnout don’t work.  In fact, they may make it worse!

What can be done?  In an article published in the Psychotherapy Networker, my long time colleague and co-writer, Dr. Mark Hubble, and I review research on the field’s Top Performing therapists.  Once again, they have something to teach us, this time about “healing the heart of the healer.”  Click here to access a PDF of the article. 

What’s the difference between a trained therapist and a compassionate friend?  Look at outcomes and you are likely to be disappointed.  For example, meta-analyses of studies comparing professionals to paraprofessionals (or students) either find that the latter group achieve significantly better results or, at worst, the same!

A clearer difference can be found in area of ethics.  Unlike one’s BFF, a therapist is bound by their commitment to a code of professional practice.  Keeping confidences and doing no harm are two prime examples.  Most clinicians spend a semester or two studying ethics during their training.  Continuing education on the subject is mandated by most state licensing boards in order for therapists renew their license to practice.

Unfortunately, much of current ethics training is focused on staying up-to-date with laws governing the profession or minimizing the risk of malpractice suits.  Even the occasional focus on ethical “dilemmas” misses the point, narrowing the focus to the unusual and acting as though once resolved, we can go back to doing what we do.

As my colleague and friend, Dr. Julie Tilsen, observed, “We have detached ethics from the whole of practice, made it an ‘add-on.’  But, whether we realize or not, everything we do—and don’t do—is a matter of ethics. There is always an ethical standard in place, and that ethic typically reflects taken-for-granted values and understandings.”  She continues, “Any approach to practice is incomplete if it fails to articulate a stance on the ethics of the work—and by this I’m referring to the effects of what we do, in every moment of every encounter, with every person—whether or not a ‘dilemma’ presents itself.”

As readers of this blog know, becoming aware of the effects of our work is what Feedback-Informed Treatment (FIT) is all about as it directly answers the question, “How do we know when clinical practice is responsible and ethical?”  After all, ethical practice requires that our work is engaging and effective—from our clients’ point of view.

You are not going to believe me when I say it. Fifty percent. It’s true. Even in studies where carefully selected therapists who receive copious amounts of training, support, and supervision, and treat clients with a single diagnosis or problem, between 5 and 10% get worse and 35-40% experience no benefit whatsoever! That’s half, or more.

What happens to these people?

Well, if the therapist formally and routinely solicits feedback regarding the quality of the relationship and progress in care, drop out and deterioration rates fall, and outcome improves.

Still, a significant percentage of people do not improve—as many as 25%!  What can we do? The ethical standards for all of the professional mental health organizations require clinicians both monitor and end ineffective treatments as well as suggest helpful alternatives to clients (ACA [C2.d], APA [10.10]).  But what?

Enter Lynn D. Johnson, Ph.D., a psychologist whose work and thinking is always a step ahead.  I’ve known Lynn for decades, met him when I was a graduate student.  As I blogged previously about, it was Lynn who in 1996 first suggested routinely measuring outcomes.  He is also responsible for the creation of the original Session Rating Scale–a 10-item version that I later shortened to four.  For several years, Lynn pushed me to do research on top performing therapists, believing they held clues to improving the practice of psychotherapy in general.