Doing More With Less: A Survey of Economic Precarity, Financial Strain, Burnout, and Secondary Traumatic Stress in Philadelphia’s Public Mental Health System

Abstract

Background: Efforts to increase the implementation of evidence-based interventions come at a time of rising inequality and cuts to public mental health funding. Clinicians in publicly funded mental health clinics face increased demands, work long hours, experience financial stress, and treat clinically severe, under-resourced patients. A detailed understanding of clinicians' economic precarity, financial strain, and job-related stressors, and an understanding of how these factors relate to treatment delivery, is needed. Methods: In July 2020, we surveyed 49 clinicians working in Philadelphia’s public mental health system who participated in a large-scale trauma-focused cognitive behavioral therapy (TF-CBT) training initiative. Respondents reported on professional burnout, economic precarity, financial strain, secondary traumatic stress, and self-reported use of TF-CBT. We examined associations between clinicians’ economic precarity, job-related stressors, and their TF-CBT use with mixed models. We used content coding to organize open-ended responses into themes.Results: Economic precarity, financial strain, burnout, and secondary traumatic stress among respondents was high. Thirty-seven percent of clinicians were independent contractors, and of those, 44% reported desiring a salaried position. Most clinicians (76%) had outstanding education loans, and of those, 38% reported over $100,000 in education debt. In the last year, 29% of clinicians went without personal mental healthcare due to cost. Most clinicians (73%) endorsed at least one symptom of secondary traumatic stress, with 22% scoring above the clinical cutoff. Education debt was negatively associated with TF-CBT use (p<0.001). Secondary traumatic stress, measured continuously and categorically, was associated with burnout (ps<0.05).Discussion: Clinicians in Philadelphia’s public mental health system experience burnout, economic precarity, financial strain, and secondary traumatic stress, which were associated with TF-CBT use. The economic strain and stress of providing care in under-resourced clinical settings may interfere with ongoing efforts to integrate scientific evidence into mental health services. Financial investment in the mental health workforce is essential.

Implementing trauma-focused cognitive behavioral therapy in Philadelphia: A 10-year evaluation

“…Turnover in Philadelphia's public behavioral health agencies is 41%, and in some agencies, it is significantly higher (Adams et al, 2019;Beidas, Marcus et al, 2016). Much like clinicians in other behavioral health systems, Philadelphia clinicians leave the workforce due to inadequate compensation as well as the demanding conditions of public behavioral health work, which generate burnout and secondary traumatic stress (Adams et al, 2019;Association for Behavioral Healthcare, 2022;Last et al, 2022). PACTS clinicians also report wanting additional clinical support (Last et al, 2021).…”