A closer look at the mental health provider shortage
By Lindsey Phillips
May 2023
Suzanne Tucker/Shutterstock.com
The current state of mental health care in the United States is troubling. Mental health organizations are understaffed. People are unable to access or afford mental health services. Counselors are overwhelmed with high caseloads, and many are leaving the field in search of better pay and work-life balance. And that was before the COVID-19 pandemic, which has only amplified the mental health crisis and provider shortage.
According to data from the Kaiser Family Foundation, 47% of the U.S. population in 2022 was living in a mental health workforce shortage area, with some states requiring up to 700 more practitioners to remove this designation. The reasons underlying this shortage are complex, causing many mental health professionals to feel there may be more challenges than solutions to this growing problem.
Counseling Today recently invited several mental health professionals to share how the shortage is affecting their communities and what steps they think the counseling profession needs to take to address this issue.
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5 reasons for the provider shortage
By John Cordray
With more people realizing the importance of mental health, the demand for licensed mental health therapists has skyrocketed in recent years, especially after the COVID-19 pandemic began. Unfortunately, the United States is facing a critical shortage of these professionals, leaving many individuals and families in distress without the help they need. This shortage is creating a ripple effect throughout the health care system, with it becoming increasingly difficult for people with mental health issues to access the care they need.
The causes for this shortage are multifaceted and complicated, but here are five key reasons for the shortage of licensed mental health therapists in the United States:
Lack of funding: The government provides a limited amount of funding for mental health services and counseling. This lack of funding is one of the major contributors to the shortage of mental health therapists. Many mental health providers must rely on private insurance or self-pay to cover their services.
Poor reimbursement rates: Mental health providers are often not adequately reimbursed by insurance companies or government programs. This leads to low provider reimbursement rates, which can deter providers from entering the field or remaining in it.
Low retention: The current number of mental health professionals does not meet the needs of the population. This is due in part to the low reimbursement rates, but it also is caused by the fact that mental health is not a particularly attractive profession to younger generations because of the stigma associated with it.
Increased need for services and limited access to care: The increased demand for mental health services is outpacing the supply of providers. In addition, clients, especially those in rural areas, often have limited access to care because of a lack of public transportation or proximity to a mental health facility. And mental health providers often choose not to work in rural areas because of poor reimbursement rates and low pay. These factors can prevent people from getting the treatment they need.
An aging workforce: Many of the mental health professionals in the United States are nearing retirement age. Low counselor retention also means that as these professionals retire, they are not being replaced by younger professionals at the same rate, creating a shortage in the field.
These are just a few of the reasons for the shortage of licensed mental health therapists in the United States. The lack of access to mental health care and the inadequate reimbursement for providers are causing a great deal of distress and difficulty for those who need mental health care. It is important to take action to address this provider shortage and ensure that those suffering from mental health issues can receive the care they need.
—John Cordray is a licensed professional counselor in private practice in the St. Louis metro area and the founder and CEO of the Mental Health Community, an online community for mental health professionals to connect, network and find jobs. He also hosts the podcast The Mental Health Today Show. Contact him at johncordray.com.
The impact of COVID-19 on the provider shortage
By Krystyne Mendoza
The COVID-19 pandemic led to a cascade of changes in our lives: The way we worked changed; the way we went to school changed; the way we communicated changed; the way we lived changed. The ramifications of such change cannot be understated. In the 2022 article “Two years of trauma,” published by Georgia State University Research Magazine, Noelle Toumey Reetz said that the COVID-19 pandemic was “the most traumatic collective event of our lifetime.” And just as with any traumatic event, we are only beginning to uncover the devastating effects.
One of those effects was the profound need for mental health care. According to a Kaiser Family Foundation report published in 2021, the percentages of those in need and without access to mental health care was astonishing, with cost, lack of insurance coverage and lack of providers named as notable contributing factors. The issue of access has been exacerbated by the dramatic shortage of mental health care professionals.
The pandemic not only sparked an increase in mental health problems for children, adolescents and adults but also negatively affected the mental health of mental health professionals themselves. The ways we communicated with others, offered services to clients, and sought and provided counselor education were rapidly moved to online modalities, despite many practicing clinicians having no previous experience with these modalities. A 2021 report by the National Council for Behavioral Health notes that low pay, increased client loads and restrictions in the way services could be offered quickly led to burnout for many mental health professionals, further deepening the shortage. And an estimated 122 million Americans, or about 37% of the U.S. population, live in areas with a mental health professional shortage, according to a 2021 article published by USAFacts.
During the pandemic, the Department of Counselor Education and Counseling Psychology at Marquette University became acutely aware of the devastating effects of the provider shortage because areas in northern and western Wisconsin were, and continued to be, in extreme need. Even now, we recognize that there are too many populations underserved and too many organizations understaffed. Evidence also shows us that the pandemic has had a more devastating effect on marginalized populations.
The COVID-19 pandemic initiated many negative changes, but it also promoted a paradigm shift, highlighting new modalities in which counselor education and mental health services could be delivered. So we honored our commitment to social justice and diversity, led by our Jesuit principles, and started an online version of our clinical mental health counseling program that aims to help reduce this shortage and address the growing need for mental health care.
In designing the program, we intentionally thought about the barriers that prevent students from obtaining a degree and took an active stance to address those obstacles. Specifically, we designed our program for working adults, creating a part-time program that can be completed in three years. We also offer courses later in the evenings to accommodate working adults because many students from marginalized populations must maintain full-time employment. And because the program is all remote, students do not have any travel expenses. This allows us to reach underserved areas in a multidimensional way: We train students who live in rural and underserved areas, which ultimately increases access to mental health care within those areas.
The program has consistently and substantially exceeded our initial enrollment expectations since it launched in fall 2021. The program’s success can be attributed to several factors, including our focus on social justice and diversity, the innovative class structure, dynamic instruction and, of course, our incredible students. As a result, we have hired additional faculty members, developed new and exciting curriculum and expanded our outreach efforts to reach a larger audience throughout the United States. We are poised to continue this growth and make a positive impact on the education of students across the nation, ensuring that all people have access to the mental health services they need and deserve.
—Krystyne Mendoza is a clinical assistant professor of counseling at Marquette University and a licensed professional counselor in Texas and Colorado.
Professional sustainability in the mental health field
By Cort M. Dorn-Medeiros
It’s hard to discuss mental health treatment without addressing the prominent elephant in the room: a massive shortage of mental health providers. In my city of Portland, Oregon, agencies and private practitioners monitor lengthy waitlists, sometimes up to six months. Youth mental health services are even more scarce. While we may all want to dismiss this shortage as another victim of the COVID-19 pandemic, I encourage a slight change in perspective.
Although COVID-19 may have forced the issue, mental health providers, particularly those working in agency settings, had long struggled within an unsustainable system. Examples of such struggles include:
Increasing client caseloads
Costly fees associated with licensure and credentialing
Low compensation and fewer benefits
Hefty student loan payments
Rising costs of living in most areas of the country
Before becoming a counselor educator, I worked as a licensed mental health and drug and alcohol counselor in various nonprofit agency settings between 2009 and 2015. During this time, I mostly managed moderate caseloads of court-mandated clients. When I was first hired in 2009, I earned $18 an hour with full benefits, and the agency paid for my required prelicensure supervision. Although this may seem like getting paid in peanuts, it was close to 14 years ago, and the cost of living here in Portland was rising but had not yet peaked to the mind-numbing heights they are today. After I became a licensed professional counselor, the same agency hired me for a different position, and my compensation jumped to an annual salary of $57,000.
So, imagine my surprise when sitting in an internship supervision class in 2017, I learned that one of my graduating students had just been offered a position with my previous employer. Her starting salary? $18 an hour. The agency could also not guarantee to cover her prelicensure supervision. I was stunned.
Let me add that my former employer was one of many nonprofits offering low starting salaries for master’s-level counselors. Our internship class spent a long time discussing the frustratingly low pay and reduced benefits for new graduates. And this discussion happened well before COVID-19 was a blip on the national map.
I don’t share this story to speak ill of agencies or agency-type work. I am incredibly grateful for my experiences working in nonprofits, the community relationships I built, and the knowledge I gained working with a widely diverse clientele. The gratitude I hold is also what I find the most frustrating. I want my students to have the same opportunities I did. But over the years, I have seen a significant shift with new graduates choosing to enter private or small group practices rather than work for agencies. And I cannot say I wouldn’t do the same if I were graduating now.
This shift, however, has caused many local agencies to be understaffed, which became a critical issue during the pandemic. The mental health crew was already abandoning the ship when the tidal wave took it out.
On the positive side, the impact of COVID-19 has forced the hand of change, at least here in the Portland metro area. During the past three years, many agencies have unionized, which has allowed them to negotiate for higher starting salaries, regular salary increases and better benefits. Some agencies even began offering sign-up and referral bonuses. And changes to state regulations now allow private practitioners and agencies to see Oregon-based clients via telehealth.
While there remains some debate about the efficacy of telehealth compared to “traditional” in-office settings, telehealth no doubt helps expand provider capacity, and it offers much-needed services to rural parts of the state. Additionally, telehealth provides a lower-cost option for counselors who desire to do private practice, need to work from home or need more job flexibility.
A lack of focus on and appreciation for sustainability in the mental health field is the root cause of our workforce shortage. Band-Aid solutions are not solutions. As a counselor educator, it is my responsibility to help my students negotiate the often-fraught landscape of being a new professional. Shortages in the mental health workforce have provided more opportunities for recent graduates than we’ve seen in many years. But it’s our job as a profession to make them want to stay. I encourage my fellow counselors and mental health employers to make professional sustainability in the workforce a priority. A sustainable workforce is a maintainable workforce.
—Cort M. Dorn-Medeiros is an associate professor and chair of the Counseling, Therapy, and School Psychology Department at Lewis & Clark College. Dorn-Medeiros is also a licensed professional counselor and certified alcohol and drug counselor (level 3) in Oregon. Contact him at dorn-medeiros@lclark.edu.
Counselor access and retention in rural areas
By Cassandra Armas and Candice Rodriguez
Western Colorado attracts many tourists throughout the year because of its beautiful scenery and abundance of outdoor activities. But those of us who live here see another side: residents who are trying to live their lives and cope with mental health challenges while faced with numerous obstacles such as high cost of living, lack of affordable housing, lack of accessible mental health resources and poor retention of mental health providers.
Challenges as a mental health provider
The cost of living in rural western Colorado has been steadily increasing over the past couple of years; however, since the COVID-19 pandemic, this dire situation has worsened. As mental health professionals we are witnessing firsthand the toll that it has on the overall mental well-being of the community, including mental health providers. Because of the low pay and high cost of living, some mental health providers obtain second jobs to make ends meet. The increase in the cost of living has also made it difficult to attract and retain mental health providers, especially school-based ones. The current counselor ratio in our area is 470 people to 1 clinician. This troubling ratio not only makes it difficult for community members to access mental health care but can also lead to provider burnout. Many mental health providers are finding themselves feeling overwhelmed because of an increase in client referrals, which then results in limited availability or a waitlist.
We would also like to highlight the unique challenges that many Spanish-speaking providers may face because of the high need of bilingual therapists in western Colorado. Spanish-speaking providers are currently struggling with being able to meet the high demands of service. These providers are often booked two to three months in advance because of the rise in demand. Additionally, Spanish-speaking providers may receive referral after referral with little to no room on their caseload. This lack of Spanish-speaking providers means some individuals who prefer or need a therapist who speaks their native language may go without treatment or they are put on a long waitlist.
All these challenges are leading to burnout and causing providers to relocate or potentially change careers.
Challenges as a community member
The communities in rural western Colorado have dealt with a shortage of mental health services for many years. And even though there have been great efforts to increase access to mental health services, especially in schools, the problem still exists — with no end in sight. Accessing mental health care in our area requires being insured or having the financial means to afford mental health care. Even though there are programs that provide financial assistance for therapy, families who are barely living above the poverty threshold often don’t meet the eligibility requirements.
Even if people in our community can afford therapy, they face another challenge: finding providers who have immediate availability. They often have to wait weeks and even months to meet with a mental health provider. This delay in access increases feelings of hopelessness and defeat, which deters people from continuing to seek mental health support. We have heard many clients say, “I have exhausted all resources. I don’t know what else to do."
Possible solutions
In a perfect world, the dichotomy between the rich and the poor would not exist and access to affordable and quality insurance would be available to everyone. However, not all hope is lost; there are potential solutions that can help solve some of the challenges we mentioned.
First, rural communities in Colorado are in need of affordable housing for both mental health professionals and others in general. Second, we need to create more programs or provide incentives to attract and retain mental health professionals. Increasing the pay for mental health professionals would prevent the need to seek multiple jobs to keep up with the cost of living. In turn, this would help decrease burnout and exhaustion. Retaining more mental health providers would also help decrease the 470-1 ratio and provide more access to mental health support in rural communities. Finally, providing access to bilingual education for providers interested in learning a new language would also improve mental health access for Spanish-speaking community members.
There will always be gaps, difficulties and challenges in the mental health profession, but it is important to continue bringing light to the existing issues contributing to the provider shortage, which is negatively affecting both therapists and the community, especially in rural areas like ours. With continued team effort and advocacy, we can make improvements to tackle these issues.
—Cassandra Armas is a bilingual licensed social worker specializing in anxiety, depression, immigration trauma and LGBTQ+ issues. She was born and raised in rural western Colorado and is currently providing school-based mental health services for Your Hope Center in Eagle County, Colorado.
—Candice Rodriguez is a licensed professional counselor whose passion is to provide trauma-informed care utilizing eye movement desensitization and reprocessing. She relocated to western Colorado from Chicago five years ago and is currently a school-based clinician for Your Hope Center in Eagle County, Colorado. She also provides teletherapy through her private practice, ALMA Counseling. Contact her at candicerodriguez@almacounseling.com.
Preparing counselors to work in rural and medically underserved communities
By Amanda M. Evans
Despite an increasing need for counselors throughout the United States, rural and medically underserved communities may be especially desperate for qualified and effective helping professionals. According to a 2020 report by the Health Resources & Services Administration (HRSA), “historically, rural and medically underserved communities have less access to care, lower or disrupted service use, and poorer behavioral health outcomes,” and these communities “experience obstacles to obtaining behavioral health services, including availability, accessibility, affordability, and acceptability, which result in distinct mental health disparities.” (Find data on medically underserved areas and populations here.) In some instances, individuals in these communities may need to visit the emergency room to disclose their behavioral health issues or forgo treatment altogether due to an absence of helping professionals and high medical costs.
Virginia consists of many rural and economically high-need communities that lack the professional personnel to develop and implement behavioral health care services. The state of Virginia has 1,034,447 residents who reside in rural communities. The median family income for these residents is $39,562, which is $18,237 below the state average. According to data from Mental Health America, Virginia ranked 47th in resident access to behavioral health care and 40th in uninsured individuals who have a diagnosed behavioral health disorder.
The lack of mental health services and health disparities is negatively affecting youth. In Virginia, approximately 10.8 million children, adolescents and transitional-age youth are experiencing a behavioral health disorder, and suicide is the second-leading cause of death among adolescents and transitional-age youth in the state.
Because of Virginia’s inability to provide appropriate and accessible services to address the behavioral health needs of constituents, behavioral health disorders stemming from previous trauma experiences are also increasing. Federal and state systems are overextended. Within the past three years, Virginia has experienced increased reports of hate crimes, increased risk of postpartum behavioral health disorders, overwhelmed hospital systems trying to serve individuals in crisis and higher incarceration rates of female offenders. Without a plan for prevention or early intervention, Virginia will continue to experience a behavioral health epidemic.
The Department of Graduate Psychology at James Madison University (JMU) decided to take steps to address the behavioral health provider shortage many rural areas in Virginia face. With a $1.6 million grant from the HRSA Behavioral Health Workforce Education and Training program, JMU started the Rural Interdisciplinary Services and Education: Unlimited Potential (RISE-UP) program, which is a specialized and interdisciplinary training program that aims to increase the behavioral health workforce in rural and high-need communities. I serve as the principal investigator for this project, along with Michele Kielty, Tammy Gilligan and Kelly Atwood, who are co-principal investigators.
Through the RISE-UP program, JMU intends to train 100 practicing clinical mental health counseling, school counseling and school psychology students over a four-year period (from 2021 to 2025) to better serve rural and medically underserved communities, with an exclusive focus on primary and behavioral integrated health, interprofessional team-based trauma-informed care and rural health. Leveraging established long-term relationships, the grant team has partnered with local community mental health centers and school systems to offer a clinician training program that focuses on rural health outcomes and reducing health disparities for children, adolescents and transitional-age youth.
Some of the RISE-UP grant funds provide practicing RISE-UP students a $10,000 stipend to offset the costs of traveling to rural communities for their clinical internship experience. In addition, the grant has allowed us to develop and implement RISE-UP training modules, which share best practices for helping professionals who work in rural and medically underserved communities. This free online continuing education program is available to all practicing counselors in the state of Virginia.
The graduate students enrolled in the RISE-UP program are also reminded of the value of interdisciplinary collaboration: School-focused students (those enrolled in the school counseling and school psychology program) must volunteer in community centers for a portion of the program, and community-focused students (those enrolled in the clinical mental health counseling program) must volunteer in school-based settings for a portion of the program. The RISE-UP team agreed that behavioral health issues are best addressed when clinical professionals are collaborative and integrative.
As we finish the second year of the grant program, the evaluation team created and is currently testing an assessment to track rural health barriers and outcomes by soliciting feedback from participating communities. The data from this assessment can be used to address sustainability efforts in the RISE-UP community and support other professionals who share an interest in rural health and reducing health disparities.
We believe that this training program and the interdisciplinary focus is helping to prepare our students in important ways. This program also helps to mitigate some of the complex and multidimensional barriers experienced by rural populations, including access to qualified professionals, long waitlists and the potential for dual relationships, by offering a free mental health provider who can readily serve clients to reduce stigmas and address presenting behavioral health concerns. As of March, the RISE-UP Program has provided almost 27,000 hours of free direct and indirect clinical services to rural and medically high needs communities in Virginia.
—Amanda M. Evans is an associate professor in the Department of Graduate Psychology and the principal investigator of the RISE-UP program at James Madison University.
The shortage of black mental health professionals
By Chris Gamble
Black people make up a relatively small portion of the mental health workforce nationally. Even working in a city as diverse as Washington, D.C., I’ve had my fair share of experiences where parents who preferred their children work with a Black male therapist were relieved when they found me.
It’s difficult to find definitive numbers for how many Black mental health professionals there are. Media outlets often only report on the numbers in select disciplines (such as psychology or psychiatry), and other sources of workforce statistics lack quality data collection methods, making the true nature of the supposed shortage of Black mental health professionals unclear. This makes developing strategies for strengthening the pipeline of Black mental health professionals even more challenging.
Although we don’t know how many Black providers there are or what the desired number would be, it is worth exploring what is being asked of those who do join the mental health field. The call for more Black therapists generally centers on the need for more culturally responsive care for Black people seeking mental health services. What does this really look like though? While there is a higher likelihood a Black therapist will share cultural reference points and understandings with Black clients, thus easing the relationship-building that is key to therapy, it’s not guaranteed since we are not a monolith. There is also the potential for Black therapists to offer helpful analyses of structural and systemic impacts on mental health. Again, even though oppressive forces in society target Black people indiscriminately, we don’t all have a shared understanding of the social situation.
Acknowledging the diversity within Black communities helps us rethink some of the motives behind recruiting new therapists, but making mental health careers attractive and sustainable for Black people will involve a few more steps. First, we need to continue strengthening the networks of Black mental health professionals already in the workforce to prevent burnout and support the clinical and scholarly work being done. Racism in the workplace, shared oppression with Black clients and undervalued intellectual work all make maintaining a career in mental health challenging. Black people joining the field need to know that we are here and willing to support them through these obstacles.
There also must be support for Black therapists and clients from providers of other identities. We must further our efforts to ensure all mental health professionals practice culturally responsive care. Recruiting more Black people into the field does not relinquish the responsibility of others to provide care in ways that do not cause harm.
Next, efforts to overhaul pay structures for all therapists should acknowledge the unique position Black therapists may find themselves in. On average, Black college graduates already have a higher average student loan debt than white graduates, which can deter them from a field known for its low pay. For those already in the field, we need to interrogate how additional emotional and intellectual labor can be fairly compensated. For instance, providing care to Black clients who face the same oppression you do takes additional emotional labor that is not typically considered by insurance companies, grants, private equity or other funding sources. Likewise, Black mental health professionals in academia who are producing scholarly work aimed at creating culturally responsive approaches are not always compensated in ways that reflect the weight of essentially overhauling the way the profession is practiced. Centering the needs of Black mental health professionals offers a lens to the conversation around pay that can ultimately benefit everyone, as workers start to understand ways of valuing their work based on what it takes to produce the outcomes of their labor.
Finally, creating a strong pipeline of Black mental health professionals requires us to recognize that therapy, especially in its traditional formulations, is not the only answer to addressing mental health. Particularly for marginalized communities, the social determinants of mental health play a significant role. We already know about the intersections between mental health and things such as urban planning, climate change and food access, so we should be growing our interprofessional collaborations with people in these sectors. This focus on preventative, upstream interventions can let prospective Black mental health professionals know that they can get creative in applying their training and skills to address issues beyond the therapy room, thereby expanding their career options. With racial trauma spreading unabated against a waning fervor around anti-racism and opportunities to build self-esteem by learning accurate Black history continuing to shrink, there is no better time to develop a robust Black mental health workforce.
—Chris Gamble is a licensed professional counselor, national certified counselor and certified clinical mental health counselor based in Washington, D.C. He is also a burgeoning independent author, writing about mental health topics through his publishing company, Blank Passage. His debut novel, Tales of a Black Therapist, releases this summer. Follow him on Instagram@chris_thecounseloror contact him through his website.
Challenges with funding, financial incentives and stigma
By Haley D. Papajohn
Several factors contribute to the shortage of qualified mental health providers in the United States. One of the major causes is inadequate funding for mental health services, particularly for those who are uninsured or underinsured. Decades of health policy have failed to appropriately prioritize spending on mental health, so funding for mental health services is lower than funding for physical health services. In turn, this disparity in funding has resulted in a shortage of quality mental health providers.
This lack of overall funding feeds into another issue: a severe lack of financial incentives to become a mental health provider. Mental health professionals are often paid less than other health care providers because their services are often deemed a lower priority service by insurance carriers and benefits managers. This lack of financial incentive makes it difficult to attract and retain qualified mental health providers.
Stigma about mental health also affects the provider shortage. Many people are still reluctant to seek help for their mental health issues because of the stigma attached to it, a dynamic that can be even more pronounced for people from certain cultural and ethnic backgrounds. This reluctance to seek help affects the mental health provider shortage in two ways: First, it leads to an underestimation of demand in any given community as individuals are not forthcoming with their mental health needs. Second, it can result in people only seeking help when they are at or beyond their breaking point, which increases the overall complexity and time needed to address their mental health concerns.
Mental health providers are already under a significant amount of stress because of the nature of their work, and the shortage of mental health providers only exacerbates this stress. Mental health providers are forced to work long hours and see a high volume of patients, which can lead to burnout.
The shortage also limits the range of services that mental health providers can offer and how many patients they can see. These limitations result in people not being able to receive the care they need or having to wait weeks or even months to see a mental health provider.
There are several solutions that can be implemented to address the shortage of mental health providers. The first and most obvious solution is to increase funding for mental health services. This increased funding could be used to attract and retain mental health providers, allow providers to service a broader geographic area, and reinforce their skill sets with ongoing training and education. The funding could also be used to increase awareness and promote the value of careers in the mental health space, which would attract more and higher qualified candidates.
Another related solution is to provide financial incentives for new and existing mental health practitioners. This could be done both by increasing the pay for mental health providers and by removing the barriers to payment, such as issues with insurance reimbursement. Increased pay would attract more people to the mental health field, help retain existing providers and allow counselors to offer new services to their patient populations.
To increase mental health access, we also need to reduce the stigma associated with mental illness. This could be done by increasing public awareness of mental health issues, normalizing the need to seek help, and providing mental health education at schools, workplaces and community organizations. Reducing stigma would allow us to adequately judge the demand for mental health services in any given market and allow people to get help sooner, thereby lowering the average complexity of mental health issues.
The shortage of mental health providers is a serious problem that needs immediate attention. The causes of the shortage are complex and include inadequate funding, lack of incentives and the stigma associated with mental illness. The shortage also poses challenges to existing mental health providers, including increased stress and limited options for patients. We need to implement solutions that tackle these challenges such as increasing mental health funding, providing financial incentives and reducing mental health stigma. By addressing the mental health provider shortage, we can ensure that all Americans can receive the care they need.
—Haley D. Papajohn is a licensed mental health counselor in Florida. Contact her through her website.
How the shortage is affecting school counselors and youth
By Jessica Holt
Like other places in the United States, the state of Georgia has been affected by the provider shortage. A 2022 article published on WABE [the NPR and PBS affiliate for the metro Atlanta area] noted that 150 out of 159 counties in the state are considered mental health care professional shortage areas. And according to Mental Health America of Georgia, Georgia is ranked 48 out of 50 states for access to mental health care, resources and insurance, and 2 in 5 children in the state have trouble accessing the mental health treatment they need.
As a school counselor, I work with students to help them with social, academic and emotional problems. My goal is to help them be successful in the school setting and to function at their highest level. This is no easy task, especially when you consider other factors such as relationship issues, mental health issues, challenges arising from the COVID-19 pandemic and the nationwide mental health provider shortage.
Since the start of the pandemic, I have noticed an increase in the prevalence and intensity of students’ anxiety, depression, frustration and anger, especially when they become overwhelmed. Adjusting to changes brought on by the pandemic can be quite difficult when you consider that many adolescents do not have adequate coping or problem-solving skills.
When students feel this way, I help them a) identify triggers, b) identify solutions and c) learn relaxation skills (such as deep breathing, grounding and mindfulness). For many students, this works, and they learn how to handle problems and manage their anxiety. However, there are some students whose issues are so pervasive and severe that they need additional mental health services. While I cannot tell a parent/guardian they must take their child to counseling, I answer questions, provide support and give them a list of community providers/resources.
Last year, we had a school-based licensed professional counselor who was able to provide services to students who needed more care, but this year, that has not been an option because of turnover. The counselor doing this job left, and the position remains unfilled. Instead, I can only offer referrals to a local mental health agency that provides services at our school and in the community. This change from providing these services at the school to asking people to go to the local agency creates barriers for some families who lack transportation and are unable to get to the clinic.
Fortunately, the mental health agency was able to provide my school with a community support person this year. This person can work with students during school hours, but they aren’t credentialed to provide counseling services. Instead, they help students with skill building, problem-solving and other techniques. Not having a school-based mental health counselor has affected the students and the school counselors. My colleagues and I are feeling strained because we have to provide extra support to the students who have severe anxiety, depression and other mental health concerns. This can be challenging as we try to balance all of our responsibilities and our large caseloads.
The provider shortage can be attributed to several factors including high turnover (which has affected our school), inadequate compensation compared to other health professionals, problems with insurance covering services and elevated levels of burnout. Not only can this lead to mental health providers quitting or moving to other states, but it can also impact the quality of services they can offer when they are overworked and underappreciated. I am cautiously optimistic that increased mental health funding, student loan forgiveness and virtual mental health services can offer solutions that can address the mental health crisis and provider shortage we are currently facing.
—Jessica Holt is a licensed professional counselor and a school counselor. She primarily works with middle and high school students to help them meet their academic, social and emotional needs.
Limited access to care and low pay
By John Patrick O’Neal
Two key issues with the provider shortage are limited access to care, which puts strain on providers, and inadequate pay and reimbursement. Limited access to care creates professional dangers such as burnout and compassion fatigue. Insufficient reimbursement generates poor counselor retention and overall discontent within the profession.
Access in rural areas
The people who have been most affected by the lack of mental health services are typically those in rural areas. In Idaho (where I live) and most of the American West, the category “frontier area” is used for remote, sparsely populated places where residents live far from health care, schools, grocery stores and other necessities.
I consult for a residential facility in Challis, Idaho, that is a frontier area. Although the county is physically larger than Rhode Island, it has less than 5,000 people. To put it into perspective, the closest Walmart is 150 miles away. The people in these communities are wonderful, independent and pleasant, but any type of health care (whether medical, dental or mental health) is limited since most people, including health care professionals, prefer to live in larger urban areas.
The question many counselors, especially those in rural areas, often wrestle with is, “How many clients can I have on my caseload and still provide quality care?” Some of the clients who are desperate to receive mental health care can also be some of the most challenging cases. When counselors are already struggling with their own self-care practices it can become a daunting task to take on more clients who have high needs.
Counselors who live in frontier areas also need to consider additional expenditures related to personal and professional travel since there are fewer resources in these communities. Some additional costs associated with professional travel include meeting with clients in their homes, participating in in-person trainings or maintaining professional relationships such as supervision or mentorships. Thus, financially it might not be feasible for counselors to live and work in these areas.
COVID-19 and population migration
The COVID-19 pandemic resulted in an increase in people working remotely and in nonspecialized work such as food delivery jobs, and this change led many people to relocate away from urban areas into more rural places. This has been the case in Idaho, where we have seen an influx of people since the pandemic began.
Part of the reason for this move is financial: The cost of living in Idaho is lower than in California or other major urban areas such as Seattle, Denver or Portland, Oregon. There is also an increased need for mental health services now because of the dynamics of working remotely and the stress that comes with this style of work. I’ve treated a few clients who are thrilled to be at home all day, but they experience agoraphobia when they need to leave their house to buy groceries or go to an appointment. The post-pandemic work habits of working remotely have also led to an increase in substance use because of the ease of accessing substances throughout the day. As a result, the demand for mental health and substance use services has risen, leading to gaps in care.
A financial problem
The underlying issues regarding the mental health shortage, of course, are complex and multidimensional. But maintaining a sustainable mental health workforce in this country will continue to hinge on the balance between the mental health of clinicians and their ability to produce income.
The bill-by-the-hour reimbursement format most agencies use is severely flawed. I’ve worked for these agencies in the past and it can be extraordinarily stressful. If a client cancels or a counselor gets sick, it affects not only the work with the client but also the counselor’s income, which can lead to more stress. The anxiety of a reduced income stream often translates into taking on more clients and risking the chance of counselor burnout.
I have also had the opportunity to work for an agency that was salary based. This is a much more equitable practice for mental health clinicians because it removes one more stressor from their lives. I also maintain a small private practice that is cash based and does not accept insurance for reimbursement, which has allowed me to have a bit more stability in income.
One possible solution to the provider shortage is for counselors to increase their business acumen and marketability. There are many benefits of having a counseling business, whatever scale that might look like, including having more control over one’s income stream and the clients that one sees. And while the counseling profession is waiting to see how the Counseling Compact changes accessibility across states, counselors can take initiative by gaining licensures in different jurisdictions. Some of my clients who have moved out of Idaho want to continue services with me, and when appropriate I have been able to continue seeing them by receiving a license in the state they moved to.
Counselors can also advocate to state and federal governments for increased reimbursement for mental health services. Having reimbursement rates match the level of skill, expertise and training counselors provide for their clients could increase counselor retention rates and lead to a healthier work-life balance.
The counseling profession is valuable in a time where there is so much distraction, trauma, addiction and heartache. Counselors have the skill set to manage these painful components of the human experience, but with the current counselor shortage people are at risk of increased suffering without treatment. The agency where I work says it well: “There is no health without mental health.”
—John Patrick O’Neal is a licensed clinical professional counselor in Idaho and Arizona. He owns a small private practice and works for an outpatient agency in Idaho Falls, Idaho. He also consults for a residential substance abuse facility in Challis, Idaho. He is a doctoral candidate in counselor education and supervision, has a loving wife with four children, and tries to find balance between work and life.
Cultivating partnerships to address provider shortages
By Loni Crumb
The nationwide shortage of mental health providers is being felt in North Carolina. Out of the 100 state counties, 94 have been designated by the Health Resources & Services Administration as mental health professional shortage areas.
This shortage is more pronounced in rural areas where there are often not many mental health providers. The maldistribution, along with the nationwide shortage, has resulted in many unidentified and untreated disorders among children and adolescents, such as ADHD [attention-deficit/hyperactivity disorder], depression and anxiety.
In addition, transportation and financial barriers prevent children, teenagers and their parents from seeking help from the small number of specialty-trained professionals in these rural areas.
Partnerships between counselors, universities, schools, the community and other professionals provide one possible solution to address the mental health needs and provider shortages in rural areas. Here are a few examples of ways counselors can create partnerships within their communities:
Clinical mental health providers can partner with local schools to provide school-based mental health services. This embeds mental health services in schools and helps youth access providers.
Universities and colleges can find creative ways to expand services to rural community residents. For example, East Carolina University’s counselor education program provides a variety of free and low-cost counseling services, resources and programs to students and residents in the surrounding rural community, which helps make professional services more accessible.
Counselor educators can create interdisciplinary partnerships with faculty in other fields such as medicine, nursing or education to co-develop programs that aim to address mental health provider shortages.
East Carolina University, for example, recently received a three-year grant that expands the statewide telepsychiatry program to more rural and remote areas to help youth receive specialized assessments and treatment using video conferencing technology. Counselors-in-training are embedded in primary care and pediatric practice sites to provide mental health services, which helps to remove help-seeking stigma, enhances compliance with appointments and allows expert consultation to rural youth and families.
The University of Oklahoma’s Project Rural Innovation for Mental Health Enhancement program is another example of a collaboration between a university and the community. Through a federal grant, this program covers the costs of training 64 school-based behavior analysts, counselors and social workers, and in exchange, these mental health professionals agree to serve two years in rural, high-need schools.
Another solution to provider shortages in rural areas involves clinical training. Counselor education programs can offer specific courses that provide counseling students with the skills and training needed for practicing in rural areas. East Carolina University’s counselor education program, for example, has a course that introduces master’s students to the practice of mental health counseling in rural communities using an integrated behavioral health approach. Course content covers the characteristics and concerns of diverse rural populations and the impact of using integrated, culturally relevant mental and behavioral health services with rural populations. This course focuses on teaching advocacy skills, including strategies to address institutional and social barriers that impede access to timely and adequate mental health care for rural clients.
Counselor education programs can also host professional development workshops. The counselor education faculty at East Carolina University has developed a workshop series to help address rural mental health provider shortages. One of the workshops — “How to start a private practice” — provides counselors-in-training with information and resources necessary to build their private practices in underserved, rural areas that experience ongoing mental health provider shortages. For this workshop, we partnered with the faculty in the College of Business Crisp Small Business Resource Center to co-lead discussions related to entrepreneurial skills, opportunity recognition, business modeling, and ways to launch and manage counseling businesses.
Economic development is key to building the mental health workforce in rural areas. Improving housing, transportation, career and educational opportunities in rural areas may help attract counselors to these areas who may start practices and launch programs to serve these communities. Moreover, rural schools are an economic driving force because these schools are often the largest local employer, and the presence of a school within rural communities is associated with increased housing values, employment rates and entrepreneurship as well as decreased income inequality, as noted by Kai Schafft in a 2016 article published in the Peabody Journal of Education. Thus, it is vital to cultivate partnerships with local schools, institutions of higher education, businesses and community organizations to improve access to mental health care, education and other essential resources for youth and their families living in rural communities across the United States.
—Loni Crumb is an associate professor in the counselor education program at East Carolina University, a licensed clinical mental health counselor supervisor and the owner of Carolina Cares Counseling & Consulting PLLC in Greenville, North Carolina.
The systemic causes of the provider shortage
By Emily St. Amant and Derek J. Lee
Anyone who is tracking health care news in the United States will be familiar with the phrases “mental health crisis” and “provider shortage,” or the lack of qualified and available mental health clinicians to meet the growing need for mental health services. Even with telehealth options and people having access to care via remote services, there still aren’t enough providers to go around.
Discussions about the mental health provider shortage, however, often miss the mark and fail to include systemic causes and drivers of the problem. One main reason for the shortage is the fact that becoming a clinician requires a high level of personal privilege, namely financial resources and access to education. In addition, remaining in the field often comes with the financial and psychological impact of low pay and occupational hazards that can cause damage to one’s physical and mental health, which when combined are a perfect recipe for burnout. Consequently, many qualified providers are choosing to shift away from working in a direct-care role. We aren’t getting enough people in the door, and once they are in, we are not doing a good job of ensuring they have a thriving wage, a healthy workplace environment and other factors required to keep them there.
A 2022 U.S. Government Accountability Office report titled Behavioral Health: Available Workforce Information and Federal Actions to Help Recruit and Retain Providers highlighted three main factors keeping people from entering and staying in a behavioral health career:
Financial factors: Low third-party reimbursement rates and low salaries
Educational factors: Limited outreach to marginalized communities to encourage them to pursue a career in mental health
Workplace factors: Limited placement opportunities for paid internships in rural areas and a lack of licensed and qualified supervisors to oversee new interns and newly graduated professionals
This report also mentioned scholarships and loan forgiveness, outreach and mentorship, and telehealth as possible solutions to the provider shortage problem. These recommendations, however, do not address reimbursement, salary and costs associated with obtaining licensure, which affect everyone, especially people from marginalized communities. There has been no movement in improving insurance reimbursement and low entry-level wages, and there has been minimal action to address financial barriers in our field such as unpaid internships and the logistical and financial hoops of licensure, including the cost of supervision. To increase the number of available providers, the counseling profession must address the factors perpetuating a high financial cost of entry to access a career as a mental health provider — a career that often comes with a low return on investment.
Access to affordable care is vital to ensure that everyone receives the services they need. However, hyperfocus on this alone is problematic for two reasons:
Many people talk about health care as a human right, but solutions for affordable access often come at the cost of the individual provider.
This narrow focus on care access ignores the need to address the root causes driving the mental health crisis.
To be able to work in the mental health field, people without preexisting personal financial privilege must make a living wage just to survive and pay for housing, food, child care, health care and other necessities. And for counselors to stay in this career long term, they need a thriving wage, work-life balance, a healthy workplace environment, a diversity of tasks and ways to contribute, and autonomy over their work, to name a few. Of course, everyone’s needs and preferences will vary.
Working extremely hard for a very low wage has somehow become the cultural norm in the mental health field. This does nothing to solve the source of the problem, which is how severely underfunded social programs and health care are in the United States. We counselors have become complicit in our own oppression by not advocating for ourselves and our colleagues and allowing our labor to be exploited. We also risk becoming complicit in the oppression of the public if we fail to advocate for funding to ensure everyone who needs support can access quality and timely counseling services. Providers and consumers are being affected, and caring about both is not optional if we want to move forward and change course.
Additionally, the mental health crisis can’t be solved by focusing just on access to care. Counseling is a downstream intervention, but the societal problems causing the crisis are numerous and systemic in nature, and they start upstream. Not addressing macro-level factors enables the people and systems creating the problems in the first place. By not advocating for policies to address problems such as financial disparities, health inequities, gun violence, climate change, racism and bigotry, and adverse childhood experiences, counselors risk becoming complicit in perpetuating oppression.
When discussing the mental health crisis and the provider shortage, highlighting only individual-level solutions is something that enables the harmful status quo. It lays the oppressive burden of the work and responsibility of coping, healing and solving problems on people who didn’t create the problem and yet are the ones experiencing the impact. We must value the dignity, life, well-being and security of those who receive mental health services, those who provide said services and those who — with preventative measures — could potentially be spared avoidable suffering in the first place.
—Emily St. Amant is a licensed professional counselor and board approved clinical supervisor (Tennessee). She serves as the counseling resources and continuing education specialist in the Center for Counseling Policy, Practice and Research at the American Counseling Association.
—Derek J. Lee is the founder and CEO of Perrysburg Counseling Services and The Hope Institute. In addition to clinical work and administrative roles, Derek is finishing his doctorate in counselor education at Ohio State University and teaches in the Department of Clinical Counseling and Mental Health at Texas Tech University Health Science Campus.
Lindsey Phillips is the editor-in-chief for Counseling Today. Contact her at lphillips@counseling.org.
The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.
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