It’s an industry that is increasingly called upon to take care of communities across the country, but it isn’t taking care of its workers.
“You’re talking to other people about deaths, divorces, pretty traumatic things, so there is secondary trauma,” says Maria Faison, a counseling psychologist at El Concilio, a nonprofit that supports the Kalamazoo area’s Latino community. “So people try to go into the field and change their mind. You have to care so much for people, but also know your limits.”
While demand for treatment has increased over the past few years – in part but not solely due to the pandemic – there has not been an associated increase in clinicians throughout the field. There are fears expressed by experts, including members of the Southwest Michigan Journalism Collaborative’s Mental Wellness Project Advisory Council, that it’s only set to worsen due to the lack of entrants into the field’s higher education system.
“Documented workforce challenges contribute to barriers in access to care and nearly half of the US population – 47% or 158 million people – living in a mental health workforce shortage area,” KFF, formerly known as the Kaiser Family Foundation, an independent and nonpartisan health policy research institute, wrote in a report this past January. “Workforce challenges are widespread and go beyond Medicaid, but shortages may be exacerbated in Medicaid” due to the higher rates of mental health needs or substance abuse of enrollees and the lower rates of new patient acceptance than in other practices of the industry.
In 2018, the Citizens Research Council of Michigan warned that the state was too dependent on federal funding, and needed to increase state funding to avoid the impact of budget cuts that were out of its control. In a January 2022 report, the CRC’s tally found Michigan could face a shortage in the thousands of behavioral healthcare workers by 2030. It noted that Kalamazoo and Calhoun counties was one of 15 counties below the statewide average of provider per population ratio, though all of the surrounding counties were at least double the statewide average.
Chris Barnes, a licensed clinical psychologist and founder of Kalamazoo ADHD Consultants, said the backlog of patients is due more or less to workforce availability.
“I would love to add new clinicians, the pool of them is so small, especially for those who can/desire to administer assessments,” Barnes wrote in an email response to questions. “This is the primary focus of my business right now, to increase the clinicians available to provide assessments and other services.”
The messaging in graduate school “that psychologists cannot make money doing this work” can also become an ironic self-fulfilling prophecy.
“I do not believe that in its full sense, but our pay is unequal to other providers in many ways,” Barnes wrote. “Those who go into mental health tend to do so because of high compassion and money is secondary to begin with. So, solving the shortage problems with money may not be the most effective.”
The University of Michigan School of Public Health Behavioral Health Workforce Research Center, in the July 2022 report Factors Influencing Behavioral Health Providers Entry to and Exit from the Workforce, said burnout can be attributed to a number of factors. One of those factors is the emotional demands of helping others’ mental healthcare. Another is lack of resources for taking care of administrative and legal tasks.
“Psychiatrists reported experiencing substantial burnout before the COVID-19 pandemic, and research suggests that the prevalence of burnout among health workers increased since March 2020,” the report said.
Barnes said the current mental healthcare system proved its ability to handle emergencies. But the less urgent needs of individuals who have gone without care can then become more urgent.
“The problem I fear is that because of some limited access, patients in low-mid level distress may not have been able to obtain services in sufficient time to delay or prevent the more significant symptoms that could lead to the need for acute interventions,” Barnes wrote. “So perhaps we saw an increase in those services as a result of poor access down the earlier pipeline.”
The swift and severe change in life brought upon by the pandemic made the workforce shortage more severe, Faison said. She attributes the increase in caseloads to many factors. Not only was there the stress of home and economic uncertainty of the lockdown and its aftermath, but young people had to pivot to virtual learning, and adults were in fear of losing basic supplies, let alone income.
“There were already problems in the home and people tend to not focus on the issue, using work and distractions, but everybody being in the home and having to face the issues and not ignore them, sometimes the problems got worse,” Faison said. “The stress level increased and more people were reaching out for services.”
For a practice within the healthcare field where hesitation to access services looms large, the pandemic couldn’t have happened at a worse time. El Concilio recognized a need for therapists within a community where Spanish is the primary if not sole language, and hired Faison as its first full-time therapist position.
“They are starting to hear that there is somebody that speaks their language and understands their culture,” Faison said.
The result, Faison said, is peers encouraging each other to reach out for support. Schools also began to request her to be there for full days. But with few other options for first-language Spanish-speaking therapists, the demand quickly created a wait list.
“When they finally reach out for services, their symptoms are at the point where they really need the counseling, or their child is out of control and they don’t know what else to do,” Faison said. Due to her wait list, “they will either find another therapist somewhere else – or use translation, which is not the same and they don’t like it – or they just decide they will figure it out themselves.”
In reporting the Mental Wellness Project stories, journalists found that multiple local experts said that the industry has thus far largely been centered around white, heterosexual people, which inhibits the basic kinship necessary to foster trust and vulnerability necessary for successful mental health support.
Faison said she was the only Latina in her class, and her cultural connection doesn’t necessarily fully translate across the borders of all of the nearly two-dozen Spanish-speaking countries in the world from which area residents in need of mental health supports may come.
Faison said the transition to virtual therapy sessions increased access and availability, but was not a fix-all. “You get a better experience with clients when you are face-to-face, especially when there are more symptoms like depression, PTSD, anxiety. You don’t get the same quality of service.”
This also reduced the availability of assessments, which are necessary for referrals and appropriate alignment between client and service provider, Barnes concurred. A transition to telehealth meant some services had to be dropped or reduced, and a further reduction in the number of mental health services providers to choose from.
Barnes said the efficiency came with another cost – less travel time meant more availability which, coupled with an increase in client demand, meant the same number of providers had a bigger caseload.
“This may link to the burnout,” Barnes said, “in that it can be difficult to say no to new clients … and subsequently lead to increased demand for clinicians.”
Those who were proactive in managing the potential burnout did so by reducing their load, Barnes said, which reduces the supply of provider availability.
Clinicians who work for government agencies or those contracted with them often raise concerns about both the lesser pay rate and the inability to have appropriate time dedicated to their clients.
“When I worked for a government health provider, there were a lot of requirements for them, like [human resources] assessments and goals,” Faison said. That’s a lot of stress for the worker, who essentially have to succumb to an unhealthy work/life balance – or pivot to private practice, which is what she and many others have done.
Regardless, the clinician needs a support network, which includes having a large enough workforce to be able to decline a larger client load or to protect vacation and other off time, without the guilt of someone in need having to go without adequate mental health care. This is vital before a worker decides to leave the practice – or a student decides to continue in their higher education program. And it all comes back to a system that should be minimizing the harm to their patients and the clinicians.
“If you have a burnt-out therapist,” Faison said, “they’re probably not performing to their best ability.”
There are a number of efforts underway nationally, in Michigan, and among local organizations to address the mental health workforce shortage. As part of the Southwest Michigan Journalism Collaborative’s latest solutions story series, Mental Health Workforce Crisis: Effective approaches to improving the pipeline, a number of regional news outlets have conducted in-depth reporting on some promising programs to combat the situation.
Here’s a quick rundown of some of those efforts, with links (as available) to stories that do a deeper dive into the topic:
– El Concilio is among the Kalamazoo-area agencies working to ensure that marginalized communities, such as people of color and the LGBTQ-plus population, receive mental-health care that speaks to their specific needs, an issue called cultural competency.
– Telehealth isn’t a silver bullet in easing the workforce shortage, but it does provide more opportunities for people to find appropriate care, especially if they live in an underserved area.
– Several Michigan universities are working to expand the ranks of psychiatric nurse practitioners, who can supplement psychiatrists and primary care physicians in serving people with mental-health needs.
– Efforts are underway to increase the number of peer-support specialists in mental-health treatment programs. And research shows those peer-support specialists can be effective as trained therapists, in some circumstances.
– Michigan has launched a new program to help pay student loans for mental-health clinicians working in underserved communities.
– Western Michigan University’s School of Medicine is having its psychiatrists serve as consultants to primary-care physicians as a way to expand access to psychiatric services.
This article is part of Mental Health Workforce Crisis: Effective approaches to improving the pipeline, a solutions-focused reporting series of the Southwest Michigan Journalism Collaborative. The collaborative, a group of 12 regional organizations dedicated to strengthening local journalism and reporting on successful responses to social problems, launched its Mental Wellness Project in 2022 to cover mental health issues in southwest Michigan.
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