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In 2016, the warnings about the future of the Texas mental health care workforce were clear.
“More than 80 percent of Texas counties are designated as Mental Health Professional Shortage Areas, which are defined as more than 30,000 residents per clinician,” the Texas Statewide Behavioral Health Strategic Plan stated seven years ago. “Many of the most experienced and skilled practitioners are approaching retirement. … Texas higher education institutions have been unable to produce enough graduates to meet the predicted demand.”
But no forecaster predicted a global pandemic that sparked months of lockdowns and restrictions on public life that left both Texas and a nation seeking to counter the resulting anxiety and depression. In a nation where agreement can seem rare, both Republicans and Democrats have come to the same conclusion: Mental health services are in direct need of a makeover and expansion.
“With the ongoing mental health challenges brought on by COVID-19, there could not be a more critical time to strengthen our nation’s mental health resources,” U.S. Sen. John Cornyn, R-Texas, said in November 2020.
“Mental health affects all of us,” President Joe Biden said last fall after announcing millions of dollars in new funding for state mental health services.
The calls resurged in Texas after a teen school shooter murdered 19 children and two adults in Uvalde last summer.
“We must provide mental health services to students who need it,” Gov. Greg Abbott said in his inaugural address last month.
Texas House Speaker Dade Phelan is calling for a more than $100 million school safety and mental health package, with nearly half of that package earmarked for children’s mental health services. Millions of dollars more are expected to be poured into a variety of services for all Texans.
Texas ranks dead last when it comes to access to children’s mental health services and 33rd for adult care, according to Mental Health America, a nonprofit advocacy group. The state has a lot of work to do first to increase the number of professionals it will take to deliver these planned new services.
Today, 98% of Texas’ 254 counties were wholly or partially designated by the federal government as “mental health professional shortage areas.”
How this happened
“We never kept up with the demand really,” said Dr. Sarah Martin, medical director for the Texas Child Mental Health Care Consortium and child and adolescent psychiatrist at Texas Tech Physicians of El Paso. “The pandemic just dropped the stigma around mental health to the floor, and it happened so rapidly that lines or waiting lists for therapists are really long.”
That’s not surprising to any Texan who has tried to get an appointment with a mental health care provider in the past three years, where waitlists can go beyond six or seven months. Some therapists have had to stop taking new appointments altogether as demands for services have begun to overwhelm the system.
“The pandemic exacerbated existing shortages in behavioral health clinicians at every level of the mental health continuum, including our state hospitals, private psychiatric hospitals and our local mental health authorities,” Michelle Alletto, chief program and services officer for Texas Health and Human Services, told the House Appropriations Committee earlier this week.
The workforce issues reach the highest levels of the mental health system. Texas currently can’t use over 700 of its 2,911 funded state psychiatric hospital beds due to workforce shortages, said officials with Texas Health and Human Services. As of Dec. 31, state hospitals had 5,987 full-time employees, a drop from the 7,409 full-time employees in 2019.
A shortage of therapists, psychiatrists and psychologists also impacts other government agencies. Several county jails, including those in Dallas and Houston, have reported long waits for people with mental illnesses who are arrested and need treatment before trial. Earlier this year, more than 2,000 people in Texas jails and prisons were waiting for a bed in the state hospital system.
And the workforce shortage is expected to worsen as many therapists, psychologists and psychiatrists head toward retirement. Texas agency officials say there’s not enough new graduates and younger professionals coming out of colleges and universities to replace them.
The Texas Behavioral Health Executive Council oversees mental health licensing for marriage and family therapists, professional counselors, psychologists and social workers. The council saw a small increase last year in the total number of licensed professionals: 80,546 licenses, with 75,327 of those license holders considered “active.” Two years ago, there were 74,890 license holders, with 69,729 of those considered active.
Darrel Spinks, executive director of the council, said despite this growth, the industry is getting completely overwhelmed by the demand. He said Texas licensing requires applicants to participate in internships and complete a certain amount of time with a supervisor before being allowed to work on their own.
“We don’t have enough people coming through the door to meet those who are coming out,” Spinks said.
The state is also dealing with a dwindling supply of providers who are willing to train graduates seeking their licenses. This hesitation stems partially from fears of liability.
“So training programs can’t pump out enough individuals, and once we get one out, we don’t have enough internship sites or post-doc sites,” Spinks said. “This further limits the number of people who can get fully licensed to be a mental health provider.”
Multiple bills are on the docket this legislative session meant to address some of the concerns of an overburdened mental health workforce.
House Bill 1211 and House Bill 1551 are both measures that would offer loan repayment assistance if a mental health provider met certain requirements. House Bill 2361 would allow school districts to request a waiver and hire a licensed master social worker if the district is unable to fill an open position for a non-physician mental health professional due to a shortage of qualified applicants.
While these bills and many more will attempt to solve the workforce shortage, there’s also the issue of burnout experienced by those already in the mental health field.
“The job itself is demanding. Nobody comes into your office having a good day,” Spinks said.
Workforce stress and burnout
Victoria Alicia Torres, a first-generation college student from Houston, has always been fascinated by mental health, but during the pandemic, she contemplated leaving the field.
“It was physically and emotionally exhausting, and there were times when I felt very overwhelmed and overextended,” she said.
She said her growing in-person caseload as a graduate student during the pandemic became too much at times.
“It really made me stop and think about whether this was the work I would want to do if I were to get really ill from interacting with others,” she said.
While Torres was able to find the motivation to continue, that’s not always the case.
“Any health care provider should be seeking their own wellness and getting their own needs met. It’s like when you're on an airplane, you have to put your own oxygen mask on before helping someone else,” said Dr. Jeffrey Khan, a psychiatrist and medical director for the Baylor Psychiatry Clinic in Houston.
There’s also the added financial burden and the current contentious political climate that mental health providers say are contributing to burnout among professionals.
“I think that in Texas and some other states, it’s kind of scary. The landscape is kind of scary. What is OK and what is not OK to say during a session?” said Dorothy Garza, senior director of mental health services at Communities In Schools of Central Texas, the largest provider of school-based behavioral health services for students in Texas. “What is in my wheelhouse to address with my clients, and what legalities might be in play?"
Another key stressor for providers in Texas is payment.
Low-income individuals who qualify for Medicaid, the nation’s taxpayer-supported health care provider, have some of the lowest paid-per-session reimbursement rates. The same is true of private insurance. That’s led many mental health providers to switch to a cash-only model.
“You aren’t going to go into the profession if you can’t make money off of it. Everyone in the industry has a servant's heart, but you don’t want to be destitute,” Spikes said.
Christy Mitchell, a project manager for Communities In Schools at Jane Langford Elementary School in southeast Austin, said she can’t blame people who make the decision to leave the profession.
“So much of the field is built on goodwill and maybe self-sacrifice, and that can be difficult to do continuously,” Mitchell said.
Not only are more providers needed, but there’s also a growing demographic imbalance when it comes to the geographic distribution of mental health workers in Texas, a state where about 40% of residents are Hispanic, 39% are white, 12% are Black and 5% are Asian. Yet a state survey done this year revealed that most of the 2,873 respondents — some 85% — identified as white.
The survey also stated only 20% of the respondents offered mental health services in a language other than English. And more than half of mental health care providers are located in urban areas, such as Harris, Dallas, Tarrant, Bexar and Travis counties.
In the end, a bigger recruiting push and a better overall state strategy is needed, industry professionals say.
“We need to recruit and actively seek out those from underserved communities that might want to return home,” said Khan.
Mitchell agreed.
“We need them in the field. We need more people of color. We need more service providers with the experiences that our clients have had to deal with as well,” she said.