The need for therapists, social workers, psychologists and psychiatrists is greater than ever. Under relentless pressure from the pandemic and inflation, wildfires and gun violence, racism and war, Californians are crying out for help.
But that doesn’t mean they can get it.
In every corner of mental health right now, a similar story is being told. There simply aren’t enough providers.
Patients receive lists of names from their insurers, only to learn none of the therapists on these so-called “ghost lists” will see them. Clinicians who do offer a spot often only accept cash.
Nonprofit mental health providers report needing to have an offer letter ready at a job interview, fearing applicants will take another position if they wait.
Kaiser mental health clinicians have been out on strike for weeks now in Northern California, describing exhausting working conditions and long delays in care for their patients. Kaiser, for its part, points a finger at a familiar culprit: the mental health provider shortage.
CalMatters spoke with more than two dozen mental health experts, public officials and providers around California to ask about the impacts of the mental health provider shortage, and what can be done about it. Their responses ranged from desperate to hopeful.
All agree we are at a pivotal movement.
In part, that’s because Gov. Gavin Newsom’s administration is investing heavily in overhauling the state’s mental health system. At the same time, the state has recently enacted laws requiring insurers to provide timely access to mental health care. Some worry a lack of providers could jeopardize these bold new initiatives. Others see this as an opportunity to reimagine how mental health care in the state is delivered.
A significant shortage
It depends on what part of the elephant you’re looking at, said Catherine Teare, associate director of the California Health Care Foundation’s People-Centered Care team. County mental health departments are struggling to hire. So are commercial health plans. So are nonprofits.
At the same time, she said, “the level of mental distress is increased.”
“For children or adults who need a lot, or need it urgently, it’s a scary time.”
Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, told CalMatters that the number of licensed behavioral health providers in the state increased by 20 percent between 2016 and 2020. But, that’s been offset by an increase in demand he calls “really unprecedented.”
For patients, how bad the shortage is depends, in part, on where you live, your insurance, your income, your age, the care you need and whether you want a clinician of color or one who speaks a language other than English.
A report published by UC San Francisco in 2018 — even before the pandemic sent need skyrocketing — predicted that by 2028, demand for psychologists and other therapists would be 40 percent more than supply. For kids, the shortage is especially dire. Close to a third of California’s 58 counties have no child and adolescent psychiatrists at all, according to the American Academy of Child & Adolescent Psychiatry.
A new report from the California Health Care Foundation shows that the Bay Area has 19 licensed psychiatrists and 73 licensed psychologists per 100,000 people — significantly more than the state averages of 12 and 44. At the other end of the spectrum, the San Joaquin Valley has six psychiatrists and 16 psychologists for the equivalent number of people.
What’s causing the shortage?
Mental health leaders will tell you the shortage itself is nothing new. But the pandemic has aggravated the problems. More providers have left their jobs, citing burnout. Or they’ve left the state, citing cost of living. New telehealth startups specializing in mental health treatment offer good pay and flexible hours; many experts said they have added to the demand by siphoning off providers from the public sector.
In a 2018 report on the behavioral health workforce shortage, Janet Coffman of UCSF also raised the concern that 45 percent of psychiatrists and 37 percent of psychologists would likely be retiring within a decade. The pandemic has accelerated this trend, she said.
Many clinicians say they’re simply exhausted. It’s not just that more people need help, but many of them are coming in sicker, with mental health issues that have gone untreated.
“Our patient population has become so much more difficult to work with than it used to be a decade ago,” said Randall Hagar, legislative advocate and policy consultant for the Psychiatric Physicians Alliance of California.
As openings go unfilled, those who remain are left to carry more of the weight, he said.
Another problem Hagar and others mention: paperwork. Doctors spend some 40 percent of their time on paperwork, he said.
Many clinicians, especially providers of color, also say they are simply not getting enough emotional support from their employers. Dominguez, the Kaiser therapist, said she founded La Clinica, a nationally recognized pilot program to serve Spanish-speaking clients, in 2016. When tragedies happen in the community, she said, they impact clinicians, too. But, “you’re just expected to plug along and keep going,” she said.
Continually witnessing trauma can be exhausting, said Jeff Capps, a social worker with Pacific Clinics in Los Angeles. He emphasizes the need to make the work more sustainable for clinicians. That includes better pay.
“Sometimes in our field, the assumption is that since you get value out of your work, you don’t need to be as compensated,” he said.
Michelle Cabrera, executive director of the County Behavioral Health Directors Association, said the state’s mental health system is so overwhelmed, everyone is poaching from each other.
“Let me be clear: It is a zero-sum game,” she said. “There’s only so many licensed or competent professionals in the state of California to do these jobs.”
In August, state Superintendent of Public Instruction Tony Thurmond announced that he had secured funding to hire 10,000 additional mental health clinicians to serve the state’s students. That effort is key to the Department of Education’s push to increase mental health care provided in schools.
Adrienne Shilton, senior policy advocate for the California Alliance of Child and Family Services, called the $200 million to establish a new scholarship program for master’s level clinicians “a big win.”
But for Cabrera, the announcement “just puts fear at the heart of county behavioral health.”
She wonders how counties can possibly compete.
“I don’t know that we’ve really had a reckoning yet on the degree to which demand so far exceeds the available supply of providers in our state,” she said.