The challenges facing the mental health workforce are nothing new, but the urgency to address these challenges is growing.
That was made evident during the Institute for Health Policy’s 2017 forum, Advancing Mental Health and Wellness, during which journalist and author Pete Earley kicked off the conversation by sharing his personal story of navigating the often intersecting mental health and criminal justice systems on behalf of his son.
In the fall of 2002, Earley was faced with an impossible choice. His son, Kevin, came home from college after experiencing psychotic episodes. Pete left the house for a short while, and while he was gone, Kevin broke into a neighbor’s house so that he could take a bubble bath. Five police officers responded to the scene, and told Pete that — even though his son was clearly experiencing a mental health crisis — he would not be able to get treatment or admitted to a hospital. Kevin would be sent to jail unless he posed a threat to himself or others.
So Pete made the impossible choice: He lied to officers, saying that his son threatened to kill him, in order to get him into care.
Over a decade after Pete’s experience, you could still hear the frustration, anger, despair, and conviction to effect change in his voice. I empathized completely. My father had schizoaffective disorder, and I served as one of his main caretakers.
Even as a health policy professional (and a person who tirelessly seeks justice), I couldn’t get my father the help he needed. In fact, I witnessed how the mental health and social service system sometimes worked against his interests.
Pete’s investigation into the mental health care system focused on the criminal justice system’s treatment of people with serious mental illnesses. These people’s experiences might seem like extreme cases, but they illuminate broader challenges we face with mental health care: We still have a “stage 4” system that reaches people only when they get to a point of crisis.
There are many reasons why this is the case, but a major factor is that the mental health care system is stretched too thin to meet all the need. The demand for mental health services is far exceeding the supply of workers, and the problem is getting worse: The number of new workers is not keeping pace with need; the current workforce is aging; and the expansion of mental health coverage — which we should celebrate as a nation — has unfortunately exacerbated the problem because demand has increased.
Our team put together a policy forum focused solely on addressing the challenges facing the mental health workforce. We acknowledged that building the pipeline is critical to addressing workforce issues, but we also elevated solutions that leverage the existing workforce and engage nontraditional supports, such as peer specialists, community health workers, and community organizations. After all, our experts said we need a paradigm shift in how we provide care, and that requires an all-hands-on-deck approach.
I followed up with 2 mental health leaders who spoke at the forum: Brad Karlin, vice president and chief of mental health and aging at the Education Development Center, Inc., and Ron Manderscheid, executive director of the National Association of County Behavioral Health & Developmental Disability Directors and the National Association for Rural Mental Health.
We explored what’s driving the mental health workforce crisis and discussed the most promising opportunities for reform, both at the delivery system and policy levels. We have a renewed opportunity to engage policymakers in this dialogue and to make change occur with the 116th Congress now in session.
Exploring the workforce crisis
Samantha DuPont: We frequently hear that the nation is experiencing a mental health workforce crisis. Can you describe what’s going on?
Ron Manderscheid: To take a systemic view of the dynamics going on in insurance: Between 2014 and 2018, the U.S. has reduced the proportion of people with mental health conditions who have no health insurance from about 30 percent to about 16 percent. We have increased demand dramatically, but we’ve made absolutely no change in our workforce. We have no new workforce programs. We aren’t training people at a faster rate, and baby boomers are leaving the workforce in large numbers. When you put that together, we’re heading toward a crisis.
Another problem I see is we have no place in the federal government or in the field that is taking leadership to accomplish workforce goals. When the National Institute of Mental Health [NIMH] was created in 1949, it was viewed as a 3-legged operation: research, practice, and training. When I came to NIMH, the training division had a staff of about 120 people and a budget of around $120 million. With the change in federal administrations in the ’80s, that program eroded down to about $3 million with one person attached to it. In 1994 the money went to zero. There were no longer any federal staff assigned to do these activities.
Brad Karlin: We have a state of substantial unmet need and unrealized quality in mental health care delivery. It goes beyond the need to recruit more mental health providers. Certainly, we need to do that, but it’s a broader problem that requires action and that, if addressed, can make a big difference in terms of who receives care and the quality of care they receive.
We also have very outdated traditional models of who provides services, how they provide services, where they provide services, and when they provide services. For example, there is a broader mental health care workforce that could be utilized more frequently, effectively, efficiently, and at earlier points in time. We’re in a system that is designed for the 1970s, but we need a system and a workforce designed for today. We’re far from that.
Maximizing the existing workforce to address quality and shortage issues
Samantha: One issue that is critical to talk about, and was central to our forum, is that getting people into the pipeline only gets us so far in addressing workforce shortages. How can we leverage our existing workforce?
Brad: We need to be more intentional in how we organize, structure, and prepare our workforce. We need to structure services so that providers’ skills are used most appropriately, effectively, and at the right time. In many systems, mental health providers — in particular psychotherapists or counselors — function more as generalists, and they’re providing services to individuals with a broad array of conditions. That’s not a very efficient way of providing care. It’s also not a great way of retaining providers, and it’s very difficult for a provider to be able to deliver evidence-based psychological treatments, learn them, and continue to adopt them across a large number of conditions.
We also need to do a better job of “treatment matching” and providing patients with right-sized interventions. Whatever the intervention is along the spectrum, it should be as timely as possible, match the level of presenting need, leverage innovations and adjuncts, and involve nontraditional members of the workforce, like peers, when appropriate. For example, stepped-care approaches, right-size treatments, and interventions based on what’s appropriate for the individual — not just providing everybody with psychotherapy or whatever the more intensive intervention might be. Stepped-care provides for more effective and patient-centered care, while using the workforce much more efficiently.
Ron: Measurement-based care also allows you to focus on what the concerns are and to keep that focus as the person goes through care, so you are not wasting personnel time going down rabbit holes. I think Kaiser Permanente is one of the entities that’s played a huge role in developing that capacity, particularly around the population of people who have depression and anxiety.
Instead of relying entirely on a provider for care, how can we rely on digital tools? For example, online cognitive behavioral therapy by evidence-based practice is as effective as in-person cognitive behavioral therapy. Why isn’t it used more online? We also need to have people play a much more essential role in their own care than in the past. In the past, we’ve said, okay, the provider is going to provide this care. The patient needs to be fully engaged as well.
Samantha: Brad, during the forum you said that there is a gap between “what we know works and what is actually delivered” when it comes to providing evidence-based treatment. Can you describe what this is and how it relates to workforce issues?
Brad: We have many evidence-based psychological treatments [EBT] that rarely reach individuals on the clinical front lines. The reason for this science-to-practice gap is multifactorial. Mental health providers often do not receive competency-based training in evidence-based psychotherapies [EBPs] as part of their clinical training. The good news is that mental health providers can be trained to robust levels of competency. The U.S. Department of Veterans Affairs, Kaiser Permanente, and other health care systems have implemented training programs that resulted in high levels of clinical competency and improvements in patient outcomes.
At the system-level, the clinical infrastructure and local systems may not support the delivery of EBPs. Competency-based training, while necessary, is not sufficient for increasing delivery of these therapies. You need to have an evidence-based treatment culture that supports the delivery of EBPs. In many health care systems, the culture is built around a supportive or palliative approach to mental health care.
At the patient-level, people are often not aware that EBPs exist and the opportunities that they afford. We need to do a better job of outreach and engagement and promoting interest, willingness, and readiness of individuals to participate in these treatments.
If we were more strategic in addressing needs at each of these levels, we would have a different mental health care delivery system with a more robust and sustainable workforce.
Using resources outside of traditional mental health care delivery model
Samantha: “Peer supporters” — people with lived experience and formal training to provide behavioral health services — are playing a critical role in supporting people with mental health conditions. Ron, you proposed a very bold goal to have peer supporters comprise 25 percent of the mental health workforce in 5 years. What will it take to accomplish that?
Ron: We now have national standards for credentialing peer supporters that are well researched, and we’re in the process of implementing them. Forty-three states fund peer support via Medicaid on the mental health side. On the substance-use side, only 13 state Medicaid programs are set up to permit peer support. So, we’ve got a much longer way to go there.
Outreach and engagement is a critical function of a peer supporter. For example, if I have a group of veterans who need care, a veteran who is a peer supporter can make all the difference, whether that person will come to care or not. They also have functions at some of the major institutional nodes that we deal with. They help people deal with the stress and trauma of the emergency room. We have peer supporters in local and county jails. We are beginning to develop peer supporters in integrated delivery systems, and as we modernize care delivery, we’ll need peer supporters to help build the bridges and do the transitions between what people have come to expect in the past and what we’re moving toward. Peer supporters are a very passionate, engaged workforce — they are highly motivated to be there and want to “do good” by the people that they’re working with.
I propose the goal of having peers comprise 25 percent of the workforce. We need to use every single peer supporter we can because they perform a broad range of functions that free up other providers.. I’m very optimistic that that’s going to happen. There’s a lot of support for the use of peers on Capitol Hill. We’ve engaged people on the Hill, and they always ask: How can we help with this? How can we break down barriers?
Samantha: There’s a lot of enthusiasm on how to leverage technology to improve the quality of care and augment traditional mental health care. There is also some skepticism about what technology can do. What are your thoughts on the use of technology?
Brad: This is a double-sided coin. There’s no question that technology can and should play an important role in the efficient delivery of a modern, integrated, stepped-care approach to mental health care delivery. And we have yet to see how much technology can add to mental health care delivery.
But I have 2 strong points of caution: There’s been a quick rush to develop and deploy technology, but we have to make sure that these technologies are supported by evidence, and we also have to be thoughtful about how we are to use them — not just thinking of them as a solution on their own, when sometimes they’re marketed as such.
My other point of caution is that we have an emerging technological transformation that the mental health care community hasn’t necessarily led or been a significant part of. For example, we have services that are designed to provide counseling or therapy to individuals for which there’s no real regulation. There isn’t necessarily science to support these technologies, and it’s largely done separately from the mental health care community. The mental health care community is watching from the sidelines, and I think that’s really unfortunate. There’s a real opportunity here — rather than these 2 worlds working in silos, there should be greater effort to integrate them into mental health services.
Ron: When I was on the Healthy People 2020 advisory committee, we advocated for the creation of a digital technology office in the U.S. Department of Health and Human Services. As far as I’m aware, there hasn’t been any action taken. In order to make progress, we need national coordination, some national standard setting — not just a Wild West-type environment, which is what we have currently in the use of various kinds of digital and mobile technologies.
Also, I don’t think the research side of mental health in the National Institutes of Health and the National Institute of Mental Health is anywhere where it needs to be in assessing effectiveness of these technologies, which are going to play a very huge role going forward.
Looking ahead: Promising policy opportunities for 2019
Samantha: What do you think policymakers most need to know about workforce issues? What is your outlook on policy opportunities for 2019?
Brad: It’s critical that policymakers recognize the importance of mental health as part of overall health. It’s also critical that they understand there are solutions, and what a system would look like with those solutions implemented. The total solution is multifaceted and multistaged, so it is important that we help them understand what it will it take to make a difference, starting with achievable, incremental changes. For example, breaking down barriers to siloed mental health care and promoting integrated care can lead to early wins. Aligning our efforts with other advocates of change, such as primary care providers, is also important.
Ron: People who represent us in Congress recognize that mental health has problems and that they need to address them. That puts us in a pretty good place to be able to work with the Hill, especially now, when we’re transitioning from the 115th to the 116th Congress. Everything resets and bills that were still alive at the end of the process die, and you start all over.
I agree with Brad that, as a field, we haven’t been as effective at suggesting viable solutions to people on the Hill as we could be. We can’t go to the Hill and say, “Some figures show that 25 percent of adult Americans have a mental illness diagnosis every year.” That is not a helpful approach to the problem. We have to go with more incremental approaches.
There’s also a huge amount of competition between the different disciplines in mental health, and that competition doesn’t serve us well. We need to do some work to build a more effective, consensus-based strategy on some of these incremental approaches that can then be taken to the Hill.
There are a number of successes we could build on. There’s a lot of positive feedback on comprehensive community mental health care clinics and how those systems are beginning to offer integrated care. Opioids have also received incredible attention from Congress and that will continue in the 116th Congress. We can build a systematic agenda that aligns with things that the Congress has been working on.
We have an agenda here going forward. Kaiser Permanente has created an opportunity for us to work together. How are we going to take advantage of that opportunity and actually move the agenda?
Visit the Institute for Health Policy’s website to watch full videos of the forum and view forum collateral. See a summary of the conversation on Twitter and continue the dialogue using #MHWorkforce and #KPIHP.