Texas mental health shortage worsens

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In 2016, the warnings about the future of Texas mental health workers were clear.

“More than 80 percent of Texas counties are designated mental health shortage areas, defined as more than 30,000 residents per physician,” the Texas Mental Health Strategic Plan said seven years ago. “Many of the most experienced and qualified professionals are approaching retirement age. … Texas institutions of higher education have not been able to produce enough graduates to meet projected demand.”

But no weather forecaster predicted a global pandemic that has triggered months of lockdowns and restrictions on public life that has left both Texas and the nation eager to counter the resulting anxiety and depression. In a country where consensus may seem rare, both Republicans and Democrats have come to the same conclusion: mental health services are in dire need of renewal and expansion.

“Given the ongoing mental health challenges caused by COVID-19, there could be no more critical time to strengthen our nation’s mental health resources,” U.S. Senator John Cornyn, D-TX, said in November 2020.

“Mental health affects us all,” President Joe Biden said last fall as he announced millions of dollars in new funding for public mental health services.

Calls have resurfaced in Texas after a teenage school shooter killed 19 children and two adults last summer in Uvalda.

“We must provide mental health services to students who need them,” Gov. Greg Abbott said in his inaugural address last month.

Texas Speaker of the House Dade Phelan is calling for a package of more than $100 million in school safety and mental health, with nearly half of that package dedicated to child mental health services. Millions of dollars are expected to be invested in various services for all Texans.

According to nonprofit advocacy group Mental Health America, Texas ranks last when it comes to access to child mental health services and 33rd when it comes to adult care. First and foremost, the State has a lot of work to do to increase the number of professionals that will be required to provide these planned new services.

Today, 98% of the 254 counties in Texas have been identified in whole or in part by the federal government as “areas of shortage of mental health professionals.”

How did it happen

“We never really kept up with demand,” said Dr. Sarah Martin, psychiatrist and medical director of the Texas Consortium for Child Mental Health. “The pandemic just threw the stigma around mental health to the floor, and it happened so fast that the queues or waiting lists for therapists are really long.”

This is not surprising for any Texan who has tried to make an appointment with a psychiatrist in the past three years, where waiting lists can exceed six or seven months. Some therapists had to stop new appointments altogether as the demand for services began to overload the system.

“The pandemic has exacerbated an existing shortage of psychiatrists at all levels of the mental health continuum, including our public hospitals, private mental health hospitals, and our local mental health agencies,” Michelle Alletto, Chief Program and Services Specialist for Texas Health and Human Services, said House Appropriations Committee earlier this week.

Staffing problems reach the highest levels of the mental health system. Texas is currently unable to use more than 700 of its 2,911 state-funded psychiatric hospital beds due to a workforce shortage, Texas Health and Human Services said. As of December 31, public hospitals had 5,987 full-time employees, down from 7,409 full-time employees in 2019.

The shortage of therapists, psychiatrists and psychologists affects other state institutions as well. Several county jails, including those in Dallas and Houston, have reported long waits for arrested and in need of treatment for people with mental illness before trial. Earlier this year, more than 2,000 people in Texas prisons and jails were waiting for their bed in the state’s hospital system.

The labor shortage is expected to worsen as many internists, psychologists and psychiatrists retire. Texas agency officials say they lack new graduates and young professionals from colleges and universities to replace them.

The Texas Executive Board of Behavioral Health oversees mental health licensing for marriage and family therapists, occupational counselors, psychologists, and social workers. Last year, the board noted a slight increase in the total number of licensed professionals: 80,546 licensees, of which 75,327 licensees are considered “active”. Two years ago there were 74,890 licensees, of which 69,729 were considered active.

Darrell Spinks, chief executive of the council, said despite this growth, the industry is completely overwhelmed with demand. He said licensing in Texas requires applicants to participate in internships and spend a certain period of time with a supervisor before they are allowed to work on their own.

“We don’t have enough people coming in the door to meet those coming out,” Spinks said.

The state is also facing a dwindling number of providers willing to train graduates seeking a license. This indecision is partly due to a fear of responsibility.

“So curricula can’t recruit enough people, and once we release them, we won’t have enough internship or postdoctoral sites,” Spinks said. “This further limits the number of people who can obtain a full license to provide mental health services.”

Several bills are being considered in this legislative session to address some of the problems of an overburdened mental health workforce.

House Bill 1211 and House Bill 1551 are measures that offer loan repayment assistance if a mental health provider meets certain requirements. House Bill 2361 would allow school districts to request a waiver and hire a licensed primary social worker if the district is unable to fill a non-physician mental health professional position due to a shortage of qualified applicants.

While these and many other bills are intended to address the problem of labor shortages, there is also the problem of burnout faced by those who already work in the mental health field.

“The work itself is demanding. No one comes to your office in a good mood,” Spinks said.

Staff 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 considered leaving the field.

“It was physically and emotionally exhausting, and there were times when I felt very depressed and overtired,” she said.

She said her growing workload as a graduate student during the pandemic has become too much at times.

“It really made me stop and think about whether I would like to do this job if I really got sick from communicating with other people,” she said.

Although Torres was able to find the motivation to continue, this was not always the case.

“Any health care provider must seek their own well-being and meet their own needs. It’s like when you’re on an airplane, you have to put on your own oxygen mask before you help someone else,” said Dr. Jeffrey Hahn, psychiatrist and medical director of the Baylor Psychiatric Clinic in Houston.

There’s also the added financial burden and the current contentious political climate that mental health providers say is fueling professional burnout.

“I think it’s a little scary in Texas and some other states. The landscape is kind of scary. What can and cannot be said during the session? said Dorothy Garza, senior director of mental health services at Communities In Schools of Central Texas, the largest provider of school mental health services for students in Texas. “What do I need to discuss with my clients, and what legal issues might be involved?”

Another key stress factor for providers in Texas is payment.

Low-income individuals who qualify for Medicaid, a taxpayer-backed health care provider, have some of the lowest reimbursement rates for per-session fees. The same applies to private insurance. This has led many mental health providers to switch to a cash-only payment model.

“You don’t go into a profession if you can’t make money from it. Everyone in the industry has the heart of a servant, but you don’t want to be a pauper,” Spikes said.

Christy Mitchell, Community in Schools project leader at Jane Langford Elementary School in southeast Austin, said she can’t blame people who make the decision to leave the profession.

“A lot of the field is built on goodwill and possibly self-sacrifice, and it can be difficult to do that all the time,” Mitchell said.

Not only are more health care providers needed, but 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% white, 12% black, and 5% Asian. However, a state poll this year found that the majority of the 2,873 respondents – about 85% – identified as white.

The survey also showed that only 20% of respondents offered mental health services in a language other than English. And more than half of mental health providers are located in urban areas such as Harris, Dallas, Tarrant, Bexar, and Travis counties.

In the end, more active recruiting and a better overall government strategy are needed, industry professionals say.

“We need to recruit and actively look for those in low-income communities who may want to return home,” Khan said.

Mitchell agreed.

“We need them in the field. We need more people of color. We need more service providers with the same experience that our customers have come across,” she said.