Charting the Way: A National Strategy for the Behavioral Health Workforce
Behavioral health challenges—notably substance use and mental health—are more prevalent than ever, but the workforce needed to provide support is shrinking, even as the need for equitable services grows. How did we get here? How can we turn the tide? And how can we incorporate social justice into those efforts? We’ll address all of these questions in the Charting the Way podcast miniseries.
In this first episode, Abt’s Sarah Steverman and NACBHDD’s Ron Manderscheid take a look at the nation’s critical behavioral health workforce needs and discuss strategies for closing the gaps.
Listen to episode 2 here and episode 3 here.
Read the Transcript
Eric Tischler: Behavioral health challenges, notably substance abuse and mental health, are more prevalent than ever, but the behavioral health workforce is shrinking even as the need for equitable services grows. How did we get here? How can we turn the tide? How can we incorporate social justice into those efforts? We'll address all these questions in this podcast miniseries. I’m Eric Tischler from Abt Associates, and joining me today are my colleague Sarah Steverman and our guest, Ron Manderscheid, Executive Director of both the National Association of County Behavioral Health and Development Disability Directors, and the National Association for Rural Mental Health.
Previously, Ron served as the Director of Mental Health and Substance Abuse Programs in the global health sector of SRA International, and in several federal mental health leadership roles at the US Department of Health and Human Services.
Sarah is a Senior Associate at Abt. Her work focuses on mental health and substance abuse policy, research and implementation. She is, among other things, the Project Director for the SAMHSA Evidence-Based Resource Center, our project to identify, evaluate and disseminate best practices to the behavioral health field.
Thank you both joining me. Let's start with the basics. When we say "behavioral health services", what are we talking about and why should be concerned about the workforce?
Ron Manderscheid: Number one, we are in the midst of a behavioral health emergency, not only because we had an inadequate workforce to begin with, but because of COVID. If you look at the epidemiology, typically the percentage of the U.S. population that suffers from these problems is about 20 percent. That has doubled to 40 percent. So, we are in the midst of a behavioral health emergency. So, an easy stat here, prior to COVID we were only caring for 50 percent of the people who had behavioral health conditions. The other 50 percent got no care.
The numbers have doubled in COVID, which means we're only caring for about 25 percent of the people with these problems currently. So, we are losing the battle here because we don't address our workforce issues. Secondly, we're also in the midst of a social justice emergency. That should be very obvious to anybody who watches television and so on, anybody who participates in the conversation about Black Lives Matter and so on, and that social justice emergency extends also to behavioral health care. We have a serious need to eliminate disparities and promote equity in our own field.
Eric: Sarah, do you want to add to that? Do you want to give your perspective?
Sarah: Sure, to even broaden this further, what we're talking about are disparities between the people seeking access: so people with low income, people of color, black and Indigenous people are less likely to access services. They're also less likely to have opportunities to be leaders in the workforce. So, I think one of the goals of our conversation today is to talk about both how we approach the workforce and behavioral health crisis in providing equitable access to care, both treatment and recovery, but then also promoting access to training and employment opportunities for people who have historically been left out of decision making and left out of the workforce.
Eric: Great, so thanks for elaborating on that. Do you want to drill down a little bit on the social justice aspect, both in terms of who needs services and who's providing services?
Ron: So yes, let me pick up on Sarah's point here. I kind of view these as going through a door. The first door you need to go through is are you able to access care at all? In that regard, we lose 50 percent at that door. Fifty percent of people with behavioral health conditions never access care. The next level of care, second door, is the care appropriate? If you used evidence-based practices to say "Is the care appropriate?" Only about 5 percent of people who receive care actually receive care that we would consider evidence-based care. Third door, the hardest door to get through, are you actually meeting the needs of the person who is receiving care?
It's in that domain that we get into issues of whether that care promotes recovery, whether that care is meeting the objectives of the person seeking care and so on. So, most of our discussion is about door one. We need to make sure we include door two and door three here as well.
Eric: We've mentioned COVID, which obviously has huge immediate impacts. Let's look first at the short term. What are some things we can do as we are hopefully turning the corner on COVID? What are some short term solutions?
Sarah: We certainly have shortages that are related to COVID. We have folks who left the workforce and probably aren't coming back, that they were providing services in person and those jobs were either lost or changed. We have problems with retirement, which I know Ron can expand on, kind of the data around the number of folks who are retiring out of the workforce. We have fewer people coming into the system. Then, as we alluded earlier, we also have issues of diversity of the workforce.
I have some thoughts on the shortages issue, and why fewer people are coming into the system. But maybe Ron, if you want to kind of expand on kind of the broader subjects first.
Ron: Okay, sure. Glad to add to this. The categories that Sarah was talking about... So first, the retirees. We're at the point now where Baby Boomers are leaving the behavioral health workforce in very large numbers. They are part of the population group that went through the economy, was always very active, and now they're retiring. An indicator of that level of retirement: 10,000 people a day start taking Social Security right now and that's going to be through every day between now and 10 years from now to give you an idea of the flow of people. Well, it's no different than behavioral health. We have that same outflow in behavioral health. Big issue for us.
Secondly, the next generation of people down are what I call the Baby Bust generation. This is the group that never really entered behavioral health because it was a difficult time. You'll think back 25 and 30 years, it was a very difficult time for behavioral health. There was very little money going into community behavioral health services. It was not widely recognized in the field. There was a fairly low level of respect for people who worked in the field.
People did not come into the field. So, we have a Baby Bust for the group that at this time would be moving into the managerial positions. The next generation down to Millennials, what happens, Millennials come in. They are at one place two or three years. They move on somewhere else. They churn. They stay at the same level. They have difficult establishing a career hold into the field, so they move so much. A large number of them actually leave the field and go on to other areas.
You can take any of those groups and look, and all three of those things together create problems for us. We also have difficulty recruiting. One indicator of that, for example, in psychiatry, is that the average age of a psychiatrist has grown from 50 to 60 years in the last 15 years. That occurs when too few young people are entering the system. If you'll look at diversity in that workforce, there are hardly any American Indian psychiatrists. There are progressively more black psychiatrists, but they're still a small number within the field, and so on.
We add a couple elements to the problem here. We have not had any federal support for training through the traditional programs that used to be operated by the National Institute of Mental Health, or by SAMHSA, since 1994. That's more than 25 years. So, we've kind of disappeared out of that environment. The one area in the federal training program that's still very active is the National Health Service Corp run by HRSA, the Health Resources and Services Administration. I believe they're currently training about 3,500 people per year in the behavioral health fields. It would be in psychiatry. It would be in psychology. It would be in social work. But, that number is just, in effect, a drop in the bucket compared to what we need.
Sarah: I've been thinking a little bit about this issue of why Millennials grew up in the recession and the behavioral health system could have been a good place for them to land to find meaningful work. I think a good bit of it is around policy and is around training, but I also wonder if one of the issues with shortages, of fewer people coming to the system, is that, while we've increased our ability to talk about mental health and substance abuse, and younger generations are much more aware and better versed in talking about mental health, mental wellness, substance abuse recovery, the behavioral health system is still a bit of a mystery.
It's difficult to access. It's often separate from medical care. When you're a kid you don't see it at all. You go to the pediatrician, then you go to the emergency department if you fall down and break your arm, but it's a bit of an invisible system. Kids are growing up and they're going to college, they're going to medical school or they're going to graduate school, they're thinking "I want to be a doctor, but I want to be an emergency medicine physician, or a surgeon. I want to go to nursing school, but I want to be a pediatric nurse, or a labor and delivery nurse," but they're not thinking about being a psychiatrist or a psychiatric nurse.
Then other professionals, like an addictions counselor or social worker, case manager to community mental health center, those are nearly unknown professions to people. We need to put those opportunities for training in front of people, and also some of it may be a bit of a PR job that we need to kind of bring the system and the workforce opportunities more out into the light so people want to be trained or want to join the workforce.
Ron: So, to support your point, most high school textbooks on health education do not even include a mental health chapter. It's absolutely correct people aren't exposed to this. I also think, to follow up on your broader point, I don't think there are many role models of people who work in this field that are visible to the Millennials and younger generations that are coming along. It just isn't very visible outside the field. You're not going to turn on TV tonight and see a program about a psychiatrist as you might see a program about a physician, or you might see a program about someone else working in another field. It just doesn't occur.
Eric: Okay, that's a lot of problems we've just listed. What are some steps we might take in the short term? What are the two of you thinking? What might we be able to do to help turn the tide here?
Ron: There are a broad number of things that can be done in the very short term future here. We need to broaden the use of peers and service delivery, both on the mental health side and on the substance use side as well. We've made a lot of progress in that arena, but there's still many, many places where we need many more peers, and they are out there and want to do this. We're gradually getting in place the payment mechanisms for CMS to do this for Medicaid and Medicare, but we need to do more and it's obvious.
Eric: Ron, I'm sorry if I can interrupt you one second, when you say "peers," do you want to explain who you're talking about?
Ron: Yes, peers are individuals who themselves have experienced a behavioral health condition and now want to help others who are experiencing these problems because they know how to access the system, they know the types of problems that will be encountered when you're seeking care, and they're very empathetic with people who have these conditions. There are literally thousands of peers who would like to work with us in the field. We have to figure out a way to make that happen.
Eric: I was just going to ask, do we have a recommendation for making that happen?
Ron: Well, the recommendation for making it happen, we have to open up the payment mechanism so that it will have it. That is happening in CMS around Medicaid and Medicare. If I know the numbers correctly, currently about 47 states fund peer support services in Medicaid for mental health. Only about 26 or 27 find peer support services for substance use. That should be 50 and 50. We have more work to do here. Same thing in the private sector. We need to make certain that private sector insurance covers peer support as an essential service, basically.
Some obvious things that in the short term can be done right now, we need to change Medicare requirements that don't require changes in law to permit additional workers to work in the behavioral health field, such as mental health counselors, such as marriage and family therapists, such as substance use counselors, such as bachelor level social workers. There're several categories here of workers who are not permitted to bill under Medicaid or Medicare currently. Literally by the flick of the pen, we could change that, and change that situation.
Sarah: I was just going to even take a step perhaps back, or concurrently as we're working on all of these issues, I think there's a bit of a gap in our knowledge of where we most need providers to land. Getting back to our opening conversation around social justice and equity, I think the answer is probably everywhere, because there are shortages everywhere. It's urban. It's rural. It's all 50 states. We know that HRSA has healthcare shortage areas that they have identified, and there are some data there but I do think that there's probably room for us to better understand what the state of the behavioral health workforce is, and specifically where those shortages are most acute and what types of providers, what level of training those providers may have.
We've done, at Abt, some work trying to drill down and work with localities to try to do an assessment of their workforce and their systems capacity, and it is really difficult work. It's difficult to know who's working and where, and whether or not they're working up to their licensure. It's difficult and time consuming work, but I think it would help us to more equitably distribute those training grants, or more equitably distribute those provider spots if we knew kind of where those shortages were most acute.
Ron: Let me add to what Sarah was just saying here. SAMHSA has funded a project at George Washington University in DC to pull together the available data on human resources in behavioral health care from wherever they can pull it. That project is well advanced, and actually is now arriving at the stage where they're able to provide estimates both nationally, by state, and down into local areas. That data will greatly help us to understand exactly the issue that Sarah was raising.
The issue going forward is, we need to collect that data on a continuing basis in effect every year, and that's not happening. Secondly, HRSA funds a center called the Behavioral Health Workforce Research Center, the purpose of which was to do a number of things. It was to develop a minimum dataset for human resources in behavioral health. That minimum dataset was taken originally from work that I did when I was in SAMHSA where we created a system called Decision Support 2000+. One of the dimensions of that was the human resources minimum dataset.
The work of the HRSA Center has updated that, but the HRSA Center is also doing fairly small local studies to understand some of the issues: do people actually work up to practice standards and guidelines, and licensure? What are the deficits in the workforce, in particular in rural areas versus urban areas? There are a whole number of things that they are taking on. So, to the credit of SAMHSA and HRSA, these things are actually underway and should be encouraged, basically.
Eric: Great. That stuff that we're talking about we can do in the relatively short term, looking down the road beyond this what should be tacking towards in terms of longer term solutions? What are the things we can do to identify the problems, identify gaps? Once identified, what can we do maybe moving forward beyond that?
Ron: Let me start again, and I guess the context on this, and I just learned this this morning, there was an article in this morning's Politico that the Congress is interested in moving ahead on behavioral health human resources, which is wonderful to hear. When they move ahead on that, what they're going to need to have in order to make progress, they are going to need to have a strategic plan. Part of what we need going forward here in the little longer run, we need to update the strategic plan that was developed for human resources in behavioral health.
Now 15 years ago, I make it applicable to the current situation, number one. Number two, we need to develop Centers of Excellence via federal grants for best practices in human resource training, and best practices in human resource practice in behavioral health that have results that can be broadly disseminated throughout the field. Thirdly, I think my own view, and I've advocated for this for years so nothing new here, we need a large federal training program. By "large," I mean $300 million to $500 million a year going into this to actually make it possible to increase the diversity of the workforce, to overcome some of the disparities that we talked about at the beginning of this podcast, and other things.
That type of concept has been proposed in the past, but has not yet gone anywhere. Because of the changed view of behavioral health, especially in this COVID era, I think there's a much more positive view of behavioral health, and those types of things would stand a chance of actually happening now where they might not have even a year or two ago.
Eric: Sarah, do you want to weigh in on the topic of longer-term solutions?
Sarah: I think we might want to talk a little bit more about what this training might look like. One of the things that we've been talking about in behavioral health workforce and behavioral health systems for a long time is integrated care. I think what we're talking about is, again, to get back to these large training grants, who are we going to train, and how are we going to train them? We've been talking about interdisciplinary care for quite a while now, or integrated care, and we've done quite a bit of work at the intersection of HIV and mental health and substance abuse here at Abt.
What we've found again and again through our evaluations and our technical assistance is that while there's been quite a movement to co-locate or to have HIV providers and behavioral health providers providing care to the same person in the same setting or the same system, with a shared EHR and a shared [inaudible 00:22:00] plan. The providers generally are working sort of independently. The HIV providers are working on the HIV screening and treatment, and are aware that their client is getting behavioral health care and vice versa. The behavioral health provider is making sure that they're seeing their HIV treatment provider, making sure that they're taking their meds, or reminding them, but they're not tracking their viral load and having much concern for the HIV treatment that's needed and their health. Do you want to talk a little bit about sort of where we can go to try to …
Ron: Yes. Yes.
Sarah: … better integrate?
Ron: Yeah, absolutely. Excellent point. I guess a couple of things to be said about this. First, if you distribute and you look at where behavioral healthcare is provided today, about 20 percent of behavioral healthcare is currently provided by specialists, and about 80 percent is currently provided by primary care physicians. So, the critical issue of how we bridge these two worlds is very important. As you say, we've been working on integrated care, or the process of integrating ,care for a while, and there are huge opportunities in that area.
That area will only work well if we develop training that prepares people to work in integrated settings. The work that's ongoing now, some of my students at USC who are doing this work, for example, is what's called Interdisciplinary team training, where they will team a behavioral health provider, like a psychiatrist with a primary care physician, not in a classroom setting, but in a practice setting where they will then look at different clients and they'll learn how they can work with each other, how they can better work as a team and so on.
That type of training, I think, is going to increase dramatically as we go forward. Transdisciplinary training goes an additional step and says, "How can I as a behavioral health person also have training in one of these other fields so I can be more effective in what I do?" I think we're going to see that type of expansion and training as well going forward. I think that's further in the future than is interdisciplinary training, which is beginning right now and is exceptionally important if we're going to be able to actually do integrated care in the way that it's been envisioned in the Affordable Care Act going forward here.
Eric: Other thoughts for the future of how we can sort of meet these needs? You pointed out Ron, there's a huge gap.
Ron: There are a few other things we can add here. One that I would want to add, I think there's a lot of progress being made in the use of virtual reality and artificial intelligence. That, today, takes the form of very short apps, and you can now actually if you practice in these fields, you can prescribe an app to people as part of their treatment. That's fully recognized by the Food and Drug Administration and so on. We need a lot more work on development of these apps, understanding which apps actually deliver evidence-based practices that make a difference, which apps don't harm you, and so on.
As we go down five years and 10 years, we're going to be moving more and more into the use of artificial intelligence to supplement some of our provider shortages, where more and more care will be given by smart systems. For example, a system trained to give cognitive behavioral therapy, which we have already. To go the next step with virtually no provider present to use those tools at the prescription of a provider because that is the type of care that is needed, and that provider can expand, I think dramatically, the number of clients they'll be able to work with using those artificial intelligence tools and virtual reality tools.
I think there's a lot of huge opportunity coming in those fields as we go ahead. That work needs good leadership from the federal level. So, it's a call again for the federal government to become much more engaged and work on apps, work on artificial intelligence and work on virtual reality.
Sarah: This exact issue that Ron is talking about is something that we've been doing quite a bit of work on through our evidenced-based research contract. As we've been digging into the literature, digging into the research, there's quite a bit of research on telehealth, what we know as sort of synchronous telehealth that has sprung up especially since COVID, where a provider provides a service that is hopefully evidence-based through a computer screen or through the telephone that normally would have done in person.
What Ron is talking about with these asynchronous apps and programs, and artificial intelligence is, I think, it's the future but I do want to underscore that the research seems to be very, very new and we do need... You can imagine a scenario where these could explode, and it would be very difficult for providers to figure out what they should be essentially prescribing to their clients, or what they should be recommending to their clients, or what a person who’s taking some amount of help and treatment, and looking at the app store or googling is about to know what they're getting is actually evidence-based, that it's going to help them and certainly not harm them.
I just want to underscore your point, Ron, that we need leadership and we need a research agenda probably around this, something very formal where these new technologies are being rigorously tested to ensure that they do work and they don't harm.
Ron: Yeah, excellent. Agree completely.
Eric: “Agree completely” is always a good place to stop.
Ron: Stop while you’re ahead, basically.
Eric: Yeah, right.
Sarah: I just wanted to... I think we set out here a lot of concerns that we have with the behavioral health workforce, and a lot to be done. There's a lot of work to be done, and there's a call for leadership and funding, and policy change, and all of that is difficult to do. But I do want to kind of bring us back to the beginning where we were discussing this as a social justice movement. I think there's two huge areas of hope, which is the first is that there's this increasing awareness of the importance of equity and social justice.
As Ron said at the beginning, we are talking about this all the time. It is everywhere, and I hope that we continue to talk about it and to reorient our systems and reorient our thinking, and reorient our policy and our research to be thinking about issues of equity and measuring it, and looking to transform our systems in a way that bends toward social justice. Then I think, in the same way, and we've mentioned this, but just to underscore that there's been also at the same time an increasing awareness in how common mental health and substance abuse needs are, that it's something that touches every family and everyone throughout the lifespan.
I think that, as both issues of equity and issues of mental health and substance use needs come more into the light, that we'll be able to make some progress on these very, very hard problems.
Eric: Very nice. Ron, anything you wanted to add?
Eric: Well, great. You guys have laid out a lot of issues that we wanted to address. The good news is, we're going to unpack at least some of this in subsequent episodes of this podcast series.
Sarah: Mm-hmm (affirmative).
Eric: Thank you both for joining me.
Sarah: Thank you.
Ron: Okay. Appreciate it.
Eric: And thank you for listening to this Abt podcast.