In the US we currently have 1 trained therapist per 20 people in need. According to NIMH, this is more than enough therapists to ensure that every person in need of care can receive the appropriate treatment for their illnesses.
If this is the case, why are so many people still not getting the care that they need? Why are we in a mental health crisis if we have the workforce to successfully address it? The answer to these questions is multi-faceted, but in many ways comes down to logistical failures in the workforce and resource organization.
5 problems with our mental health care system that we can fix
Uneven distribution of workers
There is a large geographic disparity in services and a variety of distribution of therapists across the states. Even within a single state, therapists typically reside in urban, more liberal areas, leaving many rural populations without care. Patients in rural parts of the country regularly have to drive anywhere from 45 minutes to three hours to find the care that they need. Additionally, 54% of counties in the US do not even have a psychiatrist.
An illuminating microcosm of the issue can be found in rural centers located in small however wealthy mountain towns in Colorado – such as Estes Park. Therapeutic taff can not afford to live within 45 minutes of any facility located in Estes Park without receiving low-income housing support or living off of additional outside income. Finding therapists willing to make the 45-minute drive or re-locate, exacerbates the already challenging issue of finding properly trained therapists. A teen center in this location recently had to close down, and since, there has been an abject lack of mental health care services for the rural population of Larimer County, and the situation does not seem to be getting any better.
Telehealth as an accessibility equalizer
The creation and uptake of telehealth services is a huge step in providing people living in rural counties with the care they need. Innovative uses of tech for mental healthcare are providing possibilities for treatment that were otherwise impossible for rural populations. Companies like Ophelia, Sondermind, and Antelope Recovery are on the leading edge of telehealth mental care that hopes to make significant progress in this crucial domain.
Lack of adequate training for therapists
Most therapists are not equipped to work with severe mental illnesses, eg. bipolar disorder, schizophrenia, DID, or addiction. Many graduate-level schools for therapists do not adequately teach how to treat these illnesses, or how to even engage with these patients in a way that is not counterproductive to their recovery. 60% of schools that train students to become licensed counselors require no supervision training for clinically proven therapies such as Cognitive Behavioral Therapy (CBT) or Dialectical Behavioral Therapy (DBT). In addition, 40% of therapists do not work with people who have a mental illness diagnosis and desperately need help – instead, working exclusively with high-functioning clients who want to expand their potential and increase their self-awareness. It is a therapist’s own prerogative as to who to work with, and the choice of many therapists to not work with mentally ill patients exacerbates an already dire situation.
Furthermore, Master’s programs in psychology are woefully under competitive and not taken seriously by academics in the field. Many people join Master’s programs with a prior Bachelor’s degree in an unrelated liberal arts degree. It is not competitive or rigorous training. The education generally takes two-three years to complete – and for someone receiving medical training, studying one of the most complex and least-understood aspects of the medical field, the human mind – is completely inadequate. Entering the workforce under-educated, leaves many extremely well-intentioned and loving therapists unequipped to treat their clientele, and causes high levels of burnout and stress for the therapists. And it’s not just Master’s students, mental health care workers who have a Bachelor’s degree in psychology also experience the same issues, being woefully under-prepared for any field work, and usually needing to be completely re-trained in order to work directly with clients.
The bottom line is that universities are failing to prepare students to work in mental healthcare, with devastating effects for those with mental illnesses, therapists and healthcare workers in the profession, the reputation of scientists working in the field, and the centers dedicated to caring for ill patients.
How to fix training issues
- Closure of the implementation gap. When researchers discover life-changing treatments, they are not implemented into clinical training for, on average, 20 years. Having academics and professionals actively working on closing that gap could be the difference between a healthy life and one of misery, for many.
- Supervision requirements. Supervision for therapists needs to be a requirement to ensure successful outcomes for both therapists and their client’s recovery. Learning effective treatment models and seeing actual results will help therapists feel confident in their capacity to help clientele, reduce stress and burnout, and ultimately lead to higher success rates of recovery of patients.
- Mandatory training in the most proven therapeutic modalities. There are dozens of therapeutic modalities, with varying degrees of research showing their efficacy. Despite the particular leanings of professors, departments, and universities, all therapists should be well trained in the therapeutic modalities with the most proven clinical outcomes and rates of efficacy.
Currently, patients can go to nine different therapists with the same symptoms and walk out of each of their offices with nine different diagnoses and nine different treatment recommendations. Mental health diagnostics are extremely imprecise and depending on the type of mental health professional seen, wildly different treatment plans may be prescribed for a patient. To a certain degree, this is unavoidable considering the many different types of mental health professionals, including psychiatrists, marriage and family counselors, psychiatric nurse practitioners, addiction counselors, art therapists, equine therapists, cognitive psychologists, social workers, and more. However, because of the vast differences in training, and the lack of an overarching psychological map with a place for each, it is not always obvious which professional to see. This is a major issue for those who desperately need treatment, especially if they do not have the money or time to see multiple professionals and find the right fit. And even if seeing multiple professionals is an option, or admittance into a psychiatric care center is a part of the equation, professionals do not communicate vital health records with each other, leaving a potentially invaluable route to finding correct treatments off the table. Not only does this disorganization negatively impact the mental and financial health of those who need help the most, it leads to an estimated yearly loss of one billion dollars in our healthcare system.
This fragmentation in the field is confusing and burdensome for clients and caregivers alike and puts an undue burden on the patient and their families as they navigate the complexity of conflicting diagnoses and treatment plans, as well as the fickle world of insurance.
How to solve fragment care
- Standardized electronic health records that are shareable between providers. We recommend Kipu.
- A focus on diagnostic differences and failures, and how to reduce their regularity moving forward.
- Tracking of treatment outcomes so that recommendations for treatment can become even more evidence-based and fine-tuned.
- Follow up within 7 days after being discharged from care. The first-week post-discharge is when relapse and suicide are most likely. Programs often end their primary care with no after-care plan. Including relapse as a part of the recovery process should be an integral part of healthcare plans.
- Stepped care. Step-by-step access to different programs and small incremental shifts in care allow for a refined treatment tailored to the acute needs of patients.
Currently, 57% of therapists do not accept insurance. And even when professionals do accept insurance, insurance still may not cover essential mental health treatment. Currently, insurance companies decide when mental health treatment should end without consulting with care providers. Often, inpatient treatment ends after 30 days when long-term care (4-9 months) is required for safe recovery. Private facilities usually run 15% below capacity due to insurance complications, reducing the overall access to treatment for those who need it.
Mental health care should be reimbursed by public and private insurance companies on par with other forms of acute care. Repairing the psyche after a psychotic break takes time and money, however, it is possible. When we do not give people the care they need, they often instead develop a chronic disability and have a significantly reduced lifespan, a difference estimated to be 30 years. Investing in appropriate care when needed is effective and worthwhile.
Not enough long-term care centers
Our long-term care centers are at capacity with long waitlists. In the 1950’s, we had on average 340 inpatient beds per 100,000 people, we now have 17 per 100,000 people. Currently, it takes, on average, three months for people with a mental illness to find and receive the care that they need, which is often too late when you are dealing with a severe addiction, suicidality, or a delusional patient. Usually, during that three-month period, families, communities, and care workers, who are unequipped to support the patient, end up expending large amounts of energy to prevent the worst from occurring, draining themselves and those around them. This can lead to feelings of helplessness from the caseworkers, overwhelm and fear in families, and typically, an increase in symptoms in the patient.
In addition, the long-term care centers we do have are mismanaged. Currently, 22% of the patients in long-term care centers do not actually have a mental health diagnosis. Only 10% of the patients in inpatient care are diagnosed with schizophrenia, with 21% having a personality disorder or type of neurosis. This is troubling because we estimate that 60% of people with a mental illness are not receiving care for their condition. We must find a way to get the right people to the right places for treatment.
- Long-term care centers are currently accepting inappropriate clients due to financial needs and inadequate alternatives for those clients. By fixing the insurance issues, long-term care centers will be freed up to take appropriate clients.
- Because insurance will not pay for long-term mental health care, and these centers are fairly expensive to run, it is hard for these centers to stay open. We need to adjust insurance policies to cover long-term mental health rehabilitation.
De-fragmenting a disparate and loosely connected set of healthcare systems, shifting insurance policy and views on treatment, more effectively training our workforce, and creating more accessible care options is a lot of work to do, and will not be accomplished overnight. However, more deeply understanding the factors contributing to our ineffective models of mental health care accelerates and enables the creation of the solutions that will be required for us to provide care and treatment to those who need it. And despite the size of the task, it is a necessary and worthwhile endeavor.