By Tony Liu
I was wiping down tables at an inpatient child and adolescent psychiatric unit when the intercom rang. A few minutes later, four adult security guards arrived. Their purpose? To restrain an enraged teen.
I felt conflicted, unsettled yet aware the teenager posed a risk to self and others. I also wondered how these escalated situations were prevented in the past, recalling moments when a trusted staff member calmed patients on the verge of outburst. Unfortunately, personalized preventive measures like this are less feasible as mental health care workers for youth are in short supply across the United States.
In October, a group of professional pediatric organizations declared a national emergency in child and adolescent mental health. In December, the U.S. Surgeon General added to these calls by announcing an advisory on the mental health crisis facing our country’s youth — one that emerged prior to the COVID-19 pandemic yet undoubtedly is exacerbated by it.
The Centers for Disease Control and Prevention found that from 2009 to 2019, teens experienced increased rates of mental distress, from feelings of helplessness to depression and suicidal ideation. Tragically, suicide rates among youths age 10 to 24 increased by 57.4% from 2007 to 2018.
No silver bullet exists to solve this mental health crisis, but one foundational step is having an adequate group of mental health professionals to support our youth. However, significant shortages remain. Comparing the supply of behavioral health practitioners in 2013 to demand and projected supply in 2025, the U.S. Department of Health and Human Services projects a shortage of clinical, counseling and school psychologists by 57,490 individuals; mental health and substance abuse social workers by 48,540; and school counselors by 78,050. Yikes.
These are daunting numbers, but some school districts are working to address the issue. As Mila Koumpilova recently reported for ChalkBeat, Chicago Public Schools will add 64 counselors by 2023 to meet student needs. Beyond local school districts, we must ask: What it would take to recruit more individuals to the mental health workforce and to reduce turnover in a demanding profession?
One answer is adequate compensation.
In Social Work Today, Daniel Do, a doctoral candidate at the Boston University School of Social Work, says mental health workforce attrition stems partly from inadequate compensation: “We have seen agencies try to increase their access to mental health providers over the years, and yet the pay is sharply lower when compared with other health professions such as nursing and primary care providers.”
This idea is echoed in a 2019 report by the National Academies of Sciences, Engineering, and Medicine that describes institutional barriers that may “limit the adequate payment of social workers, gerontologists and other social care workers.”
One institutional barrier is the billing landscape that funds our mental health care system. The same 2019 report by NASEM describes how under Medicare, social workers are defined as mental health providers, which means the full scope of their work, including care management and education, is not billable. Billing and coding are unglamorous, but they represent an opportunity to target the structural roots of our workforce deficit.
Efforts include the American Psychological Association’s work to increase billing options for psychologists. Legislative efforts exist, too. A bipartisan proposal, the Improving Access to Mental Health Act, would allow clinical social workers to be reimbursed 85% of a physician’s fees as opposed to 75% under the current Medicare reimbursement rate.
Additional legislation includes the Excellence in Mental Health and Addiction Treatment Act, which would increase the number of Certified Community Behavioral Health Clinics across the U.S. Based on findings from the assistant secretary for planning and evaluation, these clinics offer timely and affordable mental health services while expanding coverage to underserved populations. They also compensate social workers more adequately. As National Council for Mental Wellbeing President Chuck Ingoglia explains, CCBHCs bill for the anticipated cost of care, which allows them to build capacity in supporting patients.
Detractors say CCBHCs receive greater payments for similar services provided at other clinics, and CCBHC officials have described staffing challenges given funding uncertainty. Nonetheless, this criticism ignores the care coordination that distinguishes CCBHCs from other clinics, as detailed by Rebecca Farley David, a senior adviser at the National Council for Mental Wellbeing. Moreover, even amid staffing challenges, CCBHC officials have described how higher salaries have reduced staff turnover while assisting with recruitment.
In addressing our mental health care deficit, these bills are necessary but not sufficient. Nonetheless, urging your legislators to adopt both pieces of legislation is one action we can take toward building an adequate mental health workforce. In completing my medical training, I hope to become one of many other future individuals tending to the mental health needs of our youths, to make sure they are cared for before having to visit an inpatient psychiatric unit.
Tony Liu is an M.D. candidate at the University of Chicago Pritzker School of Medicine and co-leader of the school’s psychiatric interest group.
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