By Marnie Werner, VP, Research & Operations
We’ve been spending some time with mental health and mental health care the last few years here at the Center, and one thing we’ve found, which should be surprising to no one who follows our work or just lives in this state, is that we have a shortage of workers. Mental health care is no exception.
In fact, the shortage of mental health care workers is a big problem and only getting bigger as the demand for mental health services grow. While there are stop-gap measures that can be taken, we need to face the fact that it’s a complicated situation that will take time and focus to remedy.
A new report from the Center for Rural Behavioral Health at Minnesota State Mankato and Wilder Research, “Unfinished Business: Examining Barriers to Obtaining Center for Rural Behavioral Health and Wilder Research Mental Health Licensure Among Minnesota Graduates,” takes one big step toward understanding the problem by asking the 800-pound question in the room: With three quarters of Minnesota’s counties federally designated mental health provider shortage areas, why do half the graduates in Minnesota who complete the necessary work to get their degree not go on to ultimately get their license?
As our report from 2023 on the mental health care workforce explains, once students decide to go the route of mental health care, they need to find a college or university program that has the capacity to take them in. But what about keeping them in? And what about getting them across the finish line of not just graduation, but that all-important licensure that allows them to practice in the state?
What happened along the way?
It turns out, according to the report, quite a bit. CRBH and Wilder surveyed mental health care providers around the state, asking them about problems they encountered on the way to getting their licenses. Those factors included the overall cost of the process, from tuition to the cost of the licensure process itself, to the cost of paying for the hours they needed to practice under supervision; to what could be called the “hassle factor,” required administrative paperwork on top of the hours spent actually helping people; in the licensing process, repetitive requests for the same information, to be submitted on paper rather than electronically; “compassion fatigue” and “secondary trauma” from working long days with many people who have serious problems; to the fact that if you become licensed in one state, you need to go through the entire licensing process again to be licensed to practice in another state.
To be fair, on this last one, Minnesota recently joined a compact of several states that have agreed to recognize licenses from each other’s states. This is a huge step in the right direction, especially for communities that sit on a state border where the capacity to see people might be larger in the neighboring city right across the state line. We have a lot of these cities in Minnesota.
But it’s one step. There are many other hurdles that turn training for a very much in-demand profession into what sounds a lot like a four-year episode of “Survivor.”
In particular is the cost of becoming licensed. While license application and examination fees are to be expected, what might be more of a surprise is the cost of acquiring those supervised hours that are needed for licensing. According to Minnesota’s Board of Behavioral Health and Licensing, a master’s degree holder seeking a license must complete 4,000 hours of supervised, post-master’s clinical practice (equal to about two years after graduation), of which two hours for every 40 hours must be under direct supervision, for a total of 200 supervision hours.
The issue is that it is rare, or at least not common, for third-party payers (insurance companies, Medicare, Medicaid) to pay for the time a supervisor spends supervising, because the person actually providing the service, the student, is not licensed. So, while some clinics are able to cover the cost of supervised hours themselves, many cannot afford it, and therefore, it falls on the student to pay for those supervised hours. A quick internet search suggests that the hourly rate can be anywhere from $30 to $50 an hour. Times that by 200 hours, and the student is looking at an additional $6,000 to $10,000 added to the cost of becoming licensed, all during a time when they are working but getting paid at a low rate because … they’re not licensed.
This was just one of several catch-22s mentioned in the report that are probably factoring into why so many mental and behavioral health care students choose to take the degree and not the license. And if it’s difficult for everyone, it’s only going to be more difficult for people in rural areas. Lack of employers and finding a supervisor so they can obtain enough hours, especially specific types of hours, were some of the issues that made getting licensed while living in a rural area more difficult.
Of course, we need regulations and examinations and supervision, because these students will hopefully be working one day with some of our most vulnerable adults and children. We want to be sure they know what they’re doing, that they have the heart for the work. And they do. Said one respondent: “It’s the best job on earth, and I feel blessed. But we can basically do anything else and get paid better, and that is a shame.”
Does it need to be so hard to get into the field to begin with? It was one thing when, forty years ago, we had what seemed like an infinite number of people—the Baby Boom generation—all trying to get into only a finite number of jobs. But now that reality is reversed. As the Baby Boomers move off into retirement, we now find ourselves with not enough people to fill those jobs to address that need.
The whole issue needs more research, but in the meantime, is there something we can do to ease the load? The interstate compact allowing licensed professionals to practice in each other’s states is a fantastic start. Student loan forgiveness is also great, but ironically, students are only eligible for it after they become licensed, after they have gone through that financial trial by fire, and it’s not guaranteed.
Is there something that can be done now to hang onto that fifty percent of graduates who would drop out of the process instead stay on the track to licensure? “Unfinished Business” shows that it’s a complex problem involving many factors, and every student is unique and has a different tipping point. Therefore, it will take more than a single solution. But looking at the data, it’s apparent that we need to do something, and we need to do it soon.