There is a severe mental health workforce shortage in the US. You have heard this time and time again. In a time of unprecedented demand for mental health care – and deaths from lack of it – we simply don’t have enough therapists. And the therapists we do have aren’t representative of the communities they serve.
The solutions proposed for this problem so far are trivial. But there is a readily available solution to the mental health workforce shortage. It could immediately grow the field by thousands of qualified practitioners. It would dramatically improve diversity within the field at the same time. Even better, it would cost states virtually nothing to implement, and could be done in a week.
The scope of the problem
A quick review for the unfamiliar: We don’t have enough therapists. That’s especially true for kids, in rural areas, and for non-English speakers. But really, it’s a problem everywhere. If you don’t believe me, spend some time trying to find a therapist who takes your insurance and is accepting new clients. Good luck.
States are trying to address the issue with quick solutions: improved payment rates, reducing administrative burdens, and the like. Proposed additional solutions include expanding loan reimbursement programs and working to specifically recruit more clinicians of color into the pipeline. But loan reimbursement doesn’t do anything to help folks pay for tuition in the first place, and it arguably does harm to those who are recruited into to the field but then don’t make it through their graduate program. Such individuals don’t qualify for that reimbursement, so they’re stuck with a large bill and no degree that might help them pay it off.
Existing scholarship and loan reimbursement programs are also typically too small to make a real difference. California, for example, can provide loan reimbursement to about 200 people a year through its Licensed Mental Health Services Provider Education Program. But the state has more than 100,000 master’s-level clinicians, and needs thousands more mental health providers. The Steinberg Institute found that the existing workforce only meets about 26% of California’s behavioral health care needs.
A ready reserve of qualified individuals
It turns out that there is a waiting reserve of thousands of qualified individuals, who have completed their qualifying degrees in mental health care and all of the required years of supervised experience for licensure. Even better, this group is more diverse than the mental health professions as a whole, including significant portions of bilingual clinicians.
Only one thing stands in the way of this group immediately getting to work as licensed professionals serving the public: Their clinical exams.
These exams, including the ASWB Clinical Exam in social work, the NCMHCE in counseling, and the National and California MFT Clinical Exams in family therapy, have never been shown to predict safe or effective practice. Simply put, they don’t serve the one purpose they supposedly exist to serve: Ensuring public safety. Indeed, by keeping qualified professionals out of licensed practice without evidence of any corresponding benefit, they are hindering public safety by reducing access to care.
What clinical exams have shown are dramatically disparate outcomes by race and ethnicity. White examinees pass the ASWB Clinical Exam on their first attempt about twice as often as Black examinees do. A study in progress is showing a similar pattern on the California and National MFT exams. (The NCMHCE hasn’t been studied, because the organization that develops it hasn’t released the relevant data. But given that the EPPP in Psychology shows the same disparities, and these exams are all developed and structured in similar ways, there is no reason to expect the NCMHCE to be any different.)
The clinicians who have completed all requirements except their clinical exams are well-educated. They have years of supervised experience affirming their safety and effectiveness. They’re ready and willing to work. Their only flaw is that they haven’t yet overcome a tool of institutional racism. Let them get to to work. Let them help address the mental health crisis tearing apart families and communities.
The one-week solution
There is a solution that is both fast and achievable. It requires very little money to implement, and there is not an ounce of evidence to suggest that it would harm the safety or effectiveness of available care: Get rid of the clinical exams.
I understand that some policymakers will be reluctant to ditch these exams entirely. After all, they provide the comforting illusion of a high professional standard. Besides, getting rid of them permanently, while absolutely the correct long-term solution, requires changes in statute and regulation. Those are time-consuming processes, and likely to fall victim to inertia and infighting.
So here’s a better way. One that sidesteps all of that inertia and improves access to care immediately. It can have an fast, substantive impact in any jurisdiction with the will to do it:
- The Governor declares a state of emergency for mental health in the state. It’s an unfortunately easy case to make. (In some places, a disaster declaration can serve the same purpose. The National Council for Mental Wellbeing has already proposed that states use disaster declarations to draw down more federal funding for mental health care.)
- Use the emergency powers that come with such a declaration to pause the use of clinical exams as a condition for licensure, and direct the appropriate boards to issue licenses to anyone in good standing who has otherwise completed the requirements for licensure. This will immediately allow those caught in clinical exam purgatory to qualify for licensure, and get to work serving the public.
- Access to care improves, as does the diversity of the workforce.
While the state of emergency is ongoing, states required by statute to use a clinical exam should change their laws to permanently drop the requirement. Where possible, boards should be given deference to determine on their own what makes a person appropriately qualified for licensure. No job, interstate compact, loan reimbursement program, or other regulatory structure should require the passage of a clinical exam in mental health care unless and until such exams are demonstrated to be fair, equitable, and valid for predicting safety in practice.
If policymakers or others are concerned that such a move might “open the floodgates” and create an ongoing influx of new therapists, there’s no evidence to suggest that. The beginning of the professional pipeline in mental health care is constrained by a number of factors. These include the length, cost, and capacity of graduate programs. There’s no reason to think that would change. Those caught in clinical exam purgatory simply represent a bubble at the end of the pipeline. This time of crisis in public access to care is the time to resolve that bubble.
A plea to Governors around the country
Are you a Governor, a staff person for a Governor, or otherwise connected to a Governor’s office? First: Thanks for reading. Second: A quick request.
Your state is experiencing a mental health crisis. You have a mental health workforce shortage, and you need more licensed therapists. You have hundreds, perhaps thousands, of highly-vetted, well-qualified individuals ready and waiting. They’re right there.
Let them in.