Oregon’s mental health clinics can’t find anyone to fill a quarter of their jobs. Six Oregon counties didn’t have a single psychologist last year. Patients, especially people of color, children and rural residents, face severe challenges getting into therapy or finding help for addiction or conditions like eating disorders.

Shortages in mental health staffing are not unique to Oregon, experts say, and existed before they were exacerbated by the COVID-19 pandemic.

Those worker shortages undermine clinics’ ability to see patients, experts say. They also weaken the entire mental health system by alienating patients who face long wait times or deal with frequent turnover and worsening worker burnout, which in turn drives more care providers out of the behavioral health field.

In rural Lake County, a single psychiatric nurse practitioner manages medication for about 400 clients. In Portland, a Latino and Indigenous teen left an eating disorder clinic after finding the mostly white female counseling staff struggled to understand his needs and identity. And any given day, Oregon’s community-based mental health agencies operate with about a quarter of their positions unfilled, said Heather Jefferis, executive director of the Oregon Council for Behavioral Health.

“It’s well known that we are in a crisis and we have been in a crisis,” said Jackie Fabrick, deputy director for behavioral health at the Oregon Health Authority.

In recent years, Oregon leaders have made multiple efforts to break down workforce barriers, and providers say those initiatives are moving the state in the right direction.

Lawmakers set aside money to recruit and retain more mental health workers of color and, for the first time in more than a decade, approved substantial rate increases that help bolster the pay of mental health providers. The state helped pay down loan debt for hundreds of mental health providers. And several Oregon universities have started new programs to boost the children’s mental health workforce and get people with lived experience in the field more quickly certified as mental health or substance abuse counselors.

Oregon is making greater progress toward increasing and improving conditions for its behavioral health workforce than Jefferis has seen in the nearly 27 years she has worked in the field.

“We’re doing good things in the last few years,” she said, “really good things that are the right things to do, that will move us in the right direction.”

WHO’S IN THE WORKFORCE?

As with physical health, mental health care often takes a team-based approach.

Highly trained and licensed professionals include psychiatrists and nurse practitioners who prescribe medications and psychologists, social workers and therapists who provide psychotherapy-based services. Unlicensed providers with a range of educational credentials also work with people in distress. Credentialed but unlicensed mental health workers include alcohol and drug counselors, recovery mentors and peer support specialists who have lived experiences with mental health or substance abuse.

Oregon is seeing shortages across the board in licensed and unlicensed positions, Fabrick said. All but two Oregon counties are designated as complete mental health professional shortage areas by the federal government, according to the Rural Health Information Hub. That’s calculated using several factors including substance abuse prevalence, provider ratios and the travel time to the nearest source of care. Multnomah and Lane counties are the only exceptions.

National rankings suggest that Oregon is doing slightly better than other states. The Oregon Health Authority points to a United Health Foundation ranking that lists Oregon as having the third-highest ratio of mental health providers per capita in the country, based on the number of people who registered with the federal government to be reimbursed for any form of mental health care. The ranking does not take into account how much care a worker provides, such as whether the person works full or part time.

A Kaiser Family Foundation report based on the number of psychiatrists per capita estimates that Oregon meets about 29% of the public’s mental health needs. That’s essentially the same as the national average of 28%.

Jefferis points to low insurance payments as a prime culprit for Oregon’s historic shortage of mental health professionals. Mental health insurance payments have not kept up with the true cost of providing care or allowed mental health agencies to pay staff competitive wages, Jefferis said. Aspiring behavioral health providers can make more money working in physical health positions, she said.

The average wage of a mental health social worker in Oregon was $26.14 in 2022, according to the Bureau of Labor Statistics, while the average wage of a health care social worker was $37.09 an hour. A clinical psychologist, who needs a graduate degree, made about $64.82 an hour that year but a school psychologist with the same level degree netted only $46.72, below the salary of a registered nurse who clocked in at $51.26 and needs just an associate or bachelor’s degree. Psychiatrists net about $129 an hour, more than the average family medicine physician at $99 an hour but less than an emergency medicine physician at $147 an hour.

Fabrick, at Oregon’s health agency, said that during the pandemic, patients’ health care needs got more severe and providers burned out of the mental health system, much like in other areas of health care.

“There’s not enough providers, there’s not enough access in Oregon,” Fabrick said. “And then you have these high acuity, high complexity patients that are coming in for services. So I think that that is all just kind of hitting a crescendo.”

Porter Clements, president of the AFSCME Local 1790 union which represents Portland area behavioral health agencies, said the group is struggling most with turnover. Some agencies have reported turnover as high as 250%, Clements said, meaning that over the course of a year an average of 2.5 people cycled through a single position.

Oregon’s unlicensed providers, the segment of the workforce that is the most racially and ethnically diverse, are also the most susceptible to turnover, state reports have found.

Wage surveys by the Mental Health & Addiction Certification Board of Oregon show that mental health peer support workers reported making $18.24 in 2021 and mental health associates about $21.

“We’re hoping that people will stay in the career, but unlike physical health, because the wages are extra, extra low, it may be easier to go get a job in a different industry that’s less stressful, that pays more money more quickly,” Jefferis said.

RURAL AREAS HAVE SEVERE NEEDS

In rural northeast Oregon, a patient who calls the Community Counseling Solutions network of clinics and needs to see a mental health provider could wait two weeks for an appointment. People in crisis get in right away, said Kimberly Lindsay, executive director of the mental health nonprofit that serves Grant, Morrow, Wheeler, Gilliam and Umatilla counties, but she’d like the wait time for first-time visitors to be shorter. Five years ago, wait times were closer to one week.

“The extension of the wait time puts people off. We probably have more people that go into crisis because they’re not being seen as timely as they need to be in the beginning,” she said.

Lindsay said wait times would be better if all of her positions were filled. She said she appreciates that the state has helped her retain staff with rate increases that mean more pay and also given her more money for new positions – but still, she struggles to hire. Applications have gone down, she said. Clinics that require in-person help are competing with telehealth companies for workers. She’s lost applicants who don’t want to live in the rural communities, or who accept the offer, but then can’t find housing in the area.

Workforce issues, coupled with escalating demand for services have left her feeling “like the wind is knocked out of our sails,” Lindsay said.

On her listening tour across the state. Gov. Tina Kotek heard loud and clear about the housing shortage’s role in the behavioral health care staffing challenges, she said. She’s also heard from workers in the field who say they need more financial aid for mental health education, and that the state needs to process license applications more quickly.

“We need to take care of the people who are taking care of our most vulnerable,” Kotek said in a statement to The Oregonian/OregonLive. “These are workers we can’t afford to lose.”

A September report from Oregon’s Office of Rural Health found that Oregon as a whole has 1.15 full-time mental health providers per 1,000 people. But the state’s rural and frontier areas only have .5 full-time employees in comparison.

The five-county area that Community Counseling Solutions serves has some of the sparsest mental health staffing in the state, according to data from the Oregon Health Authority. Grant County had just one licensed counselor for 24,130 people in 2022. Wheeler and Gilliam counties had no licensed counselors or psychologists. The organization leans on unlicensed master’s level clinicians to provide services, which “saves rural parts of Oregon,” Lindsay said.

“It’s much worse than urban areas,” said Heather Ficht, executive director of East Cascades Works, which serves 10 central Oregon counties. “Yes, there are tons of people in urban areas. This is true. Do they have all the services they need? Absolutely not. But if you’re in a rural or frontier area, instead of having fewer services, you have no services. And that is not equity.”

Charlie Tveit, CEO of Lake County Health District in south-central Oregon also struggles to hire and retain workers, particularly in the more remote parts of the county’s 8,000 square miles. When a therapist left the remote northern part of Lake County, it took the district several months to find a replacement, necessitating Zoom calls and less-frequent visits from a traveling provider who filled in temporarily.

Amy Theall, the only psychiatric nurse practitioner in the county, manages a caseload of about 400 patients. Theall says she feels the impact of workforce shortages when she tries to help patients enroll in therapy to complement their medications. The wait list can stretch for a month, Theall said. And, given small-town dynamics, clients in the rural north may know the sole provider in their area on a personal level, Theall said. To keep things professional, they might have to drive hours to see a therapist in Bend or Lakeview instead.

OREGON SHORT ON PROVIDERS OF COLOR

Paula Peña noticed in 2018 that one of her teenage sons was avoiding mealtimes.

The then 16-year-old, who is Lipan Apache and Latino and practices both Catholicism and his Indigenous faith, had a gaunt look. She could see his cheekbones. A visit to her son’s pediatrician revealed that he was struggling with bulimia, anorexia and body dysmorphia. The pediatrician referred Peña and her son to an eating disorder clinic in Portland, she said. They spent several afternoons a week commuting to the clinic from Salem. But instead of getting better, her son seemed to get worse. The therapists and team at the clinic were all white females serving a primarily white female clientele, Peña said, and her son didn’t feel like they understood him. He left the Portland clinic without getting the help he needed, Peña said.

“As a mother, it is heartbreaking to seek help for my child and encounter a system that is not equipped to see and understand him as a whole person, including how his culture and his religion affect his experience,” Peña wrote in a letter to state lawmakers in 2021, urging them to fund more culturally responsive mental health providers.

As of 2020, just 4.7% of Oregon’s behavioral health workforce identified as Hispanic or Latino, compared to about 14% of the state’s population that year, according to the Oregon Health Authority. Other populations were also dismally represented. Just 1.3% of behavioral health workers were Black compared to 2.3% of Oregonians.

Oregon’s efforts to hire more behavioral health providers have emphasized addressing this discrepancy. In the past two years, state lawmakers have funneled more than a billion dollars into the behavioral health system, including $132 million in grants to help service providers stabilize their workforce and $80 million for workforce development, Fabrick said. The workforce funds have paid for housing stipends, scholarships and tuition reimbursement, bonuses and help with licensing and certification fees. More than $16 million went to loan repayment.

Fabrick said early results are promising. Mental health agencies have reported an up to 35% drop in vacancies, she said, and most grants are going to workers from underserved communities. Upwards of 30% of newly certified mental health providers are people of color, Fabrick said, and the majority of agencies that got money to boost supervision of newly trained workers or peer support services are ones that deliver culturally or linguistically specific services or serve rural communities.

In some cases, demand for those funds far outpaced supply. More than 2,300 people applied for the state’s loan repayment program for behavioral health workers, but there was only enough money for 12% of them. The average award was $60,000, Fabrick said. Roughly 70% of recipients were providers of color and a quarter lived in rural areas.

Marion County nonprofit Fortaleza Atravez Barreras, which focuses on improving access to mental health care for communities of color, used one-time state funds to help pay 15 new peer support specialists, many of whom are bilingual and bicultural, to undergo training this year, founder Lucia Mendoza-Meraz said. The community-based organization also developed a peer support training in Spanish and hosted a wellness retreat for peers of color to help prevent burnout.

“It is still not enough,” Mendoza-Meraz said, adding that providers of color still face barriers to accessing higher education. Once in the workforce, those caregivers are often underpaid and overworked due to the high demand for culturally-specific services, she said.

MYRIAD SOLUTIONS IN THE WORKS

Several Oregon universities have set their sights on training Oregon’s next generation of behavioral health workers.

The University of Oregon recently launched the Ballmer Institute for Children’s Behavioral Health, which aims to train a new workforce of undergraduates who will graduate ready to treat Oregon’s children, without going through lengthy and expensive postgraduate training. The certification or licensing process for those students has yet to be established, but Ballmer hopes to eventually graduate around 200 students a year.

Portland State University also plans to use $2.4 million from the state’s Future Ready Oregon workforce initiative to launch a new training track. Its human services degree program will prepare behavioral health and substance abuse counselors as Portland grapples with a scourge of cheap fentanyl and other dangerous drugs. The program will give students credits for their work experience or prior credentials, with the aim of allowing them to earn degrees more quickly. Current and prospective students work in entry-level positions in mental health agencies, nonprofits or the state Department of Human Services and could use those existing experiences toward their degrees.

Mt. Hood Community College has for several years been on the front lines of training the next generation of mental health workers.

Students in its associate program can enter the field quickly as drug or alcohol counselors or climb through bachelor’s and graduate programs to become licensed clinical workers and psychologists. Program Director Karen Green, a former school social worker of 16 years ran into her own challenges with burnout, she said, and wanted to teach in a program where she could help prospective mental health workers learn self care.

“If you thought you were going to get a degree and go out there and fix people, that would lead to burnout pretty darn quick,” Green told her class on Wednesday. Over the next two years, students will learn theories and interventions to work with clients, she said, and how to hold space for their clients to naturally heal.

Community college felt like a safe place for Nikki Phetmany to start her journey in the mental health field. She works as a behavioral health coordinator at a pediatric clinic near Mt. Hood’s Gresham campus and, after assisting the social workers, wanted to be able to offer the kids more support herself. While Phetmany plans to go all the way through a master’s program to get her license in clinical social work, starting at a two-year school means less debt, and less consequence, if she decides it’s not the path for her.

“I think that the community school route makes it less intimidating,” Phetmany said.

A social work degree will give Phetmany options in the mental health field, she hopes, but she’s also planning to get licensed so that she can offer individual therapy. As an adolescent, she struggled with emotional regulation, needed help managing her anger and her depression, and felt guilty about being sad. She wants to help teenagers build coping skills, so they don’t have to feel the same.

“I don’t want little kids or teenagers to be as upset as I was,” she said. “I want to be that person’s advocate to advocate for themselves.”

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Sami Edge covers higher education for The Oregonian. You can reach her at [email protected] or (503) 260-3430.