Tag Archives: Professional Issues

Professional Issues

A closer look at the mental health provider shortage

Compiled by Lindsey Phillips May 8, 2023

Help wanted sign taped in window

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The current state of mental health care in the United States is troubling. Mental health organizations are understaffed. People are unable to access or afford mental health services. Counselors are overwhelmed with high caseloads, and many are leaving the field in search of better pay and work-life balance. And that was before the COVID-19 pandemic, which has only amplified the mental health crisis and provider shortage.

According to data from the Kaiser Family Foundation, 47% of the U.S. population in 2022 was living in a mental health workforce shortage area, with some states requiring up to 700 more practitioners to remove this designation. The reasons underlying this shortage are complex, causing many mental health professionals to feel there may be more challenges than solutions to this growing problem.

Counseling Today recently invited several mental health professionals to share how the shortage is affecting their communities and what steps they think the counseling profession needs to take to address this issue.


5 reasons for the provider shortage

By John Cordray

With more people realizing the importance of mental health, the demand for licensed mental health therapists has skyrocketed in recent years, especially after the COVID-19 pandemic began. Unfortunately, the United States is facing a critical shortage of these professionals, leaving many individuals and families in distress without the help they need. This shortage is creating a ripple effect throughout the health care system, with it becoming increasingly difficult for people with mental health issues to access the care they need.

The causes for this shortage are multifaceted and complicated, but here are five key reasons for the shortage of licensed mental health therapists in the United States:

  • Lack of funding: The government provides a limited amount of funding for mental health services and counseling. This lack of funding is one of the major contributors to the shortage of mental health therapists. Many mental health providers must rely on private insurance or self-pay to cover their services.
  • Poor reimbursement rates: Mental health providers are often not adequately reimbursed by insurance companies or government programs. This leads to low provider reimbursement rates, which can deter providers from entering the field or remaining in it.
  • Low retention: The current number of mental health professionals does not meet the needs of the population. This is due in part to the low reimbursement rates, but it also is caused by the fact that mental health is not a particularly attractive profession to younger generations because of the stigma associated with it.
  • Increased need for services and limited access to care: The increased demand for mental health services is outpacing the supply of providers. In addition, clients, especially those in rural areas, often have limited access to care because of a lack of public transportation or proximity to a mental health facility. And mental health providers often choose not to work in rural areas because of poor reimbursement rates and low pay. These factors can prevent people from getting the treatment they need.
  • An aging workforce: Many of the mental health professionals in the United States are nearing retirement age. Low counselor retention also means that as these professionals retire, they are not being replaced by younger professionals at the same rate, creating a shortage in the field.

These are just a few of the reasons for the shortage of licensed mental health therapists in the United States. The lack of access to mental health care and the inadequate reimbursement for providers are causing a great deal of distress and difficulty for those who need mental health care. It is important to take action to address this provider shortage and ensure that those suffering from mental health issues can receive the care they need.

John Cordray is a licensed professional counselor in private practice in the St. Louis metro area and the founder and CEO of the Mental Health Community, an online community for mental health professionals to connect, network and find jobs. He also hosts the podcast The Mental Health Today Show. Contact him at johncordray.com.

The impact of COVID-19 on the provider shortage

By Krystyne Mendoza

The COVID-19 pandemic led to a cascade of changes in our lives: The way we worked changed; the way we went to school changed; the way we communicated changed; the way we lived changed. The ramifications of such change cannot be understated. In the 2022 article “Two years of trauma,” published by Georgia State University Research Magazine, Noelle Toumey Reetz said that the COVID-19 pandemic was “the most traumatic collective event of our lifetime.” And just as with any traumatic event, we are only beginning to uncover the devastating effects.

One of those effects was the profound need for mental health care. According to a Kaiser Family Foundation report published in 2021, the percentages of those in need and without access to mental health care was astonishing, with cost, lack of insurance coverage and lack of providers named as notable contributing factors. The issue of access has been exacerbated by the dramatic shortage of mental health care professionals.

The pandemic not only sparked an increase in mental health problems for children, adolescents and adults but also negatively affected the mental health of mental health professionals themselves. The ways we communicated with others, offered services to clients, and sought and provided counselor education were rapidly moved to online modalities, despite many practicing clinicians having no previous experience with these modalities. A 2021 report by the National Council for Behavioral Health notes that low pay, increased client loads and restrictions in the way services could be offered quickly led to burnout for many mental health professionals, further deepening the shortage. And an estimated 122 million Americans, or about 37% of the U.S. population, live in areas with a mental health professional shortage, according to a 2021 article published by USAFacts.

During the pandemic, the Department of Counselor Education and Counseling Psychology at Marquette University became acutely aware of the devastating effects of the provider shortage because areas in northern and western Wisconsin were, and continued to be, in extreme need. Even now, we recognize that there are too many populations underserved and too many organizations understaffed. Evidence also shows us that the pandemic has had a more devastating effect on marginalized populations.

The COVID-19 pandemic initiated many negative changes, but it also promoted a paradigm shift, highlighting new modalities in which counselor education and mental health services could be delivered. So we honored our commitment to social justice and diversity, led by our Jesuit principles, and started an online version of our clinical mental health counseling program that aims to help reduce this shortage and address the growing need for mental health care.

In designing the program, we intentionally thought about the barriers that prevent students from obtaining a degree and took an active stance to address those obstacles. Specifically, we designed our program for working adults, creating a part-time program that can be completed in three years. We also offer courses later in the evenings to accommodate working adults because many students from marginalized populations must maintain full-time employment. And because the program is all remote, students do not have any travel expenses. This allows us to reach underserved areas in a multidimensional way: We train students who live in rural and underserved areas, which ultimately increases access to mental health care within those areas.

The program has consistently and substantially exceeded our initial enrollment expectations since it launched in fall 2021. The program’s success can be attributed to several factors, including our focus on social justice and diversity, the innovative class structure, dynamic instruction and, of course, our incredible students. As a result, we have hired additional faculty members, developed new and exciting curriculum and expanded our outreach efforts to reach a larger audience throughout the United States. We are poised to continue this growth and make a positive impact on the education of students across the nation, ensuring that all people have access to the mental health services they need and deserve.

Krystyne Mendoza is a clinical assistant professor of counseling at Marquette University and a licensed professional counselor in Texas and Colorado.

Professional sustainability in the mental health field

By Cort M. Dorn-Medeiros

It’s hard to discuss mental health treatment without addressing the prominent elephant in the room: a massive shortage of mental health providers. In my city of Portland, Oregon, agencies and private practitioners monitor lengthy waitlists, sometimes up to six months. Youth mental health services are even more scarce. While we may all want to dismiss this shortage as another victim of the COVID-19 pandemic, I encourage a slight change in perspective.

Although COVID-19 may have forced the issue, mental health providers, particularly those working in agency settings, had long struggled within an unsustainable system. Examples of such struggles include:

  • Increasing client caseloads
  • Costly fees associated with licensure and credentialing
  • Low compensation and fewer benefits
  • Hefty student loan payments
  • Rising costs of living in most areas of the country

Before becoming a counselor educator, I worked as a licensed mental health and drug and alcohol counselor in various nonprofit agency settings between 2009 and 2015. During this time, I mostly managed moderate caseloads of court-mandated clients. When I was first hired in 2009, I earned $18 an hour with full benefits, and the agency paid for my required prelicensure supervision. Although this may seem like getting paid in peanuts, it was close to 14 years ago, and the cost of living here in Portland was rising but had not yet peaked to the mind-numbing heights they are today. After I became a licensed professional counselor, the same agency hired me for a different position, and my compensation jumped to an annual salary of $57,000.

So, imagine my surprise when sitting in an internship supervision class in 2017, I learned that one of my graduating students had just been offered a position with my previous employer. Her starting salary? $18 an hour. The agency could also not guarantee to cover her prelicensure supervision. I was stunned.

Let me add that my former employer was one of many nonprofits offering low starting salaries for master’s-level counselors. Our internship class spent a long time discussing the frustratingly low pay and reduced benefits for new graduates. And this discussion happened well before COVID-19 was a blip on the national map.

I don’t share this story to speak ill of agencies or agency-type work. I am incredibly grateful for my experiences working in nonprofits, the community relationships I built, and the knowledge I gained working with a widely diverse clientele. The gratitude I hold is also what I find the most frustrating. I want my students to have the same opportunities I did. But over the years, I have seen a significant shift with new graduates choosing to enter private or small group practices rather than work for agencies. And I cannot say I wouldn’t do the same if I were graduating now.

This shift, however, has caused many local agencies to be understaffed, which became a critical issue during the pandemic. The mental health crew was already abandoning the ship when the tidal wave took it out.

On the positive side, the impact of COVID-19 has forced the hand of change, at least here in the Portland metro area. During the past three years, many agencies have unionized, which has allowed them to negotiate for higher starting salaries, regular salary increases and better benefits. Some agencies even began offering sign-up and referral bonuses. And changes to state regulations now allow private practitioners and agencies to see Oregon-based clients via telehealth.

While there remains some debate about the efficacy of telehealth compared to “traditional” in-office settings, telehealth no doubt helps expand provider capacity, and it offers much-needed services to rural parts of the state. Additionally, telehealth provides a lower-cost option for counselors who desire to do private practice, need to work from home or need more job flexibility.

A lack of focus on and appreciation for sustainability in the mental health field is the root cause of our workforce shortage. Band-Aid solutions are not solutions. As a counselor educator, it is my responsibility to help my students negotiate the often-fraught landscape of being a new professional. Shortages in the mental health workforce have provided more opportunities for recent graduates than we’ve seen in many years. But it’s our job as a profession to make them want to stay. I encourage my fellow counselors and mental health employers to make professional sustainability in the workforce a priority. A sustainable workforce is a maintainable workforce.

Cort M. Dorn-Medeiros is an associate professor and chair of the Counseling, Therapy, and School Psychology Department at Lewis & Clark College. Dorn-Medeiros is also a licensed professional counselor and certified alcohol and drug counselor (level 3) in Oregon. Contact him at dorn-medeiros@lclark.edu.

Counselor access and retention in rural areas

By Cassandra Armas and Candice Rodriguez

Western Colorado attracts many tourists throughout the year because of its beautiful scenery and abundance of outdoor activities. But those of us who live here see another side: residents who are trying to live their lives and cope with mental health challenges while faced with numerous obstacles such as high cost of living, lack of affordable housing, lack of accessible mental health resources and poor retention of mental health providers.

Challenges as a mental health provider

The cost of living in rural western Colorado has been steadily increasing over the past couple of years; however, since the COVID-19 pandemic, this dire situation has worsened. As mental health professionals we are witnessing firsthand the toll that it has on the overall mental well-being of the community, including mental health providers. Because of the low pay and high cost of living, some mental health providers obtain second jobs to make ends meet.

The increase in the cost of living has also made it difficult to attract and retain mental health providers, especially school-based ones. The current counselor ratio in our area is 470 people to 1 clinician. This troubling ratio not only makes it difficult for community members to access mental health care but can also lead to provider burnout. Many mental health providers are finding themselves feeling overwhelmed because of an increase in client referrals, which then results in limited availability or a waitlist.

Black woman at work with laptop and a stack of files and papers. She has taken off her glasses and is rubbing her head. Overworked.

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We would also like to highlight the unique challenges that many Spanish-speaking providers may face because of the high need of bilingual therapists in western Colorado. Spanish-speaking providers are currently struggling with being able to meet the high demands of service. These providers are often booked two to three months in advance because of the rise in demand. Additionally, Spanish-speaking providers may receive referral after referral with little to no room on their caseload. This lack of Spanish-speaking providers means some individuals who prefer or need a therapist who speaks their native language may go without treatment or they are put on a long waitlist.

All these challenges are leading to burnout and causing providers to relocate or potentially change careers.

Challenges as a community member

The communities in rural western Colorado have dealt with a shortage of mental health services for many years. And even though there have been great efforts to increase access to mental health services, especially in schools, the problem still exists — with no end in sight. Accessing mental health care in our area requires being insured or having the financial means to afford mental health care. Even though there are programs that provide financial assistance for therapy, families who are barely living above the poverty threshold often don’t meet the eligibility requirements.

Even if people in our community can afford therapy, they face another challenge: finding providers who have immediate availability. They often have to wait weeks and even months to meet with a mental health provider. This delay in access increases feelings of hopelessness and defeat, which deters people from continuing to seek mental health support. We have heard many clients say, “I have exhausted all resources. I don’t know what else to do.”

Possible solutions

In a perfect world, the dichotomy between the rich and the poor would not exist and access to affordable and quality insurance would be available to everyone. However, not all hope is lost; there are potential solutions that can help solve some of the challenges we mentioned.

First, rural communities in Colorado are in need of affordable housing for both mental health professionals and others in general. Second, we need to create more programs or provide incentives to attract and retain mental health professionals. Increasing the pay for mental health professionals would prevent the need to seek multiple jobs to keep up with the cost of living. In turn, this would help decrease burnout and exhaustion. Retaining more mental health providers would also help decrease the 470-1 ratio and provide more access to mental health support in rural communities. Finally, providing access to bilingual education for providers interested in learning a new language would also improve mental health access for Spanish-speaking community members.

There will always be gaps, difficulties and challenges in the mental health profession, but it is important to continue bringing light to the existing issues contributing to the provider shortage, which is negatively affecting both therapists and the community, especially in rural areas like ours. With continued team effort and advocacy, we can make improvements to tackle these issues.

Cassandra Armas is a bilingual licensed social worker specializing in anxiety, depression, immigration trauma and LGBTQ+ issues. She was born and raised in rural western Colorado and is currently providing school-based mental health services for Your Hope Center in Eagle County, Colorado.
Candice Rodriguez is a licensed professional counselor whose passion is to provide trauma-informed care utilizing eye movement desensitization and reprocessing. She relocated to western Colorado from Chicago five years ago and is currently a school-based clinician for Your Hope Center in Eagle County, Colorado. She also provides teletherapy through her private practice, ALMA Counseling. Contact her at candicerodriguez@almacounseling.com.

Preparing counselors to work in rural and medically underserved communities

By Amanda M. Evans

Despite an increasing need for counselors throughout the United States, rural and medically underserved communities may be especially desperate for qualified and effective helping professionals. According to a 2020 report by the Health Resources & Services Administration (HRSA), “historically, rural and medically underserved communities have less access to care, lower or disrupted service use, and poorer behavioral health outcomes,” and these communities “experience obstacles to obtaining behavioral health services, including availability, accessibility, affordability, and acceptability, which result in distinct mental health disparities.” (Find data on medically underserved areas and populations here.) In some instances, individuals in these communities may need to visit the emergency room to disclose their behavioral health issues or forgo treatment altogether due to an absence of helping professionals and high medical costs.

Virginia consists of many rural and economically high-need communities that lack the professional personnel to develop and implement behavioral health care services. The state of Virginia has 1,034,447 residents who reside in rural communities. The median family income for these residents is $39,562, which is $18,237 below the state average. According to data from Mental Health America, Virginia ranked 47th in resident access to behavioral health care and 40th in uninsured individuals who have a diagnosed behavioral health disorder.

The lack of mental health services and health disparities is negatively affecting youth. In Virginia, approximately 10.8 million children, adolescents and transitional-age youth are experiencing a behavioral health disorder, and suicide is the second-leading cause of death among adolescents and transitional-age youth in the state.

Because of Virginia’s inability to provide appropriate and accessible services to address the behavioral health needs of constituents, behavioral health disorders stemming from previous trauma experiences are also increasing. Federal and state systems are overextended. Within the past three years, Virginia has experienced increased reports of hate crimes, increased risk of postpartum behavioral health disorders, overwhelmed hospital systems trying to serve individuals in crisis and higher incarceration rates of female offenders. Without a plan for prevention or early intervention, Virginia will continue to experience a behavioral health epidemic.

The Department of Graduate Psychology at James Madison University (JMU) decided to take steps to address the behavioral health provider shortage many rural areas in Virginia face. With a $1.6 million grant from the HRSA Behavioral Health Workforce Education and Training program, JMU started the Rural Interdisciplinary Services and Education: Unlimited Potential (RISE-UP) program, which is a specialized and interdisciplinary training program that aims to increase the behavioral health workforce in rural and high-need communities. I serve as the principal investigator for this project, along with Michele Kielty, Tammy Gilligan and Kelly Atwood, who are co-principal investigators.

Through the RISE-UP program, JMU intends to train 100 practicing clinical mental health counseling, school counseling and school psychology students over a four-year period (from 2021 to 2025) to better serve rural and medically underserved communities, with an exclusive focus on primary and behavioral integrated health, interprofessional team-based trauma-informed care and rural health. Leveraging established long-term relationships, the grant team has partnered with local community mental health centers and school systems to offer a clinician training program that focuses on rural health outcomes and reducing health disparities for children, adolescents and transitional-age youth.

Some of the RISE-UP grant funds provide practicing RISE-UP students a $10,000 stipend to offset the costs of traveling to rural communities for their clinical internship experience. In addition, the grant has allowed us to develop and implement RISE-UP training modules, which share best practices for helping professionals who work in rural and medically underserved communities. This free online continuing education program is available to all practicing counselors in the state of Virginia.

The graduate students enrolled in the RISE-UP program are also reminded of the value of interdisciplinary collaboration: School-focused students (those enrolled in the school counseling and school psychology program) must volunteer in community centers for a portion of the program, and community-focused students (those enrolled in the clinical mental health counseling program) must volunteer in school-based settings for a portion of the program. The RISE-UP team agreed that behavioral health issues are best addressed when clinical professionals are collaborative and integrative.

As we finish the second year of the grant program, the evaluation team created and is currently testing an assessment to track rural health barriers and outcomes by soliciting feedback from participating communities. The data from this assessment can be used to address sustainability efforts in the RISE-UP community and support other professionals who share an interest in rural health and reducing health disparities.

We believe that this training program and the interdisciplinary focus is helping to prepare our students in important ways. This program also helps to mitigate some of the complex and multidimensional barriers experienced by rural populations, including access to qualified professionals, long waitlists and the potential for dual relationships, by offering a free mental health provider who can readily serve clients to reduce stigmas and address presenting behavioral health concerns. As of March, the RISE-UP Program has provided almost 27,000 hours of free direct and indirect clinical services to rural and medically high needs communities in Virginia.

Amanda M. Evans is an associate professor in the Department of Graduate Psychology and the principal investigator of the RISE-UP program at James Madison University.

The shortage of black mental health professionals

By Chris Gamble

Black people make up a relatively small portion of the mental health workforce nationally. Even working in a city as diverse as Washington, D.C., I’ve had my fair share of experiences where parents who preferred their children work with a Black male therapist were relieved when they found me.

It’s difficult to find definitive numbers for how many Black mental health professionals there are. Media outlets often only report on the numbers in select disciplines (such as psychology or psychiatry), and other sources of workforce statistics lack quality data collection methods, making the true nature of the supposed shortage of Black mental health professionals unclear. This makes developing strategies for strengthening the pipeline of Black mental health professionals even more challenging.

Although we don’t know how many Black providers there are or what the desired number would be, it is worth exploring what is being asked of those who do join the mental health field. The call for more Black therapists generally centers on the need for more culturally responsive care for Black people seeking mental health services. What does this really look like though? While there is a higher likelihood a Black therapist will share cultural reference points and understandings with Black clients, thus easing the relationship-building that is key to therapy, it’s not guaranteed since we are not a monolith. There is also the potential for Black therapists to offer helpful analyses of structural and systemic impacts on mental health. Again, even though oppressive forces in society target Black people indiscriminately, we don’t all have a shared understanding of the social situation.

Acknowledging the diversity within Black communities helps us rethink some of the motives behind recruiting new therapists, but making mental health careers attractive and sustainable for Black people will involve a few more steps. First, we need to continue strengthening the networks of Black mental health professionals already in the workforce to prevent burnout and support the clinical and scholarly work being done. Racism in the workplace, shared oppression with Black clients and undervalued intellectual work all make maintaining a career in mental health challenging. Black people joining the field need to know that we are here and willing to support them through these obstacles.

There also must be support for Black therapists and clients from providers of other identities. We must further our efforts to ensure all mental health professionals practice culturally responsive care. Recruiting more Black people into the field does not relinquish the responsibility of others to provide care in ways that do not cause harm.

Next, efforts to overhaul pay structures for all therapists should acknowledge the unique position Black therapists may find themselves in. On average, Black college graduates already have a higher average student loan debt than white graduates, which can deter them from a field known for its low pay. For those already in the field, we need to interrogate how additional emotional and intellectual labor can be fairly compensated. For instance, providing care to Black clients who face the same oppression you do takes additional emotional labor that is not typically considered by insurance companies, grants, private equity or other funding sources. Likewise, Black mental health professionals in academia who are producing scholarly work aimed at creating culturally responsive approaches are not always compensated in ways that reflect the weight of essentially overhauling the way the profession is practiced. Centering the needs of Black mental health professionals offers a lens to the conversation around pay that can ultimately benefit everyone, as workers start to understand ways of valuing their work based on what it takes to produce the outcomes of their labor.

Finally, creating a strong pipeline of Black mental health professionals requires us to recognize that therapy, especially in its traditional formulations, is not the only answer to addressing mental health. Particularly for marginalized communities, the social determinants of mental health play a significant role. We already know about the intersections between mental health and things such as urban planning, climate change and food access, so we should be growing our interprofessional collaborations with people in these sectors. This focus on preventative, upstream interventions can let prospective Black mental health professionals know that they can get creative in applying their training and skills to address issues beyond the therapy room, thereby expanding their career options. With racial trauma spreading unabated against a waning fervor around anti-racism and opportunities to build self-esteem by learning accurate Black history continuing to shrink, there is no better time to develop a robust Black mental health workforce.

Chris Gamble is a licensed professional counselor, national certified counselor and certified clinical mental health counselor based in Washington, D.C. He is also a burgeoning independent author, writing about mental health topics through his publishing company, Blank Passage. His debut novel, Tales of a Black Therapist, releases this summer. Follow him on Instagram
@chris_thecounselor or contact him through his website.

Challenges with funding, financial incentives and stigma

By Haley D. Papajohn

Several factors contribute to the shortage of qualified mental health providers in the United States. One of the major causes is inadequate funding for mental health services, particularly for those who are uninsured or underinsured. Decades of health policy have failed to appropriately prioritize spending on mental health, so funding for mental health services is lower than funding for physical health services. In turn, this disparity in funding has resulted in a shortage of quality mental health providers.

This lack of overall funding feeds into another issue: a severe lack of financial incentives to become a mental health provider. Mental health professionals are often paid less than other health care providers because their services are often deemed a lower priority service by insurance carriers and benefits managers. This lack of financial incentive makes it difficult to attract and retain qualified mental health providers.

Stigma about mental health also affects the provider shortage. Many people are still reluctant to seek help for their mental health issues because of the stigma attached to it, a dynamic that can be even more pronounced for people from certain cultural and ethnic backgrounds. This reluctance to seek help affects the mental health provider shortage in two ways: First, it leads to an underestimation of demand in any given community as individuals are not forthcoming with their mental health needs. Second, it can result in people only seeking help when they are at or beyond their breaking point, which increases the overall complexity and time needed to address their mental health concerns.

Mental health providers are already under a significant amount of stress because of the nature of their work, and the shortage of mental health providers only exacerbates this stress. Mental health providers are forced to work long hours and see a high volume of patients, which can lead to burnout.

The shortage also limits the range of services that mental health providers can offer and how many patients they can see. These limitations result in people not being able to receive the care they need or having to wait weeks or even months to see a mental health provider.

There are several solutions that can be implemented to address the shortage of mental health providers. The first and most obvious solution is to increase funding for mental health services. This increased funding could be used to attract and retain mental health providers, allow providers to service a broader geographic area, and reinforce their skill sets with ongoing training and education. The funding could also be used to increase awareness and promote the value of careers in the mental health space, which would attract more and higher qualified candidates.

Another related solution is to provide financial incentives for new and existing mental health practitioners. This could be done both by increasing the pay for mental health providers and by removing the barriers to payment, such as issues with insurance reimbursement. Increased pay would attract more people to the mental health field, help retain existing providers and allow counselors to offer new services to their patient populations.

To increase mental health access, we also need to reduce the stigma associated with mental illness. This could be done by increasing public awareness of mental health issues, normalizing the need to seek help, and providing mental health education at schools, workplaces and community organizations. Reducing stigma would allow us to adequately judge the demand for mental health services in any given market and allow people to get help sooner, thereby lowering the average complexity of mental health issues.

The shortage of mental health providers is a serious problem that needs immediate attention. The causes of the shortage are complex and include inadequate funding, lack of incentives and the stigma associated with mental illness. The shortage also poses challenges to existing mental health providers, including increased stress and limited options for patients. We need to implement solutions that tackle these challenges such as increasing mental health funding, providing financial incentives and reducing mental health stigma. By addressing the mental health provider shortage, we can ensure that all Americans can receive the care they need.

Haley D. Papajohn is a licensed mental health counselor in Florida. Contact her through her website.

How the shortage is affecting school counselors and youth

By Jessica Holt

Like other places in the United States, the state of Georgia has been affected by the provider shortage. A 2022 article published on WABE [the NPR and PBS affiliate for the metro Atlanta area] noted that 150 out of 159 counties in the state are considered mental health care professional shortage areas. And according to Mental Health America of Georgia, Georgia is ranked 48 out of 50 states for access to mental health care, resources and insurance, and 2 in 5 children in the state have trouble accessing the mental health treatment they need.

As a school counselor, I work with students to help them with social, academic and emotional problems. My goal is to help them be successful in the school setting and to function at their highest level. This is no easy task, especially when you consider other factors such as relationship issues, mental health issues, challenges arising from the COVID-19 pandemic and the nationwide mental health provider shortage.

Since the start of the pandemic, I have noticed an increase in the prevalence and intensity of students’ anxiety, depression, frustration and anger, especially when they become overwhelmed. Adjusting to changes brought on by the pandemic can be quite difficult when you consider that many adolescents do not have adequate coping or problem-solving skills.

When students feel this way, I help them a) identify triggers, b) identify solutions and c) learn relaxation skills (such as deep breathing, grounding and mindfulness). For many students, this works, and they learn how to handle problems and manage their anxiety. However, there are some students whose issues are so pervasive and severe that they need additional mental health services. While I cannot tell a parent/guardian they must take their child to counseling, I answer questions, provide support and give them a list of community providers/resources.

Last year, we had a school-based licensed professional counselor who was able to provide services to students who needed more care, but this year, that has not been an option because of turnover. The counselor doing this job left, and the position remains unfilled. Instead, I can only offer referrals to a local mental health agency that provides services at our school and in the community. This change from providing these services at the school to asking people to go to the local agency creates barriers for some families who lack transportation and are unable to get to the clinic.

Fortunately, the mental health agency was able to provide my school with a community support person this year. This person can work with students during school hours, but they aren’t credentialed to provide counseling services. Instead, they help students with skill building, problem-solving and other techniques. Not having a school-based mental health counselor has affected the students and the school counselors. My colleagues and I are feeling strained because we have to provide extra support to the students who have severe anxiety, depression and other mental health concerns. This can be challenging as we try to balance all of our responsibilities and our large caseloads.

The provider shortage can be attributed to several factors including high turnover (which has affected our school), inadequate compensation compared to other health professionals, problems with insurance covering services and elevated levels of burnout. Not only can this lead to mental health providers quitting or moving to other states, but it can also impact the quality of services they can offer when they are overworked and underappreciated. I am cautiously optimistic that increased mental health funding, student loan forgiveness and virtual mental health services can offer solutions that can address the mental health crisis and provider shortage we are currently facing.

Jessica Holt is a licensed professional counselor and a school counselor. She primarily works with middle and high school students to help them meet their academic, social and emotional needs.

Limited access to care and low pay

By John Patrick O’Neal

Two key issues with the provider shortage are limited access to care, which puts strain on providers, and inadequate pay and reimbursement. Limited access to care creates professional dangers such as burnout and compassion fatigue. Insufficient reimbursement generates poor counselor retention and overall discontent within the profession.

Access in rural areas

The people who have been most affected by the lack of mental health services are typically those in rural areas. In Idaho (where I live) and most of the American West, the category “frontier area” is used for remote, sparsely populated places where residents live far from health care, schools, grocery stores and other necessities.

I consult for a residential facility in Challis, Idaho, that is a frontier area. Although the county is physically larger than Rhode Island, it has less than 5,000 people. To put it into perspective, the closest Walmart is 150 miles away. The people in these communities are wonderful, independent and pleasant, but any type of health care (whether medical, dental or mental health) is limited since most people, including health care professionals, prefer to live in larger urban areas.

The question many counselors, especially those in rural areas, often wrestle with is, “How many clients can I have on my caseload and still provide quality care?” Some of the clients who are desperate to receive mental health care can also be some of the most challenging cases. When counselors are already struggling with their own self-care practices it can become a daunting task to take on more clients who have high needs.

Counselors who live in frontier areas also need to consider additional expenditures related to personal and professional travel since there are fewer resources in these communities. Some additional costs associated with professional travel include meeting with clients in their homes, participating in in-person trainings or maintaining professional relationships such as supervision or mentorships. Thus, financially it might not be feasible for counselors to live and work in these areas.

COVID-19 and population migration

The COVID-19 pandemic resulted in an increase in people working remotely and in nonspecialized work such as food delivery jobs, and this change led many people to relocate away from urban areas into more rural places. This has been the case in Idaho, where we have seen an influx of people since the pandemic began.

Part of the reason for this move is financial: The cost of living in Idaho is lower than in California or other major urban areas such as Seattle, Denver or Portland, Oregon. There is also an increased need for mental health services now because of the dynamics of working remotely and the stress that comes with this style of work. I’ve treated a few clients who are thrilled to be at home all day, but they experience agoraphobia when they need to leave their house to buy groceries or go to an appointment. The post-pandemic work habits of working remotely have also led to an increase in substance use because of the ease of accessing substances throughout the day. As a result, the demand for mental health and substance use services has risen, leading to gaps in care.

A financial problem

The underlying issues regarding the mental health shortage, of course, are complex and multidimensional. But maintaining a sustainable mental health workforce in this country will continue to hinge on the balance between the mental health of clinicians and their ability to produce income.

The bill-by-the-hour reimbursement format most agencies use is severely flawed. I’ve worked for these agencies in the past and it can be extraordinarily stressful. If a client cancels or a counselor gets sick, it affects not only the work with the client but also the counselor’s income, which can lead to more stress. The anxiety of a reduced income stream often translates into taking on more clients and risking the chance of counselor burnout.

I have also had the opportunity to work for an agency that was salary based. This is a much more equitable practice for mental health clinicians because it removes one more stressor from their lives. I also maintain a small private practice that is cash based and does not accept insurance for reimbursement, which has allowed me to have a bit more stability in income.

One possible solution to the provider shortage is for counselors to increase their business acumen and marketability. There are many benefits of having a counseling business, whatever scale that might look like, including having more control over one’s income stream and the clients that one sees. And while the counseling profession is waiting to see how the Counseling Compact changes accessibility across states, counselors can take initiative by gaining licensures in different jurisdictions. Some of my clients who have moved out of Idaho want to continue services with me, and when appropriate I have been able to continue seeing them by receiving a license in the state they moved to.

Counselors can also advocate to state and federal governments for increased reimbursement for mental health services. Having reimbursement rates match the level of skill, expertise and training counselors provide for their clients could increase counselor retention rates and lead to a healthier work-life balance.

The counseling profession is valuable in a time where there is so much distraction, trauma, addiction and heartache. Counselors have the skill set to manage these painful components of the human experience, but with the current counselor shortage people are at risk of increased suffering without treatment. The agency where I work says it well: “There is no health without mental health.”

John Patrick O’Neal is a licensed clinical professional counselor in Idaho and Arizona. He owns a small private practice and works for an outpatient agency in Idaho Falls, Idaho. He also consults for a residential substance abuse facility in Challis, Idaho. He is a doctoral candidate in counselor education and supervision, has a loving wife with four children, and tries to find balance between work and life.

Cultivating partnerships to address provider shortages

By Loni Crumb

The nationwide shortage of mental health providers is being felt in North Carolina. Out of the 100 state counties, 94 have been designated by the Health Resources & Services Administration as mental health professional shortage areas.

This shortage is more pronounced in rural areas where there are often not many mental health providers. The maldistribution, along with the nationwide shortage, has resulted in many unidentified and untreated disorders among children and adolescents, such as ADHD [attention-deficit/hyperactivity disorder], depression and anxiety.

In addition, transportation and financial barriers prevent children, teenagers and their parents from seeking help from the small number of specialty-trained professionals in these rural areas.

Partnerships between counselors, universities, schools, the community and other professionals provide one possible solution to address the mental health needs and provider shortages in rural areas. Here are a few examples of ways counselors can create partnerships within their communities:

puzzle pieces with missing one indicating need for partnership and collaboration


  • Clinical mental health providers can partner with local schools to provide school-based mental health services. This embeds mental health services in schools and helps youth access providers.
  • Universities and colleges can find creative ways to expand services to rural community residents. For example, East Carolina University’s counselor education program provides a variety of free and low-cost counseling services, resources and programs to students and residents in the surrounding rural community, which helps make professional services more accessible.
  • Counselor educators can create interdisciplinary partnerships with faculty in other fields such as medicine, nursing or education to co-develop programs that aim to address mental health provider shortages.

East Carolina University, for example, recently received a three-year grant that expands the statewide telepsychiatry program to more rural and remote areas to help youth receive specialized assessments and treatment using video conferencing technology. Counselors-in-training are embedded in primary care and pediatric practice sites to provide mental health services, which helps to remove help-seeking stigma, enhances compliance with appointments and allows expert consultation to rural youth and families.

The University of Oklahoma’s Project Rural Innovation for Mental Health Enhancement program is another example of a collaboration between a university and the community. Through a federal grant, this program covers the costs of training 64 school-based behavior analysts, counselors and social workers, and in exchange, these mental health professionals agree to serve two years in rural, high-need schools.

Another solution to provider shortages in rural areas involves clinical training. Counselor education programs can offer specific courses that provide counseling students with the skills and training needed for practicing in rural areas. East Carolina University’s counselor education program, for example, has a course that introduces master’s students to the practice of mental health counseling in rural communities using an integrated behavioral health approach. Course content covers the characteristics and concerns of diverse rural populations and the impact of using integrated, culturally relevant mental and behavioral health services with rural populations. This course focuses on teaching advocacy skills, including strategies to address institutional and social barriers that impede access to timely and adequate mental health care for rural clients.

Counselor education programs can also host professional development workshops. The counselor education faculty at East Carolina University has developed a workshop series to help address rural mental health provider shortages. One of the workshops — “How to start a private practice” — provides counselors-in-training with information and resources necessary to build their private practices in underserved, rural areas that experience ongoing mental health provider shortages. For this workshop, we partnered with the faculty in the College of Business Crisp Small Business Resource Center to co-lead discussions related to entrepreneurial skills, opportunity recognition, business modeling, and ways to launch and manage counseling businesses.

Economic development is key to building the mental health workforce in rural areas. Improving housing, transportation, career and educational opportunities in rural areas may help attract counselors to these areas who may start practices and launch programs to serve these communities. Moreover, rural schools are an economic driving force because these schools are often the largest local employer, and the presence of a school within rural communities is associated with increased housing values, employment rates and entrepreneurship as well as decreased income inequality, as noted by Kai Schafft in a 2016 article published in the Peabody Journal of Education. Thus, it is vital to cultivate partnerships with local schools, institutions of higher education, businesses and community organizations to improve access to mental health care, education and other essential resources for youth and their families living in rural communities across the United States.

Loni Crumb is an associate professor in the counselor education program at East Carolina University, a licensed clinical mental health counselor supervisor and the owner of Carolina Cares Counseling & Consulting PLLC in Greenville, North Carolina.

The systemic causes of the provider shortage

By Emily St. Amant and Derek J. Lee

Anyone who is tracking health care news in the United States will be familiar with the phrases “mental health crisis” and “provider shortage,” or the lack of qualified and available mental health clinicians to meet the growing need for mental health services. Even with telehealth options and people having access to care via remote services, there still aren’t enough providers to go around.

Discussions about the mental health provider shortage, however, often miss the mark and fail to include systemic causes and drivers of the problem. One main reason for the shortage is the fact that becoming a clinician requires a high level of personal privilege, namely financial resources and access to education. In addition, remaining in the field often comes with the financial and psychological impact of low pay and occupational hazards that can cause damage to one’s physical and mental health, which when combined are a perfect recipe for burnout. Consequently, many qualified providers are choosing to shift away from working in a direct-care role. We aren’t getting enough people in the door, and once they are in, we are not doing a good job of ensuring they have a thriving wage, a healthy workplace environment and other factors required to keep them there.

A 2022 U.S. Government Accountability Office report titled Behavioral Health: Available Workforce Information and Federal Actions to Help Recruit and Retain Providers highlighted three main factors keeping people from entering and staying in a behavioral health career:

  • Financial factors: Low third-party reimbursement rates and low salaries
  • Educational factors: Limited outreach to marginalized communities to encourage them to pursue a career in mental health
  • Workplace factors: Limited placement opportunities for paid internships in rural areas and a lack of licensed and qualified supervisors to oversee new interns and newly graduated professionals

This report also mentioned scholarships and loan forgiveness, outreach and mentorship, and telehealth as possible solutions to the provider shortage problem. These recommendations, however, do not address reimbursement, salary and costs associated with obtaining licensure, which affect everyone, especially people from marginalized communities. There has been no movement in improving insurance reimbursement and low entry-level wages, and there has been minimal action to address financial barriers in our field such as unpaid internships and the logistical and financial hoops of licensure, including the cost of supervision. To increase the number of available providers, the counseling profession must address the factors perpetuating a high financial cost of entry to access a career as a mental health provider — a career that often comes with a low return on investment.

Access to affordable care is vital to ensure that everyone receives the services they need. However, hyperfocus on this alone is problematic for two reasons:

  • Many people talk about health care as a human right, but solutions for affordable access often come at the cost of the individual provider.
  • This narrow focus on care access ignores the need to address the root causes driving the mental health crisis.

To be able to work in the mental health field, people without preexisting personal financial privilege must make a living wage just to survive and pay for housing, food, child care, health care and other necessities. And for counselors to stay in this career long term, they need a thriving wage, work-life balance, a healthy workplace environment, a diversity of tasks and ways to contribute, and autonomy over their work, to name a few. Of course, everyone’s needs and preferences will vary.

Working extremely hard for a very low wage has somehow become the cultural norm in the mental health field. This does nothing to solve the source of the problem, which is how severely underfunded social programs and health care are in the United States. We counselors have become complicit in our own oppression by not advocating for ourselves and our colleagues and allowing our labor to be exploited. We also risk becoming complicit in the oppression of the public if we fail to advocate for funding to ensure everyone who needs support can access quality and timely counseling services. Providers and consumers are being affected, and caring about both is not optional if we want to move forward and change course.

Additionally, the mental health crisis can’t be solved by focusing just on access to care. Counseling is a downstream intervention, but the societal problems causing the crisis are numerous and systemic in nature, and they start upstream. Not addressing macro-level factors enables the people and systems creating the problems in the first place. By not advocating for policies to address problems such as financial disparities, health inequities, gun violence, climate change, racism and bigotry, and adverse childhood experiences, counselors risk becoming complicit in perpetuating oppression.

When discussing the mental health crisis and the provider shortage, highlighting only individual-level solutions is something that enables the harmful status quo. It lays the oppressive burden of the work and responsibility of coping, healing and solving problems on people who didn’t create the problem and yet are the ones experiencing the impact. We must value the dignity, life, well-being and security of those who receive mental health services, those who provide said services and those who — with preventative measures — could potentially be spared avoidable suffering in the first place.

Emily St. Amant is a licensed professional counselor and board approved clinical supervisor (Tennessee). She serves as the counseling resources and continuing education specialist in the Center for Counseling Policy, Practice and Research at the American Counseling Association.
Derek J. Lee is the founder and CEO of Perrysburg Counseling Services and The Hope Institute. In addition to clinical work and administrative roles, Derek is finishing his doctorate in counselor education at Ohio State University and teaches in the Department of Clinical Counseling and Mental Health at Texas Tech University Health Science Campus.


Lindsey Phillips is the editor-in-chief for Counseling Today. Contact her at lphillips@counseling.org.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Advocacy Update: National strategy to address the mental health crisis

By Sydney Sinclair April 25, 2023

A woman sitting with her elbows on her knees. A man sits across from her on a couch.

Jacob Lund/Shutterstock.com

In February, President Biden delivered his annual State of the Union address, calling for bipartisan unity and emphasizing the need for Congress to work together on legislation to move America forward. Topics covered ranged from health care to economics, as the president highlighted bipartisan legislation that can unite us all.

In the speech, Biden emphasized his plan to continue to advance progress made on the Unity Agenda that he first introduced last year. The Unity Agenda is the administration’s strategy for harnessing historical bipartisan support in four policy areas: 1) combating the nation’s opioid crisis, 2) addressing the mental health crisis, 3) increasing health care access and support for U.S. veterans and 4) continuing the Cancer Moonshot initiative

Biden’s strategy to address the mental health crisis in America has the following three objectives, which are supported by the American Counseling Association’s legislative agenda.

  1. Create healthy environments for children and adolescents. Biden highlighted the importance of protecting and fostering the mental well-being of children and adolescents. ACA is in support of programs that make students safer at schools, improve school climate and improve access to mental and behavioral health services at school. The Student Support and Academic Enrichment Grant under Title IV-A of the Every Student Succeeds Act is a flexible block that is designed to ensure that school districts provide students with a well-rounded education, use technology to improve academic achievement and digital learning, and improve conditions for student learning.
  2. Expand access to mental health services via the Counseling Compact and the Mental Health Access Improvement Act. In his address, Biden stressed the need to make behavioral health care affordable and accessible to all Americans. Last year, the Counseling Compact met the 10-state minimum needed to trigger formal establishment for interstate license reciprocity. Portability expands access to mental health services and decreases shortages of providers in certain areas by allowing counselors to practice in other compact member states. The recent passage of the Mental Health Access Improvement Act is expected to close a widening treatment gap for Medicare beneficiaries by giving them access to more than 225,000 additional licensed mental health professionals. The Biden administration plans to allocate three times more resources to promote interstate license reciprocity for the delivery of mental health services across state lines.
  3. Strengthen system capacity by expanding the behavioral health care workforce. For the system to withstand capacity, a focus is made on recruitment, funding and researching the behavioral health workforce. In December, Congress voted to pass the 1.7 trillion-dollar fiscal year 2023 omnibus package known as H.R. 2617, the Consolidated Appropriations Act, 2023. Among the provisions included in the omnibus was the Mental Health Access Improvement Act (S. 828/H.R. 432), which will expand access to mental health services by allowing licensed professional counselors to be reimbursed by Medicare. ACA has since been working with the Centers for Medicare & Medicaid Services and other partners to implement rollout by Jan. 1, 2024.

ACA also continues to fight for the inclusion of counselors as mental health providers in the U.S. Department of Veterans Affairs and the Commissioned Corps of the U.S. Public Health Service. This would reduce wait times for veterans seeking behavioral health services and would expand career opportunities for counselors, as intended by the administration.

If you would like to become involved in ACA’s advocacy efforts, visit the Take Action page or contact the Government Affairs and Public Policy team at advocacy@counseling.org.


Sydney Sinclair is the government affairs coordinator for the American Counseling Association. Contact her at ssinclair@counseling.org.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Expanding the conversation on international perspectives and practice in counseling

By Nate Perron & Sujata Ives March 22, 2023

A group of adults sitting around a table with a world map in front of them


As counselors, we are in the business of listening. All the theories, techniques and applications of our training enhance our abilities to listen to stories and narratives with great skill and make a difference in the lives of others as a result. The International Committee (IC) of the American Counseling Association is committed to heightening our listening ability across cultural, national and other identifying differences. It is the elements of listening to stories and dialoguing toward understanding that lead to shared intercultural experiences.

Although you may not have heard of the IC, ACA’s rich history reveals an IC that has taken an active role in professional advancements within the organization over the past 25 years. Our hope is to enhance our active listening as professionals so that we may boost ACA’s ability to grow while contributing to global conversations regarding counseling and mental health.

The IC is composed of nine committee members, an associate chair and a chair, all of whom are ACA members with a passion for international issues in counseling. The committee chair is appointed annually by the incoming ACA president, the associate chair is appointed by the incoming and outgoing chair, and committee members are appointed to serve three-year terms. Policy 1110.1 of the ACA Policy Manual describes the IC’s responsibilities in detail: “The International Committee shall promote, respect and recognize the global interdependence among individuals, organizations and societies. The Committee shall build bridges and promote meaningful relationships between ACA and other organizations outside the United States. The purpose of international professional collaboration shall be to promote the commonalities across these international organizations and their missions.”

Counselors commonly embrace a commitment to lifelong learning and development as an ongoing professional process. In combination with the occupational posture of listening, lifelong learning offers counselors a vast well of knowledge from which to draw indefinitely. By exploring the development of counseling internationally, and among international professionals within the United States, we have a tremendous opportunity to acquire diverse skills and knowledge that can support our work domestically through application of multicultural best practices. This learning is optimized through relationships formed among colleagues. As the field of counseling continues to grow, so does the valuable input available from around the world. Hence, growth in our profession requires both active listening and lifelong learning.

Finding just the right word in English to convey the diversity of opinions, beliefs and systems of thought by which counseling may benefit from global contributions is likely impossible. While our committee focuses on international interests, the expansive growth of counseling might also be recognized as transcultural, intercultural, cross-cultural, intersectional, multicultural, and the list goes on. International dialogue provides exciting opportunities for counselors to make an impact in a variety of spaces and places.

Committee activities

The members of the International Committee at the 2023 ACA Conference & Expo in Toronto

The International Committee members at the 2023 ACA Conference & Expo in Toronto. Photo courtesy of Rong Huang.

The passionate professionals who make up the IC are committed to expanding the conversation from the starting place of international counseling to touch the real experiences of those providing and needing services all over the globe. In recent years, the IC has taken steps to increase collaboration across associations and raise awareness of international needs and issues within ACA, including among ACA divisions that have much to contribute to overall conversations surrounding transculturalism, interculturalism and belongingness.

Here are a few of the committee’s recent achievements:

  • Toolkits: Our immediate past chair, Mariaimeé Gonzalez, facilitated the development of toolkits to address specific counseling needs expressed around the world. The international toolkits will be made available on the ACA website as resources for increasing skills and awareness regarding international counseling needs and issues. ACA members and divisions will have opportunities to incorporate this toolkit information into their current practices. The toolkits address a variety of counseling issues with an international lens, including somatic symptoms of domestic violence, broaching, global trauma, obsessive-compulsive disorder across cultures, and global adolescent mental health. Another toolkit discusses how ACA can incorporate the United Nations’ sustainable development goals for 2030.
  • Professional developments: The IC collectively reviewed updates to the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) standards. We subsequently offered a list of recommendations to include with the changes that may enhance an international perspective.
  • Strategic advisement: As the Governing Council proceeded to develop the strategic planning process for ACA, the IC contributed further input for developing global mental health and community actions from an international perspective.

Ongoing ambitions

The IC remains committed to advancing the influence of international realities, both within ACA and beyond. The following items reveal the ongoing ambitions of the IC to continue making progress in these areas.

  • Association collaborations: The IC remains dedicated to solidifying collaborations with associations, whether they exist internationally or internally within ACA. Upcoming webinars and trainings are expected to reveal focused collaboration and development in addressing international needs relating to mental health and well-being. The IC has facilitated conversations with the International Association for Counselling (IAC) to advance one of these collaborative webinars in the upcoming months, with the intent of expanding discussion about international issues that affect people around the globe on a daily basis.
  • 2023 ACA Conference celebration: The international reception has long been a consistent element of ACA Conference proceedings. While these events have not always been widely known about or understood, the IC is working to use the international panel and the reception as tools to advance the discussion further within the ACA membership. Many people can be involved in efforts to increase transcultural awareness and practice, so anyone interested in growing their perspective will benefit from these conference events.
  • Establishing a stronger presence: To attract international professionals and increase the attention paid to international issues, the IC is developing procedures to advance the status of the committee to an organizational affiliate of ACA. This would provide further recognition to address some of the IC’s same goals but with expanded support and involvement from interested members of the overall ACA body. Many other international subgroups exist within ACA; providing a centralized point of connection so that people can expand their involvement has become a top priority of the current IC. This will also be a valuable opportunity to recognize foreign-born ACA counselors that practice in the United States and beyond.
  • Ongoing association recommendations: Additional projects remain on the horizon for the IC to contribute to ongoing efforts to integrate international counseling into the fabric of ACA involvement. The IC plans to expand the toolkit focused on sustainable development goals to promote the United Nations’ proposed goals within the policies of ACA and its divisions. Another activity will involve contributing recommendations to the universal declaration of counseling principles that IAC is currently drafting. These efforts and collaborations will enhance the recognition of ACA’s focus on global needs and issues.

Path forward

In continuing to carry a keen sense of “where we have been,” both as an association and as a committee, the IC plans to help lead the conversation within ACA about “where are we going” as a collective group of global professionals. To sum up all the efforts taking place, the IC recommends we engage in the three following activities to create an international impact within our locus of control.

  • Posture of listening: A wise proverb reminds us, “Remain quick to listen and slow to speak.” So often our initial response may carry a list of assumptions that have not been presented. Taking the time to step back, give others the benefit of the doubt and consider another perspective is essential for advancing our knowledge and awareness. If we are unsure which direction to move in any of our professional decisions, we might let our ears do the walking by receiving support and insights from colleagues, especially when they can provide cultural consultation. Counselors are encouraged to maintain a healthy posture of listening to explore ways that we can each make a greater difference in the development of international counseling. Teachability and openness can define our culture of listening in profound ways.
  • Intentional learning: In conjunction with the earlier value of lifelong learning, the IC has a unique opportunity to model how counselors might seek out opportunities to hear the narratives and experiences of others. Pursuing learning opportunities for counselors in other cultural contexts will provide the type of growth that may enhance formulation of theory and practice in new avenues. This may include opportunities to seek international training specifically or it might involve increasing efforts to support international awareness in the work and educational institutions where we now serve. Being intentional about learning requires active systems that amplify the voices of those less represented. Seeking learning opportunities outside of our comfort zones offers an extended expression of cultural humility that can benefit everyone involved.
  • Symbiotic development: Growth for the counseling profession in one area of the world is growth for us all in the counseling profession. Regardless of the differences we possess and the ways in which counseling may be practiced in different settings and cultures, there are commonalities that unify us in the profession and enhance our ability to address mental health and well-being needs all over the world. Refining our collaboration and learning offers hope for improving our abilities to respond to people from a variety of backgrounds in our own communities. A focus on developing collectively and interconnectedly as a profession globally presents great opportunities to expand our minds, enhance our knowledge and refine our practices alongside colleagues all over the world. Counselors who strive to achieve the same basic goals can help foster professional development that will serve to make a difference among individuals, families and groups worldwide.


Three members of the International Committee at the 2023 ACA Conference & Expo in Toronto

The International Committee members at the 2023 ACA Conference & Expo in Toronto. Photo courtesy of Rong Huang.

The IC is excited to embark on the goals ACA has established to enhance connections and collaborations around international issues. Simply by taking the skills already “baked in” to the ingredients of professional counseling, we have discovered rich opportunities to learn from one another and to develop both individually and collectively. It all begins with listening, which leads us down a road of learning and developing so that we may expand the conversation even further and make a difference with even more individuals through the blessing of counseling worldwide.

We hope the descriptions of past, present and future IC endeavors will inspire further interest and involvement for developing greater awareness and skill to support the most people we possibly can.


2022-2023 International Committee Members:

Nate Perron (chair), Sujata Ives (associate chair), Mary DeRaedt, Hulya Ermis, Katherine Fort, Ester Imogu, Sandy Kakacek, Peggy Mayfield, Benjamin Okai, Lisa Rudduck, and Keiko Sano


Headshot of Nate Perron

Nate Perron was appointed chair of the ACA International Committee for the 2022-2023 academic year and is also a core faculty member at the Family Institute at Northwestern University in Evanston, Illinois. He remains actively involved with international counseling research, education, service and practice in a variety of ways. Contact him at nate.perron@northwestern.edu.


Headshot of Sujata Ives

Sujata Ives is associate chair of the ACA International Committee, mentor to IC intern Anniesha Lyngdoh, an avid presenter at ACA conferences and a private practitioner of employment counseling. Contact her at sujata.ives@gmail.com.



Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The loss of our ‘humanness’

By Suzanne A. Whitehead February 24, 2023

DC Studio/Shutterstock.com

Recently, I needed to undergo some medical tests in a hospital-based clinic. I arrived a few minutes early and was eventually called inside for my tests, which required four separate parts. Immediately, as I put the swaying, open-backed gown on, I began to feel my humanity slowly slipping away. I now looked like all the other patients in similar attire, and I felt the loss of myself as a human being. I started to feel like an “it” to be worked on. I had felt this way previously for other exams and tests — this was just a “refresher.”

I was prepped, injected and told to wait again; my questions went unanswered. Inside myself, I could feel my anxiety starting to well up and get the best of me. I was finally led to another room and told to lie on a table. The table was cold and uncomfortable and hurt my back, and the feeling of somehow being an “it” to be worked on, not a human being any longer, returned. I was told to raise my arms over my head, and the technician quickly left the room.

The overhanging equipment suddenly whirred noisily and began getting closer and closer to my chest and head, increasing my uneasiness. The machine rotated a bit overhead; I couldn’t see around it at all. I suddenly felt claustrophobic and a bit panicky, and finally called out for the technician after several minutes. He answered from an adjoining room and asked what was wrong.

I said I was feeling a bit anxious, asked what this test was for and asked how long it would last. He answered bluntly, “It’s for the tests you’re having.” He then aimed a fan at my head to help “with people like me,” he stated. I immediately felt demoralized again and was told it would be another five minutes under the whirring machine.

I was finally released from the “jaws” of the overhead machine. As I started to rise, I felt dizzy at first, perhaps because I had my arms stretched over my head for several minutes. I was escorted out of the room and sent back to the waiting room, again, alone with my thoughts. (It’s been my experience that human beings do not like a void of information. We try to obtain it the best way we can, and when that fails, we begin to make assumptions, which are often inaccurate. It’s simply what people do and is part of the human condition — if only the medical profession acknowledged that.)

There sat the others, all waiting for their time under the machine. I didn’t dare tell them not to worry, our eyes never meeting. Internally, I felt scared about what the tests could reveal and what else was in store. The same concern seemed etched on the faces of those in that waiting room. I wondered, “What if someone had just taken the time to explain what was happening to us and what we were about to experience?”

Taking time to connect

As I sat there worrying, waiting for my next exam, I began to wonder, “As counselors, do we take time during the essential beginning session to discuss with our clients what counseling is really all about?” Often, clients don’t know what to expect from counseling. Ours is a relatively new profession, and many clients, for example, did not even have counselors in their schools when they were growing up. Or the counselor role was so diminished, they rarely met them in person. Moreover, many schools did not even employ counselors until recently. Are we selling our clients short by taking it for granted that they simply intuitively know what to expect?

My diagnostic testing felt demeaning. With no sense of control, I felt a bit overwhelmed. In the end, I just wanted it all to be over. So, I sullenly complied with every command, didn’t ask more questions and couldn’t wait to leave. The experience — which was more psychologically than physically painful — left me with a bitter taste in my mouth, and I never wanted to return.

The parallels with counseling jumped out at me. Do our clients feel the same sometimes? Is that why many don’t want to return? For instance, according to Joshua Swift and Roger Greenberg, in a meta-analysis published in 2012 in the Journal of Consulting and Clinical Psychology, 1 in 5 clients end psychotherapy prematurely. As counselors, do we spend the necessary time to understand the culture and concerns of our clients, as well as address their fears?

Those special medical technicians who do take the time to develop a human connection first make all the difference in one’s experience. Can we say the same for ourselves as counselors? As human beings, we all crave human connection; it is the very heart of counseling. For the sake of time, are we rushing through this vital aspect of the process?

How we treat our clients

I am reminded of the many times I got extremely busy as an agency clinician and, later, as a school counselor in my own career. I would see the long line waiting at the door of our school counseling offices or sigh a bit when one of my clients finally disclosed that huge revelation they’ve been holding back the last six sessions, with five minutes left in our meeting. My heart would sink as I realized I couldn’t go over the session time because my next client was waiting. During those times, I remembered that as counselors, we are instructed not to get “too close” to our clients for fear of losing our objectivity.

Although being objective is vital to the counseling relationship and the client’s well-being, does it also mean that we must sacrifice their humanity? Sadly, I have worked with some physicians, nurses and respiratory therapists (one of my former professions) who have become cold, distant and indifferent to their patients. They have absorbed the “lesson” about not getting too close to their patients all too well and have become detached when their patients don’t respond well to their interventions or ultimately die. It allows them to not “feel” and to go on with their “routine” activities as if they were working on “machines.” Their patients know, though, and are left feeling demoralized, defeated and not heard — just like I was during my exams.

The ability to have empathy is the cornerstone of being a counselor and a counselor educator. Without this ability, we are doing our clients and students a disservice and, possibly, irreparable harm. To a degree, the ability to have empathy for the “least deserving” of our clients (e.g., individuals who have committed murder, rape or child abuse) is what sets us apart from those who are not counselors by trade. If we reject our clients for the behaviors they have committed, then we too have lost our sense of humanity for them and will judge them, harshly, just as society has.

As counselors, we never have to condone or agree with a behavior that a client has done, but we do have to see them as a human being, deserving of our care, and believe in their willingness and abilities to want to change. If we also reject these clients for the behaviors they have committed, then we have endorsed their beliefs of self-loathing and pity. We reinforce their negative self-beliefs that they are unable to ever heal and that they are undeserving of comfort, compassion and understanding. Arguably, we doom them to repeat their behaviors by our rejection, disdain and judgment. If we don’t believe in this fundamental aspect of counseling — that all persons can change and deserve our respect — then, sadly, it may be time for us to find a new career.

Finding our own balance

Not getting “too close” to our patients or clients is a self-protection mechanism. It is fundamentally a correct premise, but humanely flawed. Finding a balance between objectivity and empathy is the key. Whether we are treating patients or clients, the same premise applies. It is essential to their well-being and, I posit, to yours as well that you find your balance and always reevaluate and assess it. If you feel yourself becoming resentful toward some of your clients, or feel too rushed with them, or feel that you are becoming too preoccupied with the time spent on them, challenge yourself to be proactive to take the internal steps to work on this.

If the system needs changing, find the courage to be the voice for your clients. If working with clients in a group setting makes more sense, initiate that adjustment. If challenging the status quo requires speaking up, do so for the sake of your clients. Remember the basic tenets of your code of ethics — to always advocate for social justice, equity and cultural competence. If you need more training, obtain it. If you need more supervision, don’t be afraid to ask for it. Not only will you be following the ethical principles of self-care and wellness, but your clients will benefit from your self-investment tenfold.

If any of this resonates with you as a clinician, that is a healthy response. Human beings were not designed to be “garbage bags,” to continually just stuff our feelings until we are about to explode. If we do so outwardly, we are accused of just being too angry and emotional; when the implosion is internal, it can lead to deep and unresolved depression. No one wants to feel like they are not being listened to, are not being heard and are simply “taking up another’s time.”

If you can relate to having felt this way during a medical exam or trip to your doctor, then you can relate to what it may feel like being a client and being afraid no one will understand you. Some clients can get past some rudeness or hurriedness of staff, but they won’t do so with you as their counselor. The adage that a person may not remember everything that you say but will definitely remember how you made them feel is so true.

When we are treated as less than human, we lose our humanity. For those who do it to us, unconsciously or not, they do too. Our treatment of each other becomes rote, mechanical and unattached. The preambles to the ethics codes for both the American Counseling Association and the American School Counseling Association share the principles of autonomy, beneficence and nonmaleficence; these are essential tenets to practice our counseling craft and to live by. A basic premise of counseling is to form a therapeutic relationship of trust. It is incumbent upon all of us as counselors and human beings to always remember to do just that.

Best wishes to each of you.


Suzanne A. Whitehead is an associate professor and the program coordinator of the counselor education program at California State University, Stanislaus. She is a licensed mental health counselor, a retired school counselor and a licensed addiction counselor. Contact her at swhitehead1@csustan.edu.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Resisting a savior mentality

By Caitlin C. Regan December 5, 2022

When I first began counseling as a teenager, I often did not connect with the clinicians sitting in front of me. They lectured me. They told me what I could and could not do. They told what I should and should not feel. Needless to say, that approach was not effective. 

But when I was 23, I started working with a psychiatrist who had a different style. She provided me with information about my condition, and then she would ask how I related to that information, what I felt, if that made sense or if I was connecting with it. She didn’t tell me what I could and could not feel or what I should and should not think; she just allowed me to be myself. 

This different approach allowed me to make a lot of progress. She was the first practitioner to diagnose me with bipolar II disorder because she was the first one I felt comfortable telling about my earlier manic episodes (which I later learned are actually hypomanic episodes). I felt like I owed her a lot because of how much she helped me during therapy. 

During one of our last sessions together, I thanked her for all she did for me and told her how she had saved me and changed my life. She stopped me and said, “I didn’t save you; you saved yourself. You’re giving me credit I haven’t earned. Give the credit to yourself. You’ve done the work, you’ve taken the knowledge and made change with it, and you’ve made a difference for yourself.” Her words in that session have always stuck with me even as I now sit in the therapist’s chair working with my own caseload of clients.

A humble helper 

I too have clients who thank me at the end of counseling for the difference I have made in their lives and for saving them, but I always remember to do the same as was done for me. I do not take credit for my clients’ triumphs and successes because it is not mine to be had. I take extreme joy when I witness clients have revelations and make progress, but I do not hold it as my success. It is theirs; they have rightly earned it. As a clinician, my role is to provide clients information and the tools they need to be healthy. I have modeled empathy for them by being a shoulder to cry on and an ear to listen, which made them feel heard. So many who have come my way have not felt or had empathy in their life for the longest time. But I am not the one doing the work, making the choice to change and putting behavioral change into place, so I cannot take credit. 

As clinicians, we are not saviors. Instead, we should strive to be helpers. We do not enable clients or have them so reliant on us that they cannot choose or change for themselves. Instead, we work with our clients to help them move toward self-empowerment. I love being a counselor; I am blessed to be able to do it each day because seeing changes in clients’ lives unfold before me is a powerful experience.

It is important for clinicians to remain in a humble mindset and give clients credit for their successes. I see many clinicians who take this path and clients are more thankful for it. I once had a client, who after I told them it was not my credit to take, turned back to me and said, “Thank you. I do need to give myself credit when it is earned and stop giving my credit and my power away to people.” The client patted themself on the back and walked out the door. We worked together for several more sessions, and the client’s confidence continued to bloom to the point they no longer needed counseling, and I was thrilled to witness their success. 

When clients gain courage, confidence, strength and self-esteem in counseling, they are able to apply those skills outside the session and continue to have success even after their time in therapy ends. It will also better prepare them to face and overcome challenging moments and disappointments and move back toward living and thriving. Roy Baumeister and colleagues’ research, published in Psychological Science in the Public Interest in 2003, shows that people with high self-esteem are better able to overcome challenges. Encouraging clients to take credit for the success they have while in treatment is another way clinicians can work to increase a client’s self-esteem. In turn, helping clients increase their self-esteem allows them to make greater strides not only in treatment but also after they leave a clinician’s care.

Empowering clients 

If we work from a belief that we are “saving” clients, then we are stripping them of their ability to be empowered. Empowerment is a key aspect to any mental health treatment. The strengths-based approach in counseling, created by psychologist Donald Clifton, works on the premise that focusing on a client’s strengths, rather than their faults, allows them to see all they are capable of and develops their belief in themselves and therefore their success. Helping clients see the capabilities that lie within is the essence of clinical work. 

Moreover, if a clinician assumes the role of a savior, the client’s setbacks and successes becomes theirs as well. This belief makes it the clinician’s fault if they do not “save” a client. Clinically, we cannot make clients put actional and behavioral changes into place. We can help them learn how to make changes, but they have to want and choose to do so for themselves. So, when a client does not choose healthy actions, clinicians should not blame themselves, and at the same time, when clients do choose healthy actions, we should not take the credit for being their savior. We can rejoice with our clients for making healthy decisions that will help them progress and grow, but it is not fair to take away the client’s empowerment and say we saved them. 

I do not think that clinicians who take on this savior mentality are trying to strip clients of their empowerment. They are excited when they see clients have success, but when they assume this “savior” frame of mind, they get caught up in the wins and lose sight of their role in empowering the client. We as clinicians must constantly remember the importance of empowering the clients, not ourselves, to improve our work and therapeutic relationship with clients.

As clinicians, it is our role as to encourage, empower and guide clients as they begin to make changes and healthy life choices. We walk beside them on their journey to remind them of all they are worth. When clients are able to walk ahead in their journey because they have grown and changed and no longer need us by their side, it is something they earn themselves.


When my psychiatrist taught me to give myself credit, it allowed me to further my successes because I realized I was capable of empowering myself. If she had just said “thank you” when I gave her the credit, then I may still believe that she alone is responsible for my progress and not recognize the hard work I put into those sessions to help me develop a healthy frame of mind that now allows me to help others. Her assuming the role of a savior would have done more harm than good. What do I mean by this? I have seen how detrimental it can be to the recovery of clients when clinicians take on the role of savior. Clients in this situation become dependent on the counselor and believe they won’t be able to progress without that clinician. They may even think they are only able to make progress with the help of others rather than believing in their own ability to change. 

By assuming the role of helper, we can help clients learn to do things for themselves and give themselves proper credit. They grow in their self-esteem and belief in their own capability, rather than relying on yet another person telling them how to live and function. Clinicians need to work to remove the role enabling has played in many of our clients lives or the low self-esteem that has created the belief of not being able to do for themselves. When clients are enabled, often by clinicians and others in their lives, it leads to clients not taking responsibility for their good or bad choices. In addition, enabling often leads to lower self-esteem because clients do not feel like they are in control of their own lives. As clinicians, it is not our responsibility to “fix” people but to help people recognize all the wonderful pieces that already lie within.

Am I helping or saving?

Maybe you are asking yourself, “Am I helping or am I saving? How can I even tell?” To answer that, you first need to explore your underlying motivations by asking, “Do I rejoice in my clients progress because I am excited for them or because I think it makes me look good?” If any part of you is saying because it makes me look good, then that is a good sign you are assuming the role of the savior. 

The truth is that much of what counselors do is not about looking good. As an addiction counselor, I walk away from a lot of my sessions not feeling all that great because in addiction treatment, it is more common for clients to relapse or leave therapy against medical advice than for them to complete treatment and go on to celebrate 10 years of sobriety. At times, it does cross my mind, “What am I doing wrong? How can I fix it?” In these moments, I need to meditate and remind myself that I am no one’s savior, and I am there to help clients when they are ready to do their own work to make change. I have to constantly remind myself not to assume this role of savior because it’s easy to feel pressure to “fix” people and think you are responsible for their success. 

Another way to determine if you are saving or helping is to think about how you respond when a client thanks you for helping them. Do you remain humble and appreciative and then remind them of all the work they have done for the success they have earned? Having clients thank me for the support I show them is always a wonderful part of my job, but every time a client thanks me, I remind them of my motto, “This is credit I have earned, don’t give my credit away.” Within a week of working with me, my clients can easily repeat that motto, which helps them realize they are the ones who deserve the credit because they are the ones doing the work. 

I also do not want to diminish the work that counselors put into their sessions. Our work is hard and a labor of love. We watch every day as people grow, change, regress, learn, experience heartbreak and so much more, so it takes a lot of our own strength to do what we do. We deserve credit for our part as well, but clients should not be the ones to pay us that credit. It is essential clients build their own credit when working with us. Our validation should come from our loved ones, supervisors and bosses, so we can focus on helping our clients and not make the session about us, which is unethical. We cross boundaries when we look to clients to validate us, and this is another reason to wholeheartedly allow clients to have the credit for their own growth, which is 100% theirs.

Early on in my counseling journey, I had many clinicians who assumed the role of the savior, and it led me down a path of believing that I needed others to save me. It wasn’t until several years later when I had a clinician point out that I earned the credit myself that I was able to take the first step toward the empowered road I now walk. I am able to accept and ask for help when I need it, but I am also empowered to save myself and know how worthy I am as a person. Knowing my worth each and every day is the best gift I have ever allowed myself to receive, and every client out there deserves the same. As a counselor, I am now in a position where I can pass that message on to my clients and show them their credit is theirs to keep. It is a great honor to work in a helping profession, and it is important to always remember that we are helpers not saviors.



Caitlin C. Regan is a 35-year-old mental health and addiction counselor in Juno Beach, Florida. She has been living with a mental health diagnosis since she was a teenager, and through electroconvulsive therapy and daily self-care, she has been successfully living with it for over eight years. As a teacher and counselor, she has over 13 years of experience helping those with mental health and addictions. Her passions include helping others, mental health, seeking social justice, and spending time with her friends, family and two dogs. Follow her on Instagram and Pinterest @caitlins_counseling_corner or on her YouTube channel at Caitlin’s Counseling Corner. Contact her at caitlinscounselingcorner@gmail.com.


Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.