Tag Archives: Professional Issues

Professional Issues

5 takeaways from the 2023 Virtual Hill Day

By Samantha Cooper June 29, 2023

Empty vintage congress hall with seats and microphones

Denis Kuvaev/Shutterstock.com

The American Counseling Association hosted the 2023 Virtual Hill Day on June 14. This event highlighted ACA’s legislative agenda for the year and included a panel on how the legislative process works and another on how to prepare counselors to meet with congressional representatives. Here are five key takeaways from the event:

1) Help advocate for these seven mental health legislative issues.

In 2023, ACA is prioritizing the following seven areas: veterans’ mental health, students’ mental health, education professionals’ mental health, maternal mental health, career counseling, student loan assistance and equitable health care.

The goal is to make mental health care more accessible by incentivizing counselors to work in areas affected by the mental health provider shortage. For example, ACA supports the Mental Health Professionals Workforce Shortage Loan Repayment Act, which would reimburse one-sixth of a counselor’s student loans for every year they work in an underserved area, and the Equal Health Care for All Act, which would make equal access to health care a protected civil right and prohibit discrimination based on race, national origin, sexual orientation, gender identity, disability, age or religion.

For other important legislative issues related to mental health, visit ACA’s Government Affairs and Public Policy page.

2) Get to know your state legislature.

Know how your state legislature works. It may seem obvious, but each state works very differently. For example, some states meet every year and others every other year. In North Dakota, where Sen. Sean Cleary serves as a member of the state Senate, congressional sessions last for 80 days every other year. It’s important to know when your state legislation meets so you can determine when it’s the best time to introduce your cause to your representatives, Sen. Cleary told the audience.

3) Find allies.

Allies are invaluable for helping get legislation passed. “You do need people to be able to champion and push it [the bill] through the process,” Sen. Cleary said. “The importance of building those relationships [with allies] … when you’re advocating is tremendously beneficial.”

Washington State Rep. Mari Leavitt told counselors not to rely solely on state representatives to push legislation. Instead, she recommended they find and collaborate with “unusual allies” — other groups and organizations that support the legislation they’re pushing.

Mara Boggs, the state director for U.S. Sen. Joe Manchin of West Virginia, agreed that allies can come from places people may not typically expect. For example, she said that state staff can be helpful advocates. These people have often been on the staff the longest and therefore are some of the most influential team members, she explained. So getting to know them could increase the changes of the legislation being seen.

4) Respect people’s time. 

People’s time is important, so make sure you are organized when you meet with members of Congress, said Lisa Pino, an attorney and a Health Innovators Fellow at the Aspen Institute. She told the audience to prepare three main points about the legislation and be ready to explain why members of Congress should support it. “Being clear and consistent really helps so the agencies can more easily translate to their leadership what you’re trying to communicate,” she explained.

5) Don’t expect any guarantees. 

Congressional staff members cannot make promises or guarantee that a representative will see or pass a certain piece of legislation, noted Layla Brooks, the senior legislative assistant for U.S. Rep. Troy Carter of Louisiana. She recalled how one group got upset when the bill they supported didn’t pass because they thought that asking for her support meant the legislation would definitely be signed into law.

“We [staff members] are not supposed to make promises,” Brooks said. “Give us grace and time.”


Watch a recording of 2023 Virtual Hill Day.

Learn how to engage your legislator with ACA’s Advocacy Action Toolkit.


Samantha Cooper is a staff writer for Counseling Today. Contact her at scooper@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.

Voice of Experience: Professional organizations

By Gregory K. Moffatt June 27, 2023

black-and-white image of a speaker giving a talk in front of a large audience

Matej Kastelic/Shutterstock.com 

I’ve been a supervisor for over 30 years. During my last supervision session with prelicensed clinicians who are about to get their full license, I tell them: “After today, you will never have to speak to another professional in the field again.” 

Of course, that isn’t a recommendation but a fact. The point is that counselors can easily become isolated within the walls of their practice. Therefore, their professional interactions have to be intentional. 

Roadblocks to professional interactions 

As counselors, we often have 15 to 20 clients or more per week. On top of that, we often work unusual hours. Late afternoons, evenings and weekend appointments make it less likely we will see other professionals who have more standard working hours.  

One of my closest professional friends has her own private practice and sees clients up to 40 hours per week. I couldn’t carry that heavy of a caseload, but even if I did, having that many clients doesn’t leave much time for collegial interactions. 

Another one of my colleagues works in a private practice where she leases office space. There are more than a dozen other clinicians in that office building, and she doesn’t know anyone’s name. Everyone comes in, they go to their respective offices and they close the door. 

Even continuing education doesn’t require face-to-face interaction with peers anymore. Before the COVID-19 pandemic, my home state of Georgia had restrictions regarding online continuing education, with no distinction between synchronous and asynchronous hours. A clinician could use only 12 hours of online learning for license renewal, with the remaining 23 hours required to be in person.  

Now in Georgia it is possible to earn all 35 continuing education hours online as long as 25 of those hours are synchronous (including ethics). Although online learning has made our lives easier, this is yet another way we disconnect from professional interaction with colleagues. Synchronous workshops may not require the participant to engage, making it easy to hide in the background. 

For those who are fully online in their practice, working from home makes it challenging to interact with other professionals in the field as well.  

Benefits of professional organizations 

Professional organizations create an environment where one can acquire professional interaction on a more personal level. Conferences, workshops and lunch-and-learns create a platform for professional development. I go to at least one professional conference every year.  

I’m a hopeless introvert and my social needs are practically zero, but I value the relationships I’ve built over the years through my involvement in professional organizations. These connections have provided a fertile resource for referral options and updates in the law, ethics and board rule changes. They are also a resource for deliberating ethical dilemmas. 

Most professional organizations have specialized districts/divisions that are tailored to the needs of various geographical regions or specialized areas of practice. 

Finally, membership fees practically pay for themselves through discounts on conference registrations, free publications/journals and access to the resources mentioned above. 

Advice on joining organizations   

When I first began my career in mental health, I was a member of eight different professional organizations. I paid those membership dues every year, but eventually I realized that most of them were not serving my professional needs. I gained nothing from their publications, didn’t attend their conferences, and rarely found anything useful for my practice in their newsletters and announcements. 

Today I’m a member of half that many, yet all of them serve me. I’ve been to all their conferences at one time or another and know people within those organizations that I can contact if I have ethical questions. I am partial to state organizations, or state chapters of national organizations, because they are more attuned to the specific laws and governing bodies in one’s state. 

Counselors should also be careful about joining groups to become “certified.” Some organizations have impressive-sounding titles that, in reality, are meaningless. The American Organization of Certified Psychotherapist sounds great, but I just made it up. These fluff groups have no criteria for membership other than paying fees, but they act as if joining makes the clinician more competent or part of an exclusive club. Having one of these organizations on your resume or curriculum vita might do you more harm than good. 

I require my supervisees to be a member of at least one professional organization while under my supervision, and they must demonstrate to me how that organization serves their needs. This is a part of one’s professional growth that needs to continue long after formal supervision has ended. 

Don’t be an isolated clinician. Get involved in a regional, state or national professional organization. 


Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.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.

Behind the Book: Doing Counseling: Developing Your Clinical Skills and Style 

By Samantha Cooper June 17, 2023

A woman counseling a man; an image of the book Doing Counseling

Jude and Julius Austin seek to demystify the counseling process in their new book Doing Counseling: Developing Your Clinical Skills and Style. This book aims to help counselors, especially graduate students and new professionals, learn to put counselor training into practice. 

Counseling Today spoke with the authors to learn more about their motivation behind writing the book and the practical advice it offers counselors. Jude Austin is a licensed professional counselor and an assistant professor and clinical coordinator in the professional counseling program at the University of Mary Hardin-Baylor. Julius Austin is a licensed professional counselor and a clinical therapist and coordinator for the Office of Substance Abuse and Recovery at Tulane University.  

headshot of Jude Austin

Jude Austin

headshot of Julius Austin

Julius Austin

“We wanted to write this book because it’s the one we wish we had growing up as counselors,” the authors said during the interview. “This is a book that says, ‘Hey, it’s OK to be you, we just need to figure out what is it about you that is therapeutic.’” 


How does Doing Counseling help students put counseling theory into practice? 

It does this through dialogue. The book is a conversation that acts like a bridge. We are not wizened tenured professors or big-time therapists telling readers how to be a successful and effective counselor. The book is a conversation about how to apply theory in practical ways. We work and talk through how theoretical aspects such as vulnerability in session, awareness, genuineness, annoyance, countertransference, differentiation and transparency apply to our work with clients. Admittedly, half the time, we are just trying to make each other snort milk out our noses from laughing when reading the chapters. The other half, we are using stories from our clinical experiences and lessons taught to us by our grandpa and parents to break down thick theoretical concepts and ground counseling theory into application. 

You said a big motivation behind your book is to push back against “the invisible culture of whiteness.” What is this invisible culture and how does it hurt counselors? 

When thinking about what a counselor looks like, most people don’t imagine them wearing Jordans or having J Dilla playing in the background of a session. The more we matriculated through graduate school and especially our doctoral program, the more it felt like there was a quiet but dominant and unquestioned norm against which our racial and ethnic identities were judged in session.  

Sometimes when counselors, educators and supervisors say “be authentic,” it can feel like what they really mean is, “Make your ‘authentic self’ more like our way of being authentic.” 

What are some practical tips for counselors that you discuss in the book? 

Our book includes lots of practical advice for counselors to use in session. Some of our favorites are:  

  • Create a structure so clients feel like you’re leading them the entire way. 
  • Wear something that makes you feel good. 
  • Find comfortable chairs for yourself and the client. 
  • Be technically eclectic and theoretically pure. 
  • Don’t feel like you have to “vibe” with every client. It’s OK if you don’t.  

 Vulnerability and authenticity are important aspects to counseling, so we always stress the following advice:  

  • Vulnerability begets vulnerability. 
  • It’s best to sacrifice the therapeutic relationship for the sake of authenticity rather than maintain one for the sake of duty. 

 What does multicultural and antiracist counseling look like in session? 

There is no way for counselors to know everything about every culture, but we can be humbly curious about our client’s cultural background. Multicultural and anti-racist counseling looks a lot like effective counseling with the added, intentional focus on cultural and racial themes. These counselors ask uncomfortable questions about society and its impact on the therapeutic environment.  

What can supervisees as well as supervisors learn from your book about creating a healthy supervisory relationship? 

One big misconception that supervisees have is not taking responsibility for supervision. They often see their supervisor as an educator and supervision as a place for them to learn. But supervisees also need to play an active role in this supervisory process.  

In our book, we talk about the ways to take advantage of supervision. For example, after session, supervisees can make note of things they want to discuss in supervision later (leaving out client details, of course). They can include questions and concerns that came up during sessions. It can also be helpful if new professionals and students share what they need or want out of supervision, rather than leaving that up to the supervisor to decide.  

 How does “doing counseling” virtually differ from in person? What advice do you have for new professionals who are starting their careers in a space where virtual or hybrid sessions are more common? 

Well, there are the obvious differences such as ethical concerns, confidentiality and technical issues. But there is not much difference with the actual process and skill of counseling. Some classic ideas of good counseling remain consistent: genuineness, unconditional positive regard, empathy and immediacy.  

We have noticed, however, that virtual counseling requires us to be more intentional and curious. In person, some of the client’s experience can be deduced through body language. Remote sessions, especially phone sessions, require us to ask more questions or take chances on reflecting what we are sensing in session.  

We have also noticed that sometimes clients are more readily vulnerable during virtual sessions. Virtually, we are in their space, which can add to the deepening of the therapeutic process.  

 What advice do you have for counseling students and new professionals?  

First, we wish we would have known how important and impactful it is to have a good therapeutic process. It creates a sort of built-in trust within the process and the counselor.  

Second, we encourage students and new professionals to consider the kind of life they want to have instead of what they want to do for a living. This allows them to focus on how to use their degree and licensure to make that life possible.  

Finally, this work is hard — rewarding, but hard. It is essential for us to get real about self-care. Create a self-care plan that works for your life and be willing to flex it as needed. 


The book cover for Doing Counseling



Order Doing Counseling: Developing Your Clinical Skills and Style from the ACA Store. 




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.

Voice of Experience: Swords and shields

By Gregory K. Moffatt May 30, 2023

Man shouting with abusive words at another man who has one finger on his lips asking for silence


The lady who sat across from me was livid. Her fiery red hair was accentuated by her clenched jaw and loud tone. She was furious about a decision I’d made that she perceived had affected her son negatively. My decision had been the right one, but she wasn’t in a place where she could view things objectively. That was totally understandable.

Earlier, after a terse phone call with me, she had demanded an in-person meeting with my boss and me. During her 20-minute tirade in front of my boss, she stared through me as she assaulted my professionalism, my ethics and my competence. After she finished, she crossed her arms, sat back in her chair and muttered, “Hmmmph!” as if to say, “So what do you say to that, mister?”

I took a breath and quietly replied, “Ma’am, you are not my enemy.”

Almost anything I said could have launched us into a battle for which she was well prepared. I suspect she had run various scenarios through her head in anticipation. But she didn’t know what to do with someone who wouldn’t push back. I completely disarmed her.

“We both want your son to succeed.” I left it at that.

Her face fell and her mood changed almost as if a switch had been thrown. Within minutes, she was talking about solutions, and we actually made progress. When she left that day, she gave me a genuinely warm handshake.

In this verbal battle, she had led with her sword. Recognizing how people fight (use their swords) and defend (protect with their shields) with words and behaviors can be a powerful way to move past counterproductive actions.

People use their swords when they feel attacked, threatened or cornered and they believe that the best defense is a good offense. John Gottman’s Four Horsemen of the Apocalypse (contempt, stonewalling, criticism, and defensiveness) are examples of swords.

People use their shields when they feel attacked, threatened or cornered and they don’t believe they have the skills to fight back successfully. Substance misuse and withdrawal are shields.

Albert Ellis once said that a therapist should never be offended by what someone says. That is hard to do when we feel attacked or threatened by our clients, but the point Ellis was trying to make is that it isn’t about us. To paraphrase Ellis, when our clients are using their swords against us, it should tell us something about them, our relationship or the topic we are addressing. It isn’t about us.

Many years ago, one of my clients with borderline personality disorder (BPD) challenged me every time we had an appointment. “I was reading a book by so-and-so. … Have you read him?”

“No. Never heard of him.”

The client would react to my comment with eye rolling, disbelief and, often, sarcastic responses such as, “I thought you were a professional.”

As is often true with BPD, she wasn’t trying to insult me exactly. She was trying to prove to herself that we were equals. The sword she used was intended to cause me to question my professionalism. If I had tried to use a sword myself or defend with a shield, the battle would have either escalated or at the very least ended in a stalemate.

By refusing to use my sword, while also refusing to cower with a shield, I disarmed her.

Ironically, passive aggression is actually a sword disguised as a shield. Its purpose is to cause hurt in the one being ignored, not to protect oneself from an attack.

Self-righteousness is another example of using defense as a weapon. Making the statement “I would never have an affair like you did” is intended to hurt another.

Therapists use swords sometimes. Confrontation is an aggressive technique — more of an epee than a sword. We don’t intend to hurt, however. We are forcing our clients to think rather than to raise their own sword or shield.

Recognizing who is using a sword and who is using a shield can help couples argue more productively (and, hopefully, less) in marriage and family therapy. It can also help therapists work with resistance and anger in teens and mandated clients.

Borrowing from Freud’s concept of defense mechanisms, I formulated the following statement that has helped me many times over the years. I believe that all behaviors that are dysfunctional, that are not physiological, are defensive. If I can figure out what people are afraid of, I can tell you why they are doing what they are doing.

In a way, if I can tell what they are afraid of, I can see clearly how they are using their swords or shields. In so doing, I know what to address in therapy and, equally important, how to address it.


Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.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.

A closer look at the mental health provider shortage

Compiled by Lindsey Phillips May 8, 2023

Help wanted sign taped in window

Suzanne Tucker/Shutterstock.com

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.

Studio Romantic/Shutterstock.com

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.