Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Research shows that mental health care is critical for overall health, with a recent study published in the Journal of the American Heart Association finding that mental health treatment significantly reduces readmission of patients who’d been hospitalized for heart failure and ischemic heart disorders by 75%. Yet, the mental health workforce is shrinking.
A new report reveals that states are facing critical behavioral health workforce shortages, particularly in crisis services. The report, authored by the National Association of State Mental Health Program Directors Research Institute, known by its acronym NRI, surveyed 44 states on their workforce shortages, providing insight into how different parts of the crisis system have been affected, from call centers to mobile crisis and crisis stabilization programs.
Workforce shortages aren’t just a matter of numbers but also the specific needs of states and crisis services, says Ted Lutterman, senior director of government and commercial research at NRI. “What we are hearing is pretty much every state is having shortages, but the types of staff shortages they’re having differ,” he said, adding that shortages also vary by setting.
Crisis contact centers, for instance, primarily require social workers, licensed behavioral health counselors and bilingual staff. Staff is often a mix of paid crisis counselors and volunteers. In contrast, mobile crisis teams require a broader range of disciplines, including master’s-level social workers and peer support specialists. Crisis stabilization programs need medical staff, such as psychiatrists, nurses and nurse practitioners.
The report classifies workforce shortages into four categories: catastrophic, moderate, minor and no shortage. A catastrophic workforce shortage is so severe that it reduces service availability and produces long wait times. Those that are moderate affect timeliness and service access and may require staff overtime.
Lutterman’s team found staffing shortages most pronounced in mobile crisis and crisis stabilization programs, both critical parts of core crisis services according to the Substance Abuse and Mental Health Services Administration’s national guidelines for behavioral health crisis care. “What we seem to hear, frankly, is the call centers aren’t the biggest issue,” said Lutterman. “It’s getting 24/7 staffing for mobile crisis and crisis stabilization programs,” he adds, noting that both require more licensed professional and medical staff.
What makes staffing even more challenging is that crisis stabilization programs compete with hospitals for nurses and nurse practitioners. Without medical staff, these programs are less likely to divert people from the emergency room, especially in states that require medical clearance. Medical clearance, which determines whether a medical issue is causing or worsening a psychiatric one or if the person is physically well enough to be placed in a behavioral health facility, is often a barrier to care.
SAMHSA’s national guidelines emphasize a no-wrong-door approach, accepting everyone who comes and not requiring medical clearance from an emergency medical facility before admission. Lutterman’s organization and SAMHSA will have a public call on Jan. 28 to discuss how states are addressing this issue. “We need to ensure people can be taken directly to a crisis program and that police and EMS aren’t first taking people to an ER, circumventing the whole purpose of having crisis programs.”
Mobile crisis services also face challenges recruiting qualified professionals to work demanding overnight, weekend and holiday shifts for 24/7 crisis services. Some states have adapted by shifting their mobile crisis two-person teams to a peer and a bachelor’s level behavioral health worker. “Someone [with a graduate degree] is available on call but isn’t going out on visits because they just couldn’t hire enough MSWs for those shifts.” He emphasized that the struggle persists to hire qualified staff “even when there’s funding from the governor, the legislature.”
Hospitals and private practice often offer better pay and more regular hours, exacerbating the problem. “To get [social workers] to work overnights and weekends when they could make as much or more money working nine to five Monday through Friday is a challenge,” Lutterman said, noting their choice might be getting more pay working in an office or earning less in a more stressful situation assisting people in crisis.
Lutterman says another reason for the shortage is the rapid expansion of mobile crisis teams and crisis stabilization programs nationwide. “We saw many more new mobile crisis teams and crisis stabilization programs that all need new staff, and they then have to compete with other providers to fill those positions,” he said. In contrast, the 988 Suicide and Crisis Lifeline network has long been established, and while its rapid growth has come with challenges, many contact centers have been operating for some time and have a foundation to build on. “Some states are opening additional centers but in many cases, they’re adding to existing programs that, hopefully, have already been running 24/7,” he said, adding that having support from SAMHSA with a dedicated career section for 988 jobs has helped.
That’s not to say 988 crisis centers aren’t experiencing strain and workforce shortages. The successful implementation of 988 has come hand-in-hand with increased volume demands and burnout, resulting in some centers experiencing higher staff turnover. Lutterman says effectively responding to people reaching out to 988 through calls, texts or chats not only requires ongoing training in crisis intervention and de-escalation but also up-to-date, evolving technology and training staff on that technology. That requires adequate funding.
The report also sheds light on some innovative state initiatives helping address the workforce crisis. Many states are working with high school students and community colleges, sponsoring curricula to introduce young people to behavioral health careers and providing mentorship. Another notable strategy is integrating crisis services, with some states, like South Carolina, having their 988 contact center staff also respond to mobile crisis dispatches — an approach that not only maximizes the use of existing staff but also provides a sense of continuity for people in crisis as they interact with the same person who initially answered their call.
Lutterman highlights that one of the most pressing concerns is the lack of private insurance coverage for crisis services, forcing many states to rely on state and federal funds to cover these costs. He points to the growing frustration among state officials struggling to get private insurers to “step up and pay for crisis services” for their policyholders. To address this issue, NRI and the National Association of State Mental Health Program Directors are organizing quarterly calls focused on key challenges in crisis services, including commercial insurance reimbursement. A call scheduled for March will feature presentations from states that have made progress in getting private insurance to pay for crisis services, like Kentucky, New York and Massachusetts.
He says addressing the workforce crisis requires a comprehensive approach. Funding crisis programs is crucial but more is needed. Tuition reimbursement, increasing salaries for people working in crisis settings, investing in workforce development initiatives and holding private insurers accountable are necessary steps in building a robust and sustainable crisis care system.
“We’re striving to grow the system and we keep hearing from states that it’s been difficult,” said Lutterman. “The challenge states are facing is as much a workforce issue as staffing is a fiscal one.”
