Pandemic caused more mental illness but without staff, industry at an impasse

While emergency rooms and intensive care units have been filled with the physically ill during the pandemic, mental health centers are equally overwhelmed.

About 400 new patients will enter CNS Healthcare's eight locations this month. That's up from an average of about 150 prior to the pandemic. And the community behavioral health clinic is managing these patients with 60 fewer workers than prior to the pandemic and more than 100 new positions that could be filled.

"We're seeing more and more people experiencing levels of crisis and anxiety," said Michael Garrett, president and CEO of CNS Healthcare. "There are a lot of different stressors going on in the world, from the pandemic to economic anxiety. This isolation and loneliness is the perfect storm on our mental health system."

Blue Cross Blue Shield of Michigan is reporting a 27 percent increase in the use of mental health services among its 4.3 million members.

The pandemic has illuminated the canyon of mental health needs across the country and, by default, the gulf of providers needed.

There are an estimated 50,000 vacant positions for direct care workers in the behavioral health sector across the state, about a 21 percent vacancy rate, according to data from the Community Mental Health Association of Michigan.

Gov. Gretchen Whitmer is seeking to bolster the industry with a proposal to repay up to $200,000 in student loan debt for those working in the nonprofit mental health sector.

"We should invest in our mental health workforce so we can expand access," Whitmer said during her Wednesday night State of the State address. "Nearly 40 percent of Michiganders do not get treatment for their mental illness. We will address this shortfall by expanding Michigan's Loan Repayment Program for mental health professionals. And we will make a historic investment to retain and recruit hundreds more mental health workers."

Robert Sheehan, executive director of the Community Mental Health Association of Michigan, said the large number supporting the program may help attract private practice therapists and counselors into the more critical nonprofit space.

Sheehan also noted that the industry is two-thirds women, and many left the workforce in 2020 to handle child care during the pandemic when school closures were most common. Removing the financial barrier of student loan repayment may drive many off the sideline and back into the labor market, he said.

"We have many MSWs (master's of social work) and psychology MAs (master's of psychology) not in the market right now that may be intrigued to return with the loan repayment program," Sheehan said.

Garrett said the organization is seeing fewer and fewer applicants, despite an increase in advertising for open positions as well as higher wages. CNS has also added more paid holidays,more flexible hours and added to its benefits package.

"I don't have an answer," Garrett said. "I'm not sure where all the workers have gone."

Complicating Michigan's mental health sector is the introduction of a newer testing requirement for certification of master's level psychologists that has pushed at least some out of the field.

Many master's level psychologists — who must work under the direction of a doctoral level psychologist and who are most often found in the school and nonprofit settings — were operating under a temporary limited license in psychology and could renew that license in perpetuity. Under the new certification requirement, those with a TLLP now must take and pass the Examination for Professional Practice in Psychology test within 18 months of receiving their temporary license and achieve a score of 450. Doctoral-level psychologists must pass with a 500 or better.

Legislators adopted the testing rule in 2010 but the state did not limit the TLLP renewal limit under 2018.

Rhonda Ravenell worked as a school psychologist in Detroit Public School and Wayne County Public Schools before her TLLP expired in September 2020. She failed the new certification test and was forced out of her job and relocated to Virginia as a counselor where her education is acceptable in the public schools.

"The test went far beyond what I learned in school," Ravenell told Crain's late last year. "I was devastated. I loved working with kids and my supervisors were always impressed with my work. I am not interested in being a researcher or doctor and most of us don't need that training. But the state took away my career."

But Kristen Abraham, director of the clinical psychology master's program at University of Detroit Mercy, said the exam is in line with most other states and those not able to pass the test had plenty of time to adjust to the new requirement.

"Anyone that has earned a master's since 2010 should have been aware," Abraham said. "This shouldn't come as a surprise to anyone 11 years later. I do not believe the inability to pass the test is a widespread issue, and the job of the licensing board is to protect patients. I think the test is a fully defensible tool for the state to use."

It's unclear whether the exam has led to further shortages in the field, but shortages abound nonetheless.

To manage, CNS Healthcare has found ways to reduce paperwork for its staff as case loads grow.

"We don't believe in turning anyone away, so staff is responsible for more and more people each month," Garrett said. "I wouldn't be honest if I said this isn't a big challenge."

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Sheehan said the result of large case loads is mental healthcare workers taking on double shifts and organizations reducing the length of treatment to move more people through the system.

"There is a wait list, so they are shortening treatments for people they normally wouldn't," Sheehan said. "This is not only putting a strain on practitioners but clients as well."

Garrett said the ultimate solution isn't just the loan repayment program but also to increase mental health funding writ large, so patients can access more mental health services without breaking the bank, allowing organizations like CNS to attract more talent with broader services.

"It's time for behavioral healthcare to have parity," Garrett said. "You can't drive two or three blocks without seeing an urgent care. Yet we have nothing like that on the mental health side of the equation. It's only 10 percent of the funding, yet it's 40 percent of the market.

"A healthy person is of sound mind and body. You can't have one without the other."

Under the state's current model, mild mental health issues are covered by private insurers but severe cases are managed through a state-run and funded program. This has led to an inability to get certain services covered to prevent mild mental illness from becoming severe, Garrett said.

"If you have mild or moderate mental illness, you can't get access to 90 percent of the services our organization offers," Garrett said. "Mental illness just doesn't stop at mild, it progresses if left untreated. By the time it's severe it's very difficult to walk you back down the scale. If we could intervene earlier and receive more adequate funding, we could produce outcomes that are a heck of a lot better."

The Michigan Senate and House both have competing plans to re-engineer the state's mental health funding model, but it's unclear whether either would be successful or draw more talent to the sector.

This story first appeared in our sister publication, Crain's Detroit Business.