Three guests join the podcast to discuss the significant shortage of psychologists, counselors and social workers in the U.S., at a time when many experts agree the nation is facing a mental health crisis.
Our focus on this episode is the behavioral health workforce. More than a third of the U.S. population lives in areas with shortages of psychologists, counselors and social workers, and nearly two-thirds of shortage areas are rural. Those workforce shortages occur during a period when many experts, including those at the Centers for Disease Control and Prevention, have concluded we have a mental health crisis.
Data from the Substance Abuse and Mental Health Services Administration, or SAMHSA, indicates that for more than two decades half the people in need of behavioral health services in the U.S. did not receive them.
Joining the discussion are Karmen Hanson, a senior fellow at NCSL; Brianna Lombardi, an assistant professor at the University of North Carolina at Chapel Hill; and Jeff Shumway, the director of Utah’s Office of Professional Licensure Review.
Lombardi discussed her experiences in researching the workforce shortage and explained some its complexities. Shumway gave a state-level perspective on how regulation can affect the workforce. Hanson broke down the efforts in legislatures to address the workforce issues.
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Ed: Hello and welcome to “Our American States,” a podcast from the National Conference of State Legislatures. I’m your host, Ed Smith.
CH: Well last year we saw nearly one third of the inactive workforce bills which is about 160 were specifically addressing the behavioral health work shortages in 2024.
Ed: That was Karmen Hanson, a senior fellow at NCSL and one of my guests on this podcast. She is joined by Brianna Lombardi, an assistant professor at the University of North Carolina at Chapel Hill, and Jeff Shumway, the director of Utah’s office of professional licensure review. Our focus on this episode is the behavioral health workforce. About 35% of the U.S. population lives in areas with shortages of psychologists, counselors and social workers. In nearly two-thirds of the shortage areas are rural. Those workforce shortages occurred during a period when many experts including those at the Centers for Disease Control and Prevention it concluded we have a mental health crisis. Data from the Substance Abuse and Mental Health Services Administration or SAMHSA indicate that for more than two decades half the people who needed behavioral health services in the U.S. did not receive them. Lombardi discussed her experiences in researching the workforce shortage and explained some of its complexities. Shumway gave a state level perspective on how regulation can affect the workforce. Hanson broke down the efforts in legislatures to address the issue.
Here is our discussion starting with Brianna Lombardi and Jeff Shumway.
Brianna, Jeff, welcome to the podcast. Thanks both of you for coming on the podcast. I appreciate you taking the time to do this. And to start, I wonder if you could each tell listeners a little bit about your work in your area of behavioral health workforce. Brianna, maybe you could start.
BL: Sure. I direct the behavioral health workforce research center at the SHEP center at UNC Chapel Hill. We are one of the nine federally funded health workforce research centers and we are jointly supported by the Health Resources and Services Administration at SAMHSA to consider the behavioral health workforce. Although I largely do research and policy work now, I have a clinical background. I worked as a psychiatric social worker serving youth with suicidality and mental health conditions. And although we provided amazing care, I was very aware that individuals were not gaining access to our services and that really directed me to think about the ways that behavioral health workforce impacts access to care and particularly were guided in mental youth health care. So, the mission of the behavioral workforce research center is to produce research that informs policies to support the behavioral health workforce ultimately to improve access and quality of behavioral health services. We use national data sources and primary inflection methods to evaluate behavioral workforce compensation needs, efficiency and distribution while also examining how evolving service delivery models impact the behavioral health workforce of tomorrow. And as many of us know you know we need all hands-on deck right now to address the behavioral health workforce challenges we are experiencing and we try to examine workforces across the traditional mental health specialties like psychiatry and social work and psychology but also consider these new and evolving roles that are playing important roles in behavioral health like many health workers and peer support specialists. But also, primary care clinicians and pediatricians so our work really tries to focus on individuals across the field. And our team represents a multi-disciplinary perspective. And then we also partner with organizations that serve individuals experiencing mental health challenges as a way for us to understand what’s happening on the ground.
Ed: Jeff, maybe you could talk a little bit about your role at the Utah Office of Professional Licensure Review.
JS: Yeah, happy to. So, I come at behavioral health at a very different place than Brianna. Not at all an expert in the field so I’m a management consultant by training and so I did that in the private sector for non-profits and foundations and eventually public sector clients for a long time – 20 years -- and eventually was asked by a good friend here in Utah to come and start this new office. So, the office of professional licensure review or OPLR as we call it was patterned after a similar office in Vermont and one in Colorado. And they exist to look at licensing laws so practice acts. And so, the way we work, we were set up in 2022 and I helped to start the office and hire an initial team. We are a small office of policy analysts that sit within the executive branch in our case so within the Department of Commerce. We get approval from the legislature and then we look at a set of occupations, a deep dive once a year. And then our recommendations go back to the legislature. And we have to look at every occupation once every 10 years. And the idea is that as practices, training, technology is changing. We want the licensure laws to keep up with that and make sure that the state isn’t standing in the way of innovation that can be happening out there in the market if the state’s laws were better aligned.
So that’s how I came to this. We picked behavioral health as the first thing to look at for a lot of the same reasons that I think Brianna is passionate about this. We found that it was a real problem in Utah. Legislators were talking about it. You know family members, neighbors were talking about it and it was just clear that this was kind of the first thing out of the gate we wanted to make sure to get right.
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Ed: So, Brianna, why don’t you talk a little bit about your research and what are you finding about the shortage of behavioral health workers?
BL: You can ask anyone as Jeff mentioned. Family members, community members that the impact of the behavioral health workforce shortage is felt with limited access to services. So often you hear about long wait times or clinicians not taking your insurance or specialty treatment programs for youth that aren’t available. So, the demands are outpacing the supply of the behavioral health workforce and the work at the behavioral workforce center tries to consider the supply but also unpacks the multiple factors that contribute to access and so we really like to look at not just the supply or the availability, but also the accessibility or the distribution of the behavioral health workforce. And so, we know in rural areas that there is lower supply of behavioral health workers, but we also impact within areas of higher social disadvantage what will distribution of the behavioral health workforce there. And what we found was areas of high social need have half as many behavioral health clinicians as do areas with low social need. And so, this really unfolds a picture that it’s not just rural areas that have a maldistribution of behavioral health workers, but also some of higher need communities don’t have the supply.
But we also look at things like the accommodation or how easy it is to receive behavioral health services and so accommodation might be, are you able to access behavioral health care in your school or in your community health center or your pediatricians or primary care’s office or your public health department? And we’ve done some work really thinking about where folks across their life, are they able to gain access? And then lastly, we think about the acceptability of behavioral health services as limiting access so it’s not just, do we have the right people or the number of people, but do we have the right people. They are really thinking about how do we increase the demographics of the behavioral workforce to represent the communities that they serve that they are providing care and languages that are meeting the needs of communities and so we often think about are we training individuals from the diverse backgrounds in order to meet those gaps. So, we try to do these different aspects of the access to unpack that just so if we have the total number increases that would be amazing. But we don’t know if that would actually get us closer to access to behavioral health services. So really unpacking things like the distribution and payment, accommodation and acceptability of the behavior health workforce is what we study as well.
Ed: Yeah, this access issue in health care seems to be just tremendous. I just did a podcast on oral health care that had much of the same troubles. Jeff, you mentioned that behavioral health workforce was the first topic you took on. Why was that?Why did that standout as something that your office thought this is where we ought to dig in and start.
JS: Yeah, we started just informally talking to legislators and kind of doing a straw poll of what was on their minds because they are listening to constituents all the time and this kept bubbling up and so as we started developing that hypothesis, we started just kind of checking in and confirming with people. And uniformly people were saying yes, absolutely. Please look at that first. Once we dug into the data and we were probably looking at some of the same stuff that Brianna does in her work. We looked at some of the SAMHSA national surveys for children and for substance abuse and mental health and found that Utah, we were providing behavioral health services to about a half million people a year across all the different kind of systems. But that there was probably another 200,000 to 500,000 that were not receiving any behavioral health services. And it depends which question you look at in the surveys whether people perceived a need and were looking for services or whether they were simply probably diagnosable based on their answers to other questions and should be receiving services. But we used that to say hey, there’s a massive gap here in terms of what we are providing and that has ripple effects throughout the economy and families and communities. And so that really convinced us. The second piece of data was that we looked at some of the national databases on how we compared in terms of complaints against our providers. And we found that we also were not doing great on that and so we knew we had to kind of both maintain or improve safety and kind of lower the number of complaints we were seeing against our providers. At the same time, we increased the workforce pretty significantly. And that’s a nuance problem for a policymaker so we thought it would also be a useful place to collect data and do a deep dive.
Ed: Jeff, let me stick with you for a minute. Our audience of course is legislators and staff and other people interested in the state policy and I understand that the work that you did that you provided to the legislature also resulted in legislation last year. And can you talk a little bit about that.
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JS: Yeah. Our office is set up to do that in a sense and that’s a really privileged position that we don’t take for granted. So, we sit within the executive branch and that was intentional so that legislators, the governor, you know my boss got together and said we think we need this protected, independent, neutral voice on licensing because as you all probably know licensing bills are notoriously difficult both because they are technical and they are politically fought right. People care deeply about their occupation and how it is perceived and what they are allowed to do. And so, they wanted this independent voice. They stuck us in the executive branch I think in part because it puts us in the right area to have access to all the data. So, we can talk to the licensing teams. We can look at the data internal to commerce and that’s just there is no friction in doing so. We also go outside and look at a lot of other data and academic literature and do primary data collection as well quite a bit of stakeholder engagement. But that lets us go back to the legislature as an independent voice and say hey, here is what we are finding in the data. Here is what we are hearing from industry. Here are some recommendations that we are starting to think about. And then there’s a lot of kind of codevelopment with the legislature and with stakeholders. But by the time it gets to the legislature, we’ve got a pretty well bedded set of recommendations. We’ve got initial language we worked with the drafting attorneys at the legislature. And so, in that sense, we are really set up to try to fast-track into legislative change what we do. Again, I think we are very lucky to have that kind of access.
Ed: And Jeff, what kinds of changes were the result of that legislation?
JS: So, the legislation was Senate Bill 26 in 2024 legislative session. It really included a whole lot of different elements and a lot of them feel really simple, seem really simple when you hear about them. But, of course, politically it’s often tough to get these things done. The biggest thing we did was create two new license types for what we call extenders. And the idea there is if you think of the physical health care workforce, it’s almost this perfect pyramid shaped workforce. You’ve got a relatively small number of really highly trained folks in the doctors and advanced practitioners at the top. And then you’ve got a wide base of extenders which are typically registered nurses, licensed practical nurses that extend the expertise of those more highly trained folks. If you look at behavioral health, it’s almost exactly inverted. Almost everyone in behavioral health has a master’s or higher and that’s because most of what we are doing is talk therapy or prescribing drugs. Both of which require at least a master’s and so it begs the question is there some role for similar extenders in behavioral health. And after doing a lot of research and looking at some other states and other countries, we came up with this idea of filling in some of the gap between peer support specialists and masters level clinicians with what we call the behavioral health technician which is a one-year certification and then a behavioral health coach which is sort of a generalist bachelor’s level license. And those where you know we saw examples of that in California that were a little bit more narrow. Ours are meant to be quite broad and to be applicable in many different settings. But that was really the main kind of innovation of that legislation. We also had some limited prescribing authority for psychologists who are upscaled. We created an exam alternative for some of the master’s level clinicians so rather than having to take the national exam, we allowed people a different alternative pathway of doing additional supervision and that’s especially important for you know English language learners and some underserved communities to be able to find clinicians who are culturally competent and linguistically competent. We created a little bit more flexibility in continuing education requirements and increased our supervision requirements a bit because we were concerned about that. But really as I say, the main innovation here was creating those extenders so that there was a more natural career path, a more natural set of extenders that would create more access and hopefully at a lower cost as we were confronting this crisis.
Ed: Brianna, let me ask you, thinking about that same audience., what would your advice be to legislators, legislative staff who really want to understand this shortage in their own community. How should they go about doing that or what are the resources they should look to?
BL: So, legislators and staff can best understand their workforce needs by observing who is in their current behavioral health workforce in their state and that’s across all the specialty behavioral health clinicians like psychiatrists and psych MPS and social workers, but also these extenders that Jeff is speaking about, so the peer recovery support specialist, the community health workers and (inaudible) the whole roles. And we offer a framework for folks to consider how there might be misalignment within training payment and regulation in their state to deploy the workforce. So maybe you have a bachelor’s level role in your state, but there are no payment mechanisms for them to be reimbursed or we don’t have a certification in that they have a limited scope of practice or an overlapping scope of practice that prohibits them from delivering services.
Or we are not training folks for future models of behavior health service delivery like cyber care management or integrated behavioral health or technology in telehealth delivered service. So really, it’s not just thinking about who is in your workforce, but also what ways are we limiting the capacity of the current workforce because we have the right training mechanisms in place or the regulation when it’s their practice, but we don’t have payment solutions. And I think peers are the best example. You know peers are not new to our workforce. They have been here for more than since 1970s, but we have had very limited training opportunities for peers and then we also have a mix match certification for peers. And then only recently have we been introducing payment mechanisms for peers. And so, I think that’s a classic example of how we’ve had this current workforce for a long time, but we haven’t had the opportunity to really deploy them I the ways that we need. But also, I loved Jeff mentioned prescribing psychologists. That’s looking around in the current workforce and say who with additional training and regulation flexibilities would be allowed to fill a large gap. So, for me when I really talk with states, I think it is hard to look at who might be in the current behavioral health workforce but also thinking about incentive designing new professions or occupations which might be needed. Are there ways we can extend training, payment or regulations within our current workforce to fill gaps and deploy people more appropriately.
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Ed: Brianna, let me stick with you for a second and you mentioned some of this before. I think many of us who are not experts on any of this think supply and demand that’s what governs the workforce. And it’s a simple formula and it’s a nice one to sort of fallback on, but I think as you’ve pointed out there are more factors than that involved. Patient level issues, provider issues. Could you just talk about that a little bit more and how have states taken this up?
BL: You know definitely there are patient level barriers and that in large terms is payment, affordability of services, accommodation or ease of accessing services. I see states taking this up in different ways. One thing I’ve seen states really anchor on to is integrated behavioral health or collaborative care management or integrating behavioral health services into schools and finding ways to have school and community-based service partnerships in order to be able to deliver care in schools. So, I think there are a lot of providers or I’m sorry patient level barriers in terms of basic things like transportation and acceptability of actually going to a specialty mental health provider versus receiving care within your pediatrician’s office. So, the provider level barriers we also see are large are pathways into the behavioral health workforce is long and they are costly and so rightfully so behavioral health clinicians what to be adequately paid for their services and unfortunately a lot of our payment mechanisms are not at the level of what individuals need to be paid to make up their loans and the student loan debt.
And so, a lot of behavioral clinicians have moved to out-of-pocket payment for their services which obviously really inhibits the community based mental health service delivery that we need. But I try to ask behavioral health systems to really think about how can you offer other benefits to working in community based mental health for these folks so that you can incentivize working in community based mental health as compared to moving to private practice. And some things I think we could offer is flexibility in terms of having hybrid work arrangements so perhaps the person can work 2 days in the clinic, but also 2 days at home delivering tele and remote virtual behavioral health. So, I think some of those provider level barriers are really in folks wanting to have more flexibility in their roles and to be paid adequately for their services. And then I think behavioral health systems the ones that are innovating and really thinking about what ways they can retain their workforce are the ones that are doing better. But certainly, when we are thinking about you know it’s not just the supply, but it’s the number you know the proportion of the behavioral health clinicians who aren’t taking any insurance let along Medicare or Medicaid or something we need to keep our eye on. It’s not just the total supply of behavioral health workers but increasing the supply across rural communities and underserved areas.
It’s not just increasing the supply, but the supply that has common form strategies or is trained in new models of behavior health service. So really thinking about supply is important, but that’s just one key aspect of how we are going to need behavior health needs.
Ed: So, as we wrap up here, I’d like to ask each of you just a final thought thinking of the policy people that we are talking to. What would you leave them with? One thing that they ought to keep in mind as they think about this challenge. Brianna, why don’t you go ahead.
BL: You know, I often try to remind folks that although there is such energy around addressing behavior health challenges, these are long standing issues. You know if we look back at the SAMHSA data that Jeff mentioned, we have had 25+ years of only half of individuals who want access to behavioral health care able to receive it. We are digging ourselves out of that and I would hope that folks as they are investing in behavior health service delivery and within their workforce to know that we hope that we need to continue with this in order to see some of those benefits. But I think the current landscape is positive that you know these investments will impact the future supply of the behavioral workforce and ultimately impact access to behavioral health care.
Ed: Jeff, you get the final word. What would your parting thoughts be to leave with legislators and staff?
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JS: I will try to use them well. So, Brianna mentioned the 3-legged stool of workforce of training, regulation and payment. If you think of that from a legislator’s perspective if you are going to change anything about the higher education training, if you are going to change anything about licensing laws and scope of practice. If you are going to change anything about payment and reimbursement. Every single one of those is going to require moral courage I’ll call it right. Like you are going to have to look some people in the eye and say I’m sorry like we are going to go against your own personal interest to do what’s right for the patient. And that’s hard. That’s what legislators are hired by the people to do, but it’s hard because you are going to be saying no to some constituents to do what’s right for the broader constituency and that’s the reason, we kind of are where we are in this. And so having legislators who are willing to step up and say there is enough of a crisis here that we are going to take action on this. Like I really appreciate what our legislature did on this and I guess that’s my call for the others is to say this is going to require that.
Ed: Well, I think that’s a great place to wrap up here and I want to thank both of you. I’ve learned something here and I am pretty sure some of our listeners will hear some things here that they did not know before. So, thanks to both of you. Take care.
JS: My pleasure.
Ed: I’ll be right back after this with Karmen Hanson from NCSL. Karmen, welcome to the podcast.
CH: Thanks, Ed. Thanks for having me back. It’s nice to be here. So, I was just speaking earlier to Brianna and Jeff about the behavioral workforce shortage. Brianna sort of laid out some of the reasons why there is a workforce shortage in some of the different areas and Jeff explained what Utah specifically their licensing office was doing in terms of looking at those professions and how that was affected by state rules. I wonder what you can tell us about what that workforce shortage looks like in the states. You’ve been tracking this and drilling down on it. Is it uniformly spread across the country or is it different in some areas?
CH: Yeah thanks, Ed. There’s like any other kind of state policy issue; there are state behavioral health workforce shortages you know they vary from state to state. Some may have a shortage in a certain type of provider like psychiatry or licensed professional counselors. Or they may have shortages in certain areas of the state. Maybe some might have more urban core shortages or rural area shortages. There is really quite a bit of variety.
Ed: And so, have how legislatures responded to this?
CH: Well last year we saw nearly one-third of the enacted health workforce bills which was about 160 were specifically addressing the behavior health work shortages in 2025 and at NCSL we think of these shortages and these interventions in five buckets. There is first of all understanding workforce needs and those are maybe using a statewide assessment or a plan for measuring or increasing the behavioral health workforce. There is increasing the supply of professionals and they can do that by using career pathways or residencies, for example. And then there’s expanding the reach of existing professionals and that could include joining counseling or social work compacts with other states. And then there is addressing like we mentioned that distribution of professionals and that can be providing financial incentives to practice in a rural or underserved area using loan forgiveness or tax credits, sign on bonuses. Kind of like the things that you would see in other types of professions, but you know these are targeting those behavioral health professions specifically. And then lastly there is retaining professionals in the workforce and that could be with providing programs to address provider burnout, their wellbeing or safety in the workplace.
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Ed: So, it sounds like it’s a complex program with some complex solutions that states have taken on. So, when you look at what states are actually doing legislation wise, we are in the 2025 session coming to the end of it for many states. What kind of activity do you see going on in legislatures?
CH: So far this year, we have tracked at least 56 bills or enactments and Brianna touched on many of these. Some of the behavioral health occupations that we’ve heard most about from our members and our tracking include physicians are on social work so again licensure compacts, examinations exceptions, reimbursement, supervision requirement and things like that. Then we are seeing a lot of action on peer support specialists so credentialing, reimbursement for those positions. And then counseling and therapy. Those licensed professional counselors and their authority to diagnose or associate licensure for those folks that aren’t quite fully licensed. Maybe they are still in their supervision stage and things like that. And then there is the bachelor level degree positions so having behavioral health technicians, assistants or aides and those are really there to help support the existing professionals maybe having some of the initial diagnostics run by them or some of the paperwork. Things like that just to get that administrative burden off of them. But more information on these actions can be found in NCSL’s health workforce legislation database in our Allied Health Professions series. So, retention also continues to be a significant focus. We are seeing states enacting legislation to establish or support health care workers support programs. Emphasizing the use of those peers and other professionals with less experience. For example, peer recovery support or treatment groups for first responders. And then we are seeing state efforts to recruit health care workers broadly aiming at reducing the workload and related stresses for those providers. And then mostly reducing administrative burden and expanding the role of those allied health professionals – those bachelor level programs. Bachelor level positions to support the work of the practitioners. And then sadly you know health care workers are often the victims of violence in the workplace so we have been tracking legislation aimed at protecting the health care workforce including de-escalation and violence, prevention training in the workplace. Improving security requirements. Enhancing penalties for violence against health care workers and other options.
Ed: Well, we will certainly link to that database and other resources from NCSL so people can dive deeper into this issue. Now let me ask you the crystal ball question which is what do you see coming in 2026 and beyond in terms of how states approach this issue?
CH: Ooh we love the crystal ball questions. If I had a crystal ball, I probably wouldn’t be a policy wonk, but it keeps my job interesting so. Looking at 2026, it will take some time for any of these outcomes on these recent state actions so we will need to pack our patience, but a lot of states will continue to address the behavioral health care provider shortage because of their constituents needs. Enticing new providers into the area is one thing. But then getting them through school and training and practicums and all those supervision hours that all takes time. But legislators will keep trying to move the needle at increasing access to care and improving systems for providers and patients alike out there.
Ed: Well Carmen, thanks so much for taking the time to rundown the legislative landscape for us. I know from speaking with Jeff and Brianna and now with you that this is a really an issue that I don’t think is maybe as well understood even among our legislators as it might be. It’s a niche of the health care field that is important to know about. So, thanks so much. I appreciate you taking the time. Take care.
CH: Thank you, Ed. You too.
Ed: I’ve been talking with Brianna Lombardi, Jeff Shumway and Karmen Hanson about how states are tackling challenges in the behavioral health workforce. Thanks for listening.
You can check out all the podcasts from the National Conference of State Legislatures by searching for NCSL podcasts wherever you get your podcasts. This podcast “Our American States” dives into some of the most challenging public policy issues facing legislators. On “Across the Aisle” host Kelley Griffin tells stories of bipartisanship. Also check out our special series “Building Democracy” on the history of legislatures.
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