It’s 2022, and finally, the shortages and supply chain problems which characterized the peak of the pandemic seem to be returning to normal. Toilet paper and home gym equipment are back on the shelves. Still, there is one shortage which remains very persistent and concerning - mental health providers, and in particular, therapists.
The Therapist Shortage
As a psychiatrist, it is clear that lack of therapist availability affects patient care at many levels. For the most common psychiatric disorders, such as depression, anxiety, and PTSD, psychotherapy is a mainstay of treatment. Good therapy leads to better ability to cope with stressful events and manage psychiatric symptoms and consistently leads to higher quality of life for patients. When patients are taking psychiatric medication, there is evidence that combining both medication and therapy for many conditions is better than the medication alone (1,2). An ideal psychiatric care team consists of among others both a psychiatrist and a therapist, who can communicate to provide the best care for the patient. The connection between psychiatry and psychotherapy is so important that many psychiatric residency training programs encourage or require trainees to have a therapist themselves, to better understand exactly what the experience is like.
Despite this, trying to get a patient connected with a good therapist can often be an exercise in frustration, and is demoralizing for already-struggling patients. Few therapists are accepting new patients anywhere, and those that are often have long waiting lists (3). The problems can be greatly amplified depending on insurance coverage. Many therapists only accept cash on a per-session basis, which is far too expensive for the majority of patients who are seeking care. Private insurance such as that provided by an employer will in theory cover therapy, but finding a therapist who actually accepts this insurance can be a big challenge in some areas. For those patients who are on Medicare, Medicaid, or uninsured, the situation can be even more dire. Those few providers who are available can have waiting lists on the order of several months to get an appointment which is a tough pill to swallow for those suffering from an untreated mental health issue. People who are seeking a specific type of therapy or therapist, like a child specialist, autism specialist, or gender specialist have even more trouble. The list goes on.
So, How Do I Find a Therapist?
Unfortunately, there isn’t some secret trick to finding a provider I can give which will get you an appointment. There are, however, a few things worth trying. Insurance companies have lists of in-network providers on their websites, and calling the ones in your area may give you an idea of what wait lists look like in your part of the country. Since telehealth has become commonplace since the pandemic, you may find that therapists who would be impractical to visit in the office become good options for video therapy. I also frequently recommend the website psychologytoday.com which hosts a therapist finder that allows you to filter by insurance coverage, type of therapy and more. Keeping an open mind about what your new therapist may look like or what type of therapy they do may help you get your first appointment sooner, and you may find yourself pleasantly surprised. Those who can afford to pay cash or out-of-network rates unsurprisingly find many more options available, and it may be worth calling around to see what rates are like if this could be practical. Some patients go to a cash practice and then file claims with their insurance company themselves, getting a partial reimbursement and only paying the difference out of pocket - this is a headache and differs for each company, but it can be done. Finally, big nonprofit hospitals such as those associated with universities often have large psychiatric practices which provide quality care to anyone regardless of ability to pay (uninsured patients are typically enrolled in Medicaid programs, though each state is different) They will almost certainly have a waiting list, but it’s worth getting in line if there are few other options available.
The Normalization of Therapy
How did it get this way? It’s easy to assign blame to COVID or any one of the numerous distressing world events for creating droves of suddenly-depressed people seeking therapy. This may turn out to be partially true, but there’s much more to it than that. In fact, some of the current therapist shortage may turn out to be the doing of our own advocacy, that is, the normalization of mental health care in society in general.
Decades ago in the minds of most Americans, mental health care and psychiatry were associated with grim images of locked mental institutions filled with desperately ill patients. To suggest to someone at the time that they could benefit from therapy, even in the face of clearly debilitating mental illness, may be perceived as something of an accusation that they were “crazy” or belonged in such an institution. The practice of outpatient therapy of the time didn’t always help the image either. Psychoanalytic (or Freudian) therapy was very popular in the 1950s and 1960s, and cemented in the public mind various stereotypes about what therapy looks like which appeared unhelpful to many people - for example, having a therapist make bizarre interpretations about one’s childhood after looking at inkblots.
While Freud remains controversial in 2022, both mental health care in practice and its public image have changed a lot for the better in the past half-century. The development and widespread use of effective psychiatric medications for a variety of conditions as well as important patient-advocacy laws have led to fewer involuntary psychiatric hospitalizations, far fewer restraints, and much greater patient autonomy. Spending a short time in the hospital for depression and coming home feeling better gradually became a more common story. The reduced fear of being “locked up” led more people to get the help that they needed, in the process saving countless lives from preventable suicide. Hospitals are only a short-term solution, of course, and these patients needed good long-term care. Fortunately, around the same time there were important changes in psychotherapy. Cognitive therapy (the predecessor to modern CBT) was developed in the 1960s and quickly became popular among people seeking therapy. While other types of non-Freudian therapy had existed before CBT, CBT gained a reputation for being more practical and based in behavioral science. Therapy has continued to evolve, with modern techniques developed to help with numerous mental health problems including depression, anxiety, trauma, ADHD, OCD, schizophrenia, and more. The image of a therapist’s office - or more recently perhaps a video call - being a safe place where one can share problems and find solutions or improve one’s self-image has finally replaced the image of therapy from years past.
The constant advocacy on the part of clinicians and patients is and was absolutely necessary. Suicide is a preventable tragedy and nobody deserves to suffer from untreated mental illness in 2022. That said, the normalization of mental health treatment has undeniably led to an increase in demand for these services which existing providers have struggled to support.
Supply and Demand
The therapist shortage existed before COVID-19, but the pandemic sharply worsened the situation (4,5). Prior to COVID, most of the problem was directly related to money. It takes a lot of education to become a qualified therapist: in the US, that means several years of graduate school and several more years of supervised clinical training. It’s a big commitment of time and money, and while these professionals have a deep commitment to their patients, they need to pay their loans and make a living too. Doing quality therapy with a patient is demanding of both time and emotional energy. You can’t see too many patients in a day and still do a good job. The long and short of it is: doing therapy is expensive. Insurance companies in the US are notorious for paying medical providers low rates for providing services for patients, and therapy is no exception. Companies which employ therapists may push them to see more patients than appropriate to generate revenue. Sometimes, a combination of low payment rates and complicated reimbursement paperwork lead therapist practices to forgo accepting insurance altogether to preserve their own sanity, reducing access to therapy for those without means (6). Overworked therapists at public hospitals or insurance-accepting practices have also increasingly left for better working conditions in private practice. In a world where burnout is everywhere, who could blame them? Little by little, supply went down as demand went up.
A good therapist who accepted insurance and could take a new patient was already hard to find in many places when COVID shut down the world in 2020. The pandemic accelerated the trend. It’s not hard to imagine why: millions of people died or became seriously ill, some found themselves in total social isolation while essential workers struggled with burnout, and the news was filled with one unprecedented crisis after another. People were stressed and needed help. Therapists found themselves with a surge of referrals (7). While the overwhelming majority of therapists now provide at least some telehealth services and can see patients without having to go to the office, there still just aren’t enough therapists to see all the patients who need to be seen in a timely manner. The labor shortage which seems to permeate every part of the economy in 2022 affects health care as well, and poorly funded or managed practices struggle to hire and retain the best therapists now more than ever before.
All of this culminates in patients today making phone call after phone call and finding that they can’t get in to see someone any time soon. Fortunately there is hope for the future. The number of licensed and practicing therapists continues to grow as there is greater recognition of the need for these services (8). The White House recently released a long plan of different strategies intended to mitigate the problem (9) including increasing the number of providers, reforming payment schemes, and other measures to improve overall mental well-being among Americans. How effective these plans will be remains to be seen, but it is encouraging to see the lack of mental health care recognized even at the highest levels of government. Technology also offers some relief. Mental health apps like Rose are becoming more common and accepted by patients and health care providers. Mobile apps can help therapists practice more efficiently by helping collect diagnostic information and provide mental health resources outside of allotted application time. Another increasingly common model is collaborative care, where primary care doctors work indirectly with psychiatrists to expand the reach of mental health treatment. While the availability of therapy will probably remain difficult for years to come, the future brings new solutions in addition to challenges. We can be thankful that psychotherapy in general is more normalized in society than ever before, and use modern tools to both find the right provider and improve our own mental health.