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Mental Health Providers in Alabama: Last in the Nation
In 2018, the United Health Foundation published their annual review that focuses on health disparities throughout the U.S., providing valuable information on each state. The data was collected from 2010-2017. States were ranked based on scores in each category of determinants of “health” which is defined by the World Health Organization as being “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (1946). One of these determinants is access to mental health care, which is largely established by the presence of mental health providers.
According to the review, psychiatrists, psychologists, LCSWs, LCPs, marriage and family therapist, those who treat substance abuse, and mental health specialized nurses qualify as mental health providers. The number of these providers per 100,000 was calculated and Alabama was found to be ranked 50th in the nation. This speaks volumes as an estimated 15.3% of Alabamians reported experiencing mental distress (percentage of adults reporting mental health was “not good” for 14 or more days in the previous 30 days at the time of data collection) (CDC, 2018). These findings illuminate a pervasive need to increase availability of mental health care for Alabamians, beginning with addressing the shortage of providers. The implications of poor access to mental health care, exploration of factors related to this issue, and suggestions for improvement will be addressed in this paper.
Inadequate access to mental health care is a serious issue that continues to impact Americans. In 2017, it was found that even though 1 in 5 Americans had a mental disorder, less than half received treatment (U.S. HSS, 2017). Gamm, Stone and Pittman state that mental illness targets and impacts those who are “most vulnerable” (2003) such as the homeless and those suffering with substance abuse. It is of no surprise mental illness is also related to poverty, wars and suicide (Lake & Turner, 2017). Even mild disorders have been shown to have devasting consequences if left untreated in that they “have a higher risk of future serious outcomes, such as attempted suicide, hospitalization, and work disability” (Kessler, et.al.). Thus, one could surmise that areas lacking access to mental health care would see increases in violence, crime, poverty and physical illness. Therefore, this lack of access impacts Americans on not only within the microsystem, but also the mesosystem and even the exosystem (Gerig, 2018, p. 55).
The lack of access to mental health care can be attributed to cost, availability of providers, and stigma. It can be assumed that the actual presence of providers within a reasonable distance is paramount to mental health care access. Heilser stated that “access to mental health care depends on the number of appropriately skilled providers available to provide care” (2018). Nationally, it is reported that of the 124 million Americans are in need of mental health services, only 35.2 % of the need is met (HRSA, 2018). In Alabama, these numbers are bleaker with only roughly 23% percent of the need is met (HRSA, 2018).
Across the nation, those who are living in rural areas are continuing to be underserved (U.S. H.H.S., 2017; Duenow, Kobernick, Sohre, & Wallgren, 2017; Merwin, Hinton, Dembing, & Stern, 2003; Gamm, Stone, & Pittman, 2003). Being that roughly 23% of Alabama’s population is rural, special attention should be paid to these areas in regard to mental health care access (U.S. Census Bureau, 2018). This is particularly true for low-income areas as it was found that those with lower incomes were 1.7 times less likely to have a mental health facility than their high-income counterparts (Cummings, et. al., 2017). Poverty is also related to a lack of availability of services in that communities with higher minority proportions are less likely to have a mental health facility (Cummings et. al., 2013).
Practically, when exploring factors related to a shortage of mental health providers, it is pertinent to look at salary. For mental health counselors, the mean salary in Alabama ranged from $26,620-$42,640 according to the Bureau of Labor Statistics (2018). Utah ranked as first in the U.S. with an average salary of $66,330 (Bureau of Labor Statistics, 2018). Although, when compared to the national salary average, Alabama was only below the mean by approximately $1,990. This perhaps lessens the concern that lower salary is a determining factor in relation to the shortage. Of course, this average salary is influenced by the ability for clients to access counselors. Therefore, the logic is circular. Counselors might not pursue employment in Alabama due to the perceived lower pay, but this average may be influenced by lack of access.
Licensure requirements should be reviewed to determine whether Alabama’s supervision requirements for licensure are more demanding than the surrounding states. In Alabama, counselors must have 3000 hours (2250 hours direct and 750 hours indirect) of supervised experience before they can be licensed (ABEC, 2018). To determine whether this amount is particularly difficult to achieve, three bordering states were compared. Florida seemed to require the least amount of supervision: 100 hours of supervision in 100 weeks or more, and 1,500 hours of direct therapy with clients with 1 hour of biweekly supervision (Florida Board of Clinical Social Work, Marriage & Family Therapy and Mental Health Counseling, 2019). In Georgia, counselors have to complete a four-year internship as an Associate Licensed Counselor under an LPC (The Georgia Composite Board of Professional Counselors, Social Workers and Marriage and Family Therapists, 2019). Mississippi’s requirements are similar to Alabama’s, also requiring 3,000 hours (Mississippi State Board of Examiners for Licensed Professional Counselors, 2018). Based on this comparison, it does not necessarily seem to indicate that licensure supervision requirements as the cause of the shortage.
From 2009-2012, Alabama made deep cuts (more than 30%) to the mental health budget as well as closed some of the few remaining state psychiatric hospitals. Only three state-run mental health hospitals remain in the state (Alabama Dept. of Mental Health, 2018). This can be attributed to the national deinstitutionalization movement, the adoption of a community-based treatment approach (Gerig, 2018), and overall funding. While the use of inpatient long-term, state-run facilities is controversial, they have the potential to employ many providers, including LPCs, and interrupt the revolving-door phenomenon that the country is currently experiencing. To that point, inpatient, long-term and/or residential, affordable care could also contribute to much needed solutions to the issues involving the mentally ill and incarceration.
On that note, there are several other ways to improve the issue and strategies to deal with shortages in mental health providers. The first being the most obvious in that incentives could be provided to persuade providers to work in these low service areas. These incentives could include loan repayment and scholarships through the National Health Service Corps Loan Repayment and Scholarship Program (Hastings & Cohn, 2013; National Health Service Corps, 2010), by which there is an opportunity for providers to receive up to $25,000 a year for loan repayment.
Telemedicine could also provide services to those currently not able to receive mental health care (Bashshur, Shannon, Bashshur, &Yellowlees, 2016; Butryn, Bryant, Marchionni, & Sholevar, 2017; Keeler, et. el., 2018). Telemedicine has been shown to be able to provide rapport as well as be efficacious (Lynch, Tamburrino, & Nagel, 1997; Hian, Chuan, Trevor, & Detenber, 2004). A recent study also found that ICBT (Internet-based Cognitive Behavior Therapy) is effective at treating disorders such as “depression, GAD and social anxiety, panic disorders, phobias, addiction and substance use disorders, adjustment disorder, bipolar disorder, and OCD” (Kumar, et. al., 2017). Kumar, et.al., also state that this method of therapy is particularly useful for rural/ underserved areas (2017). Therefore, increasing the use and awareness of internet-based therapy could help to reach the clients in need of services in Alabama’s rural areas.
Another suggestion for improvement is the integration of mental health into primary care settings (Patel, Flisher, Hetrick, & McGorry, 2007). This is a seemingly decent suggestion for populations where the lack of access is purely due to location, but they may have access to medical care. While those who are unable to receive mental health services due to cost and insurance coverage would not necessarily benefit from this suggestion. Though, the integration could serve to provide an appealing work environment for potential counselors.
Perhaps the most popular suggestion is to have LPCs recognized and their services covered by Medicare. Approximately 21% of the state population are Medicare beneficiaries and 8.2% were SSDI (Social Security Disability Insurance) beneficiaries (KFF analysis of the CMS Medicare Advantage enrollment and Landscape files, 2010-2018). Licensed professional counselors are excluded from Medicare, and this, coupled with (and possibly partially responsible for) the shortage of providers, has contributed the rural mental health care disparity (Wiley, Fullen, & Morgan, 2019). With the ACA and other professional organizations lobbying to be approved providers for Medicare beneficiaries, it is reasonable to assume that if successful, this could aide in the effort to address the shortage of providers by essentially widening the pool of potential clients.
Alabama’s lack of mental health providers impacts mental health counselors in different ways. The first being that the term “providers” includes not only counselors, but other professions as well, namely psychiatrists. While this can be positive from a business perspective in that the counselors who practice in Alabama have less competition, it is inherently negative as the opportunities for collaboration and consultation are limited, not to mention the negative impact on the clients and their families who are unable to access helpful and necessary resources. The research provided throughout the paper substantiates this.
Further research should be conducted focusing on different communities within Alabama and matching them to other communities throughout the South East to determine if there are unique factors present. It could be suggested that research on what portion of the need can be met by mental health counselors and what barriers there are to meeting that need (i.e. managed care, Medicare, ect.) would be helpful. Specifically regarding counselors, statewide interviews could be done to determine what current LPCs perceive as barriers.
This issue is so broad and encompasses the mental health profession as a whole. Therefore, the impact on any future practice will be noticeable. In an agency setting, it could mean unmanageable case loads and an increased likelihood of burnout. In private practice, there could be greater success due to scarcity, but unless the factors relating to this issue are clearly defined, there is a great risk of the opposite being true. For example, if the shortage is due to the population not having the means to afford counseling, then private practitioners would surely be at a disadvantage. This shortage also impacts future clientele, who may have access to one type of provider but require an interdisciplinary approach to adequately treat them.
Due to the attention being placed on the shortage, although most of the focus is on psychiatry, it could be hypothesized that there will be a search for other avenues to meet the demands. Whether changes in coverage of mental health care will be made is not as certain, although there is quite a lot of movement towards LPC services being covered under Medicare, which is encouraging.
In January of 2019, Representative Mike Thompson (D) introduced the H.R.945 - Mental Health Access Improvement Act of 2019. This bill helps mental health counselors and marriage and family therapists be covered under Medicare part B. The bill specifically mentions the coverage for rural, federal and hospice programs. It also serves to authorize these professions to develop discharge plans for post-hospital services. It is an identical to the S.286 - Mental Health Access Improvement Act of 2019 introduced as a companion bill. Should this amendment to the Social Security Act come to pass, the shortage of mental health providers could be positively impacted.
Support of this movement may help push the cause along, and future counselors should continue to stay up-to-date and participate in the discussion. There is no denying that the shortage of mental health providers in Alabama should be addressed to meet the needs of the people who reside in the state. Personally, this author plans to aide this issue by continuing to practice in the state of Alabama after licensure and through involvement in professional organizations.
In conclusion, the complexity of this issue lends to this author’s inability to conclude that a single factor as being responsible for the shortage of mental health providers in Alabama. Perhaps the combination of stigma associated with mental illness, lack of mental health facilities, higher proportions of rural areas, and cost are what separates Alabama from other states. There has also been the suggestion that the priorities of government officials lean towards incarceration instead of mental health care. Further research could help to determine dominant factors. The suggestions presented in this paper still stand as mechanisms for improvement, particularly along the lines of Medicare coverage and incentive programs.
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