The demand for aid radically exceeds the supply of help. Providers are experimenting with how to address the emergency.
A few years ago, Christopher Page Jr.’s Colorado high school was rocked by a spate of student deaths, including three by suicide. So the longtime principal was troubled when he couldn’t fill a school psychologist job for an entire year. Nobody had applied. This summer, he finally hired a budding social worker who was still finishing her last two classes.
He helped get her an emergency license, which was not hard, because there is an emergency.
In his area and elsewhere, the student mental health crisis is unfolding as the nation’s schools face a shortage of counselors, psychologists, social workers and therapists — each problem amplified by the other, and all of them worsening since the pandemic began. “There’s just such an influx of need,” Page said.
“Not only do we have shortages, but we have attrition from the mental health field,” said Sharon Hoover, a professor of child and adolescent psychiatry and co-director of the National Center for School Mental Health at the University of Maryland’s School of Medicine. “So as demand is going up, supply is going down.”
In a moment that seems to plead for creativity, educators are finding new ways to bring support into schools. Some universities are expanding counseling programs, hoping to produce more graduates. Schools are hiring interns and trainees. Some states, including California, are offering scholarships to lure students into mental health professions, while researchers are going back to the basics, rethinking what it means to be a mental health care provider.
But the need is immediate and widespread, and services often are not. It would take 77,000 more school counselors, 63,000 more school psychologists and likely tens of thousands of school social workers to reach levels recommended by professional groups before the pandemic hit, those organizations say. Typically, the jobs require a master’s degree, meaning six or seven years of higher education. The pipeline does not flow rapidly.
John R. Weisz, a professor at Harvard University who studies youth mental health, recalled visiting a school with 600 students at which the principal was the lone person working with pupils in distress. Weisz said he’s come across therapy waitlists of 5 to 10 months in community clinics in the Boston area and elsewhere; some queues were closed because waits exceeded a year.
Even so, the situation is uneven. “There are very rich school districts where there are no problems, and there are a lot of school districts where there’s not even one counselor in a school,” Weisz said.
New options are in the works. At the University of Oregon, a well-regarded psychologist is leading a bachelor’s degree program that creates a new profession — child behavioral health specialist. In California, the state’s plans include hiring wellness coaches and peer support specialists, as part of a multibillion-dollar initiative. In Chicago, the nation’s third-largest school district provided mental health training to 300 school nurses, adding to efforts that include school-based behavioral health teams.
The school mental health workforce needs to be built out, Hoover said. Instead of relying only on clinicians with advanced degrees, the system needs a more expansive approach that uses the skills and training of a wide range of people, she said. “There needs to be something in the middle,” she said.
A 2018 research overview of that idea — often called “task-shifting” — points to challenges in implementation but is positive about the potential. It concludes that the great need and clinician shortage mean that using “nontraditional providers may be the only solution in both low- and high-resource settings, at least in the short term.”
Some question whether mental health issues are too sensitive to be handled by those with less expertise. They worry that those with bachelor’s degrees, or less, may not have adequate training and supervision, or that their well-meaning guidance could be off the mark. “With the crisis that our students are facing, I don’t know if bachelor’s-level individuals have adequate preparation to help students and their families navigate these situations,” said Blaire Cholewa, an associate professor in the counselor education program at the University of Virginia. Others also worry that over time, schools could prefer to hire lesser-trained employees because they do not have to be paid as much.
In Colorado, Page, the principal of Highlands Ranch High, was not left entirely in the lurch when he couldn’t fill the psychologist job: He had other clinicians. His school of 1,500 students already had two social workers, a psychologist and seven counselors.
Still, Page found an outside mental health provider who came one day a week — and was always booked. The school also relied on a national suicide prevention program, Sources of Strength. After the traumatic year of fall 2019 to fall 2020 — when Page said the school lost three students to suicide, one student to homicide and three students to accidents or illnesses — its students began organizing a mental health week every spring.
“We’re definitely supporting more kids in more ways than maybe we could have or would have in the past,” said Page. “That’s always good. I’m glad. But is that enough? No. We always want to do more to be better by kids.”
‘A third of the workforce we need’
Surgeon General Vivek H. Murthy recently called the youth mental health crisis “the defining public health issue of our time,” saying that it threatens “the foundation for health and well-being for millions of our children.”
Seventy percent of schools have reported an uptick in students asking for mental health services since the pandemic started. Teenage girls reported record levels of sadness and hopelessness in the most recent surveys conducted by the Centers for Disease Control and Prevention. Nearly 1 in 3 girls reported in 2021 that they seriously considered suicide — up almost 60 percent from a decade ago. Boys are suffering too. Federal data shows a rising rate of suicide from 2020 to 2021 for males, highest among those ages 15 to 24.
The isolation and disruption of the pandemic left many students unmoored, as have repeated incidents of racialized violence, a lengthy string of mass shootings and legislation that restricts rights of LGBTQ+ students. Adding to that is a wave of parent protests about what children learn and read in school; and the effects of social media.
But counselors and psychologists are in short supply in some schools. The recommended ratio of no more than 250 students per school counselor is often a distant goal, with the national average 1 for 408 students. Similarly, the standard of 500 students per school psychologist is frequently aspirational. The national average: 1 for 1,127.
With roughly 35,000 psychologists in schools across the nation, “we have about a third of the workforce that we need,” said Kelly Vaillancourt Strobach, director of policy and advocacy at the National Association of School Psychologists.
For child and adolescent psychiatrists, the numbers are worse still, with roughly 10,600 in practice across the country. More than 85 percent of counties in America do not have even one, according to the American Academy of Child and Adolescent Psychiatry.
“As a result of the workforce shortage, pediatricians have become the default mental health provider,” said Sandy Chung, president of the American Academy of Pediatrics. In Virginia, two-thirds of mental health claims in 2019 were made by primary care clinicians, she said.
A bright spot on the landscape is the Bipartisan Safer Communities Act, which committed $500 million over five years to ramp up the pipeline for school psychologists, counselors and social workers. That money is coupled with a second $500 million for efforts to recruit, retain and train staff for those positions.
The same law steers another $1 billion for school districts to promote safe and healthy learning environments; prevent and respond to bullying; and combat violence and hate. More than 30 states have distributed their money to school districts.
All told, it’s a historical investment in school mental health, and yet the pipeline moves slowly.
Many school districts steered some of their federal covid-relief money to mental health, and that money is drying up over the next year. A number of superintendents who were surveyed said they will need to reduce school specialist staff, which can include those involved in mental health, said Sasha Pudelski, advocacy director of the AASA, The School Superintendents Association.
“I’m really worried about what’s going to happen when government funding runs out after this year because that’s kind of the first thing that gets cut,” said Brett Zyromski, an associate professor and head of the school counselor education program at Ohio State University.
Others vow to keep it going.
The Desert Sands School District in California, for instance, used the money to hire 20 school-based mental health therapists — one for every middle and high school, and some at elementary schools. The district will keep the therapists on its payroll after federal funds are gone, said Laura Fisher, assistant superintendent of student support services.
Still, as school started, four of its 20 positions were open. Hiring remains competitive, Fisher said. “Everyone is looking for them, whether it’s private or public,” she said.
At the district’s Indio High School, Principal Derrick Lawson said group therapy has been critical, bringing together four to 10 teenagers at a time who need help getting through their grief, for instance, or pent-up anger. Last year, as many as 14 groups were going at various times. This year, he expects the same.
“The need is not diminishing,” he said.
Many districts pair up with community mental health providers, who often set up an office at school. Students can get help during the school day, sparing families from transportation glitches and schedule conflicts. Costs are mainly covered by private or government-funded insurance. In a similar way, more schools have also turned to mental health care by telehealth.
To boost the school pipeline, a $5.5 million federal grant-funded program at the University of Maryland Baltimore School of Social Work’s Center for Restorative Change will support the recruitment, training and development of 105 social workers a year, particularly those who are African American or Hispanic. Students of color have often lacked resources for higher education, and school social workers have been predominantly White. The program, which also involves Coppin State University and University of Maryland Baltimore County, aims to produce social workers who will be hired in its partner schools.
Russell Sabella, a professor at Florida Gulf Coast University who heads the school counseling program, said he and others redesigned their master’s degree program. It’s now virtual, with synchronous instruction, an in-person internship and a two-year time frame, rather than three. This year’s class is 25 students, three times as many as last year. “We’ve got students coming in from all over the state, and even those who are local don’t have to worry about things like gas and trying to get off work early,” he said.
At Marquette University in Wisconsin, Alan Burkard’s program is expanding, thanks to a $2.8 million federal grant aimed at preparing students of color to become school counselors; — in a profession that is overwhelmingly White. Fifty-five students are slated to earn master’s degrees over five years, with the help of tuition assistance and while doing supervised work in Milwaukee-area schools.
Necessity mothers invention
Beyond the traditional programs, less conventional approaches to the shortage are gaining traction.
One is the Oregon program, where Katie McLaughlin, until recently a psychology professor at Harvard, took the helm. The initiative is part of the Ballmer Institute for Children’s Behavioral Health, funded with a $425 million gift by Connie and Steve Ballmer. Steve Ballmer, now a philanthropist, is a former CEO of Microsoft.
McLaughlin said a few dozen students are already enrolled — to become “child behavioral health specialists” — and will ultimately work under supervision in Portland public schools and other locations, accumulating more than 700 hours over the course of two years.
Ideally, she said, the new specialists will help identify students who struggle sooner and then intervene — reducing the number who require more intensive support later. If fewer children are in need, then existing mental health professionals — psychologists, psychiatrists, social workers — will be better able to meet the need.
“Our hope is that this is a workforce solution to meet the enormous unmet need for mental health support among children and adolescents,” she said.
Ernesto Leyva, a rising sophomore, was interested fairly quickly, saying the pandemic deepened his interest in mental health. He started college as a psychology major and likes the idea of working in schools. “I wish I had somebody I could talk to when I was younger,” Leyva said.
“If that program is replicated in other universities and becomes popular nationwide, that could create a real revolution in mental health,” Weisz said.
Other efforts could also change the landscape. In California, state officials are creating “wellness coaches” to support students in school and in the community, part of a broader more than $4.4 billion effort to “transform” the system of care for children and youth. Wellness coaches would focus on education, individual check-ins, care coordination, crisis referrals and small group sessions.
California is also offering scholarships to students who agree to become school counselors, psychologists or social workers.
And Tony Thurmond, California’s state superintendent of public instruction, said in an interview that his department is assisting in a state effort to hire 10,000 mental health clinicians to support students. He said it was just beginning but has been funded. He did not specify a timeline.
“We’re in a kind of triage moment,” he said. “We know that the counselors aren’t there, but the need is there.”
Alex Briscoe, principal of the California Children’s Trust, said what is happening with children’s mental health care in his state is akin to what happened with physical medicine many years ago, when that workforce expanded to include roles such as nurse practitioner and physician’s assistant.
Mental health care for children and adolescents can take many forms, and often is not suited to a standard 50-minute therapy session, Briscoe said. Instead, interventions might look different. They might include, for instance, shorter interventions about how to manage anger or frustration, or focus on relationships or handling the stress of not understanding school work.
Looking at the shortage from another angle, a program from Harvard researchers would give digital mental health training to counselors and others who may not have trained for today’s level of mental health care needs, said Weisz, a co-principal investigator. The idea is to bolster resources inside school buildings. But the project — part of a broader program called Empower — won’t be done for another 18 months, he said, and will then require testing.
“The challenge is that the need is immediate, but the process of developing things that are well-tested and known to be effective takes longer than we’d like,” Weisz said.
If you or someone you know needs help, visit 988lifeline.org or call or text the Suicide & Crisis Lifeline at 988.
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