SAN JOAQUIN VALLEY – The task of searching for a therapist is no easy feat. Being comfortable enough with someone to open up about mental health challenges requires the right fit, and if their rates aren’t affordable to someone or they have a months-long waitlist, it’s back to the beginning.
Exacerbating this challenge is a shortage of mental health professionals throughout the United States — particularly in the Central Valley. Kimberly Warmsley, executive director of the National Association of Social Workers (NASW) California Chapter, said similar to other health care professions, the COVID-19 pandemic heightened this issue, which persists in rural, underserved communities.
“When we talk about a mental health provider/social worker shortage, we’re simply saying that (an area) faces a shortfall in the amount of social workers who are available per resident or community member,” Warmsley said. “In the Central Valley itself, we are significantly short in the amount of mental health professionals or social workers who are available … than in any other area in the state.”
Aggregate licensing data from the California Department of Consumer Affairs (DCA) best illustrates the presence of mental health professionals in the San Joaquin Valley as compared to other regions in the state.
As the state’s licensing entity, the DCA publishes data on active and new licenses for mental health professionals. When referring to mental health professionals as a whole, the term includes Licensed Clinical Social Workers (LCSW), Licensed Educational Psychologists (LEP), Licensed Marriage and Family Therapists (LMFT) and Licensed Professional Clinical Counselors (LPCC).
Licensed mental health professionals in the San Joaquin Valley represented 6.6% of all licensees in the state for Fiscal Year 2022-23, split between the Northern San Joaquin Valley and the Southern San Joaquin Valley at 2.52% and 4.08%, respectively.
The DCA classifies the Northern San Joaquin Valley as including the counties of Alpine, Amador, San Joaquin, Calaveras, Stanislaus, Merced, Madera, Mariposa, Tuolumne and Mono. The Southern San Joaquin Valley is made up of Fresno, Tulare, Kern, Kings and Inyo counties.
Combined, the two San Joaquin Valley regions had 7,798 active licensed mental health professionals in Fiscal Year 2022-23; the San Francisco Bay area had 22,494 and Los Angeles County had 32,647.
In Fresno County, there were 2,338 licensed professionals — 2.3 licensees per 1,000 residents — and in Tulare County, there were 818 licensed professionals — 1.7 licensees per 1,000 residents.
The Mid Valley Times spoke with four professionals throughout the Central Valley who work in various mental health practices to hear their views on the issue, why it exists and what can be done to improve the local mental health care landscape.
One of the most significant forces driving the shortage is the widespread mental health crisis that the United States is currently facing. Particularly since the pandemic, demand for mental health services has been at an all-time high, and the time and training it takes to become a licensed therapist cannot keep up.
“I think that as time has gone on since the pandemic, we’re just seeing an overall rise in mental health and people are asking for support in services, but we have not produced enough professional social workers who are equipped to deal with the mental health crisis we are currently in,” Warmsley said.
Based on data from 2021, the National Alliance on Mental Illness (NAMI) has said that one in five adults in the United States — nearly 58 million people — experienced mental illness in 2021. One in 20 adults — 14 million people — experienced serious mental illness and 16.5% of youth 6 to 17 years old — 7.7 million people — experienced a mental health disorder.
According to the 2011-2021 Youth Risk Behavior Survey report released by the Centers for Disease Control and Prevention (CDC) in early 2023, young people in the country are especially experiencing an increase in mental health-related issues.
The report showed that the percentage of high school students who experienced persistent feelings of hopelessness or sadness, seriously considered attempting suicide, made a suicide plan or attempted suicide all increased over the 10-year period.
In 2011, 28% of high school students surveyed reported experiencing persistent feelings of hopelessness or sadness — that increased to 42% in 2021.
Visalia-based LMFT Elizabeth Vargas, who works at the Zimmerman Therapy Group, said the increasing societal acceptance of using mental health services could also contribute to increased demand.
“The stigma around seeking mental health assistance is decreasing — slowly, we still have a lot of work to do around mental health stigma — but people are finally open to realizing that mental health is just as important as physical health, and so I think there are more people seeking assistance,” Vargas said.
Co-founder of Fresno-based therapist collective The Reclaim, LMFT Karen Huckaby shared that belief, and said that the interest in becoming a licensed therapist has likely stayed the same — unlike other health care professions where interest has declined — but the rate of people entering the field has not kept up with demand.
Access to services, training
While demand for mental health services increases across the entire country, practitioners in rural areas have more obstacles in their way as they try to keep up.
Warmsley, who was raised in San Joaquin County and is currently based in Stockton, said that the shortage of mental health professionals in the region reflects the same inequities that restrict Central Valley residents from accessing all other resources— general health care, clean drinking water, quality infrastructure and so on.
Licensed mental health professionals may gravitate toward areas where it is wealthier and more densely populated because it allows them to run a successful business.
Vargas said that in smaller towns, the infrastructure to set up a successful practice is lacking, and it can be difficult to even find a location to set up a therapy practice. Highly-populated areas are attractive to mental health professionals setting up a business because they can offer more competitive wages, benefits and support for the therapists under their employ, Vargas said.
In places like the Bay Area and Los Angeles, mental health professionals are able to charge much more per session because their clients can afford it, with or without insurance, which brings up another barrier for rural areas.
Jonathon Baird, a clinical psychologist and the founder of Fresno-based company Vitalize Behavioral Health and Psychometrics, said that the dollar amount an insurance provider will reimburse a practitioner has been stagnant even as demand and inflation rise.
When insurance only covers so much of a session, those seeking out services cannot afford to see a licensed professional who charges more, and licensed professionals cannot properly compensate themselves and their employees if they keep fees low in order to retain clients.
Additionally, county-run services may only accept certain types of insurance, which makes it more difficult for residents to access mental health care.
“Cost of living has obviously increased, inflation is a factor and forces clinicians to explore other opportunities,” Baird said. “It’s usually driven by some level of payment, and there hasn’t been a whole lot of movement in terms of pay rates and reimbursement compared to how the demand has increased since COVID.”
Opening up a private practice can be tricky, Baird said, and is more effective when the surrounding community can afford to pay higher rates.
Vargas said that many people looking for therapists are unaware that private practitioners can send them what is called a super bill, which combines multiple appointment fees that a client can send to their insurance company. Even still, insurance companies may not completely cover the costs.
In rural areas, it is also difficult to get the training that one needs to become licensed. The process requires thousands of hours of supervised work under other clinicians, which is hard to come by away from population centers.
“If someone lives in a county, city or area that’s farther away from a higher education institution, accessing classes or campuses that provide that education makes it difficult for people to continue on to receive their master’s degree,” Vargas said. “It is a quite extensive process to obtain your master’s degree and meet practicum hours to get the experience to test for your exam.”
Huckaby said that many therapists will stay near where they can get jobs, which is often in areas where they attended school.
Within the Central Valley, Huckaby said Fresno Pacific University, California State University (CSU) Fresno, CSU Stanislaus and the University of California, Bakersfield are the only schools that offer master’s programs in marriage and family therapy (MFT).
“The greater Los Angeles area and the Bay Area are awash with MFT programs and job opportunities, which can make the space in between — where we are — feel like a bit of a desert,” Huckaby said.
There are multiple approaches current and aspiring mental health professionals can take to address these challenges.
For Baird, one thing that has been helpful is expanding the services his company provides to meet different levels of need and being creative with those service offerings.
Further, in order for mental health professionals to be successful in their work and continue to attract individuals interested in becoming licensed clinicians, they need to take care of their own mental health, Baird said.
“To truly be successful as a mental health agency, you have to prioritize mental health within the culture of the agency and prioritize mental health within your staff,” Baird said. “Business models and prioritizing profit conflict with general mental health and cause stress and anxiety, so it’s about figuring out how to balance those things.”
Both Huckaby and Vargas mentioned that mental health professionals and their clients should also keep in mind the fact that licensed California therapists can provide teletherapy to clients anywhere in the state. By reaching people in different areas through virtual appointments, that can contribute to alleviating the demand, Huckaby said.
From Warmsley’s perspective, she said that elected officials need to come together with local practitioners to start problem solving so that funding for mental health services and clinician training programs get appropriated to universities and local entities.
The issue needs to be taken seriously and communities must ensure that social and mental health services are available, Warmsley said, because if left untreated, mental health issues “can change the trajectory of someone’s entire life.”
Warmsley said the best thing that professionals in the mental health field can do to address these issues is to continue to talk about them and collaborate with one another to find solutions.
“I don’t think we talk about this enough,” Warmsley said, “but I’d love to see some type of task force or collaboration that’s built to address the inequities the Central Valley faces, especially as it relates to mental health practitioners.”