“I’m in a big city. I’m in L.A. We have a lot of therapists,” she said. “So it’s just kind of wild to me that that many people are at capacity.”
It has been difficult to find mental health counseling in much of the United States for years, long before the coronavirus pandemic began. But now, after two years of unrelenting stress, turmoil and grief, many people seeking help are confronting a system at or beyond capacity, its inadequacy for this moment plainly exposed.
It is even more difficult to find specialized care for children or those with lower income. Assistance of any kind is in short supply in rural areas, where all health-care choices are more limited than they are for residents of cities and suburbia. Those hoping to find a Black or Latino therapist face even more limited options.
While all of those circumstances have long been true, the pandemic has significantly worsened conditions, according to mental health practitioners, officials at professional associations, people seeking care and a wide variety of data.
“It’s the worst it’s ever been,” said Kelly Roberts, director of Graduate Programs in Human Sciences at Oklahoma Christian University in Edmond. “I’ve never seen it like this.”
At Boston Medical Center, the safety net hospital for the city, staff recently began contacting parents of children who joined the 170-person wait list in April 2021 — a 10-month wait for a chance to receive services, said Christine M. Crawford, a child psychiatrist at the center who is also the associate medical director for the National Alliance on Mental Illness.
At a 20-practitioner branch of the nonprofit agency OhioGuidestone in Columbus, the wait list now holds 150 to 200 names, nearly double the norm.
The federal government’s mental health and substance abuse referral line fielded 833,598 calls in 2020, 27 percent more than in 2019, before the pandemic began. In 2021, the number rose again, to 1.02 million.
When the American Psychological Association surveyed its members last fall, it found a surge in demand and new referrals, particularly for anxiety, depressive and trauma-related disorders. Yet 65 percent of the more than 1,100 psychologists who responded said they had no capacity for new patients and 68 percent said their wait lists were longer than they were in 2020.
In December, U.S. Surgeon General Vivek H. Murthy issued an advisory on “the urgent need to address the nation’s youth mental health crisis.” And on Feb. 1, a Senate committee held a hearing to address the nation’s growing mental health and substance abuse problem.
“Mental health problems often lag a stressor,” said Mitch Prinstein, chief science officer of the American Psychological Association, which represents 133,000 psychologists, researchers, educators and others. “This is not a surprise.”
Prinstein and 35 colleagues predicted the current situation with remarkable clarity in a “call to action” in the American Psychologist journal in August 2020.
“The toxic psychosocial stressors that the pandemic has created (e.g., physical risks, daily disruptions, uncertainty, social isolation, financial loss, etc.) are well known to affect mental health (and thereby also physical health) adversely, and collectively encompass many characteristics that have been identified as having the greatest negative effects,” they wrote.
It is nearly impossible to generalize about the state of the entire mental health profession in a society as vast and varied as the United States. Hundreds of thousands of specialists work in a wide variety of settings, including schools, hospitals, private companies, nonprofit agencies, free-standing clinics, outpatient settings and private offices.
Traditional one-on-one talk therapy is offered by practitioners with significantly different levels of training, including clinical psychologists, who have doctoral degrees; psychiatrists, who hold medical degrees and can prescribe medication; clinical social workers, marriage and family therapists, licensed professional counselors and others.
The frustration some people encounter when trying to book time with one of them points to the serious consequences of the two-year-old pandemic and a mental health system that simply isn’t built to handle current demands.
In Avon, Ind., 24-year-old Rowan Welch, a team leader for a bank, said he has contacted every provider within 50 miles on his insurance plan’s network without success. “I am still looking, after looking in a 50-mile radius,” Welch said. “There’s not much more I can do.”
In New York, Flora Stamatiades, a gig worker who relies on insurance she purchased through the state’s exchange, said she has been looking for a therapist on and off for more than a year. She is using a list provided by the Actors Fund, which is available to her through her job as a covid safety manager for a show now in rehearsal. She is on a list for a possible opening this spring.
“It never, ever occurred to me that I would not be able to find a therapist when I needed one,” said Stamatiades, 55, who left her job with the Actors’ Equity Association in 2018 after 24 years. “I might have to wait a few months. That occurred to me. That would have been okay.
“This is not actually a new problem,” she added. “It’s just desperate now.”
And Toni Powell, an associate director of clinical quality for UnitedHealthCare in Austin, said she has contacted about 50 providers, online and by telephone, without finding one who can help with the behavioral problems her 5-year-old granddaughter is experiencing. Powell is raising the child, who she said suffers significant impairment from exposure to alcohol in the womb, cystic fibrosis, trauma and other conditions.
The child needs to be seen in person, an obstacle to finding therapy from providers who largely moved online when the pandemic began, she said. Powell recently began meeting with one specialist online, in the hope that the practitioner will see her granddaughter in person in the next few months.
“There are not enough [providers] or their specialty does not include what you need for your kid,” she said. “And then of course the pandemic.”
Gullett, a 47-year-old screenwriter, also wanted to speak with a counselor in person, which substantially narrowed her chances of finding someone. Now she is competing with an untold number of people who see the chance to emerge from the pandemic and its impact on their psyches.
“We’re all living through a mass trauma event, and that includes therapists, so their capacity to help is understandably impacted,” she said. “And so many more people need access to care.”
Unable to find a counselor, she has turned to self-care: yoga, journaling, books on grief and the online apps that have sprung up as stopgaps. Los Angeles County offered residents free subscriptions to one. She believes other people may find help in support groups, even ones offered online. But for her, the alternatives have been insufficient.
“I just really need some guide rails to go through this process,” she said, “and that has not been available.”
In interviews, therapists and experts cited the obvious causes of the backlog: the psychological and emotional toll of long-term disruption during the pandemic, prolonged uncertainty about the future, fear of infection, financial stress from lost jobs, grief over the deaths of loved ones, loss of social interaction and, especially for children, the unnatural circumstance of isolation at home.
But they also noted other factors. People who might never have sought therapy are now more willing to consider it in the wake of the pandemic, led by a younger generation that sees less stigma in acknowledging mental illness, said Saul Levin, chief executive of the American Psychiatric Association, which represents more than 37,000 psychiatrists.
“Covid in some ways exposed mental illness to the general public that the majority always ignored,” Levin said. “People have been accessing mental health care a lot more now because of covid.”
Yet insurance coverage and training slots for new psychiatrists lag far behind the demand, Levin said. In his State of the Union address last week, President Biden proposed a large increase in mental health providers. In a fact sheet, the White House noted that more than one third of Americans live in designated mental health professional shortage areas.
“We must dramatically expand the supply, diversity, and cultural competency of our mental health and substance use disorder workforce — from psychiatrists to psychologists, peers to paraprofessionals — and increase both opportunity and incentive for them to practice in areas of highest need,” the White House said.
Online therapy, a boon to patients and clinicians, especially in rural areas, has dramatically reduced no-shows and dropouts by offering the convenience of counseling at the touch of a button. This has cut into many counselors’ availability to accept new clients, experts said.
Some patients also need more time to reach their goals now, said Roberts, the Oklahoma therapist, which also delays the opening of new slots.
“It’s like the boxcars are all crashed and piling up behind, and everyone is trying to figure out how to get them back on track,” she said.
D. Giovanni Scott, a private practitioner in the District, noted that people gave up insurance and access to employee assistance programs when they lost or left jobs during the pandemic. To accommodate demand, she said, she offers a few people the option of biweekly therapy sessions when it is appropriate, and she tries to retain some insurance-only clients despite the low reimbursement rate. She keeps her waiting list short, unwilling to offer unreasonable hope to people seeking an opening.
Scott, who is Black, and others said racial injustice and 2020′s protests against police violence have also sent more people to their doors.
Crawford, the Boston child psychiatrist, said the return to school has allowed teachers and others to assess the needs of children who have been seen only by their parents in recent months. The result has been a large surge in referrals to a mental health workforce that has not expanded.
“Other adults and teachers are able to lay eyes on these kids,” she said, and they are “bringing up concerns about behavioral issues and emotional issues.”
According to the American Academy of Child and Adolescent Psychiatry, there are just 8,300 practicing child psychiatrists in the United States for the more than 15 million young people who need them. Pediatricians are doing initial assessments, Crawford said, with only the most severe cases reaching her. Children considered a danger to themselves or others are routinely held in hospital emergency rooms for a week or two waiting for beds in appropriate settings, she said.
Some providers hope the crisis will be used to overhaul a mental health system that was created after World War II and has always been crisis-oriented, by infusing mental health awareness and techniques into schools, the workplace and other parts of society. Simply doing more of the same won’t work, Prinstein said. Biden’s plan contains some elements of revamping the system.
And there is no doubt that the United States needs more practitioners, experts said.
“The nation is in the middle of a mental health epidemic, and it is up to behavioral health agencies to find solutions that will attract and retain employees who can provide access to quality mental health care,” Brant Russell, president and CEO of OhioGuidestone, the nonprofit agency, said in a statement.
But it won’t be soon enough for Gullett and others searching for help today. “Most people have given up. Nobody is looking right now that I’m aware of,” she said. “There seems to be no expectation that it’s going to change.”
Lizzy Raben and Andrew Van Dam contributed to this report.