This story is part of The Salt Lake Tribune’s ongoing commitment to identify solutions to Utah’s biggest challenges through the work of the Innovation Lab.
The kids are back in school, travelers are once again boarding planes and indoor dinner parties are back. Still, for many, a return to “normal” hasn’t included a shift in the heightened levels of stress, anxiety and depression that accompanied a long pandemic.
Although there has been great need for mental health care before, during and post-COVID, the mental health professionals who treat Americans are in short supply.
More than 150 million people live in mental health professional shortage areas, according to research from the Health Resources & Services Administration, and over 40% of psychologists questioned in 2021 by the American Psychological Association survey reported they couldn’t meet demand for treatment.
This problem is particularly acute in Utah. The nonprofit Mental Health America recently ranked Utah 48th among the 50 states and the District of Columbia, meaning the state had both a higher prevalence of mental illness combined with less access to care.
Seeking to address the access challenges, lawmakers and mental health providers in Utah were already looking to expand access to tele-mental health care long before COVID-19 and its shadow mental health crisis took shape.
In 2017, the Utah Legislature passed a measure that would prepare the state’s psychologists for the rapid shift to come. The Psychology Interjurisdictional Compact gave psychologists in the state “a leg up” when COVID-19 hit, said Nanci Klein, a clinical psychologist and director of professional affairs for the Utah Psychological Association, because those therapists who had opted into the program “were prepared to work remotely.”
The expansion of telehealth means people living in remote, rural areas can access specialized treatment without having to deal with the stigma of parking their car in front of a therapist’s office. It means a busy nurse practitioner can meet with her counselor over Zoom while sitting in her car during her lunch break. Or that college students who return to their home state for the summer can keep consistent care with a therapist they worked with during the school year.
Psychologists and licensed counselors point to interstate licensing compacts as one way to broaden the geographic borders of their practice, and provide patients living in areas with a severe shortage of mental health practitioners with more options for specialized care.
How do the compacts work?
The compact passed in 2017 allows psychologists in participating states to practice virtually across state lines with “E-Passports,” Klein said. In order to qualify, psychologists must be fully licensed in their home state and also take three hours of continuing education courses related to the use of technology in psychology.
Getting one of these licenses means that if a psychologist like Klein has a University of Utah student as a patient and that student goes home for the summer to, say, Nevada, Klein would be able to continue treatment and schedule virtual visits without violating licensing laws. However, she could not move to Hawaii and start practicing in-person without getting a license in her new home state.
Klein says the compact has helped expand “the opportunities to have uninterrupted treatment.”
More recently, Utah joined a counseling compact — which has yet to go “live,” said Gray Otis, a licensed clinical mental health counselor involved with the effort in Utah. More than a dozen states have joined, and licensed counselors will likely be able to practice in participating states by 2024.
Like the psychology compact, the counselor compact will help ensure “continuity of care when clients or counselors relocate or travel to other states,” according to a letter of support from the American Association of State Counseling Boards.
“Utah is kind of a leader in looking at behavioral health, mental health, in a positive way to support the most number of people,” Otis said. “The counseling compact is one more building block, if you will, in supporting better public health through better public mental health.”
Those wary of the compacts are concerned that multistate licensing agreements could result in less oversight of practitioners, or potentially leave psychologists or counselors without enough clients.
Otis said with COVID and the many mental health and drug and alcohol use issues which have accompanied the pandemic, “nobody’s running out of business.”
“The compacts have some very specific and important and useful guardrails in place,” Klein said. Still, she cautions against getting rid of licensure requirements entirely. During the 2022 legislative session, lawmakers passed SB283, which reduced the number of clinical hours required for social workers and clinical mental health counselors to get their licenses.
“I think that that may not necessarily be an ideal solution,” Klein said. “Because then you’re unleashing perhaps not optimally trained people to be providing services to the community.”
How to reach people where they are
Telehealth has been popular among patients and providers, said Dr. Rachel Weir, a psychiatrist and Huntsman Mental Health Institute chief of mental health integration. “They don’t have to drive, they don’t have to park, they often don’t need to take a whole half day of work off to go see their therapist.”
Still, Weir said, telehealth isn’t a cure-all to the ongoing shortage of mental health professionals in meeting client need and demand. “You are expanding your geographic reach and you’re providing access to people that might not normally have it, but you’re not expanding access,” she said.
In the end, telehealth isn’t creating more psychiatrists, psychologists or mental health counselors.
“It’s the same number of people that you’re still treating,” Weir said. “It doesn’t change my availability.”
She also noted that if out-of-state providers aren’t considered in-network by insurance companies, those therapists might choose to only accept cash payments. That could ultimately hurt, not help, underserved populations.
Compacts are just one piece of a bigger shift in health care. Weir pointed to Project ECHO as “a really innovative way to reach rural populations.” The project, which started in New Mexico, provides local providers video conferencing with a single psychiatrist to present cases.
“It gives patients through their own provider, more immediate help, rather than waiting and waiting and waiting to see a mental health professional,” Weir said.
Lastly, Weir cautioned that while there are benefits to telehealth, for some people an in-person visit with a therapist might be the only reason to leave the house, which could also be helpful to mental health. “It needs to be a hybrid,” she said.
It’s important, Weir said, to make sure that need for connection is still being met.