My stomach lurched when I answered the phone at my therapy practice. On the line was the latest worried and exasperated parent hoping to schedule a psychotherapy appointment with me for their child or teenager. I’m one of the few child and adolescent therapists in my area, and I dreaded telling this mother that my schedule is full. I listened to her, provided a couple of referrals and suggested some self-help or online resources the family can use while they wait for a therapy opening with someone else.
“But it’s urgent,” the mother said. Of course she’s right. Some parents try to keep me on the phone, hoping I’ll hear their desperation and agree to squeeze in an appointment for their child. And once in a while, I do break my promise to myself not to overbook. I know how needed my services are. But now that school has started and children’s availability for therapy becomes more limited, I can’t anymore.
There is a nationwide shortage of mental health professionals, but it’s especially acute for children and teenagers. The U.S. Department of Health and Human Services has estimated that by 2025 the nation will have 10,000 fewer mental health professionals than it needs. Even before 2020, many children and teenagers with behavioral struggles were not receiving services. The reasons included lack of financial resources, the stigma of mental health issues and, of course, the shortage of therapists trained to work with children.
High-quality training in child and adolescent therapy can be difficult to find. Most therapists in the United States, like me, are clinical social workers. We spend two years in graduate school and only a portion of our studies are spent on developing counseling and clinical practice skills. Any further child and adolescent therapy training often takes place in field placements (similar to internships), on-the-job supervised training and costly postgraduate programs. Clinical and school psychologists have opportunities for more focused and intensive training when working with kids, but these professions require lengthier doctoral-level education.
But there are other substantive reasons therapists back away from working with children, even as this population is so clearly in need.
Child therapy is not always intuitive for therapists who are used to traditional talk therapy, and talk alone doesn’t always work with children and teenagers. Instead, child therapists use play, activities and exercises, role-playing and other tools to communicate with young clients. This requires creativity, time-intensive prep work and a spacious-enough therapy office equipped with toys, games, art materials and books. These all come with price tags — both in energy and money — for therapists.
Speaking with parents, case workers and school personnel outside of the therapy session is also time intensive. These collateral contacts, as they are called, are not reimbursed by most insurance yet are crucial to good treatment. Like all clients, kids tell their stories from their unique perspectives, and getting a bigger picture from the adults in their lives is necessary.
But there are only so many nonschool hours in a week. Young children have a small window between school, dinner and bed, and therapy can compete with sports, arts, tutoring, religious education and more. This means child and adolescent therapists frequently work late afternoons, evenings and often weekends to fill up even a part-time schedule with young clients.
Child and adolescent therapists who work for mental health agencies or hospitals typically have enormous caseloads. Many are paid little. Social workers and other mental health workers typically take low-paying jobs to complete the supervised experience required for state clinical licensing. Even once we are licensed to practice without supervision, our incomes are not likely to help us make a dent in the student loan debt we take on while getting our degrees. According to the Bureau of Labor Statistics, the median income for social workers in the United States was $50,390 in 2021. The median income for psychologists was much higher, but they have longer and more rigorous educational requirements.
There are ways to lessen the child and adolescent therapist shortage by making work more sustainable for new and experienced therapists. State and federal governments can increase funding for mental health agencies so that child therapists can earn a decent wage. National legislation can require that insurance companies reimburse child therapists for collateral contacts that take up so much time and energy.
The United States can also follow England’s example and build something like Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT), a program aimed at improving and expanding the work force focused on child and adolescent mental health. In its first five years, it trained 1,000 therapists in evidenced-based psychological therapies, significantly improving the work force. Though researchers found some administrative problems with CYP-IAPT, such as hasty rollouts and lack of guidance for workers, we can learn from its mistakes and do it better. Here in the United States, the Health Resources and Services Administration has initiated a smaller-scale initiative called the Behavioral Health Workforce Education and Training program, which seeks to train more behavioral health professionals who can reach underserved communities. This investment is promising.
Parents with children who are on therapy waiting lists have some options. Digital mental health platforms offer access to game-based interventions that are promising alternatives to therapy for young people with problems such as anxiety or poor impulse control. While researchers are still investigating the effectiveness of online interventions, they could serve as a stopgap measure. But children and teenagers with more severe mental health struggles will benefit most from treatment by well-trained and experienced professionals.
If we believe that children are our most precious resource and that there is a child mental health care crisis, we should invest in those who care for our children.
Rebecca Bonanno is a licensed clinical social worker and former associate professor of human services at SUNY Empire State College. This article originally appeared in The New York Times.