The state is beefing up funding to help train new mental health care workers. But experts say improving the pipeline is just the beginning.
Oregon’s mental-health system faces a double whammy: Demand for care is at an all-time high, but the workforce is shortstaffed.
In 2022 a report by the Alcohol and Drug Policy Commission showed Oregon was short 36,000 behavioral-health care workers, and that six Oregon counties did not have a single psychiatrist. Another 2022 report compiled by the Oregon Health Authority found behavioral-health care workers were concentrated in Multnomah County and largely underrepresented everywhere else in the state.
The shortage has proven lethal: Last year a mental-health worker, who was working alone on a night shift, was allegedly killed by a patient at McCarthy Place, a Gresham facility operated by Cascadia Health.
The state Legislature responded to the challenge by passing House Bills 4071 and 2949 during the 2021 and 2022 regular sessions, which granted the OHA $60 million to build out the state’s mental-health workforce as part of its Behavioral-health workforce Initiative, as well as $20 million to provide clinical supervision to new entrants into the field. The fund includes millions in grants to eight Oregon universities — Oregon Health & Science University, Oregon Institute of Technology, Portland State University, Southern Oregon University, Eastern Oregon University, Bushnell University, Lewis & Clark College, and Pacific University — to increase their capacity to take students through housing assistance, loan repayment, scholarships and child care subsidies.
Now in its first year of distribution, the Behavioral-health workforce Initiative is already increasing the amount of students being trained in behavioral health. But experts say that staffing and recruitment play a major role in addressing the state’s behavioral health needs, finding solutions to burnout, poor administrative infrastructure, licensing challenges, and a chronically traumatic work environment will be equally critical to addressing the workforce shortage.
Christa Jones, director of behavioral health strategic projects at the Oregon Health Authority, says Oregon’s mental-health worker shortage stems from a variety of factors, all of which have remained relatively unaddressed until now.
“One thing we’ve seen is that there has been an underinvestment in the behavioral-health workforce for decades and a lack of parity between behavioral health and the medical side of things, as well as an underappreciation for the emotional toll it takes,” Jones says. “These people are paid the lowest in our system, working with the most acute individuals, and navigating some of the most extremely challenging situations. This is definitely the worst it’s been for Oregon and all across the United States.”
The mental-health worker shortage is not confined to Oregon. The National Center for Health Workforce Analysis released a 2023 report detailing the lack of behavioral-
health care workers across the country. It found 59 million U.S. adults (23% of all U.S. adults) had a mental illness and nearly half of them did not receive treatment. The report went on to find six in 10 psychologists were not accepting new patients, and the national average wait time for behavioral-health services was 48 days.
A forensic psychologist by training, Jones witnessed firsthand the impact of the COVID-19 pandemic on people living with behavioral-health issues — and the providers who served them — while working for Multnomah County’s Community Mental Health program.
“For staff, moving around rapidly and getting folks connected to the services they needed became much more challenging,” Jones says. “What we saw was increasing isolation, which resulted in increased acuity of symptoms, and we saw an increase in substance abuse. We saw an increase in those seeking services, and for the folks left in the field, they were seeing caseloads that were beyond what they could manage. And yet, because I believe the hearts of people in this profession are so unique, I think that people just kept pushing and pushing and pushing, which of course can lead to burnout and can lead to folks leaving the job — in some cases — leaving the field entirely.”
A June 2023 study of the causes of attrition in Oregon’s behavioral-health workforce, published in the journal Psychiatric Services, found five key themes that negatively affected the interviewees’ workplace experience and longevity: low wages, documentation burden, poor physical and administrative infrastructure, lack of career-development opportunities, and a chronically traumatic work environment.
Jones says the OHA’s $60 million investment is targeted toward students pursuing master’s and doctoral degrees, since she says graduates with advanced degrees are the most in-demand for the short-staffed workforce. Language in HB 2949 also requires OHA to provide funding — like scholarships and loan-forgiveness programs — that increases the number of Black, Indigenous and people of color in Oregon’s mental-health workforce. All of the funding earmarked for education stipulates that graduates commit to working in Oregon after graduation.
And while the bulk of the OHA funds are geared toward students, 25% of the funding is earmarked for workplaces.
“There are also retention bonuses and hiring bonuses, and significant funding that went directly to staff, while some of the funding also went to support indirect costs, such as improving the environment that we work in,” Jones says. “Maybe staff would be a lot more likely to stay at their job if they had a kitchenette to eat lunch rather than having to run around every day.”
Cody Christopherson, a faculty member in the clinical mental-health counseling master’s program at Southern Oregon University, says the OHA funding has allowed SOU to increase its number of behavioral- health students by six students, or 25%. He says SOU and its students play a crucial role in serving the menta-health needs of the Rogue Valley.
“SOU is by far the main source of behavioral therapists in the Rogue Valley and in our larger region as well. We’re using the grant to expand the number of behavioral-
health care workers and expand access to behavioral-health care for the people who live here,” says Christopherson, who adds that he has seen the effects of the mental health care crisis firsthand in his own private practice. “I’ve talked to many, many people whose biggest barrier to getting appropriate medical care is just access. They just can’t get in anywhere. People are on waitlists and they don’t get a call back. I myself am a clinical psychologist in private practice, and I can’t call everybody back who calls me asking to start [treatment].”
Oregon’s coastal and rural communities face particular challenges when it comes to mental-health access, including higher suicide rates — particularly for rural men over the age of 55. In September 2023, Oregon State University launched the AgriStress HelpLine, a 24-hour mental-health support line (with text and voice functions) designed specifically to support rural Oregonians and their families.
When it comes to preparing Southern Oregon students for the realities of the mental-health workforce upon graduation, Christopherson says the SOU method allows for close mentorship opportunities and fieldwork from day one, as well as a compact 20-month program able to get students into the field more quickly when compared to other programs.
“Everything starts with both an ethical lens and a multicultural lens. There’s a real emphasis on competence. Our students get professional supervision, even when they’re just practicing their skills in the very first class, the very first week of their program. They’re getting rather close professional supervision, and it starts that day and doesn’t end until they graduate,” Christopherson says. “This is not a radical departure from what we’ve been doing, just bigger.”
Cort Dorn-Medeiros, chair of the Department of Counseling, Therapy, and School Psychology at Lewis & Clark College, says the funding from the OHA is exactly what the state needs to get more students working in the field, since the financial investment in a master’s degree incentivizes some students to get onto more lucrative career tracks.
“This is the investment we need. If you want more mental-health practitioners, especially those going to work for nonprofit agencies in medical settings, supporting them through their education, from my perspective, is 100% the way to do it,” says Dorn-Medeiros, who adds the investment might allow students to choose their careers with their hearts, rather than their bank accounts. “Sometimes it’s like, ‘Well, if I could go over here and make a lot more money right off the bat, why wouldn’t I do that?’ So this is somewhat leveling the playing field in terms of investment up front, which I think is incredible and very impactful.”
Dorn-Medeiros says Lewis & Clark is up front with its students about the challenges of entering the field, and that he sees unionization as a new, accelerating way of making more hospitable work environments for behavioral-health care workers. Last summer 57 employees at Legacy Health’s Unity Center for Behavioral Health in Portland filed for union recognition with the National Labor Relations Board. Dorn-Medeiros says the push toward unionization shows it’s not always the work itself causing burnout but a lack of structure and compensation in the workplace.
“I want to say it was 2018 or so, some agencies were thinking about unionizing,” says Dorn-Medeiros. “There was no pay scale, or regular raises and people weren’t even getting cost-of-living [raises] year to year. Workloads were getting higher and higher, and some agencies were moving more toward productivity standards, saying, ‘You need to work X number of billable hours per workday. I think after a while, it just came to a head for people. I think it speaks to the fact that it wasn’t people saying, ‘I don’t like working with clients or even in really hard populations,’ it was the pay and the hours and the workload. There really wasn’t a structure for that. I think unions can provide that.”
Andy Mendenhall, president and CEO of Portland’s Central City Concern, a nonprofit supporting the city’s unhoused population, says the state’s investment is a good start — but that it will take more to address the crisis.
“The way we like to think about this is, you’ve got to attract people to the field, you then need to grow them over time, and you need to make sure their career tracks are sustainable — that these are living and family-wage jobs — and that the conditions upon which folks are working allows you the ability to do your job effectively,” Mendenhall says. “Those are all moving in the right direction. So that’s one arm. The other thing is you need to bring people in who are already trained.”
He says addressing the worker shortage will require Oregon licensing boards to make it easier for professionals from other states to get licensed in Oregon.
“Where the system needs to evolve is the individual licensing boards for each type of behavioral-health professional have to get out of their own way,” Mendenhall says. “They have to be committed to eliminating barriers for people to come into the state of Oregon and be licensed, and the ways in which those barriers can be eliminated are things like what are referred to as interstate compacts for licensure, and licensure reciprocity. We need licensure reciprocity to be something that each of the licensing boards commits to so that we don’t just rely on a multiyear pipeline to train new people.”
“MHRA is committed to removing barriers to entry into the professions we regulate,” wrote Charles Hill, executive director of the Oregon Mental Health Regulatory Agency, in an email to Oregon Business. “I’d point you to our respective websites, where you can read about a diversity study our agency completed and the changes we have implemented. Over the past two years, our boards have made significant changes to our OARs [Oregon Administrative Rules], which has had a positive impact on reducing barriers to entry. These changes also include license-fee reductions for both boards effective 1/1/24 to help reduce barriers. Also, the website contains several good newsletters that highlight many of the positive changes we have made.”
Hill went on to say that the idea of an interstate compact like that proposed by Mendenhall is a complex issue, to which his agency is taking a cautious approach. “In a nutshell, there are Oregon constitutional and statutory issues that have to be addressed by the Oregon Legislature and the Governor before our two boards can enter into any interstate compacts,” he wrote.
The state is also working to increase pay parity between behavioral-health care workers and workers in other medical professions. In April 2023, Oregon raised the Medicaid reimbursement rate to 100% for psychiatrists, becoming one of eight states with a Medicaid reimbursement rate equal to or greater than Medicare for mental-health services.
After years of delay, the OHA is also opening four peer-respite centers across the state this summer, where people experiencing mental distress can stay for up to two weeks and receive support from peer mentors who have also struggled with mental-health challenges.
For Jones, who also works on the OHA’s behavioral-health housing-investment team, the work is still just beginning. In order to address continuing issues of burnout, workplace trauma and pay parity, the OHA convened a 21-member work group as part of House Bill 2235 to deliver further policy recommendations to the Legislature by January 15, 2025. Part of the process involves surveying students as they pass through the program, as they tackle the state’s mental- health workforce crisis head-on.
“Every time someone reaches out for help and has to call multiple places, every time they show up to an appointment but have to miss it because someone called out, that’s a missed opportunity for that person’s recovery,” Jones says. “Other states have not had this kind of unprecedented investment, so I have a lot of pride in the fact that we’ve been able to push this out and make a difference.”
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