The Realities of Mental Health Staffing: Addressing the Behavioral Health Workforce Shortage

Mental and behavioral health services are in higher demand than ever before. In the wake of the COVID-19 pandemic and the continuing acceleration of mental health awareness, both public and private entities have worked to expand services. Yet, across the nation, mental health organizations—ranging from large hospital systems to small outpatient clinics—have struggled mightily with staffing. Leaders cite burnout, funding constraints, policy restrictions, and administrative hurdles as factors contributing to the crisis.

However, as illustrated by experts working on the front lines, the reality of mental health staffing is not just about policy, pay, or job titles. It revolves around the complexities of human connection, long training pipelines, and the sheer stamina it takes to develop programs that both meet regulatory requirements and retain the essential humanity needed for truly effective care. These healthcare challenges and workforce challenges are at the heart of the current mental health crisis, with behavioral health workforce shortages becoming increasingly apparent. We spoke with Damir S. Utrzan, Ph.D., LMFT of Horowitz Healthto break down the challenges and their solutions.

1. The Backdrop: Why Staffing Is Such a Challenge

Mental health needs are skyrocketing, while the workforce pipeline cannot keep up. The shortage of mental health professionals has reached critical levels, with many areas experiencing a severe mental health provider shortage. According to recent healthcare workforce statistics, the gap between demand and supply in the behavioral health workforce continues to widen. Burnout among nurses, social workers, therapists, and psychiatrists reached new heights during the pandemic, with many professionals working overtime to treat patients in increasingly high-acuity environments. The field already suffered from a limited supply: for instance, clinical doctoral programs (e.g., PhDs in psychology or related fields) graduate very small cohorts compared to other healthcare disciplines. It can take seven to twelve years for these practitioners to complete their education and clinical postdoctoral requirements. Meanwhile, demand grows steadily, and sometimes exponentially, as more individuals seek care.

Staff retention is also a major factor in the behavioral health workforce shortage. A national study by the National Council for Mental Wellbeing (formerly the National Council for Behavioral Health) found that mental health professionals have turnover rates between 30 and 40 percent annually—double the rate seen in other healthcare fields. This mass exodus compounds the strain on those who remain. In many mental health settings, such as Intensive Residential Treatment Services (IRTS) or acute inpatient psychiatric facilities, patient acuity is high and the care is complex. Staff members are exposed to emotionally taxing situations day after day, contributing to provider burnout and exacerbating the therapist shortage.

Compensation has historically not kept pace with the difficulty and importance of the work. Despite the specialized training needed, salaries and reimbursement rates have often remained stagnant or grown only modestly. The financial reality is that any mental health organization—large or small—needs revenue to cover expenses, but the reimbursement environment (particularly around Medicaid and Medicare) does not always match the complexity of mental healthcare. These healthcare workforce trends have led to a critical mental health care shortage across the country, highlighting the urgent need for comprehensive workforce development strategies in the behavioral health sector.

2. Unpacking the Policy Factor

Given the coverage that mental health has received in recent years, one might assume legislation or policy is the main issue behind the workforce crisis. In reality, mental health policy issues are just one piece of the puzzle. Yes, state regulations play a huge role, particularly in licensing new facilities or expanding existing ones. For example, in Minnesota (as discussed by Damir S. Utrzan, Ph.D., LMFT, Chief Compliance and Strategic Development Officer at Horowitz Health), any new IRTS facility must navigate:

1. Permits and Zoning: Often governed at the county or local level, these may take months to secure, especially if the local community is unfamiliar with intensive residential treatment programs.
2. Department of Health Licensing: Before serving a single patient, a supervised living facility license is typically required.
3. Department of Human Services (DHS) Licensing: State-specific standards for mental health treatment, such as Minnesota’s 245I regulations, must be met. This involves crafting comprehensive policy and procedure manuals that can easily exceed 300 pages.
4. Rate Setting and Reimbursement Approvals: Programs that plan to bill Medicare or Medicaid must undergo a rigorous process to determine their daily billing rates.

These steps can be time-consuming and expensive, representing significant regulatory barriers in the mental health field. Leaders must hire and train staff in anticipation of opening, yet the facility may not receive any reimbursements for months. While large health systems sometimes have the capital to weather this waiting period, smaller or newer organizations may find themselves in precarious financial positions. That said, the high-barrier licensing process can also act as a filter, discouraging groups whose primary focus is profit rather than true quality care. In other words, the strict licensure requirements mean that only the dedicated—those who understand the nuances of patient-centered mental health—are likely to see a new facility to its opening day. These mental health policies examples illustrate the complex landscape that providers must navigate, often facing significant administrative burdens in the process.

3. Training and the Human Element

Staff shortages are not simply a matter of “not enough bodies.” The behavioral health workforce requires individuals with advanced training and a deep capacity for empathy. Damir S. Utrzan, Ph.D., LMFT points out, the best outcomes in therapy and mental health care come not from the specific intervention or medication alone, but from the therapeutic relationship itself. Care is grounded in human connection, which means the right personality fit, combined with high-level clinical competencies, is essential.

Organizations that invest in staff training and ongoing professional development often reap the rewards in patient outcomes and employee satisfaction. For instance, new staff at IRTS facilities in Minnesota must fulfill state-mandated training requirements (often around 30 hours) before ever setting foot on the floor. On top of that, leading organizations provide:

• Enhanced Illness Management and Recovery courses (in partnership with universities or reputable training institutes).
• Integrated Dual Disorders Treatment (IDDT) models, ensuring staff are fluent in co-occurring mental health and substance use disorder treatment strategies.
• Trauma-Informed Care training, recognizing that many patients have trauma histories that influence their behaviors and challenges.
• Non-violent Conflict Intervention training that respects patient dignity and emphasizes safe, therapeutic de-escalation techniques.

This training can be expensive and time intensive. New hires sometimes struggle with the demands, and turnover is a risk if they feel overwhelmed. However, organizations that persist and embed a culture of support—where employees can ask for help, share cases, and receive mentorship—tend to see higher job satisfaction and better workforce retention. The synergy of collaborative support reduces burnout: employees feel they are part of something bigger, not just cogs in an operational wheel. This approach to workforce development is crucial for addressing the behavioral health workforce shortages and building a resilient mental health workforce. Additionally, promoting diversity in the behavioral health workforce is essential for providing culturally competent care and meeting the unique needs of diverse patient populations.

4. Ensuring Financial Viability

One might ask, “If mental health care is so crucial, and if demand is so high, shouldn’t all these facilities be profitable and stable?” The short answer is: not necessarily. Even though the need is there, securing reliable funding streams can be complex. Many programs rely heavily on Medicaid reimbursements, and rates can vary drastically by state. Facilities offering specialized programs, such as co-occurring care (treating substance use disorders alongside mental health conditions) or neurocognitive rehabilitation (for patients with conditions like Korsakoff syndrome), often command a higher reimbursement rate due to the specialized staffing ratio. Still, the up-front investment is substantial and the timeline to become “cash flow positive” can extend over many months.

Horowitz Health, for example, opens IRTS facilities with a very high staff-to-client ratio—sometimes exceeding a two-to-one staff-to-patient ratio. For a 16-bed facility, over 20 staff members may be employed. This ratio includes cooks, administrators, clinicians, psychiatrists, and other support staff. While this structure is more expensive to maintain, it allows for truly comprehensive care that can lead to better patient outcomes and stronger relationships with local counties or referral sources.

Financial success in mental health—especially in higher-acuity settings—largely hinges on:

1. Building Strong Community and County Partnerships: Counties often act as gatekeepers for local mental health systems and can provide essential referrals and operational support.
2. Data-Driven Practices: Ongoing evaluation of patient outcomes, acuity trends, and staff performance helps tailor interventions efficiently.
3. Investment in Training: While training can be costly, it ultimately yields more competent staff, fewer incidents, and better continuity of care.
4. Performance Metrics that Aren’t Punitive: Leaders may use tools like Relative Value Units (RVUs) or productivity benchmarks but need to focus on barrier removal, not blame, ensuring clinical staff feel supported and not over-policed.

Understanding and navigating reimbursement rates is crucial for maintaining financial viability while providing quality care, especially in rural areas and underserved communities where the behavioral health workforce shortage is often more pronounced. Addressing financial barriers to training and exploring options for supervision cost relief can help alleviate some of the financial pressures faced by mental health organizations and professionals.

5. The Indispensable Role of Human Connection

Perhaps the most vital takeaway from those working in the industry is that human connection remains the bedrock of effective mental health care. Whether in a telehealth environment or a 24/7 residential facility, the relationship between caregiver and patient—the trust, empathy, and mutual respect—plays a more significant role in outcomes than any single medication or evidence-based protocol. In an era of rapid technological growth, there is a temptation to rely on telehealth services or algorithms to triage patients. While these innovations can supplement care and expand reach, especially in rural areas and underserved communities, the on-site human element remains irreplaceable for individuals in crisis or living with severe mental illness.

Creating an environment conducive to healing requires staff who can connect with patients, especially when those patients are in the midst of a manic episode, severe depression, or a psychotic break. This connection cannot be “factory-assembled”; it thrives in facilities where staff feel supported, valued, and continuously trained. The ability to provide culturally competent care is also crucial, ensuring that diverse patient populations receive appropriate and effective treatment. Promoting diversity in the behavioral health workforce is essential for addressing the unique needs of various communities and improving overall mental health outcomes.

As the field evolves, primary care integration and tele-supervision are becoming increasingly important aspects of mental health care delivery. These approaches can help extend the reach of the behavioral health workforce and improve access to care, particularly in underserved areas. However, it’s crucial to maintain the human element in these new models of care delivery.

6. Moving Toward Solutions

For leaders looking to replicate successful mental health programs in their own geographic areas, there are a few key points to consider:

1. Start with Collaboration: Connect with local counties, established mental health providers, and community stakeholders to assess true needs. Gather accurate data on unmet mental health demands—such as the prevalence of substance use issues, co-occurring conditions, and housing instability—and plan accordingly. This collaboration among stakeholders is essential for addressing the lack of mental health services in many areas, including rural areas and underserved communities.
2. Understand the Regulatory Landscape: Master the licensing process in your state, from zoning and building codes to licensing manuals that can span hundreds of pages. Tailor policy to your population, rather than simply copying from existing models. Be prepared to navigate regulatory barriers and complex licensure requirements, including exploring options for interstate licensure to expand the available workforce.
3. Invest in Staff Development: Ongoing training, team consultation, and a supportive work culture is not a luxury—it is a necessity. High staff turnover in mental health can cripple a program’s effectiveness and compromise patient safety. Workforce planning should include strategies for continuous professional development and career advancement opportunities. Providing education and training opportunities is crucial for building a strong and resilient behavioral health workforce.
4. Adopt a Long-Term Mindset: Building or expanding a mental health facility can take many months (or even years) to reach stable footing. Leaders must be prepared to operate temporarily “in the red” until licensures, reimbursements, and referral networks solidify. This long-term approach is essential for addressing behavioral health workforce shortages and improving access to care.
5. Never Lose Sight of the Human Element: Clinical protocols and business strategy matter. But the most profound healing often happens within trusting, empathetic relationships. From training to daily operations, ensure that staff have the bandwidth to forge and maintain those connections. This focus on human connection is vital for addressing workforce mental health and reducing provider burnout.
6. Develop Pipeline Programs: Create partnerships with educational institutions and implement pipeline programs to attract and train new professionals in the behavioral health field. This can help address long-term workforce shortages and ensure a steady influx of qualified professionals.

Conclusion

The realities of mental health staffing are far more complex than one might gather from headlines about “staffing shortages” or “policy gridlock.” While it is true that national and state regulations can present hurdles, and that the pipeline of trained professionals is not keeping pace with rising demand, these challenges can be addressed through thoughtful planning, financial investment, and a deep organizational commitment to compassionate care.

Programs that successfully navigate these waters recognize that mental health care fundamentally revolves around relationships. They invest in recruiting, training, and retaining professionals who not only have the qualifications on paper but also the heart to connect meaningfully with patients. These organizations also form strategic partnerships with local counties, stay current with regulatory requirements, and balance financial realities with mission-driven principles.

In short, mental health staffing may look like a puzzle—consisting of policy constraints, reimbursement models, and workforce pipelines—but the essential piece that keeps everything together is the human element. As long as organizations remain dedicated to supporting their staff and fostering genuine connections between provider and patient, they can and do succeed in delivering the intensive, life-changing care that countless individuals desperately need. Addressing the behavioral health workforce shortages requires a multifaceted approach that combines policy changes, workforce development initiatives, and a commitment to improving access to care for all communities, including rural areas and underserved populations. By focusing on comprehensive workforce planning and addressing the root causes of behavioral health workforce shortages, we can work towards a more robust and effective mental health care system for all.