California suffers from a severe and worsening mental health workforce shortage. In fact, much of the US is in the same boat. There simply aren’t enough qualified mental health professionals to meet our country’s needs.

At the same time, therapists in private practice often complain about their local markets being saturated. There are so many therapists in some places, it seems, that it’s hard to get a career off the ground.

As it turns out, there’s truth to both of these perspectives.

Where we’re needed isn’t where we want to be

As some bar-napkin math at my blog showed a few years ago, therapists in California tend to cluster in urban areas, and in particular, in areas with money. (That informal-is-putting-it-lightly research was corroborated by the far more formal and detailed recent report. Its state maps by county are worth a look.) That’s not really surprising, but it is important in understanding how both shortages and saturation can exist at the same time. If you are able to work with severe mental illness in rural areas, there is huge demand for you. If you’re wanting to work with rich urbanites in a cash-pay practice, you’re going to have a lot of competition.

The supply-demand disconnect

Unfortunately, some of the more basic rules of supply and demand don’t seem to apply when it comes to mental health careers. Simply put, the jobs where there is the most need for mental health care — and the pay should therefore be highest — don’t pay very well. While there might be more competition in a richer, urban area, if you can make a practice there work, you can make more money than you can in a higher-need area.

This is a known thing, even among those hiring for those high-demand jobs. Dawan Utecht, behavioral services director for Fresno County, told the Los Angeles Daily News last year, “Pretty much any licensed clinical position is hard to fill” in her county. Like many inland counties, they use prelicensed therapists for many jobs, but those therapists leave for better opportunities once licensed (and often even before that).

The LA Daily News was appropriately matter-of-fact:

Pay is a significant factor. Salaries for behavioral health professions are lower relative to other occupations with similar education and training requirements — meaning they get the same loan debt but less of a payoff.

While the solution here seems at first painfully obvious — raise salaries! The people you want have graduate degrees and years of experience! — public systems often struggle to raise salaries for mental health workers. In California, counties literally have $2.5 billion in mental health funds just lying around, but counties’ struggles in this area can be more procedural than financial. Getting approval for significant salary bumps can be an administrative and political quagmire. So other policy solutions are being considered instead, like increased use of telehealth.

In fairness to those public systems, it’s also true that rules about supply and demand aren’t working when it comes to the hiring process. It doesn’t make sense that so few therapists would be willing to move to a more rural or high-need area, or to work in a public system. Sure, pay may be lower than in an urban area or in private practice, but other factors should balance that out (lower costs of living, better benefits, better job security). It seems that a great many therapists would rather scratch and claw for a part-time, inconsistent, cash-pay private practice — a risky endeavor — than take the relative security of a salaried position in a high-need area.

Of course, each of us is entitled to our preferences. You could argue that I’m a great example of the problem. I have a part-time, cash-pay, private practice. I have a home and a family in Los Angeles. You couldn’t pay me enough money to move to an inland county. The point here isn’t that such choices are morally better or worse. Rather, it is to note the impact when such a large proportion of mental health workforce actively rejects the jobs where we’re most desperately needed.

It isn’t just a therapist workforce problem

The medical field is facing the same concern. General practitioners are desperately needed; much of the country qualifies as a shortage area. But since new doctors gravitate toward more lucrative specialty work, states have been gradually expanding the scopes of practice of others who can meet at least some unmet medical needs. Pharmacists, nurse practitioners, and psychologists have all stepped in to fill some of the gaps left by the country’s lack of physicians (and specifically psychiatrists).

That process should be instructive for therapists looking to see what the future holds. With a shortage of qualified mental health professionals in too many areas, more of our functions will be turned over to substance abuse counselors, peer counselors, and other professionals and para-professionals. Squirm as we might at the notion that our scope of practice is being encroached upon, it’s the only way for some areas to get the mental health care they need.