Social workers are now the ‘backbone’ of Minnesota’s mental health workforce

Social workers provide the majority of mental health care in Minnesota. They are among the fastest-growing segments of the mental health workforce. And growing their numbers just might be the answer to the state’s serious shortage of mental health workers.

In the not-so-distant past, Minnesota’s social workers provided significant support and care to a wide range of clients, but they were not licensed to provide mental health services until 1987, when the Legislature authorized the creation of the Minnesota Board of Social Work.

In the just over three decades since, licensed social workers, particularly those at the licensed independent clinical social worker (LICSW) level, have grown to be the largest single group of mental health care providers in the Minnesota: At last count, they made up 75 percent of the state’s mental health care workforce. If you’re seeking mental health care in Minnesota these days, odds are high that you’re being treated by a social worker.

Teri Fritsma, senior research analyst for the Minnesota Department of Health Office of Rural and Primary Care, said that licensed social workers play a key role, providing mental health care in areas of the state that otherwise could be care deserts.

“Thank goodness for social workers,” Fritsma said. “They are the backbone of Minnesota’s mental health workforce — just like nurses are the backbone of the hospital workforce.”

Kate Zacher-Pate, executive director of the Minnesota Board of Social Work, said that licensed social workers’ share of Minnesota’s mental health workforce is similar to rates in other states. “The 75 percent figure corresponds to the national picture of data,” she said. “That number is significant, and I think that demonstrates that licensed social workers are the primary part of the mental health workforce in Minnesota.”

Three decades into licensure, the social work profession still struggles to be associated with mental health care, Zacher-Pate said.

“Psychiatrists and psychologists are much longer-standing professions,” she explained. Though the field of social work has been around for a century, she continued, “In Minnesota, licensed social workers are pretty new to the mental health scene.”

Services provided by social workers prior to state licensure may have included some informal mental health support, Zacher-Pate said. Though she can’t say what shape those services took, prior to licensure social workers were not reimbursed for providing mental health care. “The profession has existed for 100 years providing services along the continuum of social work practice, which is bigger and broader than just mental health.”

In the late ’70s and early ’80s, social workers organized for licensure, Zacher-Pate explained, because they were seeking comparable pay and status.

“We wanted to be established in the marketplace to qualify for reimbursements and really gain parity,” she said. “Social workers were in fact trained and doing that work already. The psychiatrists and the psychologists and the marriage and family therapists, those were the significant mental health professions that were already licensed and established and quite frankly getting the market benefit. We wanted to be fairly reimbursed for our work.”

Keeping up with need

Across the state, particularly in Greater Minnesota, the need for mental health providers is significant. While social work is a growing field — according to “Minnesota’s Social Worker Workforce,” a report produced by the Minnesota Department of Health, from 2016 to 2017, graduates with master’s degrees in social work increased 21 percent, while graduates with doctorates in social work increased 123 percent — the need for social workers is still greater than the availability of providers.

Zacher-Pate explained that her board has licensed about 16,000 social workers in the state. That’s a significant number, she said, but it’s not enough to keep up with the statewide need for mental health care. Licensed social workers see clients for mental health concerns in a wide range of settings, including social service agencies, schools, long-term care facilities, mental health centers and hospitals.

“If 16,000 licensed social workers equals about 75 percent of the mental health workforce in Minnesota, how can that possibly meet the demand?” Zacher-Pate asked. “As our state grows and changes, we know that the needs for mental health care are ever-increasing.”

Fueled by an aging workforce, the decline in the number of psychologists and psychiatrists practicing in the state leaves a care gap that social workers and other mental health professionals — including marriage and family therapists, licensed clinical counselors, and licensed alcohol and drug counselors — are struggling to fill. Rates of graduates in these fields are growing, and the social work workforce is much younger on average, with only 8 percent aged 65 and older and 30 percent under 35, but the number of professionals actually entering the workforce isn’t keeping up with the need.

“We are not meeting the demand in Minnesota for mental health services and arguably it’s the same across the country,” Zacher-Pate said. “The other huge gap that the data shows us is that we’re not meeting the demand outside of the metro area, not at all.”

Sue Abderholden, executive director of NAMI Minnesota, said that there are counties in Greater Minnesota with no mental health providers, and some with only one LICSW: “We have shortages all over the place.”

Social work training prepares graduates to provide a wide range of services to clients, Zacher-Pate said. This means that a robust social work workforce has the potential to fill a care gap in economically disadvantaged rural and urban areas of the state.

“A social work degree affords, in my opinion, a lot of well-trained folks to go out and pursue different parts of the social-service world, the behavioral-health world. It gives Minnesota a lot of bang for the buck in terms of qualified workers.”

Unlike other mental health professions, social work practice, though it often is focused on mental health, is not limited to clinical work, Zacher-Pate explained. Social workers can do assessments of clients, as well as services known as “macro practices,” including community organizing, policy work program development, agency management and administration.

This varied skill set could come in handy in more sparsely populated regions that are low on mental health and social service providers, Fritsma said. It’s already happening in some parts of the state.

“Social workers are the ones who are out in these small towns and rural areas providing mental health care,” she said. “In a lot of areas, that’s all you’ve got.” Licensed social workers are multidisciplinarians, she explained: “It’s a good thing they make up such a large share of the workforce.”

Barriers to practice

A requirement for social work licensure in Minnesota is that graduates complete 4,000 hours of practice overseen by a licensing supervisor. The requirement, known as a “competency requirement,” is not unique to social workers, Zacher-Pate said, but it can be a stumbling block for many would-be licensed social workers who struggle to afford the cost of completion.

Social work graduate students can see patients during their competency period, and some agencies provide paid time for licensing supervisors, but many graduate students are required to pay for their own supervision.

This requirement is key to licensure, Zacher-Pate said, and common among many mental health professions.

“This this isn’t unique to social workers. The idea is you do your clinical training before you can be granted a clinical license. That is where they are demonstrating that an individual can practice and learn under supervision. It is a critically important requirement.”

The struggle is that social work pay is lower than some other professions that require supervised practice, Abderholden said. This means that many would-be licensed social workers end up not being able to complete this part of the requirement and instead take other jobs not in the mental health field.

“There is a huge drop-off from people getting their master’s in social work and then going on to practice,” Abderholden said. “They can’t finish and get to licensure. That is a huge issue.”

Licensing supervisors also struggle to afford observing the practice of social work graduate students, Fritsma said. Many agencies do not pay for supervision time, and private insurance does not cover therapy provided by students, so supervisors and graduate students (also known as “pre-professionals”) have to work out agreements to get in the required practice hours.

“A big part of the clog in the pipeline of mental health professionals is what happens between graduation and licensure,” Fritsma said. “Somehow, students have to get in all these hours of supervised practice. They have to find a supervisor, and very often that supervision is not time that a social worker can get reimbursed for. They are doing it out of the goodness of their hearts or they are charging the student for that supervision time. I know one clinical counselor. She charges $150 an hour. She charges half of that to supervise a person out of school.”

Paying for supervision presents a struggle for many social work pre-professionals.

“When a new graduate, on top of paying off student loan debt, also has to come up with money to pay for the supervision they need to get be licensed, they may say to themselves, ‘I can do this, or I can take the degree and be a job coach or something that doesn’t require a license,’” Fritsma said. “It is a big, big, big problem for providing clinical mental health services.”

Social workers’ pay post-licensure is lower than that of other mental health professionals. According to the Minnesota Department of Health, on average, medical and public health social workers make $28.48/hour, while clinical, counseling and school psychologists make $41.40/hour. This can make paying for supervision a serious roadblock. The profession’s lower pay may be based in the fact that social work has historically been seen as a women’s profession — 88 percent of Minnesota’s current licensees are female — and, unlike nurses, most social workers, other than those employed by county or state agencies, do not have union representation.

“Pay has been a perennial issue,” Zacher-Pate said. “That does create a barrier for people considering a career in social work. It can be a real disadvantage, especially knowing that we have shortages.”

Supervisors can also get a bad deal, Zacher-Pate added. Though established licensed social workers understand the importance of providing supervision time so students can compete the competency requirement, it also takes away from their own available practice hours — and if an agency doesn’t pay for the service, or if the supervisor is in private practice, it can have a negative impact on their income.

“In those cases,” Zacher-Pate said, “supervision becomes an in-kind service. Oftentimes, if you have an independent clinician doing that mentoring and supervision, from an organizational and revenue standpoint it can take away from the bottom line, because that person is not providing services.” In rural counties where a single licensed social worker may be the sole mental health provider, making time for supervision hours seems next to impossible.

“How in the world can that one person provide supervision and also serve clients?” Zacher-Pate asked. “The shortage of licensing supervisors feels particularly acute in Greater Minnesota.”

On a state level, there have been efforts to remedy this situation. In 2015, the Governor’s Task Force on Mental Health recommended that the state provide funds for reimbursement for licensing supervisors. The recommendation was brought before the Legislature, but it didn’t get picked up. “Maybe it’s time to revisit that,” Fristma said.

Abderholden added that over the years NAMI Minnesota has supported legislative efforts to provide funding for supervisors and trainees. “We think there has to be more effort made around paying for supervision,” she said. “One of the bills we had for several years addressed the issue that private insurance doesn’t always pay for trainees. Medicaid pays for it. That makes it hard for people to provide supervision because they aren’t getting paid to do it.”

The Board of Social Work understands that this requirement can present a burden for students and supervisors, Zacher-Pate said, so it supports efforts to find ways to reimburse supervisors or provide funding for students seeking licensure.

“While it is very hard to argue with the importance of this as a mechanism to gauge competence, I’m not going to deny that there aren’t challenges around finding supervisor support from agencies or even allowing time off,” Zacher-Pate said. “There’s been conversation about this repeatedly.”

The board is in the process of conducting a comprehensive review of their practice act, she added. “We’ve been tackling things bit by bit. What’s next for us to take a look at is supervised practice.”

Diversifying the profession

Minnesota’s mental health workforce is majority white, and social workers are no exception. The “Social Worker Workforce” report finds that 92 percent of the state’s social workers are white, and 93 percent speak only English in their practice without the aid of an interpreter.

Efforts to diversify Minnesota’s social work workforce include a loan-forgiveness program funded by the Legislature to repay educational costs for licensed mental health professionals who are serving underserved populations.

“That program incentivizes working with underserved populations in urban areas, which I think is great and forward-looking,” Zacher-Pate said. “There are other initiatives in play working toward creating a more diverse workforce, but I think we’re still in the baby steps of those initiatives.”

Social workers could play an important role in providing mental health care for underserved rural communities or low-income communities of color, Fritsma said. The flexibility of their training could provide care options in isolated communities that often struggle to attract workers. And having a mental health care provider with a similar background to the people he or she is serving could encourage more people to seek mental health care.

Social workers can be licensed with an undergraduate degree, Zacher-Pate added. This helps remove barriers for people who may not have the financial resources required to earn a graduate-level degree.

“Earning a degree in social work really does afford a person a lot of options in pursuing practice,” she said. “There’s a very nice and diverse scope, which then creates more opportunity for our graduates. Licensing at the baccalaureate level is absolutely critical for our workforce.” Almost 50 percent of social work licensees are at the baccalaureate level.

Baccalaureate-level social workers can do counseling, Zacher-Pate explained, but they cannot bill as mental health therapists: “They are not doing the diagnostic assessment based in the DSM-4.”

Abderholden said that NAMI is advocating for a number of measures designed to help diversify the state’s mental health workforce.

“We have to get increased rates, more grant funding for schooling,” she said. “We don’t have enough people to carry it out. Particularly in culturally specific communities, we need to continue to do it to get rid of the barriers for training, for education.”

Zacher-Pate added that she believes that all of the stakeholders in the struggle to improve mental health care in Minnesota share similar desires.

“At the end of the day,” she said, “everyone has the same goal: to work toward creating and sustaining a qualified, diverse workforce to meet the needs of citizens.”