How a lack of supervisors keeps new mental health workers from entering the field

Sign up for The Brief, The Texas Tribune’s daily newsletter that keeps readers up to speed on the most essential Texas news.

---

It was early 2022, and Kiany Casillas was in a panic. It had been two years since she and her newborn daughter had followed her husband from California to the Texas Panhandle, and during that time, she had enrolled at Texas Tech University Health Science Center to pursue a career as a psychiatric-mental health nurse practitioner.

Casillas is considered the perfect student for Texas Tech’s online program because she lives in the rural city of Dalhart, an hour and a half northwest of Amarillo, and is willing to work there when she graduates. However, a year had passed, and Casillas and the school had yet to find a supervisor for her necessary clinical hours, and the deadline was fast approaching.

“I was anxious, nervous, and baffled. How can I help people if nobody is willing to help me? You know, I was just kind of sad,” Casillas said.

Supervised clinical hours are considered an essential part of the mental health field. They allow students to learn on the job while the supervisor, known as a preceptor in the medical field, assumes the risk of liability. However, only a limited number of mental health providers seem willing to take on this responsibility.

“I had somebody tell me, I don’t train people I don’t hire, and I don’t hire people I don’t train. So you can kind of see the roadblocks I was facing,” Casillas said.

A recent workforce survey done by the Texas Behavioral Health Executive Council found that over 75% of 10,233 mental health providers who responded indicated they were not supervising anyone currently. Over 50% of 7,600 respondents said they were not interested in serving as supervisors.

The most common response from mental health providers about why they aren’t interested in serving as supervisors for individuals working toward licensure is that there is too much liability, not enough time, and it is not worth paying for the training or the loss of client time.

The survey also included responses from mental health providers who previously were supervisors who mentioned they couldn’t do it anymore due to extra responsibilities, too much paperwork, their agency's internship program not being restarted since the COVID-19 pandemic, and it is too risky during a time when demand is this high for services.

Susan Calloway, a professor at Texas Tech University Health Sciences Center’s School of Nursing, said when they established the psychiatric-mental health nurse practitioner program in 2016, they were already having difficulty finding supervisors in both the rural and urban areas of the state.

“Now, with the number of PMHNP programs doubling in Texas and out-of-state programs recruiting PMHNP students, there is even more competition for preceptorships,” she said.

In 2022, the Texas Mental Health Care Consortium, which was created in 2019 to improve access to children’s mental health services, warned lawmakers that there was limited availability of board-approved supervisors for clinical master’s level graduates to obtain the supervision required for unrestricted licensure.

The group stated if supervision is not immediately available, these potential health care professionals must either choose to pay for their clinical supervision out of pocket, which can cost $5,200 to $10,400 per year for approximately two years, or delay their credentialing process, which impedes employment opportunities in a field that desperately needs the help during a workforce shortage.

This situation has created a backlog of interns searching for opportunities to work with a mental health provider who fits their field of interest, is willing to take on interns, and has an hourly training cost that isn’t too expensive.

“There are issues with finding supervisors for mental health professionals who are seeking clinical licensure,” said Alison Mohr Boleware, the Hogg Foundation for Mental Health policy director. “Each profession has their own requirements and thus their own challenges”

Supervised Training

Back in Dalhart, Casillas was running out of options. It had been a year and a half since she had begun her search for a supervisor, and the only option she had at the moment was to learn play therapy from a children’s psychological therapist 78 miles away from where she lived. This wasn’t an option for a mother with a toddler at home.

“I thought to myself I wouldn’t be able to continue in the program because we need preceptors for a vast amount of our over 1,000 clinical hours,” she said. “I was concerned that I wouldn’t be able to find somebody.”

The California native even had school staff help her find a supervisor in her area, but her outlook wasn’t good.

“The school was trying to help me and get in contact with people, but I was worried. I even had to talk to them and ask what would happen if I didn’t find a preceptor,” Casillas said. “They said they would continue to help me look but that I might have to take a semester off.”

The career path to becoming a mental health provider is long and involves years of schooling and tests, but one of the primary time consumers for students is the internship program. Most of the time, when students near their clinical hours requirement, they are on their own to find a supervisor if the school doesn’t already have a system in place.

The hours required for a mental health provider to get their license vary from career to career.

For example, in Texas, a licensed psychologist, professional counselor, and a marriage and family therapist need 3,000 hours of internship once they have graduated. In contrast, a licensed master social worker-advanced practitioner and a licensed clinical social worker need at least two years of professional supervised experience. Meanwhile, a licensed specialist in school psychology needs 1,200 hours, of which 600 must be in a public school.

However, all these fields are united by the common fact that supervisors must be found before a license is granted. But where are they?

The Texas Behavioral Health Executive Council, the state’s mental health licensing authority, keeps a database of supervisors across the state. As of June, there were 6,802 supervisors for licensed professional counselors, 3,871 supervisors for licensed clinical social workers, and 868 marriage and family therapists.

There has actually been a yearly increase of over 400 supervisors since 2022. So what is the problem?

“We are not able to tell in our database which licensees are actually providing supervision,” Darrel Spinks, the council’s executive director, said “We strongly suspect that some hold the supervisory status but choose not to provide supervision.”

Angie Lutts, vice president of the National Association of Social Workers’ Texas chapter, said the supervisor database isn’t too helpful because it doesn’t have details like whether supervisors offer supervision to those outside of their agency, what their area of practice is, and what specialties they have.

This can be a particular problem in rural areas where there might only be two to four mental health providers in a region. And there might only be one authorized supervisor in the county.

Lutts also believes this new generation of interns is less likely to be on Facebook or just go into an office and ask, as they were in the past.

“I am in my 40s, so that means I am a Facebook person. We have our own social worker groups, and when someone posts there about looking for a supervisor, they get 30 responses, and then some supervisors say they haven’t taken any interns because nobody has reached out,” Lutts said. “I think there is a generational divide happening. I don’t have Snapchat or Instagram or those other apps where most of this younger generation reside.”

This leaves interns like Casillas to resort to a demoralizing, almost door-to-door method of calling, emailing, or meeting mental health providers on the list at random to see if they are accepting anyone.

“I called the local mental health authority, which, you know, is funded by taxpayer dollars, and they actually told me that they only accept students from a specific school,” she said. “I called other places, and they basically told me, ‘Good luck. We really need you, but we can’t help you.’ ”

Too risky, too expensive, and too much time

Casillas was about to give up when she heard about a psychiatrist opening up a private practice near Dalhart. She quickly reached out to see if she was willing to be her supervisor and breathed a deep sigh of relief when she agreed to do so.

“It was by the skin of my teeth,” Casillas said. “It was really difficult, especially in a rural area like mine where there are roughly four mental health providers, and none of them do medication management. I would probably be still looking today if she hadn’t taken me on. It’s just a difficult process to find what supervisor is willing to take on who, if anybody.”

Mario De La Garza, program director for Southern Methodist University’s Department of Counseling, said he is one of those registered as a supervisor but doesn’t take on students.

“I wanted to be a licensed professional counselor supervisor, but then I went to work in the university setting, and I supervise and teach counseling now, but I am still authorized,” he said.

Diane Smedley, an assistant professor for the department of psychology and counseling at the University of Texas at Tyler, said this is common in the mental health field.

“Many get the supervision license and use it briefly and then don’t use it again. Many get it and only take on one supervisee.,” Smedley said. “So the numbers might show two interns to every supervisor, but that's not how it actually plays out.”

A supervisor in mental health must have several years of experience and complete multiple hours of training. Today, those already in this overworked industry struggle to find time for this responsibility.

Garza has a unique perspective of being able to see issues from both the supervisor and the student perspectives.

“What I would say is that being a supervisor is not an easy job,” he said. “You have to sign on for a lot of responsibilities and paperwork, which is good because we want our supervisors to be responsible, but when you take on a student, and they take on clients, you are the one responsible for the client's well-being.”

Smedley described the relationship between supervisor and intern in the mental health space as intimate and close but time-consuming and liability-filled.

“I think it's more of a situation of where do I put my energy? Am I putting my energy out there to provide services, to be a counselor, and to take on clients because there is such a void of mental health practitioners in the state of Texas? Or do I focus on supervising associates, which is also an effort and takes your attention, so there is a delicate balance required,” Smedley said.

Choosing which to focus on also cuts into the budgets of mental health supervisors.

“You are paying higher malpractice insurance, and technically, you have the right to charge your supervisee, but they are not making great wages and probably paying off student loans,” Smedley said. “So you are losing client sessions for an unknown return.”

This risk has seemingly scared off many potential supervisors from even considering the online options for interns.

“I think there is probably a generational gap when it comes to doing stuff online,” Garza said. “Maybe a lot of supervisors don’t want to do it because they aren’t comfortable. But another aspect of this is if the LPC supervisor is responsible for the well-being of the client, and let's say your intern has a suicidal client but lives three hours away and has no idea of the services around the client, then that adds a whole another layer of complexity to this problem.”

Smedley said there doesn’t seem to be a quick fix. However, she said there are ways the state can help by making it easier for interns and supervisors to find each other and by providing financial incentives to take on this role. But, she cautioned against making it easier to become a supervisor just because of the demand.

“There’s a delicate balance between providing access to supervisors and not reducing our quality of supervisors,” Smedley said. “It’s a tightrope walk, but that is something we have to keep in mind.”

Casillas, who graduates this weekend, plans to address this problem by getting her supervisor certification as soon as possible so that she can help students who come after her.

“I want to pay it forward as a way to thank those who helped me,” she said.

Disclosure: Facebook, Hogg Foundation for Mental Health, Southern Methodist University, Texas Tech University and Texas Tech University Health Sciences Center have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

---

The full program is now LIVE for the 2024 Texas Tribune Festival, happening Sept. 5–7 in downtown Austin. Explore the program featuring more than 100 unforgettable conversations on topics covering education, the economy, Texas and national politics, criminal justice, the border, the 2024 elections and so much more. See the full program.