As California's behavioral health workforce buckles, help is years away
Now comes the hard part — recruiting and hiring 10 certified substance use counselors and about a dozen other staff members to work at the new site, about 170 miles north of the state capital.
'Ask anyone trying to get staff and it's difficult,' said Justin Wandro, the mission's head of development. 'Try to get people who are willing to work in very intense, very difficult environments. It's hard.'
California has long struggled to revitalize its behavioral health system and expand its workforce to meet the needs of its residents, particularly in rural parts of the state like the far north.
Six years ago, the California Future Health Workforce Commission warned of a 'severe and growing' shortage across the behavioral health field, including psychiatrists, therapists, social workers and substance use counselors, and noted that two-thirds of Californians with a mental illness go without treatment. Since then, Gov. Gavin Newsom and state lawmakers have set out to transform the behavioral health system, with the Legislature dedicating more than $1 billion to train and recruit providers.
Yet, the shortage has only worsened since the pandemic, which exacerbated mental health and addiction issues for many. In April, state health officials revealed that California was short roughly a third of the 8,100 psychiatrists and 117,000 licensed therapists it needed based on 2022 data. And the state's limited training capacity is making it hard to replace the number of retiring practitioners. As a result, existing workers are buckling under the workload while patients without quick access to help during a crisis are turning to costly emergency care.
'It feels helpless, because there is more than you can fix,' said Nick Zepponi, a social worker at the Hill Country Community Clinic CARE Center in Redding. The mental health urgent care clinic is one of the last lines of defense in the fraying behavioral health system in Shasta County, where the suicide rate is more than double the state average and overdose deaths increased more than threefold during the pandemic. 'There's more people than you can help that need it,' Zepponi said.
Playing catch-up
Under Newsom, the state has increased funding for youth preventive care, revised conservatorship laws, and set up a court-based program to compel treatment for some of the state's most severely mentally ill residents.
The Democrat also championed the passage of Proposition 1, a cornerstone of his response to the state's homelessness and drug crises, saying it would add 10,000 treatment beds and housing units and increase access.
One of the biggest remaining bottlenecks is the acute shortage of psychiatrists — licensed medical doctors who can prescribe medications such as antidepressants as well as antianxiety and antipsychotic drugs. While the state has opened more slots for training in recent years, it can cost as much as $250,000 a year and requires 12 years of postsecondary education.
In 2025, 239 first-year residents enrolled in California psychiatry programs, an all-time high and up from 152 seven years ago. Yet it was far below the 527 first-year psychiatry residents the workforce commission estimated are needed annually from 2025 to 2029.
'The investments have lagged, and because they've been more recent, we're not really seeing as much of the fruit of those investments yet,' said Janet Coffman, a University of California-San Francisco associate professor who specializes in health care workforce issues. 'Some of these psychiatry programs that the state has funded haven't graduated their first class yet.'
The state has also expanded the role of other providers, such as nurse practitioners trained to prescribe behavioral health drugs and certified peer counselors who might be able to meet with patients more frequently.
Mark Ghaly, former secretary of the state Health and Human Services Agency and one of the architects of Newsom's behavioral health overhaul, said it's better to spread responsibilities among various providers, including some with shorter training timelines, to expand capacity faster.
'You're building workforce plans around models that, frankly, aren't meeting people's needs,' Ghaly said. 'If we try to chase the current models today with the demand that has grown, I don't think you catch up.'
In addition to the state's own investments, California is tapping $1.9 billion in Medicaid funds to train, recruit, and retain behavioral health workers, enticing them with scholarships and loan repayments, and helping schools fund new residencies and fellowships. But the program took effect only recently, in January, and there is the looming threat that the Trump administration could rescind the funds at any time.
In a statement, U.S. Department of Health and Human Services spokesperson Emily Hilliard said the Centers for Medicare & Medicaid Services has made clear that approved waivers remain in effect.
'That said, states should not rely on temporary demonstration funding as a substitute for sustained, direct investment in their healthcare workforce,' Hilliard added, saying the agency would continue to evaluate the outcomes of California's experiment, which sunsets at the end of 2029.
Health advocates warn that California is so behind that any slowdown in behavioral health workforce funding would be detrimental. HHS Secretary Robert F. Kennedy Jr.'s move to fold the nation's mental health agency into a new department focused on chronic care and disease prevention, national advocates say, could spell trouble for program funding generally.
Uber to the ER
Kelly Monck, who lives in a pool house behind her mother's middle-class suburban home in Redding, struggles with depression. Despite having health coverage and knowing her way around the healthcare system, she often can't get an appointment with her psychiatrist when thoughts of suicide creep in.
'We've been fighting this demon since I was 15 years old,' said Monck, 38, who is deaf and has Ehlers-Danlos syndrome, a connective tissue disorder that has collapsed her airway and left her reliant on a ventilator and feeding tube.
In April, Monck overdosed on her heart medication. Seeking help, she called her therapist, who eventually persuaded her to go to the emergency room. She took an Uber and waited in the ER for hours, she said, but there was no open treatment bed and she was released.
Rather than go to the ER a second time, Monck called Hill Country when suicidal thoughts returned the following week. She had hoped that providers there could expedite an appointment with her county psychiatrist or adjust her medications. But clinic counselors aren't licensed to prescribe medication and could do little more than ensure she wasn't an immediate danger to herself.
It wasn't until her mother drove her 250 miles to Stanford Medicine's psychiatry unit that she was able to get her medications adjusted. She didn't see her regular psychiatrist for two more weeks.
Monck isn't alone. In some regions of the state, it can take patients months to see a psychiatrist, and those who urgently need help are increasingly turning to costly ER care.
In 2022, patients with mental health or substance use disorders accounted for 1 in 3 inpatient hospitalizations and 1 in 6 emergency room visits, state data show. In ERs, doctors can often do little more than temporarily stabilize these patients, since long-term treatment beds are nearly impossible to find.
Shasta Regional Medical Center, one of Shasta County's two major hospitals, has created a temporary holding area in the ER for mental health patients, in addition to 18 existing inpatient beds, said Brenten Fillmore, the hospital's director of behavioral health.
'It's not how the system is designed to work,' Fillmore said. 'There just are not enough beds to service the need, particularly when it comes to difficult cases.'
Healthcare providers say most patients are better served in office and outpatient settings where regular appointments with clinicians could help them avert a crisis.
The state estimates Shasta County has about a third of the psychiatrists and little more than half the licensed therapists it needs, significantly below the state average.
More than once, clinicians at Hill Country have made the three-hour journey to take a client to the nearest medication-assisted detox facility, in Eureka, or farther south to San Francisco, said Brandy Gemmill, a substance use counselor. But once patients are sober, it's rare to find an opening in a longer-term residential program.
'What I struggle with is the lack of resources,' Gemmill said. 'Where do we send them? So then, they're back on the street and it's happening all over again.'
When patients repeatedly fall through the cracks, Zepponi said, workers like him are at high risk of burnout, something that has hit behavioral health clinicians particularly hard.
Every six months or so, when a slight twinge of dread starts to creep in at work, Zepponi knows he needs to schedule a week off if he wants to keep doing the job he loves.
'That's when I know I really need time off, and I have to act quickly.'
Turning to GoFundMe
In 2018, the Camp fire tore through the foothills of the Sierra Nevada in Butte County, killing 85, destroying about 14,000 homes, and displacing more than 50,000 people. Within weeks, patients with post-traumatic stress disorder, depression, and anxiety flooded into local hospitals and doctors' offices, but few providers were equipped to help them. An estimated 40 to 60 physicians left the region after the fire, deepening the shortage.
A group of local doctors set out to reverse the trend, and last year the nonprofit Healthy Rural California launched the state's first psychiatric residency program north of Sacramento. Rachel Mitchell, director of the program, said even with a $1.5-million grant from the state for planning, the organization had to cobble together roughly $75,000 via private donations and a GoFundMe campaign to welcome its first class of four psychiatry residents. The federal grant money they rely on for operations, administered by the Health Resources and Services Administration, has been a volatile funding source.
'We'd love to get six students per class, but at this point we can't afford to,' Mitchell said. Program administrators want to tap into a more stable funding stream through CMS but must first wait for its partner, Enloe Medical Center in Chico, to recruit psychiatrists to teach and supervise residents.
Its first class will graduate in 2028.
Mai-Duc writes for KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
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'If we try to chase the current models today with the demand that has grown, I don't think you catch up.' In addition to the state's own investments, California is tapping $1.9 billion in Medicaid funds to train, recruit, and retain behavioral health workers, enticing them with scholarships and loan repayments, and helping schools fund new residencies and fellowships. But the program took effect only recently, in January, and there is the looming threat that the Trump administration could rescind the funds at any time. In a statement, U.S. Department of Health and Human Services spokesperson Emily Hilliard said the Centers for Medicare & Medicaid Services has made clear that approved waivers remain in effect. 'That said, states should not rely on temporary demonstration funding as a substitute for sustained, direct investment in their healthcare workforce,' Hilliard added, saying the agency would continue to evaluate the outcomes of California's experiment, which sunsets at the end of 2029. Health advocates warn that California is so behind that any slowdown in behavioral health workforce funding would be detrimental. HHS Secretary Robert F. Kennedy Jr.'s move to fold the nation's mental health agency into a new department focused on chronic care and disease prevention, national advocates say, could spell trouble for program funding generally. Uber to the ER Kelly Monck, who lives in a pool house behind her mother's middle-class suburban home in Redding, struggles with depression. Despite having health coverage and knowing her way around the healthcare system, she often can't get an appointment with her psychiatrist when thoughts of suicide creep in. 'We've been fighting this demon since I was 15 years old,' said Monck, 38, who is deaf and has Ehlers-Danlos syndrome, a connective tissue disorder that has collapsed her airway and left her reliant on a ventilator and feeding tube. In April, Monck overdosed on her heart medication. Seeking help, she called her therapist, who eventually persuaded her to go to the emergency room. She took an Uber and waited in the ER for hours, she said, but there was no open treatment bed and she was released. Rather than go to the ER a second time, Monck called Hill Country when suicidal thoughts returned the following week. She had hoped that providers there could expedite an appointment with her county psychiatrist or adjust her medications. But clinic counselors aren't licensed to prescribe medication and could do little more than ensure she wasn't an immediate danger to herself. It wasn't until her mother drove her 250 miles to Stanford Medicine's psychiatry unit that she was able to get her medications adjusted. She didn't see her regular psychiatrist for two more weeks. Monck isn't alone. In some regions of the state, it can take patients months to see a psychiatrist, and those who urgently need help are increasingly turning to costly ER care. In 2022, patients with mental health or substance use disorders accounted for 1 in 3 inpatient hospitalizations and 1 in 6 emergency room visits, state data show. In ERs, doctors can often do little more than temporarily stabilize these patients, since long-term treatment beds are nearly impossible to find. Shasta Regional Medical Center, one of Shasta County's two major hospitals, has created a temporary holding area in the ER for mental health patients, in addition to 18 existing inpatient beds, said Brenten Fillmore, the hospital's director of behavioral health. 'It's not how the system is designed to work,' Fillmore said. 'There just are not enough beds to service the need, particularly when it comes to difficult cases.' Healthcare providers say most patients are better served in office and outpatient settings where regular appointments with clinicians could help them avert a crisis. The state estimates Shasta County has about a third of the psychiatrists and little more than half the licensed therapists it needs, significantly below the state average. More than once, clinicians at Hill Country have made the three-hour journey to take a client to the nearest medication-assisted detox facility, in Eureka, or farther south to San Francisco, said Brandy Gemmill, a substance use counselor. But once patients are sober, it's rare to find an opening in a longer-term residential program. 'What I struggle with is the lack of resources,' Gemmill said. 'Where do we send them? So then, they're back on the street and it's happening all over again.' When patients repeatedly fall through the cracks, Zepponi said, workers like him are at high risk of burnout, something that has hit behavioral health clinicians particularly hard. Every six months or so, when a slight twinge of dread starts to creep in at work, Zepponi knows he needs to schedule a week off if he wants to keep doing the job he loves. 'That's when I know I really need time off, and I have to act quickly.' Turning to GoFundMe In 2018, the Camp fire tore through the foothills of the Sierra Nevada in Butte County, killing 85, destroying about 14,000 homes, and displacing more than 50,000 people. Within weeks, patients with post-traumatic stress disorder, depression, and anxiety flooded into local hospitals and doctors' offices, but few providers were equipped to help them. An estimated 40 to 60 physicians left the region after the fire, deepening the shortage. A group of local doctors set out to reverse the trend, and last year the nonprofit Healthy Rural California launched the state's first psychiatric residency program north of Sacramento. Rachel Mitchell, director of the program, said even with a $1.5-million grant from the state for planning, the organization had to cobble together roughly $75,000 via private donations and a GoFundMe campaign to welcome its first class of four psychiatry residents. The federal grant money they rely on for operations, administered by the Health Resources and Services Administration, has been a volatile funding source. 'We'd love to get six students per class, but at this point we can't afford to,' Mitchell said. Program administrators want to tap into a more stable funding stream through CMS but must first wait for its partner, Enloe Medical Center in Chico, to recruit psychiatrists to teach and supervise residents. Its first class will graduate in 2028. Mai-Duc writes for KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
