Background

Indiana's Mental Health is in Crisis

Untreated mental illness is threatening the vitality of Indiana communities. The impacts cannot be overstated, with untreated cases costing the state an estimated $4.2 billion annually. The impact extends far beyond economics, affecting Hoosiers of all ages. Alarmingly, suicide is the leading cause of death among adolescents, and thousands of children lack access to necessary care. The problem is compounded by a severe shortage of mental health professionals, with all 92 counties in Indiana federally designated as shortage areas. Addressing this crisis by strengthening the mental health workforce is crucial for improving the overall health and well-being of Hoosiers.

Indiana's Mental Health Crisis in a Nutshell

Targeting Workforce Solutions

Every Indiana county has a federally designated shortage of mental health professionals. Federal shortage designations are based on the national population-to-provider benchmarks. Other population and systemic factors provide a context for local mental health service needs. The Playbook Workforce Assessment includes county-level resources (workforce and delivery system), community needs (population demographics and risk factors), and mental health indicators. State averages and composite scores were used to rank the counties based on their resources for meeting community mental health needs. (See here for additional details). Above-average counties have more resources (workforce and delivery systems capacity) to meet their community needs (population factors). Below-average counties have fewer resources to meet their needs. A new interactive dashboard with this information has been created to support the targeting of workforce solutions.

What professions are included in the Playbook?

Mental Health Counselors

Licensed Mental Health Counselor
Licensed Mental Health Counselor Associate

Marriage and Family Therapists

Licensed Marriage and Family Therapist
Licensed Marriage and Family Therapist Associate

Social Workers

Licensed Bachelor of Social Work
Licensed Clinical Social Worker
Licensed Social Worker

Addiction Counselors

Licensed Addiction Counselor
Licensed Addiction Counselor Associate
Licensed Clinical Addiction Counselor
Licensed Clinical Addiction Counselor Associate

Although other health care providers – such as primary-care physicians and nurse practitioners – have a role in supporting the mental and behavioral health of Hoosiers, the shortage of professionals whose practice focuses only on mental and behavioral health services will be the focus of this project.

The Opportunity

Mental and behavioral professionals who provide clinical services require specialized knowledge and skills developed through years of education and clinical training. The preparation of these professionals includes a mix of postsecondary degree programs (master’s and doctoral levels), postgraduate training (residencies and fellowships), and clinical experience requirements. Education and clinical experience are part of the pathway to licensure for professionals choosing to pursue clinical practice in mental and behavioral health care. Understanding the state’s workforce pipeline from postsecondary education to postgraduate training and clinical experience through licensure for independent practice is critical for identifying opportunities to strengthen Indiana’s workforce.

The Plan

Many organizations and individuals are actively engaged in strategies to train, recruit, and retain mental and behavioral health professionals in Indiana (see figure). Existing initiatives are generally focused on targeted workforce development strategies for specific professions (e.g., psychologists), within certain sectors (e.g., Be Happy Program for pediatric patients), or certain geographies (e.g., Evansville Stone Center). As of 2023, there is no platform to bring all these initiatives together to identify opportunities for information sharing and statewide coordination and planning.

Developing the Playbook

The Playbook focuses on identifying opportunities to strengthen Indiana’s postsecondary pipeline to practice for licensed professions dedicated to the provision of clinical mental or behavioral health services (see section on included professions above).

It is important to note that other health care, social services, and school-based professionals also make significant contributions to mental and behavioral health services in Indiana, including, but not limited to, paraprofessionals, primary care providers, school counselors, and case managers. Their contributions are an important part of the systems that support Hoosier mental health and wellbeing. Future assessments should focus on information and solutions to strengthen and support these valued professionals.

The Landscape

The state’s postsecondary pipeline to practice for mental and behavioral health professionals is shaped through regulatory policies, realized in the distribution and field strength of degree programs, and experienced by students, faculty, and employers. The identification of opportunities to strengthen the workforce requires an understanding of the unique and interrelated roles each of these factors has in the pipeline to practice.

Workforce Regulatory Policy Landscape

The regulatory policy defines the educational and experience requirements for licensure, including specific degree programs. A review of regulatory policy for the workforce, including statutes and administrative codes in Indiana, as well as other states, identified the complexity of the policy environment. Practice pathways vary across professions.

Complex

The pathways from education to clinical practice are much more complex for selected Indiana professions licensed by the BHHS board and in some cases, include specific provisions related to course content and overlapping requirements related to degree programs. For example, a masters in psychology potentially qualifies an individual for licensure application as a LMHC, LCAC, and LMFT, based on specific courses as outlined in statute.

Least Complex

For some professions, the pathway from education to licensure is straightforward. In Indiana, psychiatrists and psychiatric mental health nurse practitioners are licensed as physicians and registered nurses, respectively. No additional state licenses are required for clinical practice.

Somewhat Complex

The pathway from education to independent clinical licensure for psychologists is slightly different. Psychologists are first required to obtain a license and then apply for a separate endorsement as a Health Services Provider in Psychology.

Workforce one-pagers, created as part of the Playbook Project, help clarify the pipeline to practice pathway for mental and behavioral health professions in Indiana.

A national scan of 50-state policy reviews for mental and behavioral health professions was completed to identify how Indiana policy compares. Information from the national scan helped to identify areas where Indiana might align with other states.

Indiana does not have a formalized approach to training or credentialing/designation for clinical supervisors of BHHS licensees. Most other (44) states have a formal process in place.
Indiana has a two-level approach to psychology licensure, where the psychology license has a limited scope of practice without any indication of this in the title. In other states, the title “Psychology License” is used for a full-scope clinical psychology practice.

Education Landscape

Key questions at the beginning of the Playbook Project included:

“How may degree programs does Indiana have currently training folks for these licensed professions?” “Where are these programs located?” “How many students are enrolled?” “How many are graduating?”

When the Playbook Project kicked off in April 2023, the above questions could not be answered. Without this information, any plan to strengthen or expand the pipeline would be a shot in the dark. Additionally, people who need this information, such as prospective students/licensees and academic/career counselors, have been on their own to identify training opportunities that align with licensure in their communities.

The Indiana Training and Trends Dashboard (dashboard) serves as a resource for support systems and individual planning in Indiana6. Developed through collaboration with the Indiana Commission for Higher Education (CHE) and the Indiana Professional Licensing Agency (and their respective boards), this dashboard includes information on Indiana-based degree programs and the Indiana mental/behavioral health licenses they may correspond to.

The dashboard provides information on the locations of degree and residency programs across Indiana and the associated trends in enrollment and graduation. The BHHS dashboard can be customized according to the corresponding license type(s), program qualifying status, and programs with remote options.

Analysis of the information powering the dashboard identified several opportunities to strengthen the postsecondary workforce pipeline.

opportunities

- There are several Indiana counties where no training programs are offered (“training deserts”).
- Several BHHS degree programs have been closed since 2000 (25 in total)
- The number of programs and students with remote options in these programs has increased dramatically over the past several years.

Academic Leaders

Indiana degree programs comprise the postsecondary pipeline. These programs educate the next generation of Indiana’s workforce. Academic leaders from the programs included on the dashboard were invited to engage in the Playbook Project through various formats, including surveys, focus groups, and key informant interviews. More than 70 Indiana academic leaders provided insights into the state of their programs and where opportunities exist:

Opportunities

- Decreased student interest has led to decreased enrollment in some BHHS programs.
- Expansion of psychiatry, psychiatric mental health nurse practitioner, and doctoral psychology programs is limited by resources and infrastructure.
- Faculty recruitment and retention challenges impact all programs.
- Cost of education and wages post-graduation have been reported as barriers for some students, especially among BHHS programs.
- Shortages of and competition for clinical training experiences and internships limit student opportunities.

Detailed findings from Indiana academic leader engagement can be found in the Landscape Assessment: Training Program Perceptions of the Postsecondary Pipeline to Practice.

Employers

Indiana mental and behavioral health employers represent provider organizations and practices that deliver care to Hoosiers. These organizations hire licensed professionals, including new graduates, and have a perspective on where opportunities might exist to strengthen education and better prepare people for practice. Employers affiliated with the Indiana Council of Community Mental Health Centers (ICCMHC) and the Indiana Hospital Association (IHA) Council on Behavioral Health were engaged through a series of in-person and virtual meetings and invited to provide insights through surveys. Employers have identified the following opportunities:

opportunities

- Newly graduated professionals frequently have gaps in their understanding and knowledge of mental illnesses, substance use disorders, and other areas.
- Clinical supervisors (BHHS) do not typically receive incentives to provide supervision.
- Reimbursement of services provided by BHHS licensees completing clinical supervision (LSW, LMFTA, LCACA, and LMHCA) and interns threatens employment and wages for these professionals.

The findings from this survey are included in the Landscape Assessment: Employer Perceptions of the Postsecondary Pipeline to Practice.

Licensed Professionals

Licensed professionals are a product of the postsecondary pipeline to practice. Those who have completed their education and clinical experience in Indiana have valuable insights into opportunities to strengthen this pathway for the future workforce. Indiana BHHS and psychology professionals were invited to share their experiences and insights through an electronic survey sent to all license holders in collaboration with the PLA. More than 1,480 licensed BHHS and psychology professionals in Indiana responded to the survey, highlighting the following opportunities in Indiana:

Opportunities

- Greater clinical focus in degree programs would increase preparedness post-graduate (BHHS).
- Lack of training, guidance, and incentives are reported to limit participation in clinical supervision among qualified licensees (BHHS).
- Challenges, confusion, complexity with licensure requirements and processes caused delays and frustration (BHHS and Psychology).
- Difficulty finding clinical internships close to home threatened in-state retention (Psychology).
- Low wages make pursuing practice difficult (BHHS and Psychology).

Detailed findings from the survey administered to BHHS licensees can be accessed in the Landscape Assessment: BHHS Licensee Perceptions of the Postsecondary Pipeline to Practice. Those from the survey of psychology licensees can be accessed at Landscape Assessment: Licensed Psychologists Perceptions of the Postsecondary Pipeline to Practice.

The Playbook: Information to Action

The process of turning information on Indiana’s postsecondary pipeline to practice into actionable recommendations involved the extensive engagement of stakeholders and subject matter experts. A running list of “opportunities” identified by project advisors, licensed professionals, employers, academic leaders, trade associations, community organizations, and others was generated from research and engagement activities from August 2023 through March 2024 (see slide bar for list of organizations engaged). The opportunities were transformed into working draft recommendations with action-oriented implementation options vetted by stakeholders in person on April 23 at the Playbook Draft event at Lucas Oil Stadium (see picture) and through follow-up communications that continued through May 2024.

The final recommendations in the Playbook represent the input of many and have broad support. Implementation of these recommendations will be an important step toward strengthening the pipeline to practice for Indiana’s mental and behavioral health workforce. Now, champions are needed to pick up the ball and carry these recommendations forward!

(Image: Marriage and family therapist Megan Oed shares the licensee perspective at the Playbook Draft event prior to the panel discussion with state leaders at Lucas Oil Stadium.)

Jump to the First Solution

Secure the Pipeline

Solution One