You don’t need to be a professional therapist to realize that the mental health ecosystem in the United States is broken. Because people are restricted in accessing care across state lines, their options for finding the type of care that they need is severely limited.
Part of the solution is already underway, as certain states have agreed to let mental health providers see patients within their combined state lines. We need to supercharge that system, setting up a national infrastructure for mental health care that serves all Americans equally.
At the national level, our current mental health care system is absurdly complex and difficult to navigate. Each state establishes extremely similar but slightly different processes and criteria for a mental health worker to be licensed there. These criteria also vary depending on the type of mental health provider: a licensed professional counselor (LPC) is treated differently from a licensed professional clinical counselor, licensed clinical social worker, licensed marriage and family therapist, and licensed mental health counselor.
Patchworks of agreements between states, such as the Counseling Compact and PSYPACT, currently offer the only way for patients to see providers in states they don’t live in. But these compacts are limited, both in terms of which other states’ providers are available to patients and which types of mental health workers are covered.
This arrangement has a number of significant drawbacks. First, it limits access to mental healthcare, particularly for those in rural locations, and limits choice for patients who prefer providers with specific lived experiences, such as faith-based treatment or a provider from the LGBTQ+ community.
Second, it limits competition, leading to higher costs and poorer standards, since a patient’s selection is limited to providers in their state or compact.
Third, it hampers diversity, equity, and inclusion efforts by raising the financial barrier to entry for providers. Since the status quo requires them to pay for a license in every other state, only those who have enough existing resources can afford to provide out-of-state care.
Finally, frustratingly, it wastes capacity because care is not evenly distributed. In some pockets of the country, therapists have four-month wait times; while in others, counselors are not even fully booked.
There’s nothing wrong with states regulating mental health providers. The problem with our system is that accreditation in one state doesn’t simply carry over to others. Forcing practitioners to jump through hoops to obtain an individual license in each state is both unnecessarily onerous and harmful to people who need more care options.
We know what a better system looks like; we glimpsed it briefly when the Covid pandemic began. Emergency easing of regulations enabled people to get mental health care through telehealth wherever they were located.
This temporary regulatory easing simply worked better—for patients, for providers, for insurers, for regulators. We should use it as a guide for a new, permanent system that accomplishes the same.
Such a framework should be led by the trusted governing bodies of the mental health profession, such as American Psychological Association (APA), National Association of Social Workers (NASW), and American Counseling Association (ACA). These organizations should design common standards for all providers to meet. Some of these might include: holding a relevant master’s degree, a certain number of post-graduation hours working with patients, and completion of one of the national counseling exams.
The goal: Anyone who meets these standards is automatically granted a license to practice anywhere in the U.S.
In order for this to work, it will have to be collaborative. States will need to work together to create a process that lowers the barriers to entry for patients and providers seeking care around the nation.
When I share this framework with people outside the mental health industry, it seems like an obvious solution. To mental health professionals, the status quo is so entrenched that it feels like change is impossible.
We can make the system work better if we remember why mental healthcare services exist in the first place: to help people who are struggling to get better. If we put patients at the center of our policy conversations, they will motivate us to eliminate anti-competitive state licensure processes and open up access to mental health services nationwide.
Adam Chekroud
Adam is President and Co-founder of Spring Health, a comprehensive mental health benefit for employers and health plans that provides immediate access to high-quality behavioral healthcare. The company serves millions of members across thousands of organizations and has thousands of providers in its network. Adam is also an Assistant Professor of Psychiatry at Yale University. His research seeks to improve treatment outcomes in mental health, particularly depression, by using large datasets to anticipate barriers to treatment and likely illness courses. His research has been featured in JAMA Psychiatry, JAMA Network Open, Lancet Psychiatry, Molecular Psychiatry, and PNAS.
