Issue 17 | November 2022

Children’s advocacy centers (CACs) work hard to provide pathways to healing for children and families. However, providing mental health services onsite or through linkage agreements has become increasingly difficult as referrals outpace availability of therapists. Identifying local trauma-trained professionals, even in large urban areas with a rich pool of licensed therapists, can prove difficult. The challenge is more daunting in rural and frontier communities where far fewer licensed mental health professionals live¹. To the extent that qualified trauma-focused treatment providers exist in rural areas, they are often found in limited numbers, and families may experience long waits before therapy can be initiated. This shortage often means relying on generalist mental health professionals who do not specialize in evidence-based trauma treatment.  

Hiring Remote Therapists to Provide Telemental Health Services 

Telemental health (TMH) services can improve access to evidence-based mental health treatment for children and families in rural and frontier communities by connecting trained trauma therapists in a more populated part of a state to children in isolated regions. The COVID-19 pandemic precipitated rapid changes in service delivery models and clinician understanding of the research supporting TMH. As a result, the number of therapists utilizing TMH jumped from a handful to thousands almost overnight. This increase opens a new door to quality mental health for CACs in rural and frontier communities: employing one or more therapists to work remotely for the rural CAC and deliver therapy via TMH. According to the 2021 National Children’s Alliance (NCA) Census taken during the COVID-19 pandemic, nearly three-quarters (71.2%) of CACs offer TMH services, and nearly two-thirds (64.7%) of the CACs that launched TMH services during the pandemic plan to sustain them.  However, while the use of and comfort level with TMH has increased, the issue of continuing to develop and sustain TMH services is an important one to consider.  

WRCAC released an issue brief in September 2022 that addresses ways CACs can recruit, hire, supervise, and retain remote therapists. It outlines a series of steps to establish policies, procedures, and processes for launching mental health services and highlights key decisions to consider before moving forward. Utilizing a remote employee to provide TMH services does not relieve the CAC of the burden of a well-designed system of care and, in fact, adds to the complexity. With that said, even a small, independent CAC can design and manage a quality TMH program with proper planning and foresight. 

The issue brief covers the following topic areas:  

• Assessing agency readiness to employ and support a remote therapist (including the cost of the therapist and stability of financial resources) 
• Considering what a remote program will look like (including policy development, documentation and grant reporting data) 
• Building a strong employer brand online 
• Assessing the competition (and how to be competitive and showcase the “perks” of working at a CAC) 
• Conducting a thoughtful remote job interview (including screening candidates and developing telehealth-specific interview questions) 
• Investing in thoughtful, strategic onboarding (including remote orientation and imparting organizational culture) 
• Establishing clear expectations of the scope of work 
• Supporting skill development and understanding of technology   
• Providing administrative and clinical supervision 
• Building and sustaining connection to CAC staff and the multi-disciplinary team 
• Addressing secondary trauma 

Taking Advantage of Interstate Compacts 

Every state requires mental health providers to apply for and obtain a license to practice within the state. For therapists who live close to other states and would like to provide services to clients in the neighboring state, previously, the only option was to apply for a separate license in both states, which can be costly to maintain. Many states are making it easier for mental health practitioners to practice in more than one state by developing interstate compacts, which allow mental health practitioners licensed and residing in a compact member state to practice in other compact member states without need for multiple licenses. The goal of interstate compacts is to increase access to client care, facilitate continuity of care when clients relocate or travel, certify that practitioners have met acceptable standards of practice, and promote cooperation among compact states in the areas of licensure and regulation. Compacts have been implemented or are in development in several states, which in turn, makes TMH an even more viable option for service delivery.  

Interstate compacts may give some CACs access to more treatment providers. For CACs in states that are experiencing a workforce shortage, interstate compacts expand options for recruiting and hiring TMH providers outside the state. Additionally, CACs that are located close to large cities in an adjacent state may have connections to agencies and partners across state lines that could facilitate connections to potential providers. 

At this time, there are three compacts related to providing therapy services: 

• Psychologists: This compact is called PSYPACT and is currently accepting applications to practice in participating states. PSYPACT is the most developed of the compacts and costs about $540 to initiate the application and obtain a required “passport” to practice telepsychology. There are several requirements to obtain the ability to practice through PSYPACT that include a doctoral degree, current unrestricted license, and submission of transcripts. Detailed information about applying and what states are participating can be found here: https://psypact.site-ym.com/page/About 

• Social Workers: An initial draft of the Social Work Compact has been completed. The draft is now available for review and public comment. The Social Work Licensure Compact allows bachelors, masters and clinical social workers in member states to apply for an interstate compact license that provides a multistate authorization to practice in all compact member states. This allows a social worker to care for clients located in any compact member state without having to go through each member state’s licensure process. To be eligible, social workers must reside in a compact member state and maintain an active, unencumbered license. Learn more at https://compacts.csg.org/compact-updates/social-work/

• Counselors: This compact is in process and not yet active. To provide counseling services through the compact, counselors use the counseling license granted by their home state to apply for the privilege to practice in other member states. Counselors must have an unencumbered license, take a national exam, complete a supervised professional experience, and earn a 60 semester-hour master’s degree. Applications are expected to open in late 2023 or early 2024. This website will have application information when it becomes available: https://counselingcompact.org/

Providing Support for Waitlisted Clients 

According to the most recent State of Mental Health in America Report, the number of employed mental health care providers has been on the rise in nearly every state². However, as most of us working in the field of child abuse and neglect know, the need for mental health services, especially for children and adolescents, far outpaces the addition of new clinicians to the workforce. The report found that even in states with the greatest access to insurance and mental health services, one in three youth are still going without any treatment. In states with the least access to mental health services, it is estimated that only 12% receive consistent care.  

Adding a full-time clinician to your team will increase your capacity to provide therapy to your clients. However, there remains a limited number of clients any given therapist can see on a regular basis, and evidenced-based treatments often require, at a minimum, an average of 3-4 months of regular sessions. Whether or not they work remotely or in-person, even new therapists will soon have a waitlist for new clients due to overwhelming need. Clients may need to wait for services to be initiated but still need support. Potential strategies to address the backlog include: 

• Engage in task sharing with victim advocates to host psychoeducation groups that families can attend while they wait to start treatment. These groups would be educational in nature (rather than therapeutic) and could cover topics such as common child and adolescent responses to trauma, ways to support your child after a disclosure, advocating for your child at school, and an overview of the legal system in response to allegations of abuse. These groups are a valuable tool for family engagement and increase the likelihood of a family enrolling in therapy.

• Expand intervention options beyond TF-CBT (which requires a longer treatment protocol and may not be the best fit for some clients) by providing training to therapists or hiring therapists who have been trained in shorter evidence-based interventions such as Eye Movement Desensitization and Reprocessing (EMDR) or Child and Family Traumatic Stress Intervention (CFTSI)  

• Develop linkage agreements with private practice therapists who have been trained in approved evidenced-based therapies (e.g., TF-CBT, EMDR, CFTSI) who would agree to keep a block of client sessions open for CAC clients 

• Recruit therapists from a nearby state that have dual licenses or participate in interstate compacts for mental health providers 

If you have any questions about addressing mental health workforce issues within your CAC, please reach out to me, Amelia Siders, at asiders@rchsd.org. 

[1] Health Resources and Services Administration. 2022. “Designated Health Professional Shortage Areas Statistics.” https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport    

[2] Reinert, M, Fritze, D. & Nguyen, T. (October 2021). “The State of Mental Health in America 2022” Mental Health America, Alexandria VA