In Rural Minnesota, Kids Lack Mental Health Care

“If we could fill all of our positions, we could serve about 1,000 more children in Minnesota.”

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In October, a coalition of pediatric health providers declared a national emergency in child and adolescent mental health. The declaration reports an increase in children seeking emergency care for all mental health challenges. In Minnesota, there was a 30 percent increase from 2020 to 2021 in emergency room visits for mental health concerns in the school age demographic. Young people are experiencing “soaring rates” of depression, anxiety, and suicidal ideation after over a year of Covid-19 and amid the ongoing struggle for racial justice.

Sue Abderholden, executive director of the National Alliance for Mental Illness (NAMI) Minnesota, says, “Even as adults, we are supposed to have more tools in our toolbox [to overcome challenges]. … Many more adults are struggling with depression and anxiety now. And young people do not have the tools.”

Abderholden points to children in grades K–3 who, due to the pandemic, have never been in classrooms. She says they missed out on critical social and emotional development in school. They also do not have the words to process the trauma they might have experienced.

Pandemic-related school closures also disrupted care for the 42,295 children (as of 2020) who access mental health treatment through schools. Youth are six times more likely to complete mental health treatment in schools than in community settings. Virtual therapy sessions proved challenging for young children’s attention spans and for teens with limited privacy at home, Abderholden notes.

A study by the American Academy of Pediatrics published in December estimates more than 140,000 children in the United States lost a parent or grandparent caregiver between April 2020 and June 2021. In Minnesota, data show Black, Asian, American Indian, and Hispanic children were disproportionately affected. Researchers noted that losing a caregiver has a profound long-term impact on health and well-being.


A Patchwork System

Professionals say the pandemic has exacerbated a strained situation into a crisis. “[In the U.S.] we don’t have a fully functioning mental health system. We have a patchwork of spots here and there of mental health services,” says George Dubie, psychologist and chief executive officer of Greater Minnesota Family Services.

The Willmar-based nonprofit is one of the larger mental health providers in the state, serving families and children in 40 counties across southwest and central Minnesota. Among many challenges to providing comprehensive mental health services, Dubie says that at any given time, the nonprofit has 30 to 40 job openings. “If we could fill all of our positions, we could serve about 1,000 more children in Minnesota.”

Workforce shortages are felt nationwide in many industries, but have been more acute in rural areas. Only about 5 percent of Minnesota’s mental health professional workforce are employed in rural areas or small towns, according to data from the Minnesota Department of Health (MDH). Residents of large metro areas (Twin Cities, Rochester, Duluth) have access to one mental health provider for every 228 people, but remote regions of the state have a 1:1,600 ratio.

As of November 2021, only 27 of the state’s roughly 250 child and adolescent psychiatrists were working outside the Twin Cities metro or Rochester, home to the Mayo Clinic.

While therapists can diagnose, assess, and lead therapy, only certain professionals like psychiatrists or nurse practitioners can prescribe medication. Dubie often refers clients to the two mental health providers with psychiatric services available in his service area. For the past 10 years, clients have had wait times of 2–3 months. Since the pandemic, wait times have increased to 4–5 months. One of the two providers in the area is not taking new clients at all.

“What does that kid do?” asks Dubie, expressing concern for kids with severe depression seeking help. He says youth can take on risky behaviors like alcohol and drug experimentation during the wait time.

Abderholden adds that barriers to care are compounded by insurance plans. Many private insurance plans in particular often do not factor whether in-network providers are accepting new patients and do not cover treatments that might prevent hospitalization, like day treatments and psychiatric residential treatment facilities.

For rural Minnesotans, who often drive hundreds of miles to access health care, there are few alternatives. Preliminary MDH data shows telemedicine has allowed mental health providers to serve more rural areas. In-person care, which Dubie says is more effective, is limited by local staffing levels.


Retaining Workers

MDH researcher Teri Fritsma tracks workforce gaps. She says the workforce shortage is due in part to two factors: existing rural providers — including mental health professionals — are older and retiring, and there are challenges around retaining workers in rural and small town areas. “Rural–born and raised people are far more likely than urban people to practice in rural areas,” Fritsma says, yet people from rural areas are equally as likely to leave as they are to stay.

In 2015, the state legislature expanded its loan forgiveness program to include mental health professionals that agree to work three years in rural Minnesota. This year, it passed bills to advance access to telehealth and culturally responsive care.

Despite this, Fritsma says there is a bottleneck when it comes to getting people licensed. “We have a lot of students in Minnesota who graduate from mental health–related programs. We really have a strong pipeline of people who could be going into these professions,” she says. But unlike in other professions, many recent graduates must pay out of pocket for the required hours of supervised clinical training.

To address these challenges, Abderholden wants to see the state fund education to get more people licensed, as well as the creation of crisis homes for children.

Youth are dealing with the “ambiguous loss” of missing out on many milestones and experiencing depression and anxiety, and many face emotionally unavailable parents grappling with stress and isolation themselves. Abderholden says, “They tell you to put your oxygen mask on first … But trying to figure out how to help your kids when you are struggling too is not easy.”


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Sue Abderholden outlined priorities of NAMI for this legislative session in our public February Changemakers Alliance discussion.

In addition to increasing rates for mental health services, providing retention bonuses, and requiring open networks in insurance plans, NAMI Minnesota recommends the following:

  • Provide grants to mental health organizations, where a large percentage of their clients are on Medicaid and/or are from diverse communities, to provide free supervision of interns and clinical trainees and to subsidize the costs of licensing exams. 
  • Establish a mental health professional scholarship program to assist people currently working in the field in obtaining their master’s degree to become a mental health professional. The fund would subsidize tuition, childcare, and transportation. 
  • Increase funds to the health professional loan forgiveness program to assist more mental health professionals and make it easier for people conducting clinical supervision to qualify for the program.
  • Increase funding to train family and peer specialists. 
  • Increase funding to the Culturally Specific Mental Health and Substance Use Disorder Services grant program. 
  • Allow mental health practitioners to be case managers.
  • Create a website to be a clearinghouse to assist people to navigate the various mental health licensure programs, learn about the different loan forgiveness and scholarship programs, access licensing exam study tools, information on where to find supervision, links to loan forgiveness programs and tuition reimbursement programs, and other topics that would be beneficial to people wanting to become a mental health professional.
  • Create incentives for more nurse practitioners to specialize in mental health.
  • Allow supervision to be virtual.

Additionally, NAMI Minnesota calls on health plans to cover the services that children and adults need such as day treatment, psychiatric residential treatment facilities, and intensive residential treatment programs and to cover them in a manner that complies with mental health parity laws.


Coverage from Minnesota Reformer, February 4, by Rilyn Eischens

“Gov. Walz’s supplemental budget recommendations call for spending more than $100 million over the next three years to hire more school psychologists, nurses, counselors and social workers; implement student mental health screenings statewide; and expand capacity for youth inpatient psychiatric treatment. The House DFL hasn’t released specific proposals yet but has pushed for increased funding for student support staff like counselors and psychologists in the past.

Senate Republicans have proposed focusing on boosting student literacy and restricting screen time, which they say will improve mental health.”


UPDATED February 18, 2022 — On Thursday, the House Education Policy Committee approved legislation authored by Rep. Kelly Moller (DFL – Shoreview) which requires the Minnesota Department of Education to create two school mental health services leads who would be charged with helping schools assess their comprehensive mental health plans and develop improvement plans to implement evidence-based mental health resources, tools and practices in school districts. 

They would also be responsible with assisting schools with trauma-informed and culturally responsive school programs, and other duties.

The House Education Finance Committee will consider the legislation next. Video of the hearing will be available on House Public Information Services’ YouTube channel. Documents and other information from the hearing will be available on the committee webpage.