LOS ANGELES — When Yessica Castaneda thinks about launching her career as a social worker, she knows who she doesn't want to work for: Los Angeles County.
None of her friends has any desire to look for jobs in the county's beleaguered public mental health network either. They've heard about burnout and high caseloads, relentless hours, the emotional toll of taking on patients who are among the region's worst off — including large numbers of homeless people — and cumbersome bureaucratic rules that require hours of painstaking documentation.
"I was working for this nonprofit that was contracted by the county, and I was on 24/7 crisis call. And that's just not feasible for the long term," said Castaneda, 28, a Cal State Northridge graduate student who is currently a master of social work intern with the Los Angeles Unified School District. "I don't want to burn out."
Yet Castaneda and her peers, as well as mental health workers further along in their careers, are the types of employees the Los Angeles County Department of Mental Health badly needs.
The county faces an acute shortage of mental health workers, which has led to serious understaffing at county-run clinics and other facilities at a time of rising demand. But filling vacant spots has proven to be a major challenge.
The need for critical mental health services "is far greater now than ever," department officials said in an October report to the county Board of Supervisors, attributing the increase in part to the COVID-19 pandemic.
Some providers have left their jobs citing overwork and stress, according to the report. Others have moved out of state. The county has also seen a shortage of staff willing to work in person or in field-based positions, rather than remotely. Others have been poached by private employers or switched to other public entities such as LAUSD.
"I don't think we've ever dealt with it to this magnitude," said Lisa Wong, the mental health department's interim director, referring to the difficulty in keeping county facilities staffed.
Wong said she's seen people decline or leave positions for various reasons, including having the opportunity to work full time in telehealth. Some workers, she said, have also had a change of heart over the course of the pandemic and have decided that mental health is no longer the career they want.
"A lot of people are kind of making lifestyle decisions," Wong said.
Hiring and retention have been difficult both for county-operated programs as well as private-sector providers that have contracts with the county, Wong said.
"I think with us it's more pronounced because we have the largest sector of clinicians to hire," she said.
The nonprofit private sector is dealing with its own limited resources, experts say, including difficulties in offering high-level salaries and benefits for behavioral health workers.
Private nonprofits have turned to creative solutions to retain their staff, such as more flexibility for remote work, unlimited paid time off and summer Fridays off, said Deborah Son, executive director of the National Assn. of Social Workers' California chapter. Those strategies have attracted some, but in a state such as California, with its high cost of living, salaries play a significant role in decision-making, she said.
Castaneda, who will complete her CSUN graduate program in social work, said that interning for LAUSD has allowed her to focus on what she loves most about the mental health field.
"I like the school setting in the sense that my students are here," she said. "I can follow them, they're gonna come to me and it's just a little bit more of that environment that I like."
Interning for a school district also provides her with a work-life balance and a dependable schedule that includes holidays off and summer break, she said. The care that the Department of Mental Health provides is a valuable resource for many local families, she added, but it's probably not her "calling."
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The mental health worker shortage in California is a matter of demand outpacing supply "partly due to an aging workforce, and partly due to very limited growth in the number of master's-level clinicians being educated," said Janet Coffman, co-associate director for policy programs at UC San Francisco's Institute for Health Policy Studies.
A 2018 report co-authored by Coffman found that by 2028 the state will have 41% fewer psychiatrists than needed and 11% fewer psychologists, licensed marriage and family therapists, licensed professional clinical counselors and licensed clinical social workers should current trends continue.
Compounding the shortages, some university programs have labored to keep pace.
Though it isn't clear whether there's more or less interest in enrollment than in the past, "the need feels greater," said Jodi Brown, chair of CSUN's Department of Social Work.
"The number of students we are able to enroll has remained the same," Brown said. "We are required to maintain a 12-1 student-to-faculty ratio in order to be accredited," Brown added, "so even our online classes can't get too much bigger."
Gerardo Laviña, director of field education at UCLA's Department of Social Welfare, said that although area universities are "churning out students," research shows that there is and will continue to be "an incredible need" for more workers.
"I saw our students in their second year get to choose their agencies. And many of them ... are still choosing county mental health agency for internships, because these places are strong training sites," he said.
Still, Laviña said, colleagues and friends have told him they feel overwhelmed and stressed out by county work and that they themselves are seeking mental health assistance because of it. That kind of strain can make private-sector jobs appealing.
"You have a private practice group that's saying, 'Your paperwork is going to be either minimal or nothing, we will take care of the billing, we'll take a cut out of whatever you charge for an hour, and we'll handle everything else,'" he said. "It's very much an incentive to leave this bureaucracy that you're dealing with."
As recently as five years ago, county mental health jobs were considered enticing because new hires knew not only what to expect, but could rely on benefits such as a pension, experts said.
Today's younger students aren't as interested in those perks, said Omar López, director of workforce development stipend and scholarship programs at USC.
"Students are just not valuing it, even in their 30s," López said. "They seem to be like, 'OK, well, that's nice, but I want to have more diversity in my career.'"
For Ed Kim, 43, the pandemic provided an opportunity to assess his future. As a husband and father, he wants to ensure that he can be present for his family while also feeling fulfilled at work. Many of his peers, he said, don't feel bound to one employer for life, the way previous generations did.
"I think often people made the choice between what they brought home as a paycheck versus if you tried to have more free time, and it really didn't give you many options," said Kim, who is also a graduate student at CSUN. "I think with a pandemic, it changed the landscape. Telehealth became something that was possible. Working in an office ... became less of an expected thing."
He has thought about working for the county, he said, both for the Department of Mental Health and the Department of Children and Family Services, because of the career stability that jobs there could provide and the experience he'd gain.
"But also I heard from more than a few people about the demands of the jobs," Kim said. "What I heard from people who had been social workers, and some who had actually worked in DCFS and DMH, was that it was always understaffed, that each individual social worker was always overbooked in terms of their caseload. And so you're kind of approaching it from this standpoint of just getting through the backlog."
He's also heard people say that working for the county "would suck your soul."
"I'm not saying that's everybody's experience, but I heard it from more than one or two people that it really did burn you out," he said. "And that, at a certain point, it was easy to lose sight of why you got into the field in the first place."
Dr. Allen Lipscomb, director of online and offsite master of social work programs at CSUN, said that social workers and graduate students are looking for more flexibility in their work.
When they leave county contracts, some providers can see "at least a $20,000 increase from what they're making, at minimum," Lipscomb said. "Make more, better hours, less emotional labor. ... We're seeing a lot of folks being enticed."
Still, he said, he doesn't believe the Department of Mental Health will always face these struggles.
A $4.7 billion investment in mental health and substance abuse services for children and young people was announced by Gov. Gavin Newsom in August. The statewide plan aims to help train 40,000 more behavioral health professionals and offers tuition assistance and loan forgiveness for those who serve in behavioral health.
"There is a lot of funding that's coming down around providing mental health services," Lipscomb said, "but also looking at ways to streamline and create a pipeline for students who are interested in getting their master's."
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Andrea Cabrera Jakucs, 33, remembers the stress of always being on call and the difficulty of the cases she was handling when she worked for a county-contracted agency.
One client, she said, would constantly call and yell at her. When she and two of her bosses met that client in person, she recalls feeling scared and worrying that the woman would throw something at her.
The pay wasn't great, she said, especially considering the weight of the work.
"I was getting paid maybe $23 or $25 per hour and then once I got licensed, it was like 30 bucks or so," said Jakucs, a licensed social worker. "But in private practice, I can make $225 per session for an hour."
The draw of private practice goes beyond the financial incentive, she said: She feels less stressed because she chooses which clients she takes on.
But even though it was tough to work in the public sector, Jakucs said she became a better clinician because of the experience.
"I believe it's still a good training ground for people to start off, but just expect the tough cases," she said.
Wong, the Department of Mental Health interim director, said that although the pandemic and other factors have driven away potential hires, new waves of recruits may be willing to confront the challenges.
"I think we're getting enough distance now where we are starting to come back a bit," she said. "People are starting to get interested a little bit more."
During the pandemic, the county added restrictions that made hiring more difficult, she added.
"We had to take away some of the stipends or loan repayments or those things. So what happened was, it caused a decrease in the pool of applicants," Wong said. "Now when we're opening up, we're dealing with that decreased pool. So it's going to take us a little time to catch up."
She added that the county is looking at what incentives it can offer to bring more candidates in, including potentially using signing or retention bonuses to compete with other employers.
"I even saw one $20,000 signing bonus. That's not going to be something we'll be able to match," she said. "What we're looking for, though, are those people for whom that's not going to be the deciding factor."
Tieryn Bills doesn't plan on working a Department of Mental Health or DMH-contracted job because of the experience she's had working with a contracted agency, providing field services and case management services for homeless people.
Bills said that the caseload and productivity requirements were too high. At one point, she managed 19 cases for clients ranging from ages 33 to 84.
"A lot of times there would be crisis interventions," said Bills, a graduate student in social work at UCLA. "I would get a call from a client like, 'Hey, Tieryn, I'm in the parking lot, and I want to kill myself.' And then drive to where the client is on the phone. I've had clients call me from jail because I was the only phone number that they could remember at the time."
Her job included picking up clients and taking them to medical appointments, taking them to see housing if they were matched to a voucher, looking at housing options online and calling landlords.
It was the kind of work that made her feel close to her clients and invested in their progress. It also made losing them difficult.
Bills recalled when one client she'd been working with for a year and a half went missing. To figure out where he was, she and a colleague made a "home visit" to his hotel room.
"A hotel manager ended up opening the door" and the patient "had passed away from a drug overdose," she said. "Both of us were really upset and, frankly, traumatized by it. And we were both back at work the next day, because there was no mandate to not come to work."
As much as she loved the type of county-level work she was doing, she said, she doesn't believe it's a sustainable path.
"There's this thing in social work coming about now that you have to take care of yourself," she said. "And self-care can sometimes mean leaving a job."
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