Jennifer’s been a foster parent in Keene for about six years. In that time, they’ve taken in a dozen kids, ranging from toddlers to teens.
It’s something Jennifer’s wanted to do from a young age. Growing up in an abusive home, they wanted to become the kind of caring adult they needed in their own life.
“It’s redeeming,” they said. “That’s the best adjective to describe it.”
Being removed from home and placed in foster care can be traumatizing in itself, and one of the first things Jennifer typically does with a new foster child is try to set them up with a therapist. (We’re not using Jennifer’s last name, to protect their family’s privacy.)
But getting a therapy appointment has been a challenge lately. The local mental health center has long waitlists – and, in Jennifer’s experience, the turnover among clinicians there can make it harder for kids to build trust. For a while, they struggled to find another therapist who took Medicaid. They’d call and call, only to get no response or learn the office had closed.
“I’ve had kids just kind of in holding patterns,” Jennifer said. “They could be using that time to heal properly, and they just don’t have that ability.”
They’re not alone. More than 60% of New Hampshire parents who’ve sought mental health care for their kids said it was difficult or impossible to access, according to one survey. And that comes amid rising demand in recent years, as more young people have struggled with depression and other mental health challenges.
For many families, the shortage of therapists is exacerbated by other barriers. There tend to be fewer clinicians in rural areas. Many don’t take Medicaid because it pays less than private insurance – and some don’t accept insurance at all. And simply navigating the mental health system can be a challenge.
“It's almost like having a part-time job, finding your child health care,” said Gina Pasquale, who leads Maps Counseling Service, based in Peterborough and Keene. “And it's really concerning.”
‘All about workforce’
New Hampshire has a shortage of mental health professionals overall – but the need is especially acute in youth mental health, said Julie Wolter, a clinical psychologist and director of professional affairs for the New Hampshire Psychological Association.
The association’s most recent workforce survey, conducted in late 2022, found that nearly 90% of mental health clinicians served adult clients – but only half said they worked with teens, and fewer than one-third treated children under 13. Clinicians also reported that when they needed to refer a client elsewhere, services for children and adolescents were among the hardest to find.
Those trends are being felt across the country, not just in New Hampshire.
“Even in areas that are not considered a mental health professional shortage area, no one in that area is saying, ‘Yeah, it's so easy for me to gain access,’ ” said Brianna Lombardi, who directs the Behavioral Health Workforce Research Center at the University of North Carolina.
In the Monadnock Region, Pasquale said most therapists who work with children have no availability whatsoever, and some families spend months waiting for an appointment. Maps Counseling is actively trying to hire more clinicians who focus on young people, but it’s not easy.
“For every 10 applicants I get who would like to work with adults only, I get maybe one who is interested in doing some child work,” she said.
Monadnock Family Services, the community mental health center serving Keene, has also struggled to hire enough clinicians for children and youth. Earlier this summer, as many as 49 families in the Keene area were on a waitlist for intake assessments — the first step before they are connected with services.
Phil Wyzik, the executive director, said the center recently hired a clinician to focus on those assessments and is making progress addressing the backlog. But the growing need for youth mental health services in recent years has outstripped the center’s capacity to meet it.
“We’re seeing an increase in demand for mental health services for kids and families,” Wyzik said. “And the gap in trying to address that need is all about workforce.”
Part of that goes back to training. Local providers noted that grad programs don’t necessarily emphasize child and adolescent mental health, so many new clinicians enter the workforce with little training or experience in working with people that age.
Plus, when you’re a child therapist, you spend a lot of time dealing with parents, schools and other systems a child is involved with, such as child welfare agencies or family court.
'The financial benefits of doing child work are usually lower than if someone were to focus on adult work.'Barbara Bryce, a clinical psychologist in Keene
That’s a lot of extra work – and insurance typically doesn’t pay you for it, said Barbara Bryce, a clinical psychologist in Keene who focuses on youth.
“The financial benefits of doing child work are usually lower than if someone were to focus on adult work,” she said.
Still, Bryce said, the work is rewarding in other ways. You get to see children grow and change, and there’s a lot of variety. She thinks if early career clinicians had more opportunities to gain experience working with children, more would go into the field. But it’s not for everyone.
“Child work also takes a lot of physical energy,” Bryce said. “I may be playing Nerf basketball, up and down on the floor doing play therapy.”
Looking for solutions
In Keene, mental health providers are working to make care more accessible for families.
Along with trying to get families in the door more quickly, Monadnock Family Services has been using more group therapy, which allows clinicians to see more than one kid at a time. The American Psychological Association says group therapy is just as effective as individual therapy for many conditions, and can help with things like social isolation and stigma.
A large group of mental health professionals, school personnel and others has also been meeting regularly to find ways to improve access. Among other things, they’re working to better integrate mental health care into schools and primary care, said Rose Hitchings, a clinical psychologist at Cheshire Medical Center.
Another problem is that there’s no easy way to look up which clinicians in the area do, in fact, have openings. That makes it harder for therapists who are fully booked to refer families elsewhere.
“When somebody asks me, ‘Well, who would you recommend? Who would you refer?’” Hitchings said, “I really can't give a specific name because I don't know if they're open.”
To address this issue, Hitchings said Cheshire Medical Center and Antioch University New England are developing an online tool to track availability, which they hope to roll out to clinicians in the fall.
'Those of us picking up those phone calls, we are never aggravated by a parent calling us back, and calling us back, and calling us back. We completely understand why that needs to happen.'Gina Pasquale, Maps Counseling Service
Maps Counseling, meanwhile, is offering to pay for extra training for any employees who want to develop expertise in children and youth. Pasquale, the executive director, also hopes a recent increase in reimbursement rates from the state will encourage more therapists to accept Medicaid, which covers many children.
She said parents are right to be frustrated by the lack of availability, but encouraged them to keep trying.
“Those of us picking up those phone calls, we are never aggravated by a parent calling us back, and calling us back, and calling us back,” Pasquale said. “We completely understand why that needs to happen.”
Jennifer, the foster parent in Keene, eventually managed to connect with a great private therapist through a school counselor. They’ve sent several kids her way. But other than that, they said there aren’t a lot of options.
When a therapist isn’t available right away, Jennifer does what they can. They provide a stable presence, give kids space to process and help them figure out productive ways of coping. They also sign them up for activities like sports, music lessons or karate.
Sometimes, they said, just feeling like a normal kid goes a long way. But it’s not a substitute for professional help.
“We still do our best,” Jennifer said. “We still hope that they’re healing in some way.”
