It’s not an easy task to earn a graduate degree in counseling, marriage and family therapy or social work. It takes years of schooling, a significant financial investment and a commitment to helping others improve their mental health. But earning a degree is not the same as actually becoming a mental health practitioner. Statewide research has shown that about half of all graduates in Minnesota who complete the master’s degree required for mental health licensure do not go on to complete the licensure process.

This statistic is troubling to many who study workforce trends. There is already a significant shortage of licensed mental health professionals in Minnesota, with 72% of counties in the state designated as mental health provider shortage areas. So why would a person go to the trouble of earning a graduate degree in a mental health field and then stop short of earning the licensure required to practice? 

Roy Kammer, interim associate dean at Minnesota State University, Mankato’s College of Allied Health and Nursing, has been looking for the answer to this question for years. 

“When someone invests so much time and resources into a graduate degree but then doesn’t end up going into the field, we have to ask ourselves, ‘Why would they not want to get licensed?’” Kammer said. “We know there are a lot of people who get these degrees with the intention of getting licensed but they don’t. We wanted to understand more about why these people aren’t getting licensed.” 

To get a better sense of why so many mental health graduates don’t go on to earn full licensure, Kammer and his colleagues at the Blue Cross and Blue Shield of Minnesota Center for Rural Behavioral Health teamed with researchers at the Amherst H. Wilder Foundation to survey Minnesotans who had earned a master’s degree in mental health in the last seven years. They wanted to find out if they had completed the licensure process, and if they did not, why. 

The resulting study, “Unfinished Business: Examining Barriers to Obtaining Mental Health Licensure Among Minnesota Graduates,” identifies several challenges graduates face during the licensure process, including financial strains; burdensome application and administrative processes; strict requirements; misalignment between licensure types and between states; lack of attention to work well-being, diversity and equity concerns; supervision quality; and exams that ineffectively assess knowledge and skills.

While earlier studies looking into Minnesota’s graduation/licensure gap have taken a quantitative approach, measuring the number of graduates in the state who did not go on to complete licensure, none have taken a more qualitative approach that goes deeper to ask graduates why their plans stopped short, Kammer said. 

“We wanted to do something more empirical,” he said. “So we did a mixed-mode study. It was a quantitative and qualitative piece of research.” 

To conduct its study, the research team reached out to Minnesota institutions of higher education that offer graduate degrees in social work, counseling, and marriage and family therapy. They asked these institutions to distribute a survey about post-graduation careers to all graduates of the past seven years.

At the end of the survey, respondents were asked if they were willing to participate in a follow-up interview, explained Melissa Serafin, a Wilder research scientist who worked on the study. “At the end of the survey there was an option for folks to opt into an interview. We did most of our interviews by video,” she said.

The response to this added element of the survey was robust, with researchers conducting over 40 interviews with mental health graduates. The questions subjects were asked were follow-ups to the quantitative data that had already been gathered, going deeper for a better understanding about what motivated the individuals’ choices. “We were asking, ‘What was your experience when it comes to supervision, to the exam,’” Kammer said. “We were asking what were their stories.”  

This deeper dive was important, Kammer said, because information gathered in a traditional survey can feel limited. “A survey can only tell you so much, but when people tell you, ‘The exam is a barrier,’ or ‘Supervision is a barrier,’ or, ‘Pay is a barrier,’ we want to know why this is a barrier. We can follow up and get more information during our interviews.” 

No clear answers, no simple solutions 

The range of barriers that mental health graduates face to earning licensure can feel daunting, with no single clear solution that could help all candidates reach the goal they had in mind when they set out to earn their master’s degree, Kammer said.  

“I think people might think there is one simple, magic solution, like, ‘We have to invest money or resources,’ or, ‘We have to get more supervisors,’ but the answer is not that simple. It is so complex. There are so many barriers that are impacting people — everything from having to pay supervisors to the cost of completing unpaid internships to difficulties passing the exam.” 

The researchers weren’t all that surprised by the range of reasons respondents gave for not completing the licensure process. Graduate students in mental health degree programs come from varied backgrounds, and that diversity of experience and resources means that the barriers they face run the gamut. 

“My big takeaway is we need a complex solution to a complex problem,” Kammer said. “It is multiple pieces of the puzzle that we have to look at.” 

The report includes a number of recommendations for helping more mental health graduates successfully achieve licensure, including: 

• Increasing reimbursement rates and reducing or eliminating licensure application, renewal and exam fees;
• reducing tuition and creating new opportunities for student-loan forgiveness;
• providing one-on-one assistance to graduates throughout the licensure process and more resources to help graduates find and select a qualified supervisor and prepare for exams
• streamlining the application process and increasing flexibility of licensure requirements;
• increasing alignment between licensure types and allowing portability between states; and
• minimizing administrative tasks and paperwork and ensuring reasonable caseload expectations. 

These recommendations all focus on making the mental health licensure process more accessible for people living in the real world, where different hurdles — like family and work obligations, financial strain and other historical inequalities — sometimes make it harder to cross the licensure finish line, Kammer said. 

“We have stories from people who’ve earned a masters’ degree who say, ‘I find this licensure process very overwhelming. How can we simplify the licensure process or increase the flexibility for people who are pursuing it?’ Licensure tends to be very inflexible. Are there ways we can make it more flexible?” 

While the seven years allowed to complete the licensure process required by some boards may seem generous at the time of graduation, Serfin said that respondents told her life has a way of getting in the way of meeting that goal, and sometimes even the best laid plans can go awry. 

“If you only have seven years, what if you are working part time?” Serafin said. “How do you make time to get everything done?” Many study participants told her that the reality of having to work to support themselves or their family made completing the licensure process in the allotted time impossible. Respondents who were able to earn licensure often spoke of the social advantages that allowed them to meet that goal, she added: “We had a lot of respondents talking about how they were able to complete the process because of the privilege of having partners who were working in for-profit sectors so they could support them financially during this process.” 

Respondents from rural areas told the research team that completing the licensure process was particularly challenging for them because the relatively small number of providers in their region made it difficult or even impossible to find mental health professionals to provide supervision during their required internship hours. “These problems exist everywhere,” Kammer said, “but they tend to be more pronounced in rural areas.” 

‘I was poor for 20 years’ 

Pahoua Yang, Amherst H. Wilder Foundation vice president of community mental health and wellness and a licensed social worker and psychologist, knows as well as anyone that the process of earning mental health licensure can feel daunting. 

She also knows from personal experience that once a person achieves mental health licensure, the struggles don’t immediately end. Mental health jobs, if you can earn the credentials required to land them, don’t usually pay well enough at first to justify their cost, she said. So she understands why so many people struggle to pass this final hurdle

“People have just gone through a very expensive education,” Yang said of mental health graduate students. “They are working for free in a lot of places. Then they get a job in a field that doesn’t pay as well. They aren’t making as much because they are still working for licensure. That makes getting everything done on time tough.” 

Yang said she agrees with her colleagues at Wilder Research that changes in the licensure process need to be made in order to make it possible for more mental health graduates to enter the field. 

“These are folks who have their master’s and doctorates are already the cream of the crop of folks coming into the field who are just meeting barrier after barrier,” Yang said. “My perspective has been that we really need a multipronged approach that can look at how do we make the field more attractive and affordable to folks.” 

A few years ago, Yang testified about this problem in front of the Minnesota Legislature. 

“I said at the time that, ‘As a psychologist I was poor for 20 years,’” Yang said. “No one should have to say something like when they are going into this field. I remember my husband texting me and saying, ‘Did you just tell the whole state that we were poor for 20 years?’ I said, ‘Yes. I did it. It’s the reality.’” 

Yang said that in her role at Wilder, she’s seen first-hand the struggles that many job candidates face in the licensure process. “As a provider trying to recruit and retain good people in the field, my staff and I have identified barriers throughout the years,” she said. “How do I hire the very best people in the field and keep them in the field to do the work that I love and the work that our communities need?” 

One of the problems Yang has identified is passing the national licensure exams, tests that she said were written in a way that excludes many, especially first-generation college students and people for whom English is a second language. Yang said she’s encountered a “pretty significant percentage” of candidates who are not able to pass the national exams. But exams don’t always determine who would be the best practitioners, Yang said: “I have personally supervised people who haven’t been able to pass the test but who were excellent clinicians.” 

These realities make Yang feel passionate about the need to rethink the licensure process in Minnesota. “We have to take a look at what’s happening,” she said. Adopting the recommendations outlined in the “Unfinished Business” report is a good way to start addressing these issues. 

“There are changes that need to be made to support the profession,” she said. “These recommendations are a good way to make that happen.”

Andy Steiner

Andy Steiner is a Twin Cities-based writer and editor. Before becoming a full-time freelancer, she worked as senior editor at Utne Reader and editor of the Minnesota Women’s Press. Email her at [email protected].

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