Behavioral health access is a story of labor shortages.

In particular, rural areas are experiencing a shortage of behavioral health care workers. This leaves families struggling to find help in times of mental health and substance abuse crises. Eighty-eight of Nebraska's 93 counties are considered to have a shortage of behavioral health professionals. Twenty-nine counties don't have any behavioral health professionals at all.

“There's a shortage even in the best of areas,” said Dr. Marley Doyle, director of the Behavioral Health Education Center (BHECN), which is administered at UNMC. “And there's an extreme shortage in areas that are geographically more remote from the eastern side of Nebraska.”

“One in five Nebraskans has a mental health or substance use disorder. This is the latest data we have based on pre-pandemic levels. We also know that after the pandemic, rates of mental illness and substance use has increased nationwide.”

The need for behavioral health workers is very real. "One in five Nebraskans has a mental health or substance use disorder. This is the latest data we have based on pre-pandemic levels," Doyle said. "We also know that after the pandemic, rates of mental illness and substance use has increased nationwide." 

To address this workforce issue, the Nebraska Legislature passed LB 603 in 2009 and created BHECN. BHECN's purpose is to recruit, retain and increase the competency of the state's behavioral health workforce.

“The state funding we receive is a sign that the Nebraska Legislature appreciates the importance of behavioral health and is committed to the well-being of its citizens,” Doyle said. “They had the foresight to make this investment in the behavioral health workforce, and I think it has paid off.”

BHECN has made a great deal of progress. From 2010 to 2020, the number of behavioral health providers has increased by 32 percent among psychiatric prescribers—and 39 percent among psychologists and mental health therapists. But there is still work to be done. And under Doyle’s leadership, BHECN is standing ready to continue that work.

Doyle’s first experience with Nebraska was when she attended medical school at Creighton University.

When I interviewed, I really felt connected. I had the sense that I’d found my people—and that continued to be my experience all throughout medical school."

During medical school, Doyle was struck with how behavioral health was everywhere, underlying everything. She shared an example of someone with untreated diabetes who wasn’t appearing to respond to medication—but the underlying issue was that the patient was depressed, so they weren’t actually taking their medication.

I began to appreciate that behavioral health had to be a component of all health. Without it, you could be on all the right medications. But if your mental illness is getting in the way of you taking them, then none of that matters,” Doyle said.

"BHECN is a gem that doesn’t really exist anywhere else. We’re the first in the country to provide behavioral health workforce development funded by the state."

Leading a student-run psychiatry clinic her last two years of medical school confirmed for Doyle that psychiatry was where she was meant to be. She completed her residency at Northwestern in Chicago, where she was exposed to many of different aspects of behavioral health, including women's mental health.

“I fell in love with that as a clinical specialty. Working with women in pregnancy, postpartum infertility, menopause—all of those transition times.”

She ended up completing a year-long fellowship at Brigham and Women's Hospital, a 793-bed teaching affiliate of Harvard Medical School in Boston. Doyle then went back to Chicago to practice for several years, but found her connection to Nebraska tugging at her. She joined the psychiatry faculty at UNMC, then became the director of BHECN.

“BHECN is a gem that doesn’t really exist anywhere else. We’re the first in the country to provide behavioral health workforce development funded by the state. I love innovating, thinking about the big picture and developing ways that we can work with behavioral health on a systems level,” said Doyle.

Recruit, Train, Retain

There are three main pillars to the work the BHECN does: recruit, train and retain. The Center has programming in each area.

“One of the things that has made BHECN successful is that we focus on our mission and don’t deviate from it. We are here to recruit, retain, and train Nebraska’s behavioral health workforce,” Doyle said.

When it comes to recruiting, the Ambassador Program connects students to resources and mentors—particularly in rural and underserved urban areas. The hope is to create interest in behavioral health professions and encourage students to stay in Nebraska and serve their communities. Since 2010, more than 5,000 students have learned about careers in behavioral health through BHECN programming.

Training is accomplished through partnerships, legislative support and external funding. This includes student training opportunities like internships and clinical rotations, with an emphasis on interprofessional training. Practitioners, medical clinics, hospitals and correctional facilities can also take advantage of training in evidence-based practices.

BHECN also supports retention of Nebraska’s behavioral health workforce through professional development, training opportunities and resources that help practitioners connect with colleagues and network. In the 2020-2021 fiscal year, BHECN provided professional training for more than 4,900 individuals.

Dr. Riley Machal is one of the professionals who has benefited from BHECN’s services. Born and raised in Ord, Nebraska, she was introduced to medicine through BHECN’s health science outreach program for 8th graders and an in-person workshop at UNMC her junior year. This solidified her decision to go to medical school and become a psychiatrist.

“As a practitioner who loves to teach others about my work and encourage their interest in serving underserved populations, I’ve experienced few things as rewarding as working with the many BHECN-funded training programs in the Omaha area.”

She applied to the Rural Health Opportunities Program—which recruits and educates high school students from rural Nebraska who will return to practice in rural areas of the state—graduating from Chadron State before attending medical school at UNMC. Machal completed her psychiatry residency at The Ohio State University, where she developed a passion for improving the physical and mental health of those with severe and persistent mental illnesses (SPMI).

Since returning to Omaha in mid-2020, she has been involved with both the Creighton and UNMC psychiatry residency programs—teaching the residents on the Assertive Community Treatment Team to treat people with severe and persistent mental illnesses, including going out into the community to see patients in their homes.

Machal is also co-director of the Active Support for Psychosis in Recovery (ASPIRE) clinic at Nebraska Medicine, which is focused on helping people with psychotic disorders achieve meaningful recovery. Through support from BHECN, the ASPIRE team had the opportunity to develop a training program for psychology externs and is welcoming back their first student this July for her second year.

“We're facing this looming date over the next decade where a lot of providers are going to be retiring. It’s important to look at things like resiliency and burnout to ensure that we're not losing people who are currently in the workforce due to factors that could be prevented.”

“As a practitioner who loves to teach others about my work and encourage their interest in serving underserved populations, I’ve experienced few things as rewarding as working with the many BHECN funded training programs in the Omaha area,” Machal said. “I don’t think I would have become a psychiatrist without the many experiences BHECN was able to fund and support during my training.”

Meeting Nebraska's Behavioral Health Needs

The behavioral health care worker shortage is exacerbated by the fact that Nebraska’s workforce is aging. Addiction counselors and psychiatrists are the largest groups of healthcare professionals nearing retirement age, followed closely by psychologists, advance-practice registered nurses (APRNs) and licensed mental health practitioners (LMHPs).

“We're facing this looming date over the next decade where a lot of providers are going to be retiring,” Doyle said. “It’s important to look at things like resiliency and burnout to ensure that we're not losing people who are currently in the workforce due to factors that could be prevented.”

Looking at telehealth to supplement the need is part of the solution—but it's not the full solution.

“In rural and frontier areas, broadband service is not a given,” Doyle said. “If you don't have access to reliable internet, telehealth does not help you. We need to expand and think about telehealth as a possible solution, but we also need to increase the behavioral health workforce.”

The Nebraska Legislature allocated more than $25 million in American Rescue Plan Act funding to BHECN in 2022 to address the impacts of the COVID-19 pandemic and the shortage of behavioral health professionals. BHECN recently awarded nearly $20 million of the funds to 83 Nebraska projects that will help develop, recruit and retain our state’s behavioral health workforce—with over half of the awards allocated to rural providers or organizations.

“If that doesn’t speak to the unmet need, I don’t know what does,” Doyle said. “The more we can empower our partners and stakeholders to develop workforce in their area, the better outcomes we're going to continue to see.”