GAO United States Government Accountability Office Report to Congressional Committees March 2022 VETERANS HEALTH CARE Efforts to Hire Licensed Professional Mental Health Counselors and Marriage and Family Therapists GAO-22-104696 GAO Highlights Highlights of GAO-22-104696, a report to congressional committees Why GAO Did This Study Demand for VA mental health care is growing. The number of veterans provided mental health care services by VHA increased by 85 percent from 2006 through 2020. This growth poses challenges for VHA in maintaining an adequate mental health workforce that provides timely, high-quality services. It is compounded by the nationwide shortage of mental health professionals. VHA typically relies on four types of mental health professions to provide psychotherapy services: psychologists, social workers, and, since 2010, LPMHCs and MFTs. The Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 included a provision for GAO to review staffing levels for mental health professionals in VA, in particular for LPMHCs and MFTs. This report describes (1) VHA efforts to promote the hiring of LPMHCs and MFTs in VA medical facilities; and (2) the extent to which VA medical facilities are employing LPMHCs and MFTs and how their recent employment compares with other mental health professions. GAO reviewed VHA documents related to LPMHC and MFT hiring, analyzed VHA staffing information on employed LPMHCs and MFTs for fiscal years 2010 through 2021, and compared LPMHCs and MFTs to other mental health professions for fiscal year 2021. GAO interviewed mental health and human resources Officials from VHA and from five of its regional networks selected for variation in LPMHC and MFT employment and rurality. GAO also interviewed four associations that represent LPMHCs or MFTs. View GAO-22-104696. For more information, contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov. CE VETERANS HEALTH CARE Efforts to Hire Licensed Professional Mental Health Counselors and Marriage and Family Therapists What GAO Found The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) sets overall hiring goals for mental health professions but leaves decisions on the types of professions to hire to individual VA medical facilities based on their workforce needs. Psychologists and social workers-two professions that provide psychotherapy services-have been employed by VHA for decades. VHA began hiring two additional types of mental health professions-licensed professional mental health counselors (LPMHC) and marriage and family therapists (MFT}-in 2010. GAO found that VHA's efforts to promote the hiring of LPMHCs and MFTs included disseminating guidance and establishing funded trainee positions. VHA's guidance identifies benefits to hiring LPMHCs and MFTs, including that they may be easier to recruit and retain in rural settings. VHA has been funding LPMHC and MFT trainee positions since academic year 2015-2016. Having funded trainees is an important mechanism for creating a pipeline of qualified potential mental health staff, according to VHA. As of academic year 2020-2021, there were 42 funded LPMHC trainees and 13 funded MFT trainees. GAO's analysis of VHA staffing information shows that the total number of LPMHCs and MFTs employed in VA medical facilities had increased to nearly 500 since 2010 (see figure below) and that these professions were present in more than two-thirds (69 percent) of facilities as of fiscal year 2021. The number of LPMHCs and MFTs has grown since hiring began in 2010; however, other types of professions employed by VHA for decades make up the majority of the mental health professions providing psychotherapy services. Specifically, LPMHCs and MFTs comprised about 4 percent of mental health professions at VA medical facilities in fiscal year 2021, with psychologists at 45 percent and social workers at about 51 percent. Number of Employed LPMHCs and MFTs in VA Medical Facilities, Fiscal Year 2010 through 2021 Number employed 500 450 400 Ss orn" 350 ae wo o 300 wee y eet -o 200g wt -- ewe' oo" 200° get ~-2° 150 ge an er -o* 100 gases o° 2010 2011 Fiscal year 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 === Marriage and family therapists (MFT) » = = = Licensed professional mental health counselors (LPMHC) Combined LPMHCs and MFTs Source: GAO analysis of VHA staffing information. | GAO-22-104696 United States Government Accountability Office Contents Letter Background 5 VHA Made Efforts to Promote LPMHC and MFT Hiring by Disseminating Guidance, Establishing Funded Trainee Positions, and Updating Standards 9 LPMHCs and MFTs Have Been Employed in Two-Thirds of VA Medical Facilities since 2010 and Comprise a Small Proportion of Comparable Mental Health Professions 17 Agency Comments 21 Appendix | Information on VHA-Funded Mental Health Trainees That Typically Provide Psychotherapy Services 22 Appendix II Distribution of Mental Health Professions That Typically Provide Psychotherapy Services, Fiscal Year 2021 25 Appendix III GAO Contact and Staff Acknowledgments 28 Tables Table 1: Mental Health Professions Typically Responsible for Providing Psychotherapy Services in Department of Veterans Affairs (VA) Medical Facilities 5 Table 2: VHA's Mental Health Hiring Initiatives over the Last Decade, as of November 2021 7 Table 3: Information on VHA-Funded LPMHC and MFT Trainees, as of Academic Year 2020-2021 14 Table 4: VA Medical Facility Requests for Proposal for Funded Trainees in Mental Health Professions That Typically Provide Psychotherapy Services, Academic Years 2015- 2016 to 2020-2021 23 Table 5: Funded and Unfunded VA Medical Facility Sites and Trainees for Mental Health Professions That Typically Provide Psychotherapy Services, as of Academic Year 2020-2021 24 Page i GAO-22-104696 VHA Mental Health Workforce Table 6: Number of Department of Veterans Affairs (VA) Medical Facilities That Employed Mental Health Professions That Typically Provide Psychotherapy Services, Fiscal Year 2021 27 Table 7: Range of Mental Health Professionals That Typically Provide Psychotherapy Services Employed in Department of Veterans Affairs (VA) Medical Facilities, Fiscal Year 2021 27 Figures Figure 1: Number of Employed and Hired LPMHCs and MFTs in VA Medical Facilities, Fiscal Year 2010 through 2021 18 Figure 2: Percentage of Mental Health Professions Typically Providing Psychotherapy Services in Department of Veterans Affairs (VA) Medical Facilities, Fiscal Year 2021 20 Figure 3: Geographic Distribution of Department of Veterans Affairs (VA) Medical Facilities that Employ Licensed Professional Mental Health Counselors (LPMHC) and Marriage and Family Therapists (MFT), Fiscal Year 2021 26 Abbreviations CACREP Council on Accreditation of Counseling and Related Educational Programs COAMFTE Commission on Accreditation for Marriage and Family Therapy Education LPMHC licensed professional mental health counselor MFT marriage and family therapist VA Department of Veterans Affairs VHA Veterans Health Administration VISN Veterans Integrated Service Network This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii GAO-22-104696 VHA Mental Health Workforce GAO U.S. GOVERNMENT ACCOUNTABILITY OFFICE 441 G St. N.W. Washington, DC 20548 March 28, 2022 The Honorable Jon Tester Chairman The Honorable Jerry Moran Ranking Member Committee on Veterans' Affairs United States Senate The Honorable Mark Takano Chairman The Honorable Mike Bost Ranking Member Committee on Veterans' Affairs House of Representatives Demand for mental health services from the Department of Veterans Affairs (VA) continues to grow. From 2006 through 2020, the number of veterans provided mental health care services by VA's Veterans Health Administration (VHA) grew by 85 percent. Certain mental health conditions, such as major depressive disorder and post-traumatic stress disorder, are highly prevalent among veterans.' VA projects 30 percent growth in demand for its mental health care services from 2017 through 2030 and estimates that veterans' mental health conditions may have worsened during the COVID-19 pandemic, as has been seen in other populations across the United States. This rapid growth in demand poses challenges for maintaining an adequate mental health workforce that provides timely, high-quality mental health services across VA medical facilities.2 VHA has already faced challenges in meeting veterans' mental health needs, such as 1Specifically, we previously found that about a third of veterans who received VHA services in fiscal year 2018 had at least one diagnosed mental health condition, with major depressive disorder being the most prevalent diagnosis followed by post-traumatic stress disorder. See GAO, VA Mental Health: VHA Improved Certain Prescribing Practices, but Needs to Sirengthen Treatment Plan Oversight, GAO-19-465 (Washington, D.C.: June 17, 2019). 2in this document, we use the term VA medical facilities to refer to VA medical centers and affiliated community-based outpatient clinics that provide primary and specialty mental health services. Page 1 GAO-22-104696 VHA Mental Health Workforce staffing shortages and burnout for mental health professionals.3 These challenges are compounded by the nationwide shortage of qualified mental health professionals that is expected to continue, particularly in rural areas. For example, the Substance Abuse and Mental Health Services Administration reported in November 2016 that rural areas have few behavioral health practitioners and half of U.S. counties have no mental health professionals. VHA's mental health workforce includes psychiatrists and mental health nurses, as well as four types of mental health professions it typically relies on to provide psychotherapy services in its facilities: psychologists, social workers, and, since September 2010, licensed professional mental health counselors (LPMHC) and marriage and family therapists (MFT).5 Unlike for some mental health professions, the Health Resources and Services Administration projects that the national supply of LPMHCs and MFTs will be adequate or experience an oversupply by 2030. The Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 included a provision for us to review staffing 3See Congressional Research Service, Veterans Health Administration: Behavioral Health Services (Washington, D.C.: Dec. 3, 2019). 4See Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Rural Behavioral Health: Telehealth Challenges and Opportunities (Rockville, Md.: November 2016). 5Mental health professionals employed in VA medical facilities provide varying types of mental health services based on their background and qualifications (e.g., psychiatrists are generally responsible for managing medications). Legislation enacted in December 2006 authorized the appointment of LPMHCs and MFTs in VA. See Veterans Benefits, Health Care, and Information Technology Act of 2006, Pub. L. No. 109-461, § 201, 120 Stat. 3403, 3409 (2006) (codified, as amended, at 38 U.S.C. § 7401). VHA uses the term LPMHC to include all counselors licensed by a state to provide mental health services. Depending on where the LPMHC is licensed, the individual also may be referred to as a licensed professional counselor, licensed mental health counselor, or another variation of the term. 6The Health Resources and Services Administration projections are based on supply and utilization patterns remaining the same throughout the forecast period and therefore do not account for changes in these patterns resulting from the COVID-19 pandemic. See Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis, Behavioral Health Workforce Projections: 2017-2030 (Rockville, Md.: 2020). We have ongoing work examining what is known about the size and characteristics of the nation's behavioral health workforce, as well as federal efforts to collect and make available this information. Page 2 GAO-22-104696 VHA Mental Health Workforce levels for mental health professionals in VA, in particular for LPMHCs and MFTs.? This report describes 1. VHA efforts to promote the hiring of LPMHCs and MFTs in VA medical facilities; and 2. the extent to which VA medical facilities are employing LPMHCs and MFTs and how their recent employment has compared with other mental health professions in these facilities. To examine VHA efforts to promote the hiring of LPMHCs and MFTs in VA medical facilities, we reviewed agency documentation related to VHA's hiring standards, hiring goals, and trainee positions for its mental health professions. We interviewed officials from key VHA program offices related to mental health, human resources, and health professions training about relevant hiring and training efforts. In addition, we interviewed officials from five selected Veterans Integrated Network Systems (VISN} regional networks that oversee VA medical facilities- on overall mental health workforce needs, hiring practices for LPMHCs and MFTs, and challenges to hiring or training these professions.® We selected this nongeneralizable sample of VISNs for variation in the number of employed LPMHCs and MFTs and the rurality of facilities in each VISN.?® Finally, we identified a nongeneralizable group of four professional associations that represent LPMHCs and MFTs and 7Pub. L. No. 116-171, § 204(b), 134 Stat. 778, 797 (2020). The act also required VA, within 1 year of enactment, to create an occupational series for LPMHCs and MFTs, which are currently classified under a general occupational job series. Id. at § 501(b), 134 Stat. at 815. VA initially reported to Congress in September 2021 that it, in consultation with the Office of Personnel Management, had determined that the existing general occupational series was appropriate for LPMHCs and MFTs. VA officials told us in December 2021 that, to better meet the intent of the legislation to create a new occupational series for LPMHCs and MFTs, the Office of Personnel Management will now establish a government-wide integrated project team comprised of representatives from federal agencies that hire professionals in these occupations. 8VHA consolidated many human resources functions (non-hiring decisions such as standardized position descriptions and performance plans) from the VA medical facility to the VISN level in fiscal year 2020. VA noted that this consolidation allows VISNs to allocate staff resources across its facilities to ensure staffing needs are expediently addressed for local, VISN, and VHA-wide hiring initiatives. ®8We selected VISN 1 (VA New England Healthcare System), VISN 7 (VA Southeast Network), VISN 17 (VA Heart of Texas Health Care Network), VISN 19 (Rocky Mountain Network), and VISN 21 (Sierra Pacific Network). Page 3 GAO-22-104696 VHA Mental Health Workforce interviewed officials from these associations for their views on VHA's hiring and training of these professions and challenges in doing so.1° To examine the extent to which VA medical facilities are employing LPMHCs and MFTs and how their recent employment has compared with other mental health professions in these facilities, we obtained and analyzed VHA staffing information from HR Smart (VHA's core human resources processing system). Using VHA staffing information, we examined changes in the number of LPMHCs and MFTs employed in 140 VA medical facilities from fiscal year 2010 through 2021.11 Because LPMHCs and MFTs are newer to VHA, we focused on employment and hiring in this report; however, employment also may fluctuate due to resignations, terminations, and retirements. We also used VHA staffing information for fiscal year 2021 (the most recent year available to allow comparisons) from HR Smart to compare LPMHCs and MFTs with other types of mental health professions providing psychotherapy services. '2 We assessed the reliability of HR Smart data in several ways, including electronic and manual data testing and interviews with VHA officials knowledgeable about the data. We determined that the data used in our analyses were sufficiently reliable for our reporting objectives. Finally, we 10The two professional associations representing LPMHCs that we interviewed were the American Counseling Association and the Alliance for Professional Counselors. The two professional associations representing MFTs that we interviewed were the American Association for Marriage and Family Therapy and the California Association of Marriage and Family Therapists. T1VHA has 171 total VA medical centers nationwide. However, VHA staffing information from HR Smart includes 140 sites that represent the total 171 VA medical centers, because in many locations, one or more VA medical centers may operate together as one VA health care system to offer services to area veterans. Our analysis did not include LPMHCs and MFTs staffed in Vet Centers (sites and mobile units that provide counseling and non-medical social services to veterans and their families) located in community settings separate from VA medical facilities. We recently testified on VHA's actions to address our prior recommendations to improve Vet Center operations and on our preliminary observations from our ongoing work examining VHA's efforts to assess Vet Center clients' needs, plan outreach, and identify and address barriers to care. See GAO, VA Vet Centers: Continued Aitention to GAO Recommendations Could Help Meet Veteran and Servicemember Needs, GAO-22- 105675 (Washington, D.C.: Feb. 3, 2022). 12Not all social workers, one of the professions in our comparison, provide mental health services. VHA officials told us that it identifies mental health social workers through their respective department names in HR Smart. If a social worker is associated with a mental health department, then that employee is counted as a mental health social worker. Page 4 GAO-22-104696 VHA Mental Health Workforce Background reviewed VHA documents describing hiring goals for its mental health workforce. We conducted this performance audit from December 2020 to March 2022 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Mental Health Professions Mental health professionals employed in VA medical facilities provide Employed in VA Medical varying types of mental health services. For example, those with Facilities prescribing privileges, such as psychiatrists, are responsible for managing medications. According to VHA, four types of professions are typically responsible for providing its psychotherapy services (see table 1). Table 1: Mental Health Professions Typically Responsible for Providing Psychotherapy Services in Department of Veterans Affairs (VA) Medical Facilities Year VHA began hiring profession Mental health profession 2010 Licensed professional mental health counselors (LPMHC). LPMHCs provide services that include the diagnosis and treatment of mental and emotional disorders, including addictive disorders; consultation to individuals, couples, families, groups, and organizations; and research into more effective therapeutic treatment modalities. LPMHCs are trained to provide well-established treatments of cognitive-behavioral, interpersonal, and psychodynamic therapy. 2010 Marriage and family therapists (MFT). MFTs diagnose and treat behavioral health conditions within the context of marriage and family relationships. MFTs are trained in psychotherapy and family dynamics, and can help individuals, couples, and families address issues that can lead to marital or family distress (such as stress, substance use, and chronic illness). 1946 Psychologists. Psychologists help people deal with a range of problems, from short-term personal issues to severe, chronic conditions. They provide psychotherapy, teach, and conduct scientific research with individuals of all ages, families, and organizations (e.g., schools, hospitals, and businesses). 1926 Social workers. Social workers help people identify and deal with problems in their day-to-day lives. Social workers are trained to help people with emotional problems using modalities such as individual therapy, group therapy, and crisis intervention. Source: GAO summary of information on mental health professions from multiple sources. | GAO-22-104696 Note: According to the Veterans Health Administration (VHA), the four professions presented in this table are typically responsible for providing psychotherapy services in VA medical facilities. VHA's mental health workforce also includes psychiatrists and mental health nurses (e.g., nurses who work in outpatient or inpatient mental health care settings). Page 5 GAO-22-104696 VHA Mental Health Workforce The specific role for each type of mental health professional in a VA medical facility can vary and the same role can be performed by different types of mental health professionals. For example, an MFT could be hired in a case management role to facilitate community integration for veterans with serious mental illness. An MFT also could be hired as a general mental health clinician, such as the local mental health recovery coordinator at a VA medical facility who helps veterans with serious mental illness access recovery-oriented services. A different type of mental health professional, such as an LPMHC or social worker, also could fill a case management role or local mental health recovery coordinator role. VA is responsible for setting hiring standards for the mental health professions employed in VA medical facilities based on education and other qualifications such as licensure and experience, in collaboration with VHA subject matter experts.13 For education qualifications, VHA mental health professionals are required to hold certain degrees from accredited programs or accredited universities as defined by the agency.14 LPMHCs, MFTs, and social workers typically have master's degrees, while psychologists have doctoral degrees. There are very few national accrediting bodies for most mental health graduate programs, and there is a single national accrediting body each for LPMHCs and MFTs included in VHA's hiring standards: e The Council on Accreditation of Counseling and Related Educational Programs (CACREP), established in 1981, promotes the professional competence of counseling and related practitioners by accrediting master's and doctoral degree programs in counseling and its specialties offered by colleges and universities in the United States and throughout the world, including those from which LPMHCs obtain degrees. e The Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), established in 1978, is the only national 13Department of Veterans Affairs, Staffing, VA Directive 5005 (Washington, D.C.: April 15, 2002). 14Accreditation is a status of public recognition that an accrediting body grants to an educational institution or program that meets the accrediting body's established standards and requirements. VHA officials noted that educational institutions are typically reviewed by regional accrediting bodies, while programs are typically reviewed by national accrediting bodies. Page 6 GAO-22-104696 VHA Mental Health Workforce accrediting body for MFT graduate and post-graduate educational programs in the United States and Canada. VHA's Mental Health Hiring Initiatives VA medical facilities hire mental health professionals to meet their workforce needs, sometimes as part of VHA-wide mental health hiring initiatives. Over the past decade, VHA has implemented three mental health hiring initiatives (see table 2). Table 2: VHA's Mental Health Hiring Initiatives over the Last Decade, as of November 2021 Time frame of initiative Description of initiative Overall result(s) of initiative May 2012 - June 2013 Recruitment effort focused on hiring staff to fill an additional 1,600 mental health positions and 300 non-clinical support positions, as well as to fill existing vacancies. By the end of June 2013, VHA reported hiring: ° 1,667 new mental health staff; « 304 non-clinical support staff; and « 2,357 staff to fill existing mental health vacancies and any vacancies that opened during the initiative. June 2017 - January 2019 Aimed at supporting its top clinical priority of eliminating veteran suicides, with a goal of adding 1,000 mental health positions. By the end of January 2019, VHA reported hiring nearly 4,000 mental health positions nationwide, for a net increase of 1,045 mental health providers. October 2019 - present Provides targeted planning and human resources support for the Department of Veterans Affairs (VA) medical facilities struggling the most with maintaining adequate numbers of mental health professionals. Does not include a targeted number for hiring. This initiative is ongoing. In 2020, VA reported a net increase of 883 mental health staff. Source: GAO summary of past GAO work and Veterans Health Administration (VHA) information. | GAO-22-104696 Note: VHA does not require VA medical facilities to hire specific types of professions under these initiatives. Mental health leadership at individual facilities determine the specific types of mental health professions to recruit and hire for their facility positions, with the help of local human resources officials. VHA manages mental health hiring initiatives but does not require VA medical facilities to hire specific types of professionals under these initiatives, as facilities have varying workforce needs and, therefore, hiring decisions are at the discretion of individual facilities. For example, as part of its 2019 mental health hiring initiative, VHA assigned each VA medical facility a staffing criticality score based on the facility's total outpatient mental health staffing ratio, among other metrics.15 VHA targets its 15VHA policy sets a minimum of 7.72 outpatient clinical full-time equivalent staff per 1,000 veterans receiving mental health care. See Veterans Health Administration, Productivity and Staffing in Clinical Encounters for Mental Health Providers, VHA Directive 1161 (Washington, D.C.: April 28, 2020). Page 7 GAO-22-104696 VHA Mental Health Workforce support toward helping these facilities increase their overall mental health staffing levels, such as by providing data on staffing gaps and projections, as well as sharing hiring, recruitment, and retention strategies to increase staffing levels.16 VHA's outpatient staffing ratio and targeted support are aimed at increasing a facility's overall mental health workforce and are not specific to increasing the staffing levels of each type of mental health profession. Training for Health Professionals in VA Medical Facilities As part of its mission to help provide an adequate nationwide supply of health personnel, VA offers advanced clinical training to various health professions. Clinical training in a VA medical facility is an opportunity for a trainee to provide direct patient care under a supervising practitioner in the same profession. To offer clinical training, a VA medical facility must have an affiliation agreement with the educational institution responsible for providing the trainee's degree (hereafter, the academic affiliate). 17 VHA requires that both the educational institution and its graduate program be accredited. VA medical facilities may offer unfunded trainee positions or apply for funded trainee positions from VHA's Office of Academic Affiliations. e Unfunded trainee positions. VHA officials told us that facilities can offer unfunded trainee positions for 60 types of health professions, including most mental health professions. e« Funded trainee positions. Facilities also may apply for funded trainee positions for 17 types of associated health professions (excluding dental, medical, and nursing professions and advanced fellowships that are under separate funded training programs). To become a funded training site for a health profession, the facility must show that it meets certain criteria, such as having leadership commitment from the facility, VISN, and academic affiliate. VHA determines the types of mental health professions (such as LPMHCs and MFTs) eligible for funded trainee positions in each academic year. VA medical facilities can then submit requests for proposal to be new funded training sites for eligible professions or to expand the number of funded trainee positions for eligible professions at their 18In its October 2021 staffing improvement plan for mental health providers, VA described the number of overall mental health providers needed, by VISN, to fill open positions. VA based these estimates on both growth and adequate population coverage in each VISN. VA also identified the steps taken at each level of the organization to address overall mental health staffing needs, such as its mental health hiring initiatives. 17Veterans Health Administration, Veterans Health Administration Educational Relationships, VHA Handbook 1400.03 (Washington, D.C.: Feb. 16, 2016). Page 8 GAO-22-104696 VHA Mental Health Workforce existing funded training sites. VHA also awards preference to facilities that meet its identified priority areas in each academic year. For example, in academic year 2020-2021, priorities included preference for facilities that had a rural health setting or that did not previously host funded trainees. VHA Made Efforts to Promote LPMHC and MFT Hiring by Disseminating Guidance, Establishing Funded Trainee Positions, and Updating Standards VHA Disseminated Guidance to VA Medical Facilities to Encourage Hiring of LPMHCs and MFTs VHA began disseminating guidance in 2014 to various groups of mental health and human resources officials from VA medical facilities and VISNs to encourage the hiring of LPMHCs and MFTs and to increase the numbers of these mental health professionals. The guidance VHA disseminates includes information on the benefits of including LPMHCs and MFTs in hiring efforts and on updated LPMHC and MFT hiring standards. VHA has noted in its guidance that LPMHCs and MFTs 1. complement the skills of other mental health professionals, 2. can be a cost-effective way to extend mental health services, and 3. are often easier to recruit and retain in rural settings. Mental health officials at individual facilities have discretion to determine the specific types of mental health professions to recruit and hire for their Page 9 GAO-22-104696 VHA Mental Health Workforce facility positions, with the help of local human resources officials.'8 For example, a facility may open a position to only social workers or open the position to both social workers and LPMHCs.19 These officials may have different views on whether to hire certain types of mental health professions for their mental health workforce, including on whether to hire LPMHCs and MFTs. e Preferences for hiring professions other than LPMHCs and MFTs. Officials from four of five VISNs said that mental health supervisors at VA medical facilities may prefer hiring those with the same professional background as themselves or may have concerns related to variation in LPMHC and MFT training and backgrounds. Officials from three VISNs noted that supervisors may be unfamiliar with LPMHCs and MFTs, therefore preferring to hire those with a similar background. Similarly, officials from all four professional associations that represent LPMHCs and MFTs noted concerns among their membership that there were longstanding preferences among mental health leadership in some VA medical facilities to hire psychologists and social workers. e Benefits of hiring LPMHCs and MFTs. Despite concerns about preferences, officials from four of five VISNs said that opening mental health positions to include LPMHCs or MFTs is a good practice that VA medical facilities use to address hiring gaps when other types of professions, such as social workers, are more difficult to hire. For example, officials from one VISN described how a facility in its region that was one of the first to hire LPMHCs originally did so out of necessity. That facility now continually opens its positions to LPMHCs due to its success in hiring them in its rural location and its 18Until recently, VHA used entities known as professional standards boards to conduct activities such as determining an applicant's eligibility for employment per VA standards. VA required that members of these boards be comprised of three or five employees from the same profession as the individual being considered. In early 2020, VA removed the professional standards boards for certain professions, including LPMHCs, MFTs, psychologists, and social workers. The role of determining an applicant's eligibility is now the responsibility of human resources officials, with hiring decisions belonging to the VISN or VA medical facility director. 198VHA has a number of professions that VA medical facilities have identified as having severe staffing shortages. Specifically, in fiscal year 2021, 60 facilities selected psychologists and 30 facilities selected social workers as having severe shortages. In contrast, one facility selected LPMHCs and one facility selected MFTs as having a severe shortage. See VA Office of Inspector General, O/G Determination of Veterans Health Administration's Occupational Staffing Shortages: Fiscal Year 2021, Report No. 21-01357- 271 (Sept. 28, 2021). Page 10 GAO-22-104696 VHA Mental Health Workforce improvement in psychotherapy performance measures that coincided with increased LPMHC hiring. In addition, officials from three of five VISNs said that hiring LPMHCs and MFTs can help cast a wider net in rural areas in particular. Officials from three of four associations representing LPMHCs or MFTs similarly noted that these professionals were more likely to be located in rural areas that lack other mental health professionals. To help ensure all facilities were encouraged to hire LPMHCs and MFTs, VHA disseminated guidance primarily through internal presentations. Specifically, officials said that VHA's Office of Mental Health and Suicide Prevention provides presentations on LPMHCs and MFTs to groups that would benefit from additional information (Such as social work supervisors) or to leadership at a VISN or facility that is struggling to hire mental health professionals and asks for assistance. Disseminating guidance related to hiring LPMHCs and MFTs was also geared toward helping VHA meet the overall goals of each mental health hiring initiative. For example: In October 2018 (during VHA's hiring initiative that began in 2017 and met its overall goal in 2019 of hiring 1,000 mental health positions), VHA issued a memo with nine recommendations to help VA medical facilities reach the agency's mental health hiring goals. One of these recommendations was to ensure that broad recruitment of all licensed independent mental health providers included LPMHCs and MFTs. In September 2020 (for VHA's current hiring initiative that began in 2019 and provides targeted support for individual VA medical facilities), VHA offered a course titled "Expanding Mental Health Staffing by Hiring LPMHCs' as part of a learning program focused on improving the hiring and retention of mental health providers. The course described the LPMHC hiring standards and positions LPMHCs have in VA medical facilities. Officials told us that they plan to continue monthly organization-wide presentations, which include information on hiring LPMHCs and MFTs, as part of VHA's current mental health hiring initiative. Page 11 GAO-22-104696 VHA Mental Health Workforce VHA Established Funded Trainee Positions for LPMHCs and MF Ts That Are Dependent on Relationships with Academic Affiliates and Availability of Supervisors at VA Medical Facilities Our review of VHA documentation shows that, in academic year 2015- 2016, VHA began funding LPMHC and MFT trainee positions to promote the hiring of these professions nationwide. Trainees at VA medical facilities help provide a pipeline of qualified potential staff as trainees are exposed to key mental health programs and can be directly hired by facilities instead of going through longer hiring processes, according to VHA. Officials also said that growing a profession's funded trainee positions demonstrates VHA's investment in that profession. Officials from the VISN with the largest number of LPMHCs employed in its facilities noted that facilities typically have higher confidence in hiring when they can "grow their own," so it is important that LPMHCs receive training and experience in the VHA system. For example, according to the VISN, two of its facilities have had success in hiring LPMHCs because of their funded LPMHC trainee positions. VHA's Office of Academic Affiliations' funded training announcement states that, because LPMHCs and MFTs are still relatively new professions within the agency and decisions to hire these professions may vary by individual VA medical facility, the office has encouraged facilities to offer clinical training for these two professions to promote increased hiring. VA medical facilities seeking approval to become funded training sites for LPMHCs or MFTs must meet two key VHA requirements, as described in each year's funded training announcement: e Relationship with academic affiliate. VA medical facilities must have a letter of support from an academic affiliate-the accredited LPMHC or MFT graduate program.2° Officials from VISNs all noted the importance of academic affiliations for establishing a pipeline for a facility's mental health workforce. For one VISN, officials noted that its facilities have strong academic affiliations with social work programs from state and Ivy League universities, which help supply the workforce needed to meet its mental health care demand. In contrast, they do not have similar academic affiliations for LPMHC or MFT programs and therefore do little hiring of these professions. One association representing LPMHCs indicated that VA medical facilities could have difficulty establishing academic affiliations for LPMHCs because only about half of LPMHC programs in the country are accredited by CACREP. However, officials from VHA's Office of 20To offer clinical training, a VA medical facility must have an affiliation agreement with the educational institution responsible for providing the trainee's degree, known as the academic affiliate. Page 12 GAO-22-104696 VHA Mental Health Workforce Academic Affiliations did not identify the availability of accredited LPMHC programs as a challenge for VA medical facilities interested in funded LPMHC training positions, as made evident by the high approval rate for facilities that applied for a funded LPMHC training site. They further noted that, in the Office of Academic Affiliations' regular communication with facility leadership responsible for administering funded training sites, facilities have not indicated any challenges in applying for funded LPMHC trainees due to the lack of an accredited graduate program to serve as the facility's academic affiliate. e Available supervisors. VA medical facilities must also have, for any profession, a minimum of two supervisory staff at the funded training site who are in the same profession as the trainee (e.g., at least two LPMHCs to supervise all LPMHC trainees at the site). Officials from VHA's Office of Academic Affiliations said that the primary challenge encountered by the few VA medical facilities that were interested in becoming a funded training site but were not eligible was that they did not have enough LPMHCs and MFTs to supervise these trainees.7' VHA may choose to limit the types of professions eligible for funded trainee positions to those for which investment is needed, such as to meet the demand for mental health professions. In most academic years since VHA established funded LPMHC and MFT training positions, these professions were the only type, or one of only a few types, of mental health professions for which VA medical facilities could become a funded training site. For example: e VHA limited funded trainee positions to only LPMHC and MFT professions in academic year 2020-2021. e Intwo academic years (2017-2018 and 2018-2019), VHA identified LPMHC and MFT trainees as one of its priority areas, giving additional preference to facilities that included these professions in their requests for proposal. 21For MFTs, one of the two supervisory staff can be a faculty member at the accredited MFT graduate program as long as that supervisor has a "without compensation" appointment (that is, is an individual considered to be a VA employee but who does not receive salary or benefits from VA) at the VA medical facility. Officials from VHA's Office of Academic Affiliations said that VHA gave facilities this flexibility due to the low numbers of MFTs in the organization, which limits facilities' ability to meet the supervisor requirement. In addition, at least one of the MFT supervisory staff also must have an "approved supervisor" credential from the American Association for Marriage and Family Therapy. Page 13 GAO-22-104696 VHA Mental Health Workforce Most VA medical facilities that submitted a LPMHC or MFT funded training site proposal received approval, with 42 funded LPMHC trainees and 13 funded MFT trainees through academic year 2020-2021 (see table 3). Table 3: Information on VHA-Funded LPMHC and MFT Trainees, as of Academic Year 2020-2021 Number of VA medical facilities that submitted a proposal to were approved Number of Mental health profession be a funded training site (percent approved) funded trainees Licensed professional mental health counselors 20 18 (90) 42 (LPMHC) Marriage and family therapists (MFT) 10 7 (70) 13 Source: GAO summary of Veterans Health Administration (VHA) information. | GAO-22-104696 Note: For each academic year, VHA determines the types and number of professions for which Department of Veterans Affairs (VA) medical facilities can apply. VA medical facilities can apply to be a new funded training site for eligible professions or can expand the number of funded trainee positions for eligible professions at their existing funded training sites. For example, in academic year 2020-2021, VHA limited funded trainee positions to LPMHC and MFT professions and allowed VA medical facilities to apply for a maximum of three funded trainees for new training sites and two additional funded trainees for existing training sites. For more information on funded LPMHC and MFT trainees, including how these trainee positions compare to those for other mental health professions providing psychotherapy services, see appendix |. VHA's Most Recent Update to Its LPMHC and MFT Hiring Standards Included Changes to Each Profession's Educational Requirements In April 2018, VHA issued updated hiring standards for LPMHCs and MFTs, noting for VA medical facilities that updates to each profession's educational requirements were necessary for the recruitment and retention of these professions. VHA officials told us that VHA conducts an internal review before determining what updates, if any, are needed for a profession's hiring standards. VHA conducts such a review on a periodic basis or ad hoc (e.g., when there are significant changes in a profession's assigned responsibilities). The 2018 updates to the LPMHC and MFT hiring standards resulted from a periodic review and included the following changes to help VA medical facilities hire LPMHCs and MFTs: e VHA allowed LPMHCs to meet its educational requirement with either a master's or doctoral degree from a CACREP-accredited program, while previously only a master's degree from a CACREP-accredited program was allowed to satisfy this requirement. VHA officials told us this update was based on a prior request from within the agency to Page 14 GAO-22-104696 VHA Mental Health Workforce broaden the types of LPMHC degrees that could be used for hiring and was subsequently made possible by legislation. 22 VHA also added a senior-level LPMHC position to bring the types of positions available to this profession more in line with comparable professions such as social workers. The senior-level LPMHC position requires the same educational requirements-either a master's or doctoral degree from a CACREP-accredited program. e VHA allowed MFTs to meet its educational requirement with a degree from a program that has COAMFTE or regional accreditation, while previously only a program that had COAMFTE accreditation was allowed to satisfy this requirement. VHA made this change in response to legislation that required the agency to consider an MFT qualified for VHA employment regardless of whether the MFT had a degree from a program with national accreditation by COAMFTE.23 As included in its initial hiring standards, MFTs also have the option of holding comparable mental health degrees (e.g., social work) that meet the current VA hiring standard of that profession. VHA officials said that the April 2018 update included input from internal LPMHC and MFT subject matter experts who collect documentation and review data to help inform VHA's hiring standards. VHA officials noted that they are beginning their next periodic review of the LPMHC and MFT hiring standards, which is likely to be completed in 2023.24 VHA uses these periodic reviews to ensure the accuracy of and 22The original legislation enacted in December 2006 establishing qualifications of LPMHCs in VA included only master's degrees. See Veterans Benefits, Health Care, and Information Technology Act of 2006, Pub. L. No. 109-461, § 201, 120 Stat. 3403, 3409 (2006) (codified, as amended, at 38 U.S.C. § 7402(b)(11)). Subsequent legislation enacted in December 2016 included doctoral degrees in addition to master's degrees. See Jeff Miller and Richard Blumenthal Veterans Health Care and Benefits Improvement Act of 2016, Pub. L. No. 114-315, § 613, 130 Stat. 1536, 1576 (2016). 23See Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response and Preparedness Act, Pub. L. No. 114-223, § 239, 130 Stat. 857, 883 (2016). VHA still requires advanced and supervisory MFT positions to hold degrees only from programs accredited by COAMFTE. VHA officials told us that its MFT subject matter experts recommended this hiring standard for senior-level positions to ensure these individuals have sufficient training to provide the family therapy services an MFT would be expected to provide. 24V/HA is required to review and consider updates to its hiring standards at least every 5 years or on an ad hoc basis when it determines that significant changes have occurred in areas such as education or licensure. See VA Directive 5005. Page 15 GAO-22-104696 VHA Mental Health Workforce make any planned edits to a profession's hiring standards. Officials said that the updates they anticipate making to the LPMHC and MFT hiring standards include clarifying certain documentation requirements that would help facilitate the hiring of supervisory MFTs.25 In addition, VHA officials said that their next review may also include a determination of whether another national accrediting body (the Masters in Psychology and Counseling Accreditation Council) in addition to CACREP may be appropriate for LPMHC hiring standards. Officials from one professional association that represents LPMHCs noted that adding another accrediting body would help expand the numbers of LPMHCs employed by VHA by making more individuals eligible for hiring. VHA officials said the agency's LPMHC subject matter experts will be evaluating in fiscal year 2022 whether to include the new accrediting body in its hiring standards, which would include an assessment of the accrediting body's standards and whether the accreditation is required by any state licensure laws. 25VHA requires that supervisory MFTs have approved supervisor credentials from the American Association for Marriage and Family Therapy. VHA officials told us that an update to VHA's hiring standards was necessary to detail how supervisory MFTs should show they have this credential as the American Association for Marriage and Family Therapy no longer issues letters to document when the credentials have been earned. 26The Masters in Psychology and Counseling Accreditation Council received recognition from the Council for Higher Education Accreditation in May 2021. The Council for Higher Education Accreditation scrutinizes accrediting bodies, such as programmatic accrediting organizations, for their effectiveness in advancing academic quality and serving higher education, students, and the public. Professional associations told us that LPMHC and MFT graduate programs with national accreditation are not widespread across the country. For example, both professional associations that represent LPMHCs said that CACREP accredits approximately half of the country's counseling programs (accredited programs being predominantly in the South and Midwest regions of the country) and is required for licensure by only a few states. Both professional associations that represent MFTs noted that while less than 10 percent of the MFT programs in California have COAMFTE accreditation, about half of all licensed MFTs are located in that state. Page 16 GAO-22-104696 VHA Mental Health Workforce LPMHCs and MF Ts Have Been Employed in Two-Thirds of VA Medical Facilities since 2010 and Comprise a Small Proportion of Comparable Mental Health Professions Number of LPMHCs and MF Ts Has Increased to Nearly 500 across 69 Percent of VA Medical Facilities since VHA Began Hiring These Professionals in 2010 Our analysis of VHA staffing information shows the number of LPMHCs and MFTs employed in VA medical facilities increased in the aggregate from fiscal year 2010 through 2021 to 492 (423 LPMHCs and 69 MFTs). This overall growth in employment since VHA began hiring these professions coincides with increases in the hiring of both professions during each of VHA's three mental health hiring initiatives.2" For example, during the 2012 initiative, the number of LPMHCs hired by facilities increased from 29 in fiscal year 2012 to 73 in fiscal year 2013, and the number of MFTs hired by facilities increased from 7 to 33 in that time frame. Similarly, hiring of LPMHCs and MFTs increased again during the two initiatives that followed in 2017 and 2019 (see fig. 1). 27In addition to hiring, other factors such as turnover due to retirements, terminations, and resignations contributed to the number of staff employed in VA medical facilities. Page 17 GAO-22-104696 VHA Mental Health Workforce Figure 1: Number of Employed and Hired LPMHCs and MFTs in VA Medical Facilities, Fiscal Year 2010 through 2021 Number employed 500 450 400 350 300 250 200 150 100 50 2010 ©2011 2014 2015S 2016 «(20172018 =: 2019: 2020 2021| Fiscal year === Employed marriage and family therapists (MFT) =» = == Employed licensed professional mental health counselors (LPMHC) ia Hired MFTs Hired LPMHCs YEAR] Mental health hiring initiatives Source: GAO analysis of VHA staffing information. | GAO-22-104696 Note: The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) started hiring LPMHCs and MFTs in September 2010. Employment numbers represent the total amount of individuals in each profession who were employed in VA medical facilities as of the last month of each fiscal year and includes hires, as shown in the figure, as well as other factors, such as staff turnover (which is not captured in the figure). Hiring numbers are the total amount of individuals in each profession who were hired in a fiscal year. The time frames for VHA's three mental health hiring initiatives were from May 2012 to June 2013, from June 2017 to January 2019, and from October 2019 to present (as of November, 2021). Page 18 GAO-22-104696 VHA Mental Health Workforce Licensed Professional Mental Health Counselors and Marriage and Family Therapists Employed in Vet Centers The Veterans Health Administration's (VHA) Readjustment Counseling Service is responsible for hiring activities at its 300 Vet Centers, which are sites and mobile units that provide counseling and non-medical social services, such as employment assessments and explanation of benefits, to veterans and their families and are located in community settings separate from Department of Veterans Affairs (VA) medical facilities. Veterans and their families can seek these services at Vet Centers in conjunction with or entirely separately from their care at VA medical facilities. GAO's analysis of VHA staffing information shows that from fiscal year 2010 through 2021, licensed professional mental health counselors (LPMHC) and marriage and family therapists (MFT) employed in Vet Centers increased to 287 (166 LPMHCs and 121 MFTs). A larger proportion of MFTs were employed in Vet Centers, while a larger proportion of LPMHCs were employed in VA medical facilities. Source: GAO analysis of VHA information. | GAO-22-104696 The number of VA medical facilities that have employed at least one LPMHC or MFT also has increased since 2010. Over two-thirds of VA medical facilities (about 69 percent) employed at least one or more LPMHC or MFT as of September 2021. (See sidebar for information on LPMHC and MFT hiring in Vet Centers, which operate separately from VA medical facilities.) For example: e By June 2013, the end of the 2012 mental health hiring initiative, 31 percent (43 of 140) of VA medical facilities had ever employed at least one LPMHC or MFT. e By January 2019, the end of the 2017 mental health hiring initiative, 56 percent (78 of 140) of VA medical facilities had ever employed at least one LPMHC or MFT. Examining each profession separately, 63 percent of VA medical facilities have employed at least one or more LPMHC, and 31 percent of facilities have employed at least one or more MFT as of September 2021. For more detail on the geographic distribution of LPMHCs and MFTs employed in VA medical facilities for fiscal year 2021, see figure 3 in appendix II. LPMHCs and MFTs Comprise a Small Proportion of Comparable Mental Health Professions in VHA's Workforce According to VHA staffing information for fiscal year 2021, LPMHCs and MFTs comprise 3.6 percent of mental health professions that typically provide psychotherapy services in VA medical facilities. Psychologists and social workers, which have been well established in VA medical facilities for several decades, make up the bulk of the mental health professions providing psychotherapy services, as of fiscal year 2021 (see fig. 2). Page 19 GAO-22-104696 VHA Mental Health Workforce Figure 2: Percentage of Mental Health Professions Typically Providing Psychotherapy Services in Department of Veterans Affairs (VA) Medical Facilities, Fiscal Year 2021 3.1% (or 423) LPMHCs 0.5% (or 69) MFTs 51.3% (or 6,908) Social workers 45.0% (or 6,063) Psychologists Source: GAO analysis of VHA staffing information. | GAO-22-104696 Note: According to the Veterans Health Administration (VHA), those employed in the four professions presented in this figure are typically responsible for providing psychotherapy services in VA medical facilities. VHA began hiring licensed professional mental health counselors (LPMHC) and marriage and family therapists (MFT) in 2010, while psychologists have been in its workforce since 1946 and social workers have been in its workforce since 1926. Percentages may not add to 100 due to rounding. In general, each VA medical facility employed fewer LPMHCs or MFTs compared to other types of mental health professions in fiscal year 2021. Most VA medical facilities that employed LPMHCs or MFTs did so in small numbers (employed five or less). Almost all VA medical facilities employed lower numbers of LPMHCs and MFTs than social workers (97 percent, 136 facilities) and psychologists (97 percent, 136 facilities). Likewise, the largest numbers of LPMHCs and MFTs employed in a single VA medical facility were lower than for the other professions. The most LPMHCs and MFTs employed in VA medical facilities were 38 LPMHCs and nine MFTs, while the facilities with the most psychologists and social workers had 135 and 259 employed in those professions, respectively. For information on the range of each profession employed in VA medical facilities, see tables 6 and 7 in appendix II. In addition, the employment of mental health professions varied depending on the location of VA medical facilities. VA medical facilities categorized as rural employed a higher percentage of LPMHCs than comparable mental health professions. Specifically, rural facilities Page 20 GAO-22-104696 VHA Mental Health Workforce Agency Comments accounted for 14 percent of employed LPMHCs, compared to 6 percent of MFTs, 5 percent of psychologists, and 8 percent of social workers. We provided a draft of this report to VA for review and comment. VA provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Secretary of Veterans Affairs, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at silass@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs are on the last page of this report. GAO staff who made major contributions to this report are listed in appendix III. Sh 7 Sharon M. Silas Director, Health Care Page 21 GAO-22-104696 VHA Mental Health Workforce Appendix |: Information on VHA-Funded Mental Health Trainees That Typically Provide Psychotherapy Services As part of its mission to help provide an adequate nationwide supply of health personnel, the Department of Veterans Affairs (VA) offers advanced clinical training for different types of health professions, including mental health professions. In academic year 2015-2016, VA's Veterans Health Administration (VHA) began establishing funded trainee positions to promote the nationwide hiring of licensed professional mental health counselors (LPMHC) and marriage and family therapists (MFT). Funded trainee positions already existed at that time for other mental health professions that typically provide psychotherapy services in VA medical facilities, with officials estimating that funded psychologist trainees were established in the 1940s and funded social worker trainees were established since at least the early 1960s. VA medical facilities may apply for funded trainee positions from VHA's Office of Academic Affiliations through a request for proposal. VHA determines the types of mental health professions (such as LPMHCs and MFTs) eligible for funded trainee positions in each academic year. VA medical facilities can then apply to be a new funded training site for eligible professions or expand the number of funded trainee positions for eligible professions at their existing funded training site. Table 4 shows the number of funded trainee requests for proposal submitted by VA medical facilities and approved by VHA in each year, by each mental health profession that typically provides psychotherapy services, since VHA began funding LPMHC and MFT trainee positions in academic year 2015-2016. Page 22 GAO-22-104696 VHA Mental Health Workforce Appendix |: Information on VHA-Funded Mental Health Trainees That Typically Provide Psychotherapy Services Table 4: VA Medical Facility Requests for Proposal for Funded Trainees in Mental Health Professions That Typically Provide Psychotherapy Services, Academic Years 2015-2016 to 2020-2021 Number of requests for proposal submitted by VA medical facilities and approved by VHA in each academic year Mental health profession 2015-2016 2016-2017 2017-2018 2018-20197 2019-2020 2020-2021 =Total Licensed professional mental health counselors (LPMHC) Submitted 7 0 1 4 0 8 20 Approved 7 0 1 2 0 8 18 Marriage and family therapists (MFT) Submitted 0 4 2 3 0 1 10 Approved 0 1 2 3 0 1 7 Psychologists" Submitted 30 27 27 7 0 0 91 Approved 25 19 9 5 0 0 58 Social workers Submitted 20 0 13 0 0 0 33 Approved 16 0 5 0 0 0 21 Source: GAO summary of Veterans Health Administration (VHA) information. | GAO-22-104696 Note: For each academic year, VHA determines the types and number of professions for which Department of Veterans Affairs (VA) medical facilities can apply. As a result, not every profession is included in each academic year. For example, in academic year 2020-2021, VHA limited funded trainee positions to LPMHC and MFT professions and allowed VA medical facilities to apply for a maximum of three funded trainees for new training sites and two additional funded trainees for existing training sites. In the table above, cells that have no submitted or approved proposals generally indicate that the profession was not included as part of VHA's funded training positions for that academic year. *V/HA awards preference to facilities that meet its identified priority areas in each academic year. In these two academic years, VHA identified LPMHC and MFT trainees as one of its priority areas, giving additional preference to facilities that included these professions in their requests for proposal. >Funded LPMHC, MFT, and social worker trainees are in pre-master's program internships, while funded psychologist trainees are in full-year doctoral program internships and 1- or 2-year postdoctoral fellowships in areas such as neuropsychology. VA medical facilities also may offer unfunded trainee positions. Table 5 shows the number of funded and unfunded training sites and trainees for each mental health profession, as of academic year 2020-2021. Page 23 GAO-22-104696 VHA Mental Health Workforce Appendix |: Information on VHA-Funded Mental Health Trainees That Typically Provide Psychotherapy Services Table 5: Funded and Unfunded VA Medical Facility Sites and Trainees for Mental Health Professions That Typically Provide Psychotherapy Services, as of Academic Year 2020-2021 Number of Total number Total number funded Number of of funded and of funded and Mental health profession training sites fundedtrainees unfunded training sites? unfunded trainees? Licensed professional mental 16 42 18 44 health counselor (LPMHC) Marriage and family therapist 6 7 24 (MFT) Psychologist® 131 700 134 1,205 Social worker 146 1,048 156 1,276 Source: GAO summary of Veterans Health Administration (VHA) information. | GAOQ-22-104696 Note: For each academic year, VHA determines the types and number of professions for which Department of Veterans Affairs (VA) medical facilities can apply. For example, in academic year 2020-2021, VHA limited funded trainee positions to LPMHC and MFT professions and allowed VA medical facilities to apply for a maximum of three funded trainees for new training sites and two additional funded trainees for existing training sites. 8V/HA information on unfunded training sites and trainees is self-reported from each VA medical facility. As of October 2021, information on unfunded training sites and trainees was not yet available for academic year 2020-2021. Therefore, unfunded numbers are as of academic year 2019-2020. 'Funded LPMHC, MFT, and social worker trainees are in pre-master's program internships, while funded psychologist trainees are in full-year doctoral program internships and 1- or 2-year postdoctoral fellowships in areas such as neuropsychology. Page 24 GAO-22-104696 VHA Mental Health Workforce Appendix II: Distribution of Mental Health Professions That Typically Provide Psychotherapy Services, Fiscal Year 2021 The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) typically relies on four types of mental health professions to provide psychotherapy services in its facilities: psychologists, social workers, and, since September 2010, licensed professional mental health counselors (LPMHC) and marriage and family therapists (MFT). In fiscal year 2021, VHA employed LPMHCs in 76 of 140 VA medical facilities and MFTs in 35 of 140 VA medical facilities (see fig. 3). Page 25 GAO-22-104696 VHA Mental Health Workforce Appendix Il: Distribution of Mental Health Professions That Typically Provide Psychotherapy Services, Fiscal Year 2021 Figure 3: Geographic Distribution of Department of Veterans Affairs (VA) Medical Facilities that Employ Licensed Professional Mental Health Counselors (LPMHC) and Marriage and Family Therapists (MFT), Fiscal Year 2021 VA medical facilities with LPMHCs e e a e e e e e co e e e e e - a ry BO G ° : - e zs ¥ e ee ¥ e ee . e e a e ie e Z Pe e e e e : : S a ; e e e e U e e e e e e Os , e e e e VA medical facilities with MFTs e e e e . e e e ° x a e ee e e e e°? e e e es e e e e e e 3 e Number employed by location 1 5 10 Source: GAO analysis of VHA staffing information. | GAO-22-104696 Page 26 GAO-22-104696 VHA Mental Health Workforce Appendix Il: Distribution of Menta | Health Professions That Typically Provide Psychotherapy Services, Fiscal Year 2021 Note: VA medical facilities that employ zero LPMHCs (64 facilities) or MFTs (105 facilities) are not shown, including VA medical facilities located outside of U.S. states (e.g., Puerto Rico or Manila, Philippines), whose boundaries are not included on the maps. Almost all 140 VA medical worker in fiscal year 2021, facilities employed a psychologist or social with different ranges for facilities with LPMHCs or MFTs. Table 6 shows the number of VA medical facilities with various ranges of each type of these mental health professions. Table 6: Number of Department of Veterans Affairs (VA) Medical Facilities That Employed Mental Health Professions That Typically Provide Psychotherapy Services, Fiscal Year 2021 Number of facilities 11 or more Mental health profession None employed 1-5 employed 6-10 employed employed Licensed professional mental health counselor 64 52 12 12 (LPMHC) Marriage and family therapist (MFT) 105 34 1 0 Psychologist 2 3 6 129 Social worker 1 3 4 132 Source: GAO analysis of Veterans Health Administration staffing information. | GAO-22-104696 Note: In this analysis, the total number of VA medical facilities is 140. The professions shown in the table represent the mental health professions that provide psychotherapy services and are therefore most comparable to LPMHCs and M Table 7 shows the median mental health professions Table 7: Range of Mental Health Professionals That Typically Provide Ps Veterans Affairs (VA) Medical Facilities, Fiscal Year 2021 FTs. , minimum, and maximum number of employed in VA medical facilities. ychotherapy Services Employed in Department of Number employed Mental health profession Median Minimum Maximum Licensed professional mental health counselor 1 0 38 (LPMHC) Marriage and family therapist (MFT) 0 0 9 Psychologist 34.5 0 135 Social worker 40 0 259 Source: GAO analysis of Veterans Health Administration staffing information. | GAO-22-104696 Note: In this analysis, the total numb: er of VA medical facilities is 140. The professions shown in the table represent the mental health professions that provide psychotherapy services and are therefore most comparable to LPMHCs and M Page 27 FTs. GAO-22-104696 VHA Mental Health Workforce Appendix III: GAO Contact and Staff Acknowledgments GAO Contact Sharon M. Silas, (202) 512-7114 or at silass@gao.gov. Staff In addition to the contact named above, Hernan Bozzolo (Assistant Director), E. Jane Whipple (Analyst-in-Charge), and Colin Ashwood made Acknowledgments key contributions to this report. Also contributing were Jennie Apter, Emily Binek, Debra Draper, Keith Haddock, Cynthia Khan, Ethiene Salgado- Rodriguez, and Jennifer Whitworth. 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