After months of crying all the time, barely being able to stay awake and regularly skipping lunch to get her work done, Ashley knew she needed to leave her job as a mental health therapist in UPMC’s network.

Ashley worked for the healthcare giant for several years. As a therapist most recently focused on women’s mental health, she found her work deeply fulfilling.

But when the pandemic created more demand for mental health services, Ashley’s schedule became unmanageable. Before the pandemic, the no-show rate for appointments was high, which providers like UPMC factored into scheduling requirements. But once telehealth became widely available, the no-show rate dropped, and Ashley said she began seeing seven patients per day, rather than her usual four to six. 

Outpatient therapists typically spend about an hour with each patient, helping them work through issues such as anxiety or depression. Mandatory meetings no longer counted toward therapists’ productivity quota, a change management made during the pandemic, according to Ashley and two other therapists. Ashley would sometimes have to type patient notes while with a different patient, she said, just to not fall behind. UPMC did not respond to questions about the change in the meeting policy.

The stress depleted Ashley’s own mental health and her ability to provide quality care. “I couldn’t do it anymore,” Ashley said. She left for a job in private practice in the spring. “I was heartbroken when I had to leave,” she said. “It almost was a sense of UPMC came in and cracked down.”

Heavy workloads, high productivity standards and low pay are causing many therapists to leave community mental health centers like UPMC Western Psychiatric Hospital and Pittsburgh Mercy Behavioral Health, according to current and former employees. PublicSource agreed to withhold the names of sources due to fears about termination or concerns that speaking out after leaving could harm them professionally.  

As a result, the therapists say some patients are waiting longer for appointments. The therapists left behind have to take on the extra workload, and they’re concerned that the quality of care has declined. The problem is cyclical: The more therapists that leave, the worse the conditions get for the ones who remain, prompting many to seek jobs elsewhere.

The problem is not unique to UPMC and Pittsburgh Mercy. Andy Carter, president and CEO of The Hospital and Healthsystem Association of Pennsylvania [HAP], said mental health resources are “profoundly lacking” across Pennsylvania as providers try to meet skyrocketing demand for services during the pandemic.

“We are in the middle, if not the first third, of truly one of the most challenging healthcare workforce shortages we’ve ever encountered,” Carter said.

Turnover at community mental health centers is typically high because private practices generally offer better pay and more scheduling flexibility. But executives at both UPMC and Pittsburgh Mercy Behavioral Health (which is not affiliated with UPMC) acknowledged that the problem worsened during the pandemic.

In an April interview, Pittsburgh Mercy Chief Operating Officer Dave Grabowski said many providers had left for private practice due to higher pay, less paperwork and the ability to work completely from home. 

In a September email statement to PublicSource, Melissa Nossal, Pittsburgh Mercy’s vice president of behavioral health services, said wait times for new patients had been about three to six months, and at one point, the center stopped accepting new patients due to capacity. 

But the problem has since improved, Nossal wrote, and the wait time for new patients is now between two and four weeks. Most of Pittsburgh Mercy’s outpatient therapist positions are now filled, she said, adding that some vacancies were due to internal promotions. “Positions were not only vacated due to burn-out or leaving the agency,” Nossal wrote.

In an email statement to PublicSource, UPMC spokesperson Ashley Trentrock said the organization is working to balance increased demand for mental health care, providing care safely and promptly and being mindful of employees’ capacity. 

Community mental health centers primarily serve low-income people with Medicaid insurance. As therapists leave those centers for private practice, it has also meant fewer mental health providers able to care for patients with Medicaid. The increase in vacancies was an “exodus” of Medicaid providers to private practice, making it harder for people with Medicaid to receive care, Deborah Brodine, president of UPMC Western Psychiatric Hospital, said in April. 

In September, Pennsylvania extended its telehealth suspensions and waivers through March of 2022. It’s unclear whether the widespread use of telehealth will continue beyond then and how that might affect no-show rates.

Providing behavioral healthcare is challenging work, Carter of HAP said, and the pay can be lower than other types of health care. “We, over time, need to pump more resources into behavioral health care so we can pay workers better, so more people will be attracted to providing behavioral healthcare services to fill vacancies,” Carter said.

In April, Pittsburgh Mercy’s chief operating officer said providers were leaving for private practice due to higher pay, less paperwork and the ability to work completely from home. (Photo by Kaycee Orwig/PublicSource)

According to the U.S. Bureau of Labor Statistics, mental health counselors in Pennsylvania made an average of $48,450 per year in 2020. In comparison, registered nurses made an annual average of $74,170.

“I struggle at sometimes giving good quality care, feeling competent, and that’s just an awful feeling as a therapist,” one current UPMC therapist said of her heavy caseload. “I don’t know if I could go another year and a half of what I’ve been experiencing.” The therapist is looking for a new job.

One former employee of Pittsburgh Mercy, who left recently after more than a dozen years there, said the turnover is “directly related to the company not listening to the employee’s needs.” Employees are concerned about having too much paperwork and low pay.

When a therapist leaves, their patients often go on a waitlist before being transferred to another therapist. “So they have to wait, they have to have that lapse in care, and then they have to start over with another therapist,” said a Pittsburgh Mercy Behavioral Health employee. They, too, are planning on leaving their job in the next few months. 

Nossal of Pittsburgh Mercy said productivity standards have not changed during the pandemic, and patients whose therapists leave their positions are now reassigned to a new therapist “almost immediately.”

At UPMC, when therapists leave, staff attempts to reschedule patients without a gap in care, Trentrock wrote in an email to PublicSource. Sometimes that means assisting them to find another provider outside of UPMC, she said. 

Research shows that a heavy workload can reduce therapists’ effectiveness in caring for patients, though study results differed on how much. Performance suffers when therapists see 25 or more patients per week, and it drops off more at 30 patients per week, said Carina Vocisano, a psychologist who researched the topic nationally. 

Trentrock of UPMC said its therapists are expected to see between 26 and 28 patients per week, but that most therapists actually see fewer than 25. But three employees told PublicSource they are expected to schedule 35 appointments per week, and if almost every patient shows up, they can end up seeing 30 or more in one week. UPMC did not answer questions about the scheduling expectation.

At Pittsburgh Mercy, therapists are expected to have 28 billable hours per week and schedule additional patients to account for cancellations, Nossal wrote. She said the organization is considering adjusting its scheduling expectations since telehealth has decreased the no-show rate. 

Because of the shortage of therapists, returning patients who used to be seen every two or three weeks must now wait four to six weeks between appointments, the UPMC employees said. New patients often wait even longer, they said, and may have an initial appointment with a therapist, then be transferred to a different one almost immediately.

Trentrock said wait times depend on the clinic, and that UPMC is actively recruiting more staff.

Long wait times — including those that can span months —  are a statewide problem for behavioral health services, said Carter of HAP. “The wait times for services are just heartwrenching … We really need to get on top of it in Pennsylvania, and fast.”

After Ashley put in her resignation notice, she said she was expected to continue seeing new patients each day as part of her roster. The new patients were not told ahead of their appointment that she wouldn’t be the one continuing to see them, which often made patients angry, she said. “It’s so hard to work up the courage to share your story a first time. But then to have to turn around and tell your story all over again? I can’t even imagine,” she said. 

Two therapists who are seriously considering leaving UPMC told PublicSource they might stay if they could see fewer patients each week. “This isn’t sustainable, for our patients or for us,” one said.

Since March 2020, the declining mental health of doctors and nurses has received international attention. But even before the pandemic, therapist burnout was ubiquitous. 

As a current UPMC employee put it: “If the mental health system wasn’t already collapsing previously, with the pandemic, I’m scared to see the aftermath of that.”

Juliette Rihl is a freelance reporter. She can be reached at juliette@publicsource.org or on Twitter @julietterihl

This story was fact-checked by Linden Markley.

Mental health reporting has been made possible with funding by the Staunton Farm Foundation, but news decisions are made independently by PublicSource and not on the basis of donor support.

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Juliette Rihl

Juliette Rihl reports on criminal justice, public safety and mental health for PublicSource. Her 2020 series on how court debt impacts low-income Allegheny County residents prompted the county to join...