Angelena Plummer, owner of a counseling practice in Rapid City, knows what it’s like to wait for mental health care.

A few years ago, she called a therapist after a distressing life event. When she found out the wait was three months for the next available appointment, Plummer recalled, “it was a literal jaw drop.”

“My memory of that was a lot of curse words, bewilderment and ‘yes I’ll still take the appointment,’” she said. 

The first session brought up additional issues. So, when the therapist wasn’t available again for over a month, Plummer felt “alone and worse off than I was when I entered the session.”

Lengthy waitlists are still a concern in Rapid City, reflecting a statewide problem. Several bills in the recently concluded legislative session — including one providing $2 million for suicide prevention, which passed — addressed the issue.

Considering South Dakota saw record-breaking suicide numbers in 2021 (statistics for 2022 are still provisional), there’s concern that the shortage has become critical. 

The shortage is “the worst we’ve seen,” according to Anthony Raaphorst, president of the West River Counseling Association. “Over the last two years, we have seen a major change, where it’s like, ‘We need more help,’” he said.

The total number of licensed counselors and marriage and family therapists in the state has actually grown over the last few years. Last year saw the largest increase in at least seven years, according to data from the Board of Examiners for Licensed Counselors and Marriage & Family Therapists. 

The shortage may therefore be explained by rising demand. Certain types of counselors and social workers will be in high demand through 2030 with higher-than-average annual job openings, according to projections published last year by the South Dakota Labor Market Information Center. 

The coronavirus pandemic has increased the demand for mental health care, professionals in the field say, while decreasing the stigma against seeking services. The stigma is still there, but “people are accepting that it’s OK to get help,” Raaphorst said. 

This surge in demand “has overwhelmed mental health services, resulting in burnout of providers and incredibly long waitlists” in Sioux Falls, as reported in the Mental Health Needs Assessment of Sioux Falls, published in January by the Augustana Research Institute. 

Younger South Dakotans are seeking services more often, the report says. 

Every county in South Dakota faces a shortage of mental health professionals, either for the entire county or for a group of people living in the county, according to the Health Resources & Services Administration. These shortages are typically defined as areas, which may span multiple counties, with no more than one psychiatrist per 15,000-30,000 people.

Clients ‘desperate for help’

The shortage is one reason why Beverly Dafler, owner of Crossroads Counseling Services in Rapid City, hasn’t fully retired from her practice.

“I’m semi-retired, and I’m still getting calls from people who are saying they’re desperate for help,” Dafler said. 

Due to obstacles like cost, transportation or the stigma of seeking care, people don’t tend to seek mental health care until they really need it.

“Much like the dentist, they don’t go until it has reached a critical state,” said Duane Kavanaugh, director of counseling services at South Dakota Mines. 

If clients don’t get the care they need, their health may worsen, Raaphorst said. Or, they may turn to unhealthy coping techniques like substance abuse. 

Ultimately, he said, ripple effects may impact the families of those seeking care.

“It’s a domino effect,” Raaphorst said. “The shortage means that the person isn’t getting the help they need, and that affects those around them.” 

Certain communities may find it especially difficult to find a provider, according to the Mental Health Needs Assessment of Sioux Falls. This includes non-English speakers, rural clients, and non-white clients looking for a provider of a similar racial identity or cultural background.

Lower income clients have few options for affordable care, the report said, and organizations with sliding scale fees often have the longest waitlists. Months-long wait times for services in Sioux Falls were described, with some of the longest wait times for psychiatrists.

In Rapid City, South Dakota Searchlight found wait times between less than one week and over six months for therapists and psychiatrists. Larger organizations had the longest waitlists.

At the Monument Health Behavioral Health Center, counseling services are booked until July. Psychiatry services are booked until September for adults and July for children.

Across the state, children wait up to 4-6 weeks for mental health care, as described by mental health and juvenile justice system workers during summer meetings of the Legislature’s Study Committee on Juvenile Justice. Rep. Taylor Rehfeldt, R-Sioux Falls, used testimony from those meetings to inform a resolution encouraging further research into childhood mental health, but the resolution didn’t pass during the legislative session.

Students waited at least two weeks for counseling services at every state university last semester, with some counselors at BHSU working over their lunch breaks “out of the goodness of their hearts,” said Caleb Weiland, president of the South Dakota Student Federation. 

He also referenced the problem at a legislative hearing in January, where the president of the South Dakota State University Students’ Association, Blake Pulse, revealed that over 100 students were on a waitlist for counseling services at the university. The topic of the testimony was the suicide prevention bill that passed during the legislative session. It provides funds to support suicide prevention and loss programs for youth and young adults.

 

‘You might get no one to apply’

Some mental health organizations have struggled to hire enough employees to meet the demand. 

“Years ago, you’d get applicants. But now, depending on where you are, you might get no one to apply to work there,” Kavanaugh said. 

In early February, there were 66 vacancies at a Behavior Management Systems Agency in western South Dakota with 160 employees.

Of those, 44 were in outpatient counseling and case management, as heard in testimony for a bill in the Legislature that didn’t pass, but would have appropriated scholarship funds for students entering the behavioral health field.

In December, there were 64 full-time vacancies across 12 behavioral health organizations that primarily serve Rapid City, according to a survey facilitated by the John T. Vucurevich Foundation of a group of providers, the Systems of Care Collaborative, who meet to discuss youth-centric issues.

Over 70% of those positions required a graduate degree while under 30% required only a bachelor’s degree.

Potential job titles ranged from case manager at the bachelor’s degree level to psychiatrist at the doctoral degree level. 

The highest percentage of vacancies required a master’s degree but not a doctoral degree, with potential positions of counselor, social worker or psychiatric nurse practitioner. 

Workforce issues extend across the state — Sioux Falls providers reported hiring challenges heightened by high turnover rates, as described in the Mental Health Needs Assessment of Sioux Falls. Low pay, along with the long process of obtaining a license, were driving factors.

Filling the pipeline with students

SDSU offers the only master’s degree in counseling on the western side of the state at an off-campus center in Rapid City, where enrollments have increased over the last few years.

Scholarships would have a “profound impact” on recruiting new students since none are currently offered, said Moneik Stephens, the SDSU program coordinator for Rapid City. 

Similar support may attract students to the state’s only clinical psychology Ph.D. program at the University of South Dakota. Clinical psychologists, unlike counselors, can test clients for psychological conditions like attention-deficit/hyperactivity disorder or autism.

“Higher stipends, tuition remission and providing health insurance for graduate assistants would be the biggest help in attracting students to our program,” said Beth Boyd, director of the clinical psychology program at USD, in an email.

For West River students, limited availability of local graduate programs may influence their career decisions.

“Ideally we would have a Ph.D. program locally or a second master’s program,” said BHSU Psychology Professor Emilia Flint. When someone realizes they need to move away to advance, she said, “sometimes it’s like seeing the wind knocked out of their sails.”

‘People should at least be able to survive’

Low wages create retention issues for some professions. 

“We have a high turnover rate in mental health. A lot of times, it can get to people. Pay is not as high as some people think that it is,” Raaphorst said.

Counselor Charlie Hartpence works 60-70 hours per week split between two employers to care for her child as a single mom in Rapid City.

“I love the work that I do — it’s really fulfilling, but I regret taking this path in life,” Hartpence said. 

Her first full-time job at a social services agency paid $16 an hour in 2020. Now, she divides her time between a counseling practice and an adolescent care center. She has $120,000 of student loan debt from her undergraduate and master’s degrees, she said, “and I make less money now than I made working as a barista.”

“In school, they talk about not doing this job for the money, but I think people should at least be able to survive if not flourish,” Hartpence said. 

School counselors, who need a master’s degree to practice, also face low compensation that affects retention. The average salary for school counselors in Rapid City is $42,340.

“If the starting salary was higher, they would be more inclined to stay in the state,” said Daniel DeCino, associate professor in the Division of Counseling and Psychology in Education at USD, in an email.

‘Ecosystem’ support needed

In this strained system, some clients look beyond professionals for help. 

When people can’t get into a therapy appointment right away, they sometimes visit peer support groups run by the National Alliance on Mental Illness, said Sheri Nelson, executive director for the alliance in South Dakota.

“It’s not in place of therapy — it’s in addition to therapy — and it’s a good connection point for people who are waiting to see a mental health provider,” Nelson said.

On college campuses across the state, students find support in peer-to-peer mentorship programs run by Lost & Found, a suicide prevention nonprofit.

The mentors are not trained to be counselors — instead, they offer a listening ear, teach life skills like boundary setting, and connect their mentee to other mental health resources if needed. 

For “students who are at subclinical levels of depression and anxiety, this is exactly what they need” to prevent those conditions from becoming bigger issues, said Carrie Jorgensen, senior prevention program specialist at Lost & Found.

More of this “broader ecosystem support” could help providers by easing the strain on their services, said Erik Muckey, executive director of the nonprofit.

“It’s no fault of anybody, but we have to respond,” he said. “There is no other time that we can wait for this to pass because it’s not going to pass. It’s just going to continue.”