South Carolina has struggled to meet the demand for youth mental health services amid what experts are calling a “national emergency” in children’s mental health.
At a time when emergency self-harm calls are rising faster among South Carolina children 14 and under than any other age group, the shrinking number of mental health clinicians working in South Carolina schools is inadequate to meet students’ growing needs, a recent audit of school-based mental health services found.
The audit, conducted at the request of Gov. Henry McMaster, found school-based behavioral health services offered by the Department of Mental Health were available in less than half of the state’s public schools.
It recommended the state augment and restructure its program, which has shrunk considerably over the past year as mental health counselors left their jobs during the COVID-19 pandemic for less stressful or better-paying opportunities.
The state Department of Mental Health has lost more than a quarter of its school-based mental health workers since 2020, and as a result serves 214 fewer schools than it did just two years ago, according to data provided by the agency.
South Carolina Health and Human Services Director Robert Kerr, whose agency audited the program, called the state’s current ratio of one mental health counselor for every 1,300 public school students “woefully inadequate.”
The “gold standard,” which few, if any, states meet, is one counselor for every 250 students, Kerr said.
“Our goal is going to be to cut (our counselor-to-student ratio) in half initially, and then hopefully cut it in half again,” he told the Joint Citizens and Legislative Committee on Children last week.
Expanding choice in school-based mental health
Kerr’s ambitious plan to boost the number of school-based counselors involves empowering districts to hire their own clinicians and reassess their mental health programs rather than relying solely on school-based services provided by the Department of Mental Health.
While some schools already employ their own counselors or contract with private therapy providers, the majority that offer counseling services use DMH clinicians.
For the most part, parents and school staff are satisfied with DMH’s services, but the agency’s dwindling number of counselors are stretched increasingly thin and often find themselves traveling between multiple locations each day as they attempt to juggle burgeoning caseloads.
One of the primary barriers to schools hiring their own counselors has been the state’s Medicaid reimbursement rate, which pays school districts and private providers less than half what it pays DMH for identical counseling services, the audit found.
Kerr, who was tasked with spearheading the state’s plan to expand school mental health services because his agency sets Medicaid rates and is the primary payer for school-based counseling, wants to change that.
On July 1, he plans to raise reimbursement rates for schools and other non-DMH providers under the assumption the additional money flowing into districts will enable them to hire their own counselors at competitive salaries, contract with private counselors to provide in-school therapy services , or some combination.
Health and Human Services will tap into its cash reserves to front the rate hikes this year and plans to request more money from the General Assembly to maintain them in the future.
Kerr believe that if schools have the financial flexibility to hire their own clinicians at market rates, as the audit found a majority of them would prefer to do, they’d no longer be relying on DMH counselors and could develop more robust and integrated mental health programs.
“By shifting control into the districts, we’re going to pay the districts directly so they now decide how many counselors they need,” he said. “They can assign that to DMH, they can assign it to a private provider, but they’re in charge of their counseling load.”
Improving counselor quality is also on Kerr’s agenda.
His agency is partnering with the University of South Carolina to develop school-based mental health resources and professional development opportunities for K-12 school counselors, specifically on crisis intervention, which the audit found few DMH clinicians are trained to provide.
It’s also looking at phasing in a requirement over the next three years that school counselors get professionally licensed, as only about one-third of all DMH mental health counselors currently hold licenses.
A licensure requirement would ensure clinicians are better trained while also likely reducing insurance claim denials, which on occasion leave privately-insured students with large, surprise bills for in-school counseling.
Children on Medicaid or the state’s health plan pay nothing for school-based mental health services and uninsured children pay on a sliding scale determined by family income. But because many private insurance plans don’t cover school-based services or services delivered by unlicensed counselors, privately-insured families are sometimes left to pick up the bill when their child sees a counselor at school.
The proposed changes to South Carolina’s school-based counseling framework won’t necessarily eliminate private insurance denials, Health and Human Services spokesman Jeff Leieritz said. They may, however, decrease the likelihood school districts pass additional costs on to families, which the audit found sometimes prevents students from seeking the help they need.
Deborah Blalock, DMH’s deputy director of community mental health services, said her agency is generally supportive of Kerr’s efforts and acknowledges that South Carolina needs more school counselors than the Department of Mental Health can provide.
She is worried, however, that non-DMH providers will “cherry-pick” the children who are easiest to serve, leaving the more challenging students to seek therapy elsewhere or simply fall through the cracks.
“DMH serves the entire spectrum of children, so I’d want to make sure that happens regardless of the provider,” she said.
The agency has struggled to attract and retain quality counselors due in large part to the low salaries it pays workers.
The agency’s starting pay for a master’s-level counselor is $36,500, a rate Kerr called uncompetitive and “woefully insufficient” to entice candidates.
Blalock said the agency is well aware of its meager salary scale, but lacks the authority to raise it.
Mental Health officials have asked the state Department of Administration for the go-ahead to hike counselor pay and expect a response by mid-May. Blalock said the agency wants to boost its salary floor by at least $10,000, which would make it competitive with other state agencies and some private companies that have successfully lured away counselors in recent years.
If the Department of Administration signs off on higher clinician salaries at DMH, the challenge then becomes finding the dollars to support the more generous compensation plan.
None of the state’s current budget plans include money to pay for the proposed agency salary increases, Blalock said.
Mental health resources
If you or someone you know needs mental health support, a variety of in-state and national resources are available.
DMH operates a mobile crisis support service for anyone experiencing a mental health crisis with teams able to assess and respond on-site to crises, with law enforcement, if appropriate. Mobile crisis support is available 24/7/365 at 833-364-2274.
The Suicide Prevention Lifeline, a nationwide service available at (800) 273-TALK (8255), is another 24-hour resource for those experiencing a mental health crisis.
For anyone in need of assistance who isn’t ready or able to call into a hotline, the Crisis Text Line is an option. South Carolinians can reach the line 24 hours a day by texting HOPE4SC to 741741.