In 2021, nearly one in every seven adults in California experienced a mental illness, yet close to two-thirds of those adults, and two-thirds of adolescents with major depressive episodes, did not get treatment, according to a 2022 report compiled by the California Health Care Foundation (CHCF).

And while there are many barriers to mental health care – language, poverty, lack of health insurance, legal status, acculturation and stigma – one looms larger than the rest. California is facing a shortage of mental health providers, and in the Inland Empire, the shortage is critical.

The number of mental health providers in the Inland Empire is the second lowest in the state, with both San Bernardino and Riverside counties deemed federally designated mental health provider shortage areas.

Stacy Forcino, assistant professor of psychology and director of Cal State San Bernardino’s Community Counseling Center, explained, “Basically, there are not enough licensed mental health providers to cover the needs of the population. We’re an under-resourced area for a lot of professional services. It’s been historically difficult to have enough providers to meet both the general health and mental health needs of our local community.”

But CSUSB’s Community Counseling Center, now in its 50th year, is doing its part to address the shortage by providing hands-on training for a new generation of marriage and family therapists.

“The Community Counseling Center is a clinical training ground for students who are pursuing a master of science (M.S.) degree in clinical/counseling psychology,” Forcino said. “It’s a two-year program designed to meet the educational requirements for licensure in California as a licensed marriage and family therapist (LMFT).” Forcino said training in the center is a required course, and “gives our students practical, yet essential skills in counseling through supervised training and experience.

“We have the dual mission of student training and community service,” Forcino said. “It’s important to us that we’re serving the needs of the community in terms of mental health care, and our students typically stay in the local community, so we’re also creating a pipeline of clinicians in the community.”

The center “typically serves about 30 clients from throughout the Inland Empire per academic year and we typically train 12 therapists, who we closely supervise,” Forcino said.

“If a potential client is dealing with issues such as suicide, alcohol or drug addiction, we refer them to other providers or agencies,” Forcino said. “Our typical clientele are children and adults who are dealing with general life stress, anxiety, depression and child behavior problems. We provide diagnoses and therapy for mental health disorders, as well as more general counseling for wellness and self-exploration counseling.”

CSUSB students begin seeing clients, who are carefully screened by faculty members, the first semester of their first year, unlike most programs that begin clinical training in year two. The clinical time helps student therapists accrue the 3,000 hours of supervised professional experience, including 104 supervised weeks, needed to apply for licensure. During the second year of the program, students are assigned internships, where they continue accruing hours toward licensure.

Clients schedule an initial 30-minute consultation with Forcino, and once they begin seeing a student therapist, usually pay between $10 to $25 per session based on their ability to pay. “One of the barriers to getting mental health care is financial, and providing therapy on a low-cost sliding scale is something that we offer to the community,” Forcino said. Christina Deaton, B.A.’10, psychology, M.S. ’12, clinical/counseling psychology, earned her LMFT designation in 2016 and today is the clinic director of Lutheran Social Services in Big Bear, where she supervises a staff of 20.

“One of the reasons I chose Cal State was the cohort is so small – they keep it to 12 people. We really got a personalized education. When my mom went through a similar program at a private university, there were 60 people in her cohort. You’re not going to get the same level of education in a cohort that size,” she said.

Deaton began the first year of the program in mid-August and saw her first client less than two months later, in early October. “I was terrified,” she admitted with a laugh.

Student therapists are assigned one client during the fall semester and two clients during the spring semester, who they follow throughout the academic year, and each therapy session is recorded. Every week, the recordings of the sessions are reviewed by faculty and cohort members and each student is critiqued.

“Again, I have to emphasize the small cohort,” Deaton said. “We all watched these videos together. We were in every class together. We were talking about clients all the time together. I got to see how different people interacted with their clients. I really got to witness firsthand different ways of doing therapy for two years rather than reading it from a book or hearing how the professors did it.”

According to Forcino, “Our cohort size allows us to provide high-quality education and training, of both reasonable class size and trainee-to-clinical supervisor ratios.”

Studies have shown an increase in anxiety and depression as well as substance abuse since the onset of the COVID-19 pandemic, further increasing the demand for mental health providers.

Forcino explained that providing therapy remotely through online telehealth sessions was picking up some momentum before the pandemic, “but then COVID pushed it right over the edge and everybody switched to telehealth, including us,” she said. “We now offer telehealth as an option for clients who prefer it and who are appropriate for it.”

She noted that from one-third to one-half of the center’s clients now attend therapy sessions remotely. “Telehealth reduces barriers to access in pretty significant ways,” she said. “Especially for folks who are dealing with multiple demands in their life and don’t have the time or resources to drive out to the physical center on campus. That can really help.”

Sam Worrall, B.A.’16, psychology, M.S.’18, clinical counseling/psychology, earned his LMFT designation a little over two years ago and has been working full-time as a therapist since graduating. He’s worked primarily with clients who have experienced trauma and are managing addiction and substance abuse. He has seen both the positive and negative impacts of COVID-19 on mental health therapy providers and clients.

“The pandemic has absolutely changed how therapists operate for sure, and how we deal with things,” he said. At the pandemic’s onset in 2020, he was working at an addiction medicine facility in Moreno Valley, and for about a year, nearly all therapy sessions were virtual.

“The (facility) has always struggled with access because Riverside County is a giant county and it’s spread out. We covered patients out in the desert in Indio and Palm Springs and Palm Desert, and for them to drive an hour to get to us, and then an hour back, not counting traffic, could absolutely be a huge obstacle,” he said.

In addition, he said, “substance use and addiction tends to drain the finances. So, telehealth was a huge step in the right direction from my perspective. Plenty of peers would disagree, but I want to help as many people as possible, and telehealth allowed me to do that. It allowed me to see patients that I couldn’t normally see,” he said.

At the same time, the high rates of anxiety and depression placed new demands on mental health professionals, Worrall said. “The pandemic really strained the therapists on staff. All our caseloads increased by 40 percent during the pandemic, which was not something we were prepared for. I was salaried, working 40 hours a week, but I was showing up two hours early to do paperwork, working through lunches to see patients, and usually staying an hour or so after work. I did that for roughly a year before I couldn’t do it anymore – burn out.”

Worrall added that since the pandemic began, “there have been a number of colleagues who have left the field, and there have been a number of colleagues who have just found that it’s better going into business for themselves.” He notes that he himself plans to launch his own business within the next year or so.

“A year and a half, two years ago, would I do that? No, I had zero interest. I would have said, ‘I don’t want to do the business stuff. I’m here to do therapy. That’s what I want to do,’” he said. “Since the pandemic, since working as much as I have, since gaining the skills I have developed over the years that are not necessarily akin to a therapist, now, absolutely.”

Julelisa Beltran, B.A. ’17, psychology, M.S. ’20, clinical counseling/ psychology, is now in business, partnering with a colleague who launched a firm that provides assessment, consultation and treatment services for clients with behavioral disorders throughout the Inland Empire.

Since graduating, Beltran helped the Redlands Unified School District launch its mental health program from the ground up as she accrued licensure hours for the LMFT designation. During the same time, she pursued designation as a board-certified behavior analyst (BCBA), which she received in August.

“I work with clients in-home, in-clinic and at a non-public school in Hesperia,” she said. “Once I’m an LMFT, our firm will be implementing mental health services,” she said. “I utilize my therapeutic skills – displaying compassion and having an empathetic ear – every day. But then I also engage with my clients through practical, action-oriented steps, creating goals through a behavioral lens.

“I feel like I get burnt out doing mental health therapy 100 percent of the time. I get burnt out doing behavioral health therapy100 percent of the time. If I can find a good balance of providing mental health therapy to clients as well as my behavioral therapy too, that would be awesome.”