TABLE 2.

Key themes and representative quotations from interviewees (N524) in the behavioral health system in Oregon

Theme	Quotation
Low wages	“We have a lot of people in the field [who] want to be here … but they can’t afford … this job. They’re trying to put two halves together to make a whole.” (residential treatment director) “There’s no attraction. Why would you want to work here when you can [work] elsewhere and make more than we have the ability to offer?” (community mental health program director)
Documentation burden	“How do we have the experience of our workforce be directed at supporting community members, rather than meeting all of the administrative requirements? This work is so hard, and those requirements on top of it [are] wearing our folks down.” (county behavioral health director) “We’re always constantly changing things … [in order to meet reporting standards], which then puts an additional strain on clinicians and staff alike, because they’re trying to run and catch up to things.” (residential treatment director)
Poor administrative and physical infrastructure	“I heard it from one of my legislators—he’s saying, ‘What about all the new money?’ Well, it doesn’t cover [current needs]. [The] infrastructure that hasn’t been dealt with. You can slap a coat of paint on something that is not working well, but … you may need to replace it or you may need to take it down to bare wood.” (community mental health program director) “We have different funders for every activity that we do as a behavioral health business. There is no flexibility in any of the funding streams.” (behavioral health association administrator) “[Billing for dual-diagnosis clients is really difficult], because you either have to bill [service delivery] on the substance use disorder side or you have to bill it on the mental health side. It’s as if a person is split down the middle. It’s just this constant battle for billing.” (certified community behavioral health clinic director)
Lack of opportunities for career development	“Peers do so much across the state. How can that movement be in a positive direction for peers to not only be able to know that they can advance, but also have a track that they can grow incrementally, education-wise, and be incentivized by the pay structure?” (former peer provider, current administrator) “It has to be a system that allows people to leave work to be trained. Right now, folks are so busy with making sure they’re seeing the people they’re supposed to see [to] generate the revenue that their organizations need. There isn’t time to be able to move away from that grind to actually be engaged in ongoing training.” (state agency administrator)
Chronically traumatic work environment	“In our setting [county behavioral health], we tend to see people who are very ill for very long times; we don’t have the satisfaction of seeing people get better. The community is taking care of people who 10 years ago would have been in a hospital. It’s putting out fires almost every single day. You can only do that for so long [before] you are going to be burned out.” (community mental health program director) “The amount of work and … trauma this workforce goes through is immense, [including] enormous caseloads because of a shortage of other staff. [They are] having to work … longer and harder, because they don’t have that access to the higher level [of care]. So, they are enduring all the stress and trauma and burnout and overwork.” (former peer provider, current administrator)