David Kaplan, chief professional officer for the American Counseling Association, delivered the following keynote presentation at the American Association of State Counseling Boards on Jan. 4. He can be contacted via email at firstname.lastname@example.org or by phone at 703-823-9800 ext. 397.
“I am a prisoner in my own state.”
These were the words of a professional counselor who had called ACA in tears. She had been licensed and practicing in Wisconsin for over 20 years. Then, through no fault of her own, she fell in love. And love lead to a proposal of marriage. The complicating factor was that her fiancée lived in a state 900 miles away. No big deal, she decided to transfer her license to her new state and start her new life and family. But when she contacted the state licensing board in her fiancée’s state, she was told – despite the fact that she had been licensed for two decades and despite the fact that she had a spotless record without any complaints made to her licensing board – that she was not eligible to be licensed. She had to choose between practicing in her home state and leaving the counseling profession to be with the man she loves.
We have a real crisis in counselor licensure. Counselors are trapped in their own states.
My goal for our time together is that by the end of my talk you will understand the problem. But I want to go way beyond that. I am hoping that you will take ownership of the problem because you are the ones with the power to solve it. And, if you are not too furious at me by the time I get to it, I want to propose a way that we all can work together to solve this longstanding and painful issue.
Let me read to you from an op-ed that just came out in the January Counseling Today by Thomas Sherman, a licensed counselor and a clinical supervisor with the military OneSource program which provides counseling and support services to active duty, National Guard, and Reserve service members and their families. I would like to read an extended portion because I think it really gives you a feeling for what counselors are going through when they try to transfer their license to a new jurisdiction. [Read complete Counseling Today opinion piece, “License portability: One counselor’s journey across state lines”]
License portability: One counselor’s journey across state lines
January 2012 | Opinion
Thomas J. Sherman
As an existentially oriented counselor, I am well versed in the absurd, but I was not quite prepared for how far my ability to accept it would be stretched when I moved three hours away and across state lines. I graduated with my doctorate in counselor education in May from a well-known university and, following graduation, moved to join my partner who had received an outstanding job in another state. Being a licensed counselor, I assumed it would be easy for me to follow her and get a job practicing counseling. How wrong I was.
When I graduated with my master’s degree, I moved to a state that required unlicensed counselors to be under the supervision of a licensed professional. In three years, I completed the 4,000-hour clinical residency, which included 2,000 hours of direct client contact and 200 hours of supervision required for licensure in the state. In June 2010, I passed my state licensure exam. In April 2011, when my partner and I knew we would be moving to a different state, I began reviewing the requirements for transferring my license to the new state.
The requirement for transferring a license is listed as either two years of practice as a licensed counselor or 2,000 hours of clinical professional counseling experience. Despite these requirements being listed twice on the licensing forms, I called the state counseling board to confirm that I met the requirements and was completing the correct forms. After outlining my experience, I told the person at the counseling board that I had held my license in the other state for only one year but that I possessed well over 2,000 hours of clinical experience. The person with whom I spoke at the board notified me that, given my clinical experience, I should be able to transfer my license.
By the end of May, I had gathered the required signatures from my professors and former supervisors, collected transcripts from all of the schools I had attended, written the required check to the board and mailed a license verification form to the state counseling board where I currently held my license so it could sign and return the form to the new state to which I was moving. After waiting several weeks into June, I called the counseling board in the state to which I was moving to see if it had received my licensure verification form. I was told the person with access to the files was on vacation and would “be back sometime next week.” The next week, I called several times before reaching the person with whom I needed to speak, only to be informed that the form had not yet been received. This person also told me that if the form was not received by July 15, I would have to wait until Aug. 15 for the counseling board to review my application.
Having this information, I called my former licensing board to inquire about my licensure verification. A voice mail greeted me, informing me the board had a high volume of applications and instructing me to leave a name and number, which I did. The following day, having not received a return phone call, I called several times until finally reaching an actual human whom I could ask about the status of my license verification. I told this person the check for the verification fee I had sent with the form had been cashed in June, but as of July, my new counseling board had not received the form. This person told me my former counseling board met only once per month and had already convened in June prior to my request being received. I inquired as to when the counseling board would meet next. The response: “Sometime in July.” The person could not provide a date when the board would meet to sign my form.
This raised a second concern for me. Because I had submitted all of my forms in June, I had allowed my license in my former state to lapse at the end of that month, not seeing the benefit of paying for and carrying two licenses in different states. I attempted to call my former licensing board again to determine if this lapse would affect the verification of my license because the board would not be reviewing it until July. Once again, I was unable to reach anyone, so I left my question on voice mail. I never received a phone call. Instead, on July 15 I received an email indicating the board had mailed out my licensure verification. The email didn’t address my question of whether my license was still valid.
After waiting another week, I called my new counseling board to confirm receipt of the licensure verification form. It was at this point I was notified that I did not meet the requirements for transferring my license because I had not held my previous license for two years. I told the person at the board I was getting different messages and asked if I could speak with someone higher up. I was given the number of the board’s director. I reviewed my previous conversations with the director, indicating that someone at the board had confirmed my understanding of the state’s licensure requirements. The director said the expectation was that if an individual had a counseling license for two years, he or she would also have 2,000 hours of clinical practice, meaning that a person was required to have both, not either/or, despite the wording on the forms. I shared that the state where I previously had been licensed required 1,000 more contact hours and 100 more hours of supervision than did my current state’s licensure requirements. I was told I had two options: I could wait for the board to review my application in September and inform me of its decision in October, or I could send in another check, complete a different set of forms and mail back in the application for regular licensure — and still wait until October.
Exasperated, I communicated to the director that I had been unemployed for three months while following the instructions provided by the board to get my license transferred. When told the earliest I would hear whether my forms were correct would be October — another three months away — I asked how the board could justify the delay in responding given that a license is required to practice. The director told me that even if the board had received my application materials in June, they still would not have been reviewed until September. In May and June, the director explained, the board reviewed disciplinary issues that kept its members from approving licensure applications, and then the board was on recess through July and August, despite what the person at the counseling board had previously told me regarding the board’s meetings. For four months (fully one-third of the year), the counseling board did not review applications, and when it would review them, it would take 30 days to respond. Following a response, applicants must still sit for a counseling law exam and/or a licensure exam. I finally asked if I could speak to someone on the licensing board who might possibly give me some concrete answers. The director said she could make the request but added that the board did not usually honor such requests.
As of mid-August, I still had not received a response from the counseling board.
In October, I finally received my letter from the board indicating that I could sit for the licensing examination within a week. The letter indicated I would need to bring a license to confirm my identity. On the letter, my name was incorrect. When I attempted to contact the person listed on the letter to follow up, I reached her voice mail, which informed me she would be out of the office until after the date of the exam. Through the counseling board’s main number, I was able to reach a person who could correct my name. Finally, at the end of October, nearly six months after I began the licensing process, I received my counseling license in the new state.
Unfortunately, what I heard from the counselor in Wisconsin and what you just heard from the op-ed is not unusual. ACA receives a dozen calls a week – a week – from licensed counselors who have been stymied and frustrated in their attempts to transfer their license to a new state. We hear horror story after horror story. I’ll bet you do, too – or at least your administrator does.
So how did this nightmare develop? There are two levels of answers to this. The simple explanation for why license reciprocity for professional counselors is so difficult is that there is a patchwork of licensure titles, scopes of practice, and sets of education requirements. There are over 45—45! — titles used by state counseling boards including: Licensed Professional Counselor, Licensed Associate Counselor, Licensed Associate Professional Counselor, Licensed Mental Health Counselor Associate, Licensed Professional Clinical Counselor, Clinical Counselor intern, Clinical Counselor Trainee, Provisional Licensed Professional Counselor, Licensed Professional Counselor of Mental Health, Licensed Associate Counselor of Mental Health, Registered Mental Health Counselor Intern, Associate Professional Counselor, Licensed Clinical Professional Counselor, Licensed Clinical Professional Counselor Intern, Licensed Clinical Mental Health Counselor, Licensed Professional Mental Health Counselor, Registered Counselor Intern, Professional Counselor Intern, Licensed Professional Counselor Intern, Certified Professional Counselor Intern, Conditional Licensed Clinical Professional Counselor, Conditional Licensed Professional Counselor, Registered Counselor, Certified Professional Counselor, Licensed Graduate Professional Counselor, Limited Licensed Professional Counselor, Provisional Licensed Professional Counselor, Licensed Clinical Professional Counselor, Licensed Mental Health Counselor, Provisional Mental Health Counselor, Licensed Mental Health Practitioner, Licensed Independent Mental Health Practitioner, Licensed Mental Health Practitioner – Certified Professional Counselor (that is seven words!), Provisional Licensed Mental Health Practitioner, Provisional Professional Counselor, Limited Permit, Licensed Professional Counselor Associate, Professional Counselor/Clinical Resident, Registered Counselor Trainee, Registered Intern, Professional Counselor with Provisional License, Licensed Professional Counselor-Mental health, Licensed Professional Counselor-Mental Health Service Provider, Certified Counselor, Agency Affiliated Counselor, Licensed Professional Counselor Trainee, and Provisional Professional Counselor.
One licensing board alone uses five different license titles! How can that be anything but confusing to the public? There is one state with a “Certified Mentor” credential and another with a “Certified Advisor” credential. What the heck do those mean? Some states have one tier. Some have two tiers.
Your scopes of practice are just as confusing. Some permit the diagnosis and treatment of mental disorders. Some don’t. Some focus on human growth, life-span development, and wellness. Others don’t. Some include career development. Others don’t. Some include play therapy. Others don’t. Some include couples and family counseling. Others don’t. Some allow testing. Others allow assessment. Some allow treating personality disorders. Others don’t. Some include sexual dysfunction. Others don’t. Some include treating substance abuse. Others don’t. Some include working with disabilities. Others don’t. Some include consultation. Others don’t. Some include crisis intervention. Others don’t. Some include group counseling. Others don’t. Some include guidance. Other don’t. Some include research. Others don’t. I could go on, but you get the point. In a nutshell if you read any 20 state counseling board scopes of practice, you will see 20 different skill sets.
Are education requirements any better? What do you think? Some states require 60 graduate credits. Some require 48 credits. One state even specifies 42 credit hours – how they got 42, I (and the public?) honestly have no idea. Some do not specify the number of credits at all. Some of your state boards utilize the CACREP guidelines. Others don’t. One (it was 2 for a short period of time) requires a CACREP degree. Everyone else doesn’t. Some include CORE. Others don’t. Many do not mention either CACREP or CORE. One licensing board requires 1,500 hours of supervised experience. Others require 2,000 hours. Still others require 3,000 hours of supervised experience. One requires 3,200 hours. Another requires 3,500 hours. Another 3,600 hours. Two boards even require the interesting number of 3,360 hours. There are also boards that require 4,000 hours. If the board with the greatest number of hours wins, it is New Jersey with a required 4,500 hours of supervised experience. If, however, the prize goes to the jurisdiction with the smallest number of supervised hours it is Puerto Rico with 500. What does it say to the public when there is a difference of 4,000 hours of required supervised experience across counseling licensure boards (and even if you want to discount the lowest number the range is still 3,500 hours)? Wait- but there’s more! One board requires all supervised experience to be obtained within a 7 year period. I’m not sure why – maybe they thought it was a doctoral dissertation. There is also a board that requires all supervised experience to occur within the 5 years prior to the application.
Some counselor licensing boards require 1 year of experience. Others require 2 years. Still others require 3 years of experience. There is one board that requires 21 months of experience and a board that requires 4 years of experience. Some states allow part time experience to count. Others only count full time employment.
Some states require the NCE exam. Others require the NCMHCE. Some licensing boards allow either the NCE or NCMHCE. Some require both. Some will allow the rehabilitation counseling exam to count. Others won’t. A few jurisdictions don’t trust national exams at all and make up their own. One board has an oral exam. Another, an essay exam. A third requires a videotape sample. And, in a display of unparalleled flexibility, one state allows applicants to submit the results from any of 7(!) different examinations including the ATCB, CBMT, PEPK, AAODA, and EMAC, none of which I have any idea what they are.
And if this confusing stew of credits, supervised hours, years of experience, and exams isn’t enough, there are the education requirement permutations. Check out this idiosyncratic rule in one state: “An applicant may subtract 1,000 hours of the required professional experience for every 15 graduate semester hours (or 22.5 quarter hours) obtained beyond the master’s degree from a regionally accredited academic institution , provided that the coursework is clearly related to the field of professional counseling.” Woe to the counselor who takes advantage of this rule and then moves down the line to another location only to be told that their new jurisdiction does not have such a rule and they are thus ineligible for licensure.
I mentioned that the simple answer as to why the crisis in license portability has occurred is the patchwork and jumble of licensure titles, scopes of practice, and sets of education requirements. The deeper cause relates to the mindset of counselor licensure boards – that would be you. I apologize but I am going to continue to gore a few oxen. Counselor licensure boards seem to operate from four peculiar world view generalizations:
World view generalization #1: Our state is the only state that licenses qualified counselors. We can’t trust the credentialing process of any other state.
World view generalization #2: We can’t cooperate with other licensing boards because we will lose the appearance of complete independence.
World view generalization #3: We don’t need to provide anything resembling customer service to counselors because we are here for the public.
World view generalization #4 – and the one I would like to focus on: Licensure reciprocity and portability are not our concern because they are guild issues, not public protection issues.
I want to tackle the last world view generalization and convince you that license portability is very much a public protection issue. Because if I can do so, then the other world view generalizations will fall into place. You will see the need to cooperate with other states and jurisdictions and to provide decent customer service for your licensees. You will also – hopefully – be open to the plan to assist you that I will be talking about in a bit.
I would propose that there are three reasons why licensure portability is a public protection issue and should therefore not only be on your radar screen, but be a priority for counselor licensure boards. The first is the fact that in order to meet your mandate to serve the public, you need more licensed counselors in your state or jurisdiction. This may come as a surprise to those of you who live in cities or university towns where there are plenty of mental health providers competing with each other for clients. To find the problem, you have to look behind rocks, over creeks, and through the leaves and tall grass. Specifically, there is a dire shortage of counselors in rural areas. How short? Myers and Gill found that 60% of rural areas are designated mental health shortage areas by the federal government. Current estimates (as of this past Sept, 1) from the U.S. Department of Health and Human Services are that there are over 3,600 mental health shortage areas with a total population of almost 89 million people living in them – that is 1 in 4 Americans. I have a listing of every designated mental health shortage county in the United States with me if you want to check out your state. HHS estimates that it would take almost 6,000 additional mental health providers to meet the needs of citizens who live in rural areas.
We have known about the shortage of rural mental health professionals for a long time. It was documented by the U.S. Department of Health Education and Welfare in 1969. The Report of the National Action Commission on Mental Health of Rural Americans highlighted the problem in 1988. And President Bush’s New Freedom Commission on Mental Health made the lack of access to mental health services by rural Americans a key point of focus in 2002 (and I testified on behalf of ACA and the counseling profession).
Counselor licensure boards must focus on rural Americans. That is because they constitute especially vulnerable populations. The HHS report Rural Mental Health in America states, quote, “Groups at greater risk for mental disorder – the elderly, the chronically ill, the poor, and the dependent – are disproportionately represented in rural areas. Myers and Gill add rural women to the list. They report that 41% of poor, rural women self-report significant depression, in part because they often experience, quote ”low self-esteem, low perceptions of ability to set or achieve life or career goals, a lack of feeling of empowerment, and an external locus of control.” The researchers report that as a result, lower SES rural women, “frequently resort to negative coping behavior, notably substance abuse.” In response to these issues, Myers and Gill developed a multi-factor wellness model for counselors to use with rural women. So professional counselors know what to do to meet the mental health needs of rural Americans. Unless you want to write off these vulnerable rural populations and say that your mandate only applies to those who have the good sense to live near a city or university town, you need more counselors. And you need programs to encourage licensed counselors to live and work in rural areas. The development of those programs is a topic for another talk on another day. But the good news is that many professional counselors – especially when compared with other mental health professions – seem to be rural types. And so facilitating the ability of licensed counselors – especially those who want to live in the boondocks – to emigrate to your state is in the best interest of the rural population of your state or jurisdiction.
The second reason why licensure portability is a public protection issue has to do with your mandate to meet the needs of underserved populations. The U.S. census bureau estimates that minority populations comprise 34% of the United States and they are growing rapidly. Ten years ago, the President’s New Freedom Commission on Mental Health found that the unmet needs of underserved populations was so great that it set improving access to quality care that is culturally competent as a major goal. Let me read you a small portion from the section of the report titled, Minority Populations are Underserved in the Current Mental Health System: “Racial and ethnic minority Americans comprise a substantial and vibrant segment of the U.S. population, enriching our society with many unique strengths, cultural traditions, and important contributions. As a segment of the overall population, these groups are growing rapidly; current projections show that by 2025, they will account for more than 40% of all Americans. The mental health system has not kept pace with the diverse needs of racial and ethnic minorities, often underserving them. Racial and ethnic minority populations are less likely to have access to mental health services and so are less likely to receive needed mental health care.” The President’s New Freedom Commission on Mental Health also reported that, “racial and ethnic minorities are seriously under-represented in the core mental health professions.” So just as you need to recruit counselors to meet the needs of rural citizens, you need to recruit experienced minority counselors and majority counselors who can provide services to underserved populations. And that means facilitating license portability.
The third reason why licensure portability is a public protection issue has to do with the roaming characteristics of the public we serve. The U.S. Census Bureau – them again – says that 7.6 million Americans move to another state each and every year. That is a lot of public – 7.6 million people. And you have an obligation to look out for them when they move to your state or jurisdiction. It seems to me that a major part of your public protection role is not to confuse the hell out of them. But how can you do otherwise when there are 45 counselor licensure titles out there, a potpourri of licensure scopes of practice, education requirements that vary from no stated credits to 60 credits, a variety of accreditations, experience that ranges from one to four years and 500 to 4,000 hours, and nine exams or combinations of exams? How are the 7.6 million U.S. citizens who move from state to state every year supposed to know what they are getting in a licensed counselor? They don’t and can’t, given the current state of counselor licensure boards. And we all know that when someone is confused about what they are getting in a licensed professional, they tend not to get any help at all. I have moved to six different states since I started working. If each state had different qualifications for a physician and I had no idea what a primary care doc would be called, what their training was, or what they could do, or what I would be getting in my next state, I think I would stop seeing physicians. How many people have stopped seeing counselors for the same reasons? Standardizing counselor licensing requirements across states is in the best interest of the 7.6 million Americans who move each year. And the good news is that standardizing requirements will facilitate license portability which will allow you to more easily recruit counselors who want to work with the underserved rural and minority populations. See how this all fits together?
So at this point I hope that you see the need to fix the nightmare that is portability and that it is in the best interest of the public to do so. And I also hope that you are thinking, “What do we do about this mess?” I am here to propose a solution on behalf of the profession of counseling. In order to do so, I need to transition from my role as ACA’s Chief Professional Officer to my role as the Administrative Coordinator for 20/20: A Vision for the Future of Counseling.
I know that some of you have been around a while and are familiar with 20/20 and that others are new to licensing boards and may not know much about this initiative. So for those less familiar with 20/20, let me give you some brief background. I know that Barry Mascari will be speaking more about this initiative during his keynote and that is only appropriate, since Barry can be considered the father of 20/20 as it was generated from his doctoral dissertation. 20/20: A Vision for the Future of Counseling is the United Nations of the counseling profession. Co-sponsored by you – AASCB – along with ACA – 20/20 involves all of the organizations that identify themselves as clearly falling within the profession of counseling. There are 31 organizations involved including AASCB, ACA and its divisions and regions, NBCC, CACREP, CORE, CRCC, NRCA, and CSI. I apologize for throwing out all of those initials, but if I gave the full name of the associations we would be here till eleven o’clock. For the past six years, these 31 organizations have worked together and focused on the heady goal of developing a 15 year strategic plan for the counseling profession, hence the play on 20/20 as both having excellent vision and planning for the year 2020. As such, 20/20: A Vision for the Future of Counseling is historic in that it marked the first time that the counseling profession had decided to proactively plan its future rather than simply react to events and challenges as they occurred. As such, 20/20 is a milepost in the maturation of our profession.
To date, 20/20 has had two historic – there is that word again – achievements. The first is the document Principles for Strengthening and Unifying the Profession (also known as the Statement of Principles). The Statement of Principles is the first time that counseling has endorsed core principles that bind all of our specialties and organizations together into one profession. It is also the first time that the organizations that represent counseling have put on paper and endorsed that we are one unified profession.
The second historic achievement is the consensus definition of counseling. Until now, professional counseling has had multiple definitions of what it is that we do – if you look at five “Introduction to Counseling” textbooks you will find eight definitions of counseling. The 20/20 delegates wanted to promulgate a concise definition of counseling that would become the standard for the public and with legislators. The delegates did an outstanding job and the result was a definition endorsed by both the delegates and participating organizations: Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals. Now, for the first time in the history of the counseling profession, we have one definition of what it is that we do. We have promoted the 20/20 definition of counseling and are seeing it appear on websites, business cards, syllabi, and in books. We appreciate that at least one licensing board – thank you Arkansas – has agreed to use the new consensus definition of counseling in general public presentations.
Which brings us to the current 20/20 initiative: The Building Blocks to Portability Project. Now that we have a firm foundation with the Statement of Principles and the consensus definition of counseling, the 31 organizations that represent the counseling profession are focusing their efforts on licensure portability. To do this, the delegates are working on developing three things: a consensus license title, a consensus license scope of practice, and consensus licensure education requirements.
How are they doing this? By using a modified Delphi approach – the same approach that we used successfully to construct the consensus definition of counseling. A Delphi is a research methodology that is used to help a number of individuals with different perspectives and thoughts on an issue come to a reasoned and solid decision. So when you have delegates from two and a half dozen organizations trying to agree on one title, one scope of practice, and one set of education requirements, it fits the bill nicely!
The delegates have been divided into three workgroups representing the three building blocks to portability – license title, license scope of practice, and license education requirements. Each group first develops a list of possibilities. They can use data to assist them in exploring the initial options. For example, the scope of practice workgroup has asked for a content analysis of all of your 52 scopes of practice (52 – don’t forget about DC and Puerto Rico). Each workgroup then evaluates and rates all the possibilities within their building block and works with those concepts that float to the top. They combine the most highly rated items and then revaluate and re-rate the new ideas. Rinse and repeat. As they go through these iterations, the best ideas merge and synthesize until one option in each building block is the clear winner.
At that point, the draft title, scope of practice, and education requirements will be circulated to all delegates and a consensus achieved. We usually do the final group evaluation at an in-person meeting at the ACA conference. Essentially, we lock them in a room and say that they can’t leave until they complete final tweaks to the workgroup results. We consider an item to have achieved consensus when at least 90% of the delegates sign off on it. We will then circulate the consensus title, scope of practice, and education requirements to the leadership of the 31 participating organizations and ask for organizational endorsement.
And here is where you come in. Once these building blocks are developed and endorsed by the delegates and participating organizations, we will be able to promote them as our profession’s recommended requirements to counselor licensing boards. Our goal is to persuade every one of you to agree with the profession and to adopt our title, scope of practice, and education requirements. We know that this will not be easy and will obviously take time, but states that do adopt the consensus licensure requirements will have a much easier road to establishing reciprocity – and thus portability – since their requirements will be equivalent.
So I am here to give you a heads up that the counseling profession will be coming out with a consensus license title, scope of practice, and education requirements. And I am also here to request that you work with the profession to implement these building blocks to portability. If our time together this morning has had any impact, then the old excuses about portability won’t apply – that you don’t trust other licensing boards enough to standardize requirements, that you will lose independence or that it is not your problem. It is your problem because the lack of license standardization in the United States is not just creating prisoners out of licensed counselors, it is hurting the public you are sworn to protect.
So please work with us – the counseling profession – to solve the portability crisis through your commitment to the careful consideration of adopting the consensus license title, scope of practice, and education requirements that will come out of the 20/20 Building Blocks to Portability Project.