An emerging mental health crisis is proving increasingly frustrating and alarming to counselors.
More and more military personnel are returning from Iraq and Afghanistan in dire need of mental health services, but according to Veterans for America, a leading veterans rights group, the ratio of providers to clients throughout the Department of Defense and the Department of Veterans Affairs is grossly disproportionate, with the need greatly outweighing the available resources. Both the VA and TRICARE, the DOD’s health care system for active duty and retired service members and their eligible family members, mandate unnecessary supervision of licensed professional counselors and refuse to recognize the full value of these professionals. Because of the stance taken by the federal government, many LPCs aren’t able to or have given up trying to help the men and women of the U.S. Armed Forces. The current shortage of qualified mental health professionals to treat military personnel has led to longer wait times, with more and more people falling through the cracks, says Stephen Robinson, the government relations director for Veterans for America, a program of the Vietnam Veterans of America Foundation.
The circular logic is maddening to many mental health professionals, especially when the answer appears to be so simple: The DOD and VA should allow LPCs to do the work for which they are qualified and pay them fair wages for their services. Unfortunately, that seemingly simple solution is wrapped up tight as a mummy in red tape.
TRICARE is the health care system for military personnel and their dependents, covering an estimated 10 million individuals. Although LPCs have been TRICARE providers for many years, they still lack independent practice authority under the program. Under current law, licensed mental health counselors are the only mental health professionals required to operate under physician referral and supervision.
Service members are first required to see their doctor, who then must refer them to an LPC. TRICARE will only reimburse LPCs if the referring doctor signs off on (supervises) the treatment. The physician-referral requirement means that mental health services are often overseen by a physician who has little to no education, training or experience in the use of therapy for treating mental and emotional disorders.
“Almost a year ago, a TRICARE client came to my office with a doctor referral from her physician,” says Jim Latham, an LPC in San Antonio. “I provided the PCP (primary care physician) with progress notes. I submitted the claims to TRICARE with a copy of the PCP authorization and a note certifying I had sent progress notes to the PCP. TRICARE informed me I had to provide proof of supervision. The PCP had not commented on my progress notes, so I assumed he agreed with my treatment. When I requested a statement of supervision, he informed me that he was not going to supervise anyone.” The doctor did not consider nonresponse to the progress notes as supervision, Latham says, so TRICARE denied the claim.
Latham was naturally upset with the outcome but says the fault ultimately lies with TRICARE policy, not the “supervising” physicians. “Military doctors don’t have a lot of time, and they aren’t going to take on an obligation like that,” he says. “If you were an internist, would you take on the responsibility of supervising a mental health practitioner when you don’t have any training in it? It just doesn’t make any sense.”
Because of the hassle of doing business with TRICARE, Latham now refuses to accept those clients. “For me, this is particularly hard because I was a naval officer during the Vietnam conflict. I’m ex-military,” Latham says. “With my military experience. I can relate to these people — I’ve been through it. I have a knowledge base that a lot of therapists don’t have, and I can’t serve the people that want to be served. It’s not a monetary thing so much, but attempting to work with TRICARE is a horror show for LPCs. It’s too frustrating trying to do what they ask, then their doctors won’t cooperate with supervision. TRICARE treats us like second-class citizens.”
Many parties involved in the TRICARE conflict say that requiring physician referral and supervision not only discriminates against LPCs but provides yet another obstacle in properly caring for a population that is already hesitant to seek out mental health services. Additionally, many experienced counselors say they find themselves losing clinical supervisor positions within the DOD to less experienced social workers and psychologists. Others say counselors in DOD clinics and hospitals are often asked to provide services only under the direct supervision of another type of provider or to have their clinical notes reviewed by a supervisor.
On June 22, the Senate passed legislation authorizing defense spending for Fiscal Year 2007 but failed to include language establishing independent practice authority for licensed TRICARE mental health counselors. The House of Representatives passed a defense authorization bill in May that includes a provision sponsored by Rep. Robin Hayes (R-N.C.) granting independent practice authority to licensed mental health counselors practicing under TRICARE. The defense authorization legislation will now go to a House-Senate conference committee, which will work out the differences between the two bills.
Although several Senate offices expressed interest in adopting the House-passed counselor language, staff members for the Senate Armed Services Committee continue to oppose independent practice authority for licensed TRICARE mental health counselors. The American Counseling Association is working with the American Mental Health Counselors Association to lay the groundwork for gaining conference committee approval of the House-passed independent practice authority provision, but progress is slow.
“Every time we talk to (the Senate Armed Services Committee), we get a new answer as to why they oppose it,” says ACA Legislative Representative Brian Altman. “The variations range from the fact that (LPCs) are not covered under Medicare to that beneficiaries aren’t asking for this provision to be considered.” He notes that marriage and family therapists are allowed to practice independently even though they are not covered under Medicare.
To discriminate against LPCs based on their education and training is not justified, Altman explains, because TRICARE and DOD both allow independent practice and reimbursement of other master’s level providers (including clinical social workers and marriage and family therapists) with similar education and training requirements.
As a result of this policy, service members and their families have only limited access to the 80,000 mental health counselors licensed nationwide. Allowing counselors independent practice authority could help address staffing shortages and oppressive waiting lists for mental health services, Altman says, especially in remote locations and other underserved areas. He says ACA is working with military personnel advocacy groups to gain their support on this issue.
“I think it would be a most unfortunate turn of events if the conference committee didn’t include payment for LPCs like other trained mental health professions,” says Latham, who continues to see some military and dependent clients on a sliding scale basis. “It’s not so much for the benefit of the LPCs but for the military people.”
Advocating for counselors is a little trickier than it may seem, Altman says. “A lot of counselors want us to go to (Capitol) Hill and say it’s unfair that LMFTs and social workers can practice independently but (counselors) can’t,” he says. “But the committee members don’t want to hear us complain that we aren’t being treated as well as social workers. They are more concerned about serving the military personnel and are reluctant to get involved in a turf war regardless of if it’s fair or not. We have to show them it’s not that trivial; that it’s about military members and their families not having access to adequate and timely care.” For the committee to truly take note, he adds, it’s imperative that military personnel and their families speak out about their difficulties in receiving mental health services.
Robinson of Veterans for America suggests the government may be reluctant to bring in more mental heath professionals because it fears losing vital manpower to mental health diagnoses. “We as an organization are currently working on the National Defense Authorization Act to force the military to look at doctor-patient ratios, including mental health provider-patient (ratios), and to seek outside services at problem installations where the ratio is out of whack and creating long waiting lines,” Robinson says. “We’ve said all along that the military does not have the capacity to address the needs of soldiers with mental health issues. But we got pushed back by DOD over bringing in outside civilian service providers. They say that (the civilian counselors) might be more prone to actually diagnose PTSD (post-traumatic stress disorder).”
Call to action
Counselors are urged to contact their senators concerning the TRICARE issue. Senators’ offices in Washington, D.C., may be reached by calling the Capitol Switchboard at 202.225.3121 or 202.224.3121. A sample message for discussing TRICARE can be found in the “ACA Call to Action” column on page 45. However, Altman urges ACA members to tell their lawmakers their own personal stories surrounding this issue.
Department of Veterans Affairs
LPCs also face significant employment obstacles within the Department of Veterans Affairs’ Veterans Health Administration and its hospitals, clinics and programs across the country. While some ACA members have found positions within the agency either on a contract or full-time basis, barriers to independent practice, advancement and hiring remain. “At the VA, it’s an internalized version of the TRICARE issue,” Altman says. “There are discrepancies in pay, title and supervision requirements between social workers and LPCs.”
Though licensed clinical social workers are able to practice independently and serve as clinical supervisors in the VA, counselors find themselves struggling to achieve similar recognition. Currently, the VA cannot hire mental health counselors at the pay grade equivalent to that of clinical social workers, even though LPCs may have more education and experience. Psychiatrists, psychologists and clinical social workers fill most supervisory positions at the department’s hospitals and outpatient clinics. There are very few full-time mental health counselors.
In addition, social workers on staff develop many of the new positions in mental health services, meaning the agency is more likely to hire social workers first. The VA says no formal policy exists that excludes LPCs from being hired, but some ACA members have found that the VA does not recognize their licensure and, therefore, refuses to hire them or relegates them to nonclinical positions. The lack of recognition of LPCs by the Office of Personnel Management exacerbates this problem. (Note: The OPM sets the federal pay scale, General Schedule (GS), with the highest rank being GS-15.)
“The Office of Personnel Management decides the title and pay scale of all civilian contractors for the military, and it doesn’t recognize licensed professional counselors,” Altman says. “You can’t be hired as an LPC. They have to hire counselors under a different name, such as vocational rehabilitation specialist or readjustment counselor.” He notes that the “name game” applies for counselors in the DOD as well. LPCs in the VA hit the proverbial glass ceiling around GS-8 because their hired job description does not allow them to progress into a supervisory position. It’s not uncommon for an LPC with several years of experience and a doctorate in counseling to be supervised by a social worker who is a few years out of graduate school, according to Altman.
“I am licensed (certified) through NBCC (the National Board for Certified Counselors) and hold the NCC (National Certified Counselor) and the MAC (Master of Addictions Counselor),” said one counselor who did not want to be identified for fear of repercussion from the VA. “I have a master’s degree in counseling psychology. I have been with the VA for over 18 years, the past 10 years as a readjustment counseling therapist. I treat combat veterans. I have had to have someone else co-sign my consults after I screened patients who were suffering from PTSD. And the person has no experience in PTSD.”
Another LPC who wished to remain anonymous said, “I have been a mental health counselor for the past 15 years. I have worked for the Veterans Administration for the past three years. The VA is utilizing my license, credentials and experience but is not compensating me adequately for the duties I perform. Even more frustrating is the fact that there are people in the VA system who have no higher education who are providing mental health counseling and are a GS-11 or above.”
On May 16, Reps. Jerry Moran (R-Kan.) and Michael Michaud (D-Maine) introduced the Veterans Mental Health Care Access Improvement Act (H.R. 5396), which includes language to explicitly add both LPCs and licensed marriage and family therapists as recognized providers of mental health services in the VA health care system. This language is identical to that in Section 5 of the Veterans Health Care Act of 2005 (S. 1182), which passed the U.S. Senate last December. This formal recognition would foster appropriate recognition of LPCs within the VA. The bill would also make mental health counselors eligible for better paying jobs with a greater chance of promotion at the VA. Moran and Michaud are both members of the House Veterans Affairs subcommittee on Health.
“There have been studies that show that the VA doesn’t have the capacity to handle all the mental health needs,” Altman says. “If they hire LPCs and allow them to practice on their own within the VA, then they are opening up the opportunity to increase access to care. The most concrete action counselors can take is to contact their U.S. representatives and urge them to co-sponsor H.R. 5396. That will allow LPCs to be appointed to positions in the VA, and it will force the OPM to create more appropriate job titles with equal compensation. It won’t force them to hire a certain number of LPCs, but it would allow them to.”
Robinson agrees that the federal government desperately needs to hire more mental health professionals at the VA. “Because the provider-patient ratio is so bad,” he says, “it makes care virtually inaccessible. We estimate that based on the 500,000 military personnel that have gotten out (of the military) and the 168,000 that have been seen by the VA — that’s roughly one-third — that when the 1.3 million total come home from this war that the VA could see 200,000 to 300,000 mental health care cases alone.”
Call to action
Counselors are urged to contact their representatives to ask them to co-sponsor the Veterans Mental Health Care Access Improvement Act. Your Congress members’ offices in Washington, D.C., can be reached by calling the Capitol Switchboard at 202.225.3121 or 202.224.
3121. You can find out who your U.S. representative is or send your representative an e-mail by visiting the ACA Internet Legislative Action Center at http://capwiz.com/counseling.
ACA’s Office of Public Policy and Legislation has provided the following sample message for counselors to use but stresses the importance of personalizing the message.
“As a constituent, I am calling to ask that the representative co-sponsor H.R. 5396, the Veterans Mental Health Care Access Improvement Act. This legislation would add licensed mental health counselors to the list of providers who are eligible to be appointed to positions in the Veterans Health Administration. This issue is especially important given the excessive number of veterans returning from Iraq and Afghanistan with symptoms of mental illness. Currently, LPCs cannot be hired at the skill level and pay grades that other master’s level mental health professionals can be hired. However, LPCs are recognized by the Health Resources Services Administration and the Substance Abuse and Mental Health Services Administration, and are covered by TRICARE. In addition, LPCs have the same expertise and meet virtually identical educational and training requirements as current VHA employees. Please co-sponsor H.R. 5396, the Veterans Mental Health Care Access Improvement Act.”
Letters should be addressed as follows: The Honorable (full name), U.S. House of Representatives, Washington, D.C. 20515
Continue to check for updates on legislation mentioned in this article at www.counseling.org/PublicPolicy/. For additional questions on how to get involved, contact Brian Altman at firstname.lastname@example.org.
Iraq war guide for counselors
The National Center for PTSD is regarded as one of the world’s leading organizations related to diagnosing and treating soldiers and helping them readjust. The National Center for PTSD has collaborated with Walter Reed Army Medical Center to produce “The Iraq War Clinician Guide.” The guide, now in its second edition, was developed specifically for clinicians to help them address the unique needs of veterans of the Iraq war. A free PDF of the guide is available for download at www.ncptsd.va.gov/war/guide.
Counselors involved in treating individuals returning from the war in Iraq may not have an understanding of the experiences of military clients, the military system in which they serve, the military medical services available to them or the potential impact of medical decisions on these service members’ future military career. This guide can assist mental health care professionals who treat casualties from Operation Iraqi Freedom in gaining relevant knowledge of the military.
Stephen Robinson, government relations director for Veterans for America, a program of the Vietnam Veterans of America Foundation, strongly advises that counselors read the guide if they want to work with military personnel or their dependents. “Many soldiers will think that if you haven’t served over there or you are not in the military, then you can’t really relate,” he says. “I know there are great civilian providers and that trauma is trauma, but soldiers don’t necessarily know that. However, the resources are available to educate yourself about the soldiers’ experience.”
Military personnel often fear the consequences of seeking out mental health services on base, so Robinson urges private practitioners to get involved with their local military installation and make their services known. “You have to educate yourself and be up-front with the veteran,” he advises. “Say to them, ‘I know I haven’t served, but I do know about trauma, and I’m here to help. I’m not here to judge or report back to your chain of command. This is a safe place. Let’s try to get you some help.’”
For more information on the National Center for PTSD or “The Iraq War Clinician Guide,” go to www.ncptsd.va.gov/index.html.
— Angela Kennedy