Counseling Today, Member Insights, Opinion

The Affordable Care Act and counselor licensure

By R. Tyler Wilkinson May 1, 2014

Insurance-SmallIn February 2013, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the Department of Health and Human Services (HHS) released a four-page research brief discussing the anticipated impact the Affordable Care Act would have on mental health and substance use coverage. As of Jan. 1, all new small group and individual market health insurance plans are required to include mental health and substance abuse coverage “at parity with medical and surgical benefits.” According to the ASPE report, it was anticipated that 32.1 million individuals who previously had no mental health insurance coverage would gain coverage, while an additional 30.4 million people would benefit from better coverage in “one of the largest expansions of mental health and substance use disorder coverage in a generation.”

This means the HHS estimated that more than 60 million individuals would have new or improved mental health and substance abuse insurance coverage. While many individuals now have greater access to these services, it is still unclear what systemic impact this will have on professional counselors. I believe the increased access to mental health and substance abuse services created by the Affordable Care Act will only increase the receptivity toward and desire for private practice counseling services in the general public. However, I also believe this will further challenge an already strained mental health system to provide services to the public.

The need for licensed professional counselors (LPCs) is immense. According to the American Counseling Association, approximately 120,000 professional counselors were licensed at the highest level in their respective states in 2011. These are the professionals many health insurance companies recognize as being eligible for reimbursement. While the anticipated influx of consumers to the marketplace is potentially beneficial for LPCs, it is unclear what larger impact it will have on counselors who are in the process of pursuing licensure or future graduates of counseling programs. It is now more important than ever to ensure that the system we use to license counselors introduces safe, competent professionals into the public market without creating an undue and unnecessary burden on those pursuing licensure. Most states require somewhere between 1,000 and 4,000 hours of supervised, clinical experience prior to becoming licensed. This is one of the most disparate portions of state licensing laws, though many states average around 3,000 hours and follow the model set forth by the National Board for Certified Counselors (NBCC).

This disparity in laws became quite apparent to me as I moved to a different state after my master’s degree to pursue my doctoral degree in counselor education and then moved again a few years later for my first faculty appointment. I found myself growing frustrated with the process of getting licensed and became curious if others shared the same experiences. Anecdotally, my peers did share my experiences. I knew many professionals who would drive 30 minutes from where we were located to the neighboring state to practice as counselors because that state required fewer supervised hours postgraduation. Others, because of the requirement to be supervised only by an individual with the state’s “approved supervisor” credential, had to drive two hours one way to meet with someone with those credentials.

Moreover, I conducted a phenomenological study in which I listened to the experiences of individuals pursuing licensure in the state in which I resided while getting my doctoral degree. Many shared feelings of frustration and being alone in the licensure process. Others described working multiple jobs either to meet the demand of required experiential hours or to afford the cost of supervision. As more and more individuals receive formal mental health and substance abuse insurance coverage under the Affordable Care Act, the counseling profession will need more LPCs. I believe now is the appropriate time to discuss the need to reform states’ postgraduate experiential requirements for licensure as a professional counselor

In my opinion, current postgraduate experiential requirements for licensure affect new professionals in one or more of the following ways:

1) They undermine the quality and intensity of the graduate education that new professionals just received.

2) They create a financial burden at a time when new professional counselors are most susceptible to financial strain.

3) They create a work environment that inadvertently strains the employer-employee relationship, leading to potential “overwork.”

4) They ask new professionals to complete an ambiguous number of hours that are not backed up by empirical support.

Undermining graduate education

More and more counselor education programs are seeking accreditation from the Council for Accreditation of Counseling and Related Educational Programs (CACREP) and implementing counseling programs that are 60 credit hours in length. Moreover, many states use the course requirements from CACREP standards as a guide for the educational component of their licensing laws. What has begun to be discussed in some detail is the impact of the 60 credit hours on counseling students.

I would assume the move toward longer graduate counseling programs was made to, in theory, create better trained, more qualified counselors, yet the number of supervised experiential hours has not been adjusted in an inverse manner. In my view, this would seem to undermine the graduate education the students receive. As students spend more time in their educational pursuits, they increasingly want to be recognized for the hours they dedicate to that effort. Consider that completion of a 60-hour graduate counseling program plus 3,000 hours of supervised clinical experience can mean that it takes an individual at least six years in total before being recognized as an LPC. The message this communicates is that “you are qualified but not quite qualified.”

Consider NBCC’s requirements for its national certified counselor (NCC) credential. Graduates of CACREP-accredited programs are not required to obtain postgraduate experience to qualify for the credential. NBCC seems to acknowledge that a thorough, accredited graduate education is sufficient for credentialing as an NCC. Although NBCC does not imply that the NCC credential is a license, it does seem to be the standard by which many licensure laws are written, and these laws are designed to protect the public.

Regarding public protection, many states only have title laws in place, not practice laws. In such states, individuals with zero credentials can practice privately in the behavior of a professional counselor as long as they do not use the language of “professional counselor” in their title. This does not seem to do much in terms of public safety as it relates to practice in these states. Moreover, states with these types of laws may decrease the incentive of graduates to pursue licensure to avoid any undue costs and stress. This will lead to fewer LPCs being available to meet the growing needs of the public.

A financial burden

The postgraduate requirements of many states create a financial burden above and beyond that accrued during counseling students’ graduate studies, thereby making the pursuit of licensure more difficult. This has prompted some students to not pursue licensure at all, especially in states that have title laws rather than practice laws. Also, in a recent phenomenological study I conducted with individuals pursuing licensure in Alabama, recent graduates described the process as discouraging, financially troubling and possible cause to pursue a change of professions.

As students graduate from counselor training programs, they should be welcomed into a system that encourages the pursuit of state licensure. This would strengthen our identity as a profession and provide more legitimacy to our field at various social and political levels. With the introduction of the new federal mental health and substance abuse coverage policies, it will require as many LPCs as possible to adequately serve the public’s needs.

The current system by which students must gain the required supervision and experience is less than ideal. On average, it seems that most postgraduate, prelicensed professionals are required to do approximately one hour of supervision per week (varying between individual and group). In my experience, students receive supervision in three ways: 1) paying out of pocket for each hour of supervision, 2) receiving free supervision from their employer if they contractually agree to continue working there for a set number of years post-licensure or 3) being among the fortunate few to know or find someone who will provide supervision free of charge. Options one and two both create burdens on new professionals pursuing licensure. Financially, paying out of pocket is difficult for many new graduates.

It is unclear what impact student loan debt will have on graduate counseling students as programs move from 48 to 60 credit hours. In 2013, Yahoo published an article identifying counselors as among the worst-paid professionals relative to their amount of education. Some counselor educators have begun to bring this discussion forward (for example, see John McCarthy’s opinion article, “Are counseling degrees approaching an economic tipping point?” in the July 2012 issue of Counseling Today).

Let’s say that a graduate counselor has secured a job making the O*NET stated median income of $40,000. Before new professionals can pocket that money, they must pay their student loans, supervision costs and taxes. Data for graduate loan debt is not widely available, but according to Trends in Student Aid published in 2012 by the College Board, the average amount of undergraduate student loan debt was $23,800. Let’s assume a recent graduate of a counseling program has the same amount of debt upon completing his or her program. According to an online financial aid calculator, payment over 10 years for this amount of debt would be approximately $274 per month or $3,288 per year. Moreover, consider the out-of-pocket costs for supervision. At a rate of approximately $70 per hour, this creates an additional financial burden in the neighborhood of $6,900 per year. What is more is that those payments come after taxes. Totaling this up, it is safe to assume that recent counseling graduates can anticipate paying approximately $10,000 per year in student loan debt and out-of-pocket supervision costs. That is a significant amount of money when subtracted from a median income of $40,000.

A strained work environment

When I was a new graduate, the admonishment I received from seasoned professionals was “just buy your time” and “go get your hours.” I have always found this “deal with it” response to be somewhat inefficient and discouraging. After being trained in the skills of accurate empathy, it was discouraging to enter the working culture of counselors and find it seemingly void of empathy and support.

As I have noted, it is a burden for new professional counselors to pay for supervision, and it is difficult to find an agency that provides “free” supervision. If a new professional is employed by an agency that provides supervision, that new professional is often asked to commit to a set number of years of employment with the agency post-licensure. I believe this creates a strain between the agency and the counselor. If you work closely with new professionals in counseling, they will tell you that they are underpaid and overworked. Whether deliberately or not, when individuals are contractually obligated to work at an agency to pay off a provided service (think years of service in the military), this creates a work environment in which the employer has significant leverage over the workloads of the employees. Counselors are essentially bound to this system unless they risk paying back all of the supervision they have received.

Unsupported claims

The postgraduate experience required of professional counselors who are pursuing licensure should be thoughtfully analyzed. I have found little research to support the need for such a high amount of postgraduate experience, and I think the indirect consequences of this training model have negatively affected the financial, emotional and psychological health of new counseling professionals. I believe this has created a system in which many counselors have given up on or chosen not to pursue licensure during a time when the need for licensed professional is growing. I do think having some time to allow new professionals to transition into the field is necessary. However, I question the amount of time that is required. It undermines the success of our educational institutions, creates strained relationships between counselors and their employers, and decreases the already low earning potential faced by many new counselors in the field.

I believe lowering the hurdles for trained professionals to get licensed would increase the strength and identity of the counseling profession. New professionals should be some of the most energetic and proud members of our community. When that energy and pride is nurtured, these new professionals will enhance the profession’s voice, thereby increasing our legislative lobbying power (both federally and at the state level), strengthening our ability to be available across multiple insurance options and further legitimizing our professional field. Additionally, licensure provides professional freedom that allows counselors to move into underserved areas and expands our ability to provide more individuals with mental health services.

What is unclear and does not seem to be supported in research is what amount of experience should be considered “adequate” without also creating an undue burden on new professionals. Is postgraduate experience for the professional counselor necessary to help protect the public? If so, how much experience is necessary? Should counselor training programs be designed in such a way that states would consider individuals competent to receive a professional credential upon completion of their graduate training? Timely research and dialogue in this area is desperately needed.

As NBCC President and CEO Thomas Clawson stated in an NBCC Perspective article titled “California: The closer,” published in the March 2010 issue of Counseling Today, licensure pursuits since the 1970s have “the counseling profession … well positioned for continued growth,” so “we should not let that experience go to waste.” The political climate is always changing, and we should strive to fight for legislation to change alongside it. After all, we only saw California move toward recognizing LPCs in 2009.

As new health insurance laws are being implemented, as we reach some solidarity for a common counselor scope of practice (as a result of the 20/20: A Vision for the Future of Counseling initiative) and as we continue to fight for recognition within the Department of Veterans Affairs and TRICARE, I believe the timing is right to look at how current licensing laws are affecting new professionals and what potential impact this might have on available services in the marketplace. As we know, plenty of other mental health fields will be happy to work with our potential clients.

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R. Tyler Wilkinson is an assistant professor in the Department of Counseling at Indiana University of Pennsylvania. Contact him at tyler.wilkinson@iup.edu.

Letters to the editor: ct@counseling.org

8 Comments

  1. Trecina Bowen

    I am a grad student for counseling and I agree with the author 100%. I came into my graduate program excited and passionate about becoming a counselor. However, as I’ve learned more about the requirements and recieved advise from professors I’m more discouraged than excited. That’s no way to come into a helping profession, the purpose of which it to encourage. I believe that after 48-60 graduate credits that include a 10 month internship from a CACREP accredited college should be honored with the ability to become fully licensed after testing. Certainly nothing more than 6 to 12 months as a supervised associate is sufficient. It is an injustice to the profession, the professionals, an the clients to cultivate a system that leaves new counselors regreting their decision to become counselors. We should be careful not to create professionals that need more counseling then they themselves can provide.

    Reply
  2. Heidi Hughart

    This article expresses exactly what is happening to new counselors and it disgusts me. I graduated a year and a half ago with distinction from a CACREP mental health counseling program, I passed the NCC exam and am facing a $74,000 + student loan that I can’t pay because no agency will high unlicensed clinicians in CT. This is the ultimate catch 22. I have written to my local government officials and they just don’t “get it”. I don’t know what else to do. I ended up openning a private practice because I really didn’t see any other option, hiring my own supervisor but because I am unable to take insurance because I am not licensed I am struggling to get clients. Many therapists have told me that they would gladly refer to me but that has not materilized. When established clinician hear of my plight the usual reaction is “boy am I glad I’ve been doing this for so long and have my license”. Why can’t new counselors get a license after graduation from a CACREP program and just increase the number of required supervision hours. I would gladly pay for supervision for a longer period of time if I could just get my license enabeling me to get on insurance panels. This has got to change. Too late for me to reconsider, I’m already in debt up to my eyeballs.

    Reply
    1. Louis

      Heidi Hughart’s comment is spot on. I graduated from a none CACREP school, but I’m experiencing a similar problem. Because I’m a retired teacher I decided to go back to work as a teacher since getting started as a counselor is such a problem now. I think the whole CACREP issue is too tied to politics and has made it impossible for those of us who don’t have this type of stamp of approval to be considered for certain jobs. There are programs that are good programs that aren’t CREPed out, or should that be CREPed in?

  3. John Burik

    There are many valid and compelling points made in Wilkinson’s article. There is much that needs to be re-thought and well-articulated at both the state and national levels. With respect to licensure, a number of states DO offer a license at the immediate post-grad, post-exam level. My current interns are scheduled for Internship II next semester, when they will also qualify to sit for the NCE. Upon graduation mid-December, they will be eligible for an Ohio LPC. Two of my last year’s interns followed that path and were employed as counselors on January 1st. While I am less familiar with the laws and rules of Kentucky and Indiana, it is my understanding that they offer a similar pathway to licensure and employment. Not a bad deal at all.

    The Ohio LPC is a dependent license, meaning the LPC must be supervised for clinical work for an additional 3,000 hours to be able to take the NCMHCE and qualify for the independent LPCC. The additional supervision makes a lot of sense to me for independent practice. That Ohio LPC can work and be paid as a counselor — not a “community support provider” or “tech” — all the while gaining valuable supervised experience. Again, not a bad deal at all.

    Where the current system fails abysmally is at the national level and, you guessed, CACREP — a well-intentioned but less than comprehensively thought “solution.” The 60 hour masters in defined areas, practicum and internship are laudable standards, but there’s no reason on earth they need to be coupled with the CACREP imprimatur. To be sure, CACREP’s continued existence depends in large part on the fees it charges for accreditation and yearly membership, resulting in a good deal of self-promotion. That’s not justification to discredit exemplary regionally-accredited non-CACREP programs. Yet that’s where we are on the national level.

    Come January 1st, 2015 — without a rule change — literally thousands of professional counselors will be forever banned from Tricare credentialing. That likely includes a de facto ban in the Veterans Administration and entire Department of Defense. Certainly, a CACREP degree might serve as prima facie evidence that a graduate meets an acceptable educational standard, but there need to be alternate pathways to establish competence, including the opportunity to remediate any deficiencies in one’s transcript. Appropriate and deserved recognition of ALL its members should be ACA’s number one priority.

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  4. Keith

    Tyler,

    I enjoyed this piece and you brought up some interesting points! Certainly there are obstacles to licensure such as the 3 years of supervision, CACREP issues, and financial costs. On the one hand, I think that these can be difficult for graduate students. However, on the other hand, I don’t believe that 1 year of internship/practicum is sufficient for someone to be independently licensed. In Georgia it is similar to Ohio in that once you receive your degree, pass the NCE, you can apply for the Associate License which opens up some employment opportunities. Then after 3 years of supervision, you obtain your independent license.

    I see clinicians all the time that graduate with their degrees and open up a “private practice” without experiencing further training of what it is like to work with a disciplinary team. Then they come with a lot of ethical questions that would be addressed if they hadn’t “jumped the gun” and started their own thing (even though private practice is technically unethical in GA). I believe that it is important that recent graduates continue in supervision for at least 2 years after they graduate. This further develops their clinical skills, enhances their ability to utilize ethical decision-making models for complex issues, and helps them explore issues that may interfere with their work with clients (i.e. countertransference). Maybe if licensure was achieved after graduation on the contingency that counselors continue in supervision….could that be a compromise?

    Some of this is exactly why there is the 20/20 Vision from ACA so there can be license portability and standardized requirements for licensure can occur. However, this has been a slow process.

    I would love to check out your phenomenological study on licensure! Thanks for this piece.
    Keith

    Reply
  5. Keith

    I meant to say that private practice in GA as an LAPC is technically unethical even though many do this by carefully managing certain “loopholes.”

    Reply
  6. Hildegarde Stansell

    Great Article. piece ! I believe that after 48-60 graduate credits that include a 10 month internship from a CACREP accredited college should be honored with the ability to become fully licensed after testing. Certainly nothing more than 6 to 12 months as a supervised associate is sufficient.! If anyone know, if my company could possibly find a fillable NYC RPIE-2010 Instruction example to type on ?

    Reply

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