Licensure is a “rite of passage” for most mental health professionals. When new professionals graduate with either a master’s or doctorate in counseling, they usually have great expectations of taking the world by storm. There is one pesky reality standing in the way, however.
I am of course referring to going through the multiyear licensure process, which involves taking a board exam and practicing under supervision for several thousand hours. In my case, this process has been more burdensome than I ever imagined because I am in a difficult life situation.
My birth was difficult, and I sustained significant brain injury because of a lack of oxygen. As a result, I have quadriplegic cerebral palsy and am confined to a wheelchair. I have random motion and a speech impediment. The use of my hands is poor to nonexistent, and because of this I can do few things for myself, relying on others for all my daily needs.
Nothing has come easily for me, but I have experienced many successes and surprises in my life. This is due to the hard work and perseverance of many people who have worked tirelessly with me and to my own determination to prevail despite the odds. I also demonstrated a few abilities from a young age. For example, I had an interest in helping others who were going through difficulties by listening to them and being present with them. My thought in early adolescence was that I should go into a field where I could help people with disabilities. Through the years, beginning in high school, I had a number of mentors in the counseling field, including some who were disabled themselves, who encouraged me to join the profession.
I always did well in school, attaining high marks and honors in high school and beyond. When I graduated from high school, I went on to college and then graduate school. Because of my disability, it took me about twice the time as other students to complete my undergraduate and graduate degrees. By the time I finally was done, I was in my mid-30s. My major in graduate school was mental health counseling. Upon finishing, I had planned to go through the state licensure process. This is when some of the toughest obstacles in my life began.
Hitting a brick wall
There were multiple considerations I had to think about to make my “dream” a reality. For the sake of simplicity, I will boil it down to two general factors. The first was my disability and how I would be successful in gaining employment with my type of challenges. The second factor was going through a licensure process. Both of these factors interact.
I worked with two rehabilitation counselors and other community career counselors plus my own therapist. I went on some interviews, but many of my inquiries simply went unanswered. After six months to a year of being rejected, I became frustrated. I continued looking for another year, at which point I had to quit because I found the whole process soul destroying. From talking to people, I gathered I could not third-party bill because I did not have a license, and this was a major obstacle to obtaining employment in the field.
I was tired at that point of looking around for other placements. So, in 2009, I found a volunteer job as a mental health clinician counseling people with intellectual disabilities. I had to hire my own supervisor because there were no counseling professionals on staff, but I began trying to accrue hours for licensure. I wanted to clear the “examination hump,” so I took that in 2011 and passed.
All this time, I was seeing very few clients because the population served by the day habilitation facility was considered too severe to be counseled. At the same time, I knew I had a total of 3,360 hours to fulfill for state licensure in Massachusetts. With so few clients available, I had difficulty gaining enough hours, even on a six-year part-time basis. During the past six years, I have looked periodically for other volunteer opportunities, but for whatever reason, other places never materialized.
The psychological toll
As with any disappointment or heartache in life, this experience has been a daily rollercoaster. It has really caught up with me in the past couple years, and this year has been the hardest so far. I guess that is because I am nearing 50 and it looks doubtful that I will achieve the type of career I dreamed of so long ago. I feel like I am still back in my 20s and no further along in my career aspirations. I still feel like a student or an intern who is just learning when I should be capable of practicing on my own with expertise, specializations and much experience.
I keep wondering how I got into this mess. What didn’t I see or plan for? Where was the point where I went wrong, and should I have known it? Was I ever meant to be a counselor, or was it all just a pipe dream gone terribly wrong? Was all that effort, all these years, all for nothing? Who am I anyway? These are the questions that haunt me daily.
I do not want people to feel pity for me. That is not the purpose of this article. Most of us in the counseling profession know that we respond with empathy not pity. To correct or manage a problem, we first have to understand it and how it impacts people. This is a core principle in our profession, and I hope by briefly explaining how deeply disappointed I am about this whole situation, perhaps counselors can begin to understand this problem — not only for me but for others who find themselves in similar situations, dealing with a disability or other difficult circumstances, who try to obtain a start in the counseling profession.
What the literature says
Despite claims that counseling is a scientific field, the profession (and related others that practice psychotherapy) has failed to validate what it takes to be an effective counselor. All the states seem to have differences in the total number of supervised hours needed to qualify for a counseling license, although it seems to be 3,000 on average. I once posed the following question on the ACA Connect forum: “Where did the number 3,000 or more hours and all the subtotals come from and why?” Nobody could or would answer this question.
Paul Lowinger published a study in the Journal of the National Medical Association in 1979 saying that nonprofessionals could diagnose 70 percent of psychiatric outpatients and that an even larger proportion (80 percent) of 36 patients evaluated could be treated by nonprofessionals. In 1967 in the American Journal of Public Health, Truax reported therapeutic mastery with five novice counselors who took a 100-hour training course.
In a 2005 study that appeared in the Journal of Consulting and Clinical Psychology, Wampold and Brown found factors such as the therapist’s age, gender, education and experience had little effect on client outcome. Nyman, Nafziger and Smith, writing in the Journal of Counseling & Development in spring 2010, pointed out the possibility that supervised paraprofessionals might be as beneficial as licensed and advanced clinicians. In the March 2014 issue of Counseling Today, R. Tyler Wilkinson commented about the inequities of the licensure process (“The Affordable Care Act and counselor licensure”). It is as if the profession and the states have said to candidates who struggle, “You’re good but not good enough” when some of those candidates could be effective therapists.
It appears to me from this brief analysis that the high bar of total clinical hours is arbitrary and not based on real objective proof. In fact, some research would suggest that one could make due with fewer post-degree clinical hours and still perform just as well as those with the thousands of hours now required. In my view, the licensure laws around the country seem created mostly out of subjective cognitive constructionist criteria rather than being based on objective standardized measures designed to benefit society.
Achieving licensure inclusion
The American Counseling Association (along with its divisions and branches), outside organizations such as the National Board for Certified Counselors and the states need to work toward inclusion for licensure. If a person wants a license, he or she should be given every chance to achieve that status. Here are a few ideas:
- Counselor education programs could have two-year residency periods so that universities would be responsible for placements and assist with supervision after graduation, similar to what medical schools do.
- All students should be educated about the licensure process as part of their course work or by attending extra seminars. They should also be made aware of alternative career paths within the mental health field in case counselor licensure is not a practical pathway for them.
- Students with disabilities should be encouraged early on to seek counseling about licensure from faculty.
- State boards should be consulted early about unique circumstances that may require special accommodations.
- Achieving licensure should not be the only way to be paid in the mental health field. There should be another certification that is recognized by insurance plans, the government and the profession when an individual obtains a degree and is working toward licensure.
- The licensure process might be able to be streamlined if a new national standard were adopted, with all states and professional organizations agreeing on a uniform number of hours and other requirements needed for licensure.
- Some states may need to modify rigid licensure laws to allow licensure boards more flexibility in dealing with special circumstances while still complying with competency standards.
- A robust and active disability interest network needs to be established within ACA to, in part, advocate for counselors with disabilities.
- Employers in counseling centers need to be educated about the unique opportunities inherent in employing a counselor with a disability, no matter the severity of the limitation. People striving through adverse situations may make some of the best therapists.
The road toward licensure inclusion will be long, but we have to take on this challenge. The counseling profession preaches cultural diversity, but when a person with a different set of life circumstances comes along, I find there is little consideration given to that person. The profession may drive away capable people by promoting high standards without providing a way for those professionals to succeed.
I understand that the counseling profession has to protect the public, but we can do this while providing extra support in becoming credentialed. For the profession to achieve the ideals ACA has set forth, we need to be more inclusive — not exclusive — in licensure and employment practices.
This article asks what the soul of the counseling profession really is. Are we content to exclude potential licensed professionals because they have difficult life situations, or do we welcome them into the practice of counseling? Disability, financial concerns and difficult family situations, among other circumstances, may be keeping some people from achieving licensure.
I do not know if I will ever become licensed, but I hope this article might change the way licensure is handled and give new professionals in difficult life situations a chance at this wonderful achievement. There has to be a way!
Kevin Wreghitt is a mental health clinician counseling people with disabilities in day habilitation and college settings in Massachusetts. Contact him at firstname.lastname@example.org.