Tag Archives: TRICARE

An Open Letter from the ACA President and President-Elect

Cirecie West-Olatunji and Robert Smith May 19, 2014

acaCorpLogoCirecie West-Olatunji and Robert Smith address recent changes to the counseling profession.


The past few years have been significant for the counseling profession. Among other advancements, we have secured licensure in every state, crystallized our professional identity, and opened up new frontiers for employment. The new counselor job description in the Department of Veterans Affairs (VA) and TRICARE independent practice status are clear examples of growth.

Advancing the profession is certainly important to our future.  However, we are fully aware that recent changes have been cause for concern, anxiety, and stress for many ACA members.  While the vast majority of counseling positions do not require increased educational requirements, we realize that the requirement of a CACREP degree for employment in the VA, paneling by TRICARE, and (starting in 2018) licensure in Ohio shuts out well-qualified ACA members who were trained in a time when these requirements were either not available or required.

We want to make it clear that while ACA is committed to advancing the counseling profession and committed to CACREP and its affiliate CORE as the accrediting body for the profession, we are also just as committed to doing whatever we can to ensure that ACA members who do not have CACREP-accredited degrees will not be left behind. ACA is working tirelessly for grandparenting provisions and holding meetings to address the need for flexibility with constituencies as new job options open for professional counselors. As examples:

  • On Feb. 27, 2012, ACA submitted a letter to Assistant Secretary of Defense for Health Affairs Jonathan Woodson and asked him to consider removing the stipulation that only counseling degrees from CACREP-accredited programs be recognized after this calendar year.
  • In testimony to the House Committee on Veterans’ Affairs, Feb. 13, 2013, then-ACA President Brad Erford recommended that the VA expand the hiring eligibility criteria for Licensed Professional Counselors to include those who may have graduated from programs that were not CACREP accredited.
  • In recommendations submitted to the White House Interagency Task Force on Military and Veterans Mental Health, ACA urged the Obama administration to direct TRICARE and the VA to create alternative pathways to hiring eligibility for LPCs who received their degrees from non-CACREP-accredited programs.
  • ACA has held a number of discussions and meetings with CACREP and NBCC to secure their commitment to promoting grandparenting for those without CACREP degrees.  These discussions will continue.

In closing, please know that ACA values all of our members and fully recognizes the need to be an advocate for all who are struggling with workforce requirements. We are as fully committed to members who graduated from non-CACREP-accredited programs as we are to members who graduated from CACREP-accredited programs.

Thank you for your continued support.

Cirecie West-Olatunji, Ph.D.
ACA President, 2013–2014

Robert L. Smith, Ph.D.
ACA President-Elect, 2014–2015




Click here for PDF version of the letter.



Effective treatment of military clients

By Keith Myers August 1, 2013

militaryThere is sound research available that demonstrates the efficacy of certain evidence-based treatments when working with the military population. However, most of that research seems to disregard the necessary prerequisite for counselors in achieving reliable treatment outcomes — the ability to build trust with a client population that has a general disposition to distrust others, especially those outside of the military, which probably includes most of you reading this article. The prerequisite of trust illustrates the primary importance of establishing a level of multicultural awareness that will empower clinicians to achieve a more meaningful therapeutic relationship with military clients. In turn, this will lead to an improved quality of life for those clients.

Trust is the foundation for all meaningful personal and professional relationships. It is what causes a child to laugh when his father hoists him high into the air, knowing that he will always catch him on the way down. If a veteran does not trust you, then your treatment outcomes will have poor results virtually every time. One of my former military clients put it to me bluntly: “I’m not going to let you screw with my mind before I get to know who you are and what you represent.”

Therefore, each clinician should work diligently to establish that level of trust before proceeding with more intensive treatment such as trauma work or other aspects of a mental health treatment plan. Whether you currently work with this population or are simply considering it, I would like to offer some practical ways to build trust with military clients.

Be aware of their grit and character

Merriam-Webster dictionary defines grit as “sand, gravel; a hard, sharp granule.” Another definition includes “firmness of mind or spirit; unyielding courage in the face of hardship or danger; indomitable spirit.”

If you are planning on working with military veterans or active-duty members, then you should be aware of their inner character and grit. This grit is what helps keep them alive in theater, motivates them in spite of roadblocks and allows them to persevere under dire conditions. Military training and culture advances and enhances this inner fortitude.

This culture of character is evident in the language taken from an actual Army NCO Evaluation Report (officer evaluation). It states, “Army Values: Loyalty — bears true faith and allegiance to the U.S. Constitution, the Army, the unit, and other Soldiers; Duty — fulfills their obligations; Respect — treats people as they should be treated; Selfless Service — puts the welfare of the nation, the Army, and subordinates before their own; Honor — lives up to all the Army values; Integrity — does what is right legally and morally; Personal Courage — faces fear, danger, or adversity.” Each branch of service has its own set of values by which its members are expected to live and conduct themselves, but they all speak to an overarching theme of maintaining a high moral and ethical code.

It has been my experience that military clients can activate this grit while in treatment and that it can motivate them to achieve outcomes that might be more difficult for nonmilitary clients to achieve. Having an awareness of this “hard, sharp granule” within military clients gives you more insight into this population, thereby helping you to form trust and rapport earlier in the therapeutic process.

Respect their service

My late father, a World War II Navy combat veteran, would become both angry and empathetic when viewing TV footage of Americans belittling, mocking and even spitting on returning Vietnam veterans. He would exclaim, “How dare those people spit on our troops’ faces when those are the same people for whom they lost their lives!”

Regardless of your personal political views on the Vietnam War, I hope all of us can acknowledge the disrespect our own culture showed Vietnam veterans after they returned from service. It stands as a horrific example of how not to treat our veterans. Sometimes, the best lesson for learning what to do is deduced from learning how not to behave.

On the other hand, one practical way that counselors can show respect for their military clients is to honor all military holidays in their own practice or clinical setting. At the same time, counselors should be mindful that the holidays could invoke memories of buddies who were lost in service or some intrusive thoughts surrounding combat trauma. Some of these holidays include Memorial Day, Veterans Day and birthdays of the different branches of service.

Be comfortable with spirituality

Among the spiritual statements I have heard previous military clients make are, “I don’t know what happened. My spirit died out there” and “Before deployment, God told me that I would return injured but promised me that he would not let me die.”

It is common for spirituality and the veteran population, especially combat veterans, to be intertwined. Therefore, being comfortable with veterans exploring their faith and/or spirituality during a counseling session is vital to building trust and effectively treating this population.

Edward Tick, a clinical psychotherapist who has worked with veterans for more than 30 years, authored the influential book War and the Soul, which contends that posttraumatic stress disorder is a psychospiritual condition or “soul wound.” On the basis of his work during the past three decades, Tick further asserts that a significant part of this wound is caused and further exacerbated by the absence of warrior rites of passage that were present in ancient civilizations. He explains that these spiritual and communal rites of passage are oftentimes missing within the U.S. military system, especially when military members return home. Tick cites storytelling and reconciliation retreats as two such spiritual rites of passage. He further explains, “Reconciliation retreats are one of the most effective tools for addressing the healing needs of both veterans and nonveterans. Such retreats incorporate the individual, group, aesthetic and spiritual dimensions of healing, while relying on the healing power of the story.”

To maintain multicultural relevance and effectively treat combat veterans, counselors and other mental health clinicians must possess knowledge about spirituality and faith as well as the spiritual effects of war.

Use some disclosure to enhance rapport

Regarding my own establishment of professional boundaries with clients in the past, I always erred on the side of caution when disclosing any personal information. Ethically speaking, disclosure comes with certain risks, including the possible crossing of boundaries. It can open the door for a role reversal of sorts if the client listens to the counselor’s issues and begins providing emotional support. As I often emphasize to my students, “You are the therapist, not the client.”

However, aren’t we being incongruent if we believe that authenticity is vital for clients yet never disclose any personal information at all in our role as counselors? Is there a way to balance being genuine with clients while simultaneously keeping other meaningful parts of our lives private? I believe this balance must exist if we are to be effective in treating veterans. Some amount of disclosure during the intake session can enhance rapport and trust, which strengthens the therapeutic alliance going forward in treatment.

I typically share three disclosures with military clients after informed consent: the personal meaning I derive from serving veterans, my previous work in clinical settings and that members of my family have served in the military. For example, I often inform these clients that helping them is rewarding to me because it allows me to “serve those who served,” which I consider to be one of the highest honors. Furthermore, I explain to them that I feel this allows me to give back in some indirect way to my family members who have served. Therefore, my “service” of working with veterans and active-duty members enriches my own purpose and meaning both on the professional and personal levels.

Several clients have reported that these disclosures significantly reduced their initial distrust of me and allowed them to be more open-minded in developing a therapeutic relationship.

Advocate for them

According to the Online Etymology Dictionary, the word advocate is a technical term derived from Roman law that refers to “one whose profession is to plead cases in a court of justice.” It can also mean “one who intercedes for another” or “a pleader.”

If counselors wish to build rapport and establish professional relationships with military clients, then they need to develop the skill of interceding on behalf of their clients. Counselors would be wise to learn from the sister profession of social workers, who have gained a reputation for being master advocates for the clients they serve. In order to remain true to the ACA Code of Ethics, counselors should be aware of the role that advocacy implies and address these expectations clearly with clients before moving forward.

Some practical ways to advocate for veteran clients include communicating treatment goals and progress with their other providers (such as primary care physicians and other providers within the Department of Veterans Affairs) and linking these clients to other community resources. A client once informed me, “I know you care because you are willing to be my voice.”

At times, clients have asked me to accompany them to their physician appointments so I could help articulate their needs. Because I work with clients in an intensive outpatient program, it is possible for me to meet that request. Depending on your practice setting and the level of care you provide, accompanying your client to appointments may not be convenient or even possible. But you might be able to help articulate your client’s needs to other providers by writing a letter that the client presents at these appointments.

Getting started

Maybe you are a clinician and have always been interested in working with the veteran population but are confused about where to begin. As many of us probably realize, the Department of Veterans Affairs has been slow to recognize professional counselors as having equal standing with social workers in job placement. There are a few other possibilities available for exploration, however.

First, it is helpful to discover the location of your closest Wounded Warrior Project chapter. Wounded Warrior Project is a national nonprofit organization whose mission is “to empower and honor wounded warriors.” This mission is accomplished in part by holding community events, providing mental health education to warriors and their families, and promoting recreational interests that connect wounded warriors with each other. By networking with your local chapter of the Wounded Warrior Project, you will be exposed to opportunities for obtaining counseling referrals to work with the veteran population.

Second, if you are independently licensed by your state, have graduated from a counseling program accredited by the Council for Accreditation of Counseling and Related Educational Programs and are providing therapy in a private practice setting, another option involves enrolling with the TRICARE panel. TRICARE is the insurance plan for the Department of Defense (DOD). Getting listed as a TRICARE in-network provider will make it possible to receive counseling referrals directly from the DOD. The American Counseling Association website has a “Private Practice Pointers” section that includes helpful information on starting the application process for TRICARE (from counseling.org, click on “Knowledge Center” and then “Private Practice Pointers”). Unfortunately, this process can take several months, so considerable patience is required.

A final helpful tip for getting started is to attend national, regional and local conferences that offer education about veterans. Whether it is the national ACA Conference or a local conference offered by your state counseling branch, this can be a relatively simple way both to absorb more knowledge about this culture and to network with other clinicians about possible referrals.

Final thoughts

A client recently shared with me that another therapist had made the following statement to him during a session early in the counseling relationship: “Trust me. I’m your therapist.”

This phrase was insulting to the client because actions speak louder than any attempt at shallow reassurance. If simply offering verbal reassurance of your trustworthiness as a therapist was a helpful intervention with veteran or active-duty clients, this article would have been composed of one succinct paragraph. However, it is never that simple with any population, much less with veterans and active-duty members who have a heightened tendency to be guarded with others.

Developing practical skills related to how to “treat” military clients will bolster your ability to connect with them and advance the goal of building trust in the therapeutic relationship. Accomplishing this prerequisite goal will help your military clients to achieve greater clinical outcomes and ultimately lead them to an enhanced quality of life.



Keith Myers is a licensed professional counselor in Georgia, where he works at the Shepherd Center’s SHARE Military Initiative program in Atlanta serving active-duty members and veterans who have traumatic brain injury and posttraumatic stress disorder. He is intensively trained in eye movement desensitization and reprocessing therapy and is a doctoral student in counselor education and supervision at Mercer University, Atlanta. He also serves as an adjunct faculty member with both Argosy University in Atlanta and Point University in East Point, Ga. Contact him at doc355@yahoo.com.

Letters to the editor: ct@counseling.org


What you don’t know could hurt your practice and your clients

Elaine Johnson, Larry Epp, Courtenay Culp, Midge Williams & David McAllister July 1, 2013

QuestionAre you a mental health counselor? If so, you may be only vaguely aware of the ways in which CACREP (Council for Accreditation of Counseling and Related Educational Programs)-only language in hiring, credentialing and reimbursement policies could impact your practice. As practicing mental health counselors and board members of the Maryland and Massachusetts chapters of the American Mental Health Counselors Association, we have watched recent developments with increasing alarm. Our practices and livelihoods are under serious threat, and the public faces greatly reduced access to care, by growing efforts to restrict the practice of mental health counseling to those who attended CACREP-approved graduate programs. It is imperative that professional counselors everywhere understand these developments and take action to protect what we have worked so hard to achieve — our right to practice independently.

The hidden threats to practice

TRICARE is the health care program for all active-duty and retired military personnel and their families. Licensed mental health counselors have served this population for many years but could do so only with physician referral and supervision. “Interim” regulations issued in 2011, based on a study by the Institute of Medicine (IOM), created a new classification of TRICARE providers (TRICARE certified mental health counselors, or CMHCs) who are allowed to practice independently. An interim period was created, during which current providers could ostensibly move to independent status by taking the National Clinical Mental Health Counseling Examination (NCMHCE) and meeting supervision requirements. The goal of the change, according to its announcement in the December 2011 Federal Register, was to increase access to mental health care by eliminating the physician-referral/supervision requirement. Yet, the result is quite the opposite.

TRICARE supervision rules: A major problem lies with the supervision requirement in the interim rule, which states that all of one’s post-master’s supervision hours must have been obtained under a licensed professional counselor. (It has come to our attention that this rule is not being applied consistently. This may be relieving for some, but haphazard enforcement is not a solution to an overly restrictive rule.) If we follow the rule, it prohibits most of the board members of the Maryland and Massachusetts AMHCA chapters from TRICARE participation because at the time we graduated, there were virtually no counselors who could have supervised us (since licensure laws were relatively new). Thus, this rule disqualifies the most-seasoned counselors in many states from becoming CMHCs. The American Counseling Association has requested the removal of this stipulation (for example, in a letter from ACA Executive Director Richard Yep to the assistant secretary of defense for health affairs in February 2012), but it remains on the TRICARE application. We do not believe the IOM intended to create a profound roadblock to CMHC status, but efforts so far to change the regulation have been unsuccessful.

It is also critical to recognize that at the conclusion of the interim period in December 2014, providers who cannot achieve CMHC status will no longer be able to participate in TRICARE at all because the physician-referral provider status will be eliminated. If you are currently a TRICARE provider who cannot meet this supervision requirement, you will either terminate your military clients or go unreimbursed — unless the regulations are changed.

CACREP restriction in TRICARE: The second problem with the TRICARE rules is that once the interim period expires, all graduates from programs not approved by CACREP will be permanently excluded from participation in TRICARE even when duly licensed by their own states. After December 2014, if you did not graduate from a CACREP-approved program, you cannot and will not ever be able to join the TRICARE network.

The CACREP-only rule, in combination with the supervision rule, will disqualify thousands of currently licensed practitioners. For example, ACA’s own 2011 study found that only 13 percent of licensed mental health counselors in New York graduated from CACREP-approved programs. In addition, because only 32 percent of U.S. master’s programs in counseling and only 11 percent of 60-credit mental health counseling programs are accredited by CACREP (see the 2010 text Ethical, Legal and Professional Issues in Counseling by Theodore Remley and Barbara Herlihy), there are undoubtedly thousands of current counseling students in the country who will be permanently excluded. Again, as an example, in Massachusetts and Maryland, 32 programs train mental health counselors. Two (one in each state) are accredited by CACREP.

Our country faces a critical shortage of mental health counselors to serve legions of our veterans, including those from the recent wars. It is a travesty that the majority of current and future mental health counselors will be excluded from providing services to these veterans. They deserve more and better, as opposed to more restricted, access to therapists.

CACREP-only language has moved into regulations in other important areas:

1) The Department of Veterans Affairs (VA) recently created a new job classification for professional counselors. These jobs are open only to graduates of CACREP-approved programs.

2) No state currently requires graduation from a CACREP-accredited program for licensure. Yet, CACREP’s stated goal (see, for example, Barry Mascari and Jane Webber’s article, “CACREP Accreditation: A Solution to License Portability and Counselor Identity Problems,” in the January 2013 Journal of Counseling & Development) is to restrict state licensure to graduates of CACREP-approved programs. Under regulations adopted in New Jersey in 2006 (and ultimately reversed by the grass-roots efforts of licensed counselors and educators), graduation from a CACREP-accredited program would have become a requirement for all new counselors in the state and any counselor moving into New Jersey. State counseling boards are continually lobbied by CACREP to restrict licensure to graduates of programs bearing their accreditation.    

3) A bill recently introduced in the U.S. Senate (S. 562) would, if passed, extend Medicare eligibility to licensed professional counselors. Although there are no restrictions by type/accreditation of degree program in this bill, we are very concerned by the precedent that has been set in the regulations we have already described. If a CACREP-only restriction were to be inserted into Medicare regulations, we believe that Medicaid and private insurers would quickly follow suit, and in relatively short order, the practices of all graduates of programs not affiliated with CACREP would be obliterated.

These challenges to the majority of practicing professionals and counseling students in the country need a vigorous response. The rules need to be changed, and further restrictions must be prevented.

What is happening now

Practicing professionals, for whom CACREP may have seemed an “academic” issue, may not be aware that it serves only one slice of master’s- and doctoral-level training programs. The only programs eligible for CACREP accreditation are those in “counseling” or “counselor education.” CACREP does not serve programs that grant degrees with “psychology” in the name (for example, a master’s in counseling psychology) or whose core faculty have degrees in psychology, identify as psychologists or are otherwise interdisciplinary, despite the fact that these graduates are license holders and license eligible in all 50 states.

Ironically, if Carl Rogers wished to hold a core faculty position in a CACREP program today, he would be prohibited due to the requirement that only counselor educators may occupy such positions. Many of us received excellent education and training from psychologists and others whose training was in other disciplines. We do not believe that national certification and reimbursement should be restricted to those who were trained solely or primarily by counselor educators, thus excluding qualified license holders in every state.

We applaud and support the educational standards that CACREP has developed and the efforts to promote these standards nationally. However, other accrediting bodies with equally impressive standards exist that accredit the programs that CACREP does not. Many of our members are graduates of or students in these programs. A notable example is the Council on Rehabilitation Education (CORE).

All accrediting bodies share the same mission — to train and graduate counseling professionals of the highest caliber. We can coexist peacefully and strengthen each other by supporting strong common core training and diversity in faculty background as well as programs’ specialty areas of expertise.

What needs to be done

1) We believe that CACREP-only restrictions should be removed from hiring and credentialing processes for TRICARE and the VA and should not be included in any future regulations (for example, state licensure laws, Medicare and private insurance regulations). Restrictive supervision rules in the TRICARE regulations must also be removed. ACA has consistently requested TRICARE policymakers to expand the original, restrictive criteria, and we ask the leadership to redouble efforts to press for those changes. The TRICARE rules are “interim final rules” and can be changed. Because ACA’s requests of regulators have not been effective to date, we ask the ACA membership to join us in lobbying our congressional delegations to change the rules. Please send an email to your representatives in Congress and urge them to oppose the restrictive TRICARE and VA regulations on your behalf.

2) Until CACREP-only language and the restrictive supervision rule are removed from TRICARE regulations, the current interim rules for transition to CMHC status in TRICARE should remain open. Established and emerging professionals who can meet the supervision requirement should be allowed to move into independent CMHC status.

3) The requirement for CMHC applicants to pass the NCMHCE (the clinical counseling exam) should commence in 2017, giving states that do not currently use this exam a chance to move to it in a reasonable way.

4) Please write (emails are more effective than letters) to your senators and congressional representatives and ask them to support S. 562, which would allow professional counselors to participate in Medicare. We believe it is very important that regulations are written to allow all currently licensed professional counselors to participate. This is a matter of honoring the right of states to determine the qualifications for professional practice and to provide much-needed services to citizens in
every state.

5) Regarding training standards, the profession of mental health counseling stands at a historic moment. Importantly, delegates to the 20/20: A Vision for the Future of Counseling initiative did not reach agreement that graduation from a CACREP-accredited mental health counseling or clinical mental health counseling program should be included in model licensure language. We believe that a more inclusive endorsement of educational standards is needed and should be part of all future federal and state credentialing processes. Please join with us in calling on the leadership of ACA and its divisions to recognize and affirm the value that CORE has long brought to the training of professional counselors and that other accrediting bodies bring in providing an alternate route to accreditation for counseling programs in related academic departments. Future initiatives and regulations should recognize and incorporate these accrediting bodies alongside CACREP. In doing so, ACA will affirm and continue its rich and diverse intellectual history and serve the best interests of all of its professional counseling members.



Note: This article was submitted as a joint effort of the boards of the Maryland and Massachusetts chapters of AMHCA.

Elaine Johnson is the graduate program director at the University of Baltimore. Larry Epp and Courtenay Culp are president and executive director, respectively, of the Maryland chapter of AMHCA. Midge Williams and David McAllister are executive director and associate executive director, respectively, of the Massachusetts chapter of AMHCA.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Update: Department of Defense clarifies TRICARE rule in Response to ACA Request

March 15, 2013

acaLogo3012The Department of Defense (DoD) has clarified aspects of its interim final rule (IFR) establishing certification criteria for licensed mental health counselors participating in the TRICARE program, in response to a request submitted by ACA. In a letter to ACA Executive Director Richard Yep, Assistant Deputy Director Mary Kaye Justis confirmed that counselors who meet the education, examination and supervision requirements in effect during the transition period – now through Dec. 31, 2014 – will continue to be recognized as independently practicing mental health counselors after the transition period ends. ACA asked DoD to clarify this issue because several members were being told that they would not be recognized after the transition period ended. DoD’s letter expressed appreciation to ACA for bringing this issue to their attention, and stated “We have discussed this issue with the TRICARE Regional Offices to ensure accurate implementation of the IFR by the Managed Care Support Contractors who interface with applicants.”

During the transition period, the IFR allows certification of counselors with a degree from a regionally (but not CACREP) accredited program, completion of 2 years/3,000 hours of post-master’s supervised experience, and passage of the National Clinical Mental Health Counseling Exam (NCMHCE). When the transition period ends, on Jan. 1, 2015, the certification criteria will require that counseling degrees be from CACREP accredited programs.

In its letter, DoD stated that counselors wishing to become certified as mental health counselors within TRICARE under the transition period requirements must complete those requirements before the transition period ends. However, “…while these certification requirements must be completed prior to Jan. 1, 2015, the IFR permits an applicant to become a CMHC [certified mental health counselor] after the transition period if all of the certification requirements were completed before the end of the transition period.” [emphasis in original]

ACA has confirmed with DoD staff that while completing the requirements must happen before January 1, 2015, counselors can become certified after that date. ACA has asked DoD to consider both extending the transition period and to allow counselors to complete the supervision and examination requirements after Jan. 1, 2015, as long as they have met the degree requirement (which does not require CACREP accreditation) during the transition period. The supervision and examination requirements in effect beginning in 2015 are the same as are required of counselors with regionally accredited degrees during the transition period.

According to DoD staff, the agency will issue a final rule on counselor certification, which may include changes to the requirements.  There is no word yet on when the final rule will be released.

In other news, TRICARE will be impacted by the sequestration taking place across most federal programs and agencies.  TRICARE staff and civilian personnel may be furloughed for one day a week, constituting a 20% pay cut.  Contracts, however, should not be affected.  It is unclear at this point if, or how, TRICARE reimbursement rates will be affected by sequestration.

For more information on TRICARE issues, contact Scott Barstow with ACA at sbarstow@counseling.org.