Training in mental health is unreasonably long

2010-07-20 Black windup alarm clock faceJust as a quick thought experiment, go over to this piece at Slate discussing medical training, and every time it references “medicine” change that to “mental health.” (Accordingly, change “physicians” and “doctors” to “therapists.”) You’ll find most of it applies perfectly. To wit:

Over the past century, there have been additions to, but few subtractions from, the training process. Residency and fellowship programs became longer and longer … and longer.

and

The long process doesn’t just weed out the incompetent and the lazy from the potential pool of physicians—it deters students who can’t pay for so many years of education or who need to make money quickly to support their families. That introduces a significant class bias into the physician population, depriving a large proportion of the population of doctors who understand their background, values, and challenges.

and

The fundamental problem here is that the argument between traditionalists and reformers [debating the appropriate length of training] is essentially theoretical — we are in an evidence vacuum.

In the time I’ve been in academia, I’ve watched as the requirements for training in mental health have increased dramatically. Family therapist training in California increased from 48 to 60 units based not on science but on workplace competitiveness. (MFTs were fighting clinical social workers for some of the same jobs, and since LCSWs need 60 units of training, MFTs couldn’t really argue that their training at 48 units was equivalent.) I’ve also watched as education in general has gotten much more expensive, and loans harder to come by. And I’ve been enlightened by learning that our 3,000-hour supervised training requirement is based entirely on tradition, and is in virtually no way linked to the science that we now have available (though admittedly, it isn’t much) on how therapist skill develops over time.

Our old apprenticeship model is broken. It’s as true in therapy as it is in medicine. It will be interesting to see how experimentation with medical training goes, as it can blaze the trail for similar efforts in other health care professions like ours. I’m just not sure we should be waiting for doctors to do it first.

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How long does it take to get an MFT license?

State laws vary, but typically, you need a two-year masters degree and two more years of full-time, supervised experience. Here are the steps to becoming a licensed family therapist.

                                                                                                                                                                                                                                                                                                           

2010-07-20 Black windup alarm clock faceIf you are planning or considering a career as a marriage and family therapist, it is important to give thought to the time and money it will take to work your way to licensure. The timing of steps along the way could impact your choices for when to get married, have children, or maintain employment in another field.

Presented here are the typical steps to an MFT license and some common timeframes. The steps and timeframes listed here do not account for individual circumstances or the many state-to-state differences in licensure laws. You should check the web site of your state MFT licensing board (AAMFT offers a handy directory of state MFT licensing boards) to learn the specific requirements of the state where you want to license. I have some emphasis on California in this post because it is the state I call home, and because about half the MFTs in the country are here.

Note that a “typical timeframe” here means a common amount of time needed for those who are accomplishing that step through full-time work or study. If you build your career in MFT through part-time work or study, to allow you to balance family responsibilities, maintain outside employment, or for any other reason, naturally your timeframe will be longer.

Progression to licensure as a marriage and family therapist usually follows these steps:

  1. Complete a bachelor’s degree in psychology, family studies, or a related field. Many schools will be OK with a major in a different field if you can demonstrate adequate base knowledge in psychology and family development, through specific prerequisite classes, GRE subject test scores, or other means. Typical timeframe: 4 years.
     
  2. Complete a master’s degree in marriage and family therapy, counseling psychology with an emphasis in MFT, or a closely related field. Note that some states, like California, have specific requirements for what degree titles will make you eligible for MFT licensure. In most states, you will need to demonstrate that your master’s degree program was accredited by COAMFTE (the accrediting body for MFT programs), or is equivalent to COAMFTE standards. I’ve written in the past about the benefits of attending a COAMFTE-accredited program, and I’ve also offered tips for admissions interviews at MFT programs. You might want to consider a doctorate in MFT, though it will take longer. Typical timeframe (masters degree): 2-3 years.
     
  3. Complete additional supervised experience under a licensed MFT. In some states, including California, other licensed mental health professionals can supervise you as well; check with your state to see what their supervision standards are. Note that some states require your pre-licensed experience to be under an AAMFT Approved Supervisor. (A directory can be found here: Find an AAMFT Approved Supervisor.) During the time between graduation and licensure, while you are working under supervision, your state may call you an “intern” or an “associate” depending on the state. A few states use other titles. Most states require a total of 3,000 hours of supervised experience for you to be eligible to sit for licensing exams; there is some variability here, too, however. (Pennsylvania’s governor just signed a bill reducing that state’s requirement to 3,000 hours from 3,600.) Some states simply phrase this as two years full-time experience or the equivalent. Also note that in California, some hours gained within the master’s degree program can count toward the 3,000 total needed for licensure. (Other states tend not to allow this.) Typical timeframe: 2 years.
     
  4. Pass your state’s licensing exam(s). California is the only state that uses its own exams rather than the National MFT Exam. Many states require a state law and ethics exam in addition to the national exam, since state laws vary in key areas like child abuse reporting requirements. While an exam itself is over in a day, the licensing board needs time to process your MFT exam eligibility application, you need time to prepare, and you will need to schedule an appointment with a nearby testing facility. I’ve previously offered tips for preparing for MFT licensing exams, four myths about MFT licensing exams, and some discussion about whether MFT exam prep courses are worth the money. Typical timeframe: 6 months – 1 year. Longer if you need multiple attempts to pass.

Once you make it through that last step, congratulations! The state can now make you fully licensed as a marriage and family therapist, able to work independently in a private practice if you choose.

Overall, it’s good to plan for a total of at least 4-5 years from the start of your masters degree all the way through to licensure. Your time may be longer based on your circumstances; it would be possible (at least in CA) but unusual for your time to be any shorter.

In most states, the timelines for masters-level licensure are similar among clinical social workers, counselors, and MFTs. California is a noteworthy exception there: Only MFTs can count pre-degree hours of experience toward the 3,000 hours required for licensure, so it tends to be faster to get an MFT license in California than the other masters-level licenses. Licensing as a Psychologist requires a doctoral degree (typically 5 years, sometimes as short as 4) plus a postdoctoral internship (in California, 1,500 more hours, or about another year of full-time work) for a total of 5-6 years. Again, though, your individual circumstances may make your time longer.

Ed. note: This post originally published March 26, 2012. Some links updated June 11, 2018.

Four myths about MFT licensing exams

Go ahead and be anxious about your licensing exam process — it’s a big deal! But don’t buy into grumbling falsehoods about it. Test items are written by actual MFTs, and there are no trick questions.

Every person who becomes a licensed marriage and family therapist has to go through an examination process. In most states, that means passing the National MFT Exam. Many states also supplement the national exam with a second exam covering areas of state law (for example, ensuring that therapists are familiar with that state’s requirements for child abuse reporting). In California, the exam process is a bit different; California MFTs must pass two state-run exams, the MFT Standard Written Exam and the MFT Written Clinical Vignette Exam. [Update: The California MFT licensing exams change structure on January 1, 2016.] The overall content and structure of California’s exams are similar to the National MFT Exam — they’re multiple-choice tests that use a combination of factual questions and case-vignette-based questions.

Regardless of what state you’re in, if you haven’t taken the exam(s) yet, you may be dreading them. Even if you have gone through the exam process, you may not have fond memories of it. I hear complaints about the licensing exam process on a regular basis — most of them based on total mythology. It’s as if we (quite understandably) have anxiety-based associations with our testing process, past or future, and then (far less understandably) conjure up rational-sounding but totally baseless complaints about the process in an attempt to justify those fears.

It’s okay to be anxious about the process on its own merits. The exams are high-stakes; if you fail, you typically have to wait several months to try again. That impacts your standing among your peers, your employment options, and potentially your income. I still remember completing California’s Written Clinical Vignette exam and feeling certain I had failed. In a matter of moments, I was mentally planning how I would explain the failure to my employer, and how I would plan to do better next time. It turned out I had passed, but the memory of those anxious moments before getting my results stays with me.

If I had failed, I wanted to blame someone else: How dare that test be too hard for me! It must be the test’s fault! I’m glad I didn’t take much of a walk down that road, but if I had, I would have had plenty of company. Once a rumor has started that serves to explain why the tests feel so frightening and why we feel so unsure of ourselves going into them, it is easy for that rumor to be perpetuated. Such stories are factually wrong, and ultimately do more of a disservice to future test-takers by making the exams look cruel and unpredictable. But to someone who has failed a test (or is worried they might), the stories offer comfort — and someone else to blame. So they live on each year.

Here are the four myths I hear about MFT licensing exams the most:

  1. There are trick questions. Simply put, a licensing exam that uses trick questions would not be legally defensible. Test developers go to tremendous lengths to make sure any potential exam item works well, through several layers of review and pilot testing. If too many people are missing a question, it gets flagged for even more review. If a question appears to be tricking people, either by design or by accident, it is removed.
  2. There is secret knowledge. Test-prep companies make a lot of money perpetuating the mythology that they can provide you with “secrets” or other insider knowledge to help you pass the tests. Nonsense. Both California and AMFTRB (developers of the national exam) offer study guides that say what will be covered on the exams, and they ultimately draw their questions from the same textbooks and journal articles that graduate programs use to teach their students.
  3. They are meant to assess whether you are a good therapist. If I may be blunt, your licensing board does not care whether you are a great therapist or a lousy one. They only care about whether you can practice marriage and family therapy competently enough so as to not be a danger to the public. That’s what the exams are meant to assess. Yes, it is sometimes true that ineffective therapists pass their licensing exams, and effective therapists fail. But effectiveness and potential dangerousness are two different things. If you want an outside evaluation of your quality as a therapist, look elsewhere. (Back in 2008, I examined in more detail the question of whether licensing exams lead to better quality therapists.)
  4. They are written by people who aren’t therapists. Both California and the AMFTRB use licensed therapists to write their test items. In California, you can apply to be a subject matter expert involved in writing the exams. Elsewhere in the country, AMFTRB intermittently recruits MFTs with relevant expertise. Every test item on both the California and National MFT Exams is written by one or more practicing MFTs.

If you’re anxious about your own upcoming exams, instead of buying into the falsehoods above, you’ll likely be better off to do something about that anxiety. Maybe that means simply more studying, or maybe it means more directly addressing the anxiety through meditation, therapy, or other means. (Test-prep programs may be of questionable value overall, but if they can help you feel more knowledgeable and less anxious as you take the tests, they may well be worth your time and money.) Rest assured the exam process, and those who designed it, are not out to get you or to trick you. With the right preparation, you can do well on exam day.

If you know someone else who is anxious about their exams, or even who has failed an exam, by all means, comfort them and empathize with them. Sometimes we just have bad days. But please don’t support any of the mythology above — those ideas just make the testing process look bigger, scarier, and less under your control than it really is.