Call for Change group erroneously calls California licensure threat “unsubstantiated rumor”

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A group of well-meaning MFTs has been trying to make AAMFT more transparent and accountable. But their latest report about the LPCC license in California, which claims to have found deception by AAMFT, gets the important facts wrong.
          
          
          
          
          

Nuvola apps error* See updates below.

If you’re a member of AAMFT or have been connected in any way with the “Call for Change,” you may have received an email with an unsettling headline:

Unsubstantiated Rumor Influences AAMFT’s Strategic Plan

The email goes on to say that this “unsubstantiated rumor” was the notion that there was a threat to MFT licensure in California connected to the development of the state’s Professional Clinical Counselor (LPCC) license. You can read the CFC’s complete report online: CA LPC Deception Revealed.

Because the threat posed by LPCC licensure was all “unsubstantiated rumor,” the CFC logic goes, perhaps someone at AAMFT knowingly ginned it up for political reasons:

What could be the motives behind generating such rumors, fear, and speculation within our membership in relation to a document and process as significant as a long range Strategic Plan? Since the truth of this matter was already known by AAMFT leadership, could the reason be political?

For anyone unfamiliar, the CFC group is made up largely of well-meaning MFTs who want a more open, accountable professional association. That’s a laudable goal, and they have pushed AAMFT into making some much-needed changes, especially around organizational transparency. There is surely more work to be done on that front, and for that reason, a subgroup like CFC can sometimes ultimately be a positive thing for the larger association they criticize.

In this case, though, CFC gets the important facts wrong, and loses a great deal of its own credibility in the process. It starts by reporting that Kim Madsen, the California Board of Behavioral Sciences Executive Director, told them “there had been no current or past discussions regarding replacing the LMFT license in California with the LPC license” (I’m quoting the CFC’s paraphrase of Ms. Madsen). I of course was not in on this phone call, but I suspect what Ms. Madsen said was that no such discussion took place at the BBS. And, with that kind-of-important detail, that’s true — the BBS never had a public meeting or vote where replacing the MFT license was discussed or voted on.

For the CFC to extrapolate that to the notion that no one in California ever discussed eliminating the MFT license, however, is a rather significant error. CAMFT (which is not affiliated with AAMFT or its California Division) specifically discussed replacing the MFT license. You can see it in page 14 of this California legislative committee report, and the same text was in an email to members that CAMFT sent in May 2007 (emphasis mine):

CAMFT states, “At some time in the future, we project that there will only be one masters level profession in California, with individuals specializing within that license. Thus, those who wish to specialize in systems work will do so; those who wish to specialize in art therapy will do so, etc. The current system with a variety of acronyms is confusing for consumers who just want to be helped and do not perceive greater value from one professional compared to the next.”

When CAMFT was negotiating changes to various versions of the LPCC bill, they sought to make MFTs and LPCCs as indistinguishable as possible. And without distinctiveness between professions, it becomes much harder to argue that distinct licensure should be maintained. Sure enough, the following language was inserted into a version of the 2008 LPCC bill (which ultimately failed; again, emphasis mine):

The Department of Consumer Affairs and the Board of Behavioral Sciences shall collaboratively evaluate the licensing requirements and scope of practice for licensed professional
counselors, licensed clinical social workers, licensed educational psychologists, and marriage and family therapists. The evaluation shall include a recommendation on whether or not these licensed professions should become a general license category, and if such a recommendation is made, how it is proposed to occur.

CAMFT projected a one-license future, and that proposal found its way into proposed legislation. These are facts on the public record. They are indisputable. That legislation may have become law had AAMFT-CA and the California Psychological Association not worked diligently in opposition. For CFC to dismiss the threat to California MFT licensure as “unsubstantiated rumor” is clearly and demonstrably incorrect.

CFC goes on to question how CAMFT could possibly have any influence over license transitions, since it is the BBS and not any professional association that enforces licensure standards. This is shockingly naive. CAMFT does a tremendous amount of work (often very good and beneficial) on state legislation, and the licensure standards the BBS exists to enforce are written in state law; the BBS has no right or authority to refuse to enforce a law once it takes effect. Almost every major piece of state legislation that has impacted California MFTs in a generation has had CAMFT’s fingerprints on it. If CAMFT wanted MFTs to become LPCs, they wouldn’t politely ask the BBS to make it happen. They would seek to change the law, and they have the resources to do so. As you can see above, a change in the law is precisely what could have happened.

Even after the final version of the LPCC law passed in California, CAMFT has continued to work hard at making MFTs and LPCCs seem indistinguishable. When even the relatively minor barrier of a “gap exam” for MFTs seeking grandparenting into LPCC licensure arose, CAMFT not only fought it, they sued the BBS — a suit that could have, among other things, led to a court ruling that the professions are not distinct.

Thankfully, CAMFT largely lost that suit. There will be a gap exam, and the BBS is supporting distinctiveness between MFTs and LPCCs in other ways. But for CFC to suggest that there never was a threat to the MFT license in California — or indeed, to even suggest that threat has fully abated now — is simply out of line with reality.

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Full disclosure: I have served as a consultant to AAMFT in the past (not currently), and still volunteer regularly for the California Division, though I hold no official role there. I was part of the AAMFT-CA negotiating team on California LPCC legislation. I’m a former CAMFT member; their lawsuit against the BBS led me out the door.

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Updated 3-16-2011: The Call for Change folks have posted a rebuttal to my post here. See: CFC rebuttal // My response

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The image above is the semaphore sign for “error.” Think I’m out of line with reality? Post a comment below or email ben[at]bencaldwell.com. Follow my Twitter feed.

In “Gap Exam” and supervision rulings, California licensing board says MFTs and LPCCs are different

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In a unanimous vote, the California Board of Behavioral Sciences (BBS) today determined that a Gap Exam will be necessary for marriage and family therapists (MFTs) seeking licensure as professional clinical counselors (LPCCs). A separate ruling on supervision has similar themes.                                            

JudgesTools IconThe “Gap Exam” for currently-licensed MFTs seeking to grandparent into LPCC licensure will be shorter than regular licensing exams, and will focus on the differences in practice between MFT and LPCC.

In a separate vote, the BBS also agreed to move forward with a legislative proposal that would require LPCCs to complete additional coursework and experience in couple and family work in order to supervise MFT interns and trainees.

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Gap Exam

Today’s vote was the fourth the Board has taken on the Gap Exam issue, which has become controversial because of its broader implications about the distinctiveness of the professions. (For some of the history, see “CAMFT sues California licensing board” and “Ruling mixed in CAMFT-BBS gap exam lawsuit.” Full disclosure: I resigned CAMFT membership in response to their actions on this issue.) Earlier votes had been set aside for a variety of reasons; the most recent prior vote was set aside after CAMFT sued the BBS, and won on their argument that the BBS had not first consulted with the state’s Office of Professional Examination Services, as required in the law. The court ordered the BBS to set aside its prior vote and do the required consultation.

In that required consultation, OPES said they believed a Gap Exam was indeed necessary (last pages of PDF), and the BBS today voted to move forward with the Gap Exam. The exam development process will start immediately. Today’s hopefully-final vote supports the notion that while mental health professions have much in common, there are still meaningful differences between the practices of the specific professions.

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Supervision

Similar themes arose in discussion on supervision in mental health care. In current law, LPCCs must complete additional coursework and experience to be able to legally assess or treat couples and families. The question at hand was whether LPCCs who had not met those requirements should be able to supervise MFT trainees and interns who would be providing direct services to couples and families.

I argued the AAMFT-CA perspective, that one should not be legally able to supervise an activity that is outside of one’s own scope of practice. The BBS voted in agreement. Unlike the exam ruling, however, this vote was by no means a final determination. It merely moves forward proposed legislation that would allow LPCCs to supervise MFTs only if the supervisor has completed those additional requirements. The proposal still must go through the legislature and be signed by the Governor to become effective. CAMFT indicated they will oppose that provision during the legislative process. If CAMFT moves to simply kill the proposal, and is successful in doing so, LPCCs will be left with what is in current law — which prevents them from supervising MFT interns or trainees at all.

California’s complex plan to save mental health funding by slashing it

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To balance the state’s budget, Governor Jerry Brown has proposed raiding a state fund set aside to transform public mental health care. In return, he’s promising long-term fixes to the structural underfunding of public mental health. Is it a fair trade?

          
          
          

Side View Sacramento CapitolCalifornia Governor Jerry Brown has inhereted a budget deficit estimated at $25 billion, which everyone agrees will require significant changes in state services. One fix the Governor has proposed is raiding Mental Health Services Act (MHSA, originally known as Proposition 63) funds, an idea voters rejected as a budget fix in 2009.

This time around, Brown is proposing a novel compromise: let the state raid the MHSA fund on a one-time basis, and in return mental health services will get a longer-term, structural fix to chronic underfunding. It’s an intriguing proposal.

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Thanks to a the MHSA, a voter-approved tax on millionaires*, California currently has about $2 billion set aside specifically for the improvement of its public mental health system. This money is meant to be used to provide new and expanded services, train public mental health workers in current research-supported approaches, and generally transform the system to one that is modern, client-centered, and accountable. (By law, the money specifically cannot be used to pay for existing services, which are chronically underfunded.) Many marriage and family therapists are employed in public mental health in California, often in clinics funded by Medi-Cal.

Of course, in a budget crisis, it is easy to see how elected officials could view $2 billion sitting in the bank as a budget-solution-in-waiting. Governor Schwarzenegger proposed raiding this fund in 2009, asking voters to shift $460 million from MHSA funds into the state’s General Fund. The proposal was defeated by a landslide.

In contrast to the failed 2009 proposal, Governor Brown proposes a scheme that — at least in theory — could help the state budget in the short term and preserve mental health funding in the long term. It includes several moving parts:

  • Shifting $861 million from the MHSA reserve account to the General Fund. The shift would pay for current mental health services for the 2011-2012 fiscal year. Net impact: Bad. But could be worse. Obviously, this is a setback for planned MHSA-funded new and expanded programs, but the money would still be used to pay for mental health services, and would be a one-time shift.
  • Shifting responsibility for three mental health programs from the state to counties. The programs include Early and Periodic Screening, Diagnosis and Treatment (EPSDT); Medi-Cal mental health managed care; and special education mental health services (known to professionals as AB3632). Net impact: Unclear. “Local control” is sometimes better in concept than in reality; state administration ensures careful auditing to ensure money is being spent wisely, and consistency in program standards. County control of these services may lead to some cost savings, but those are often overstated.
  • Changing how the state funds mental health. Starting in the 2012-13 fiscal year, mental health services would be given an additional dedicated portion of state sales tax and vehicle license revenues. These are projected to grow at approximately a 6% annual rate. Net impact: Good. Currently, mental health programs are funded through a mechanism that grows at about 2% a year, according to the California Council of Community Mental Health Agencies — lower than normal inflation, and certainly not enough to account for any growth in patient population. This is a prime example of structural underfunding, which leads to ever-increasing caseloads and access-to-care problems.

All of this adds up to a proposal that has public mental health leaders more cautious than optimistic. The California Mental Health Directors Association asks a long list of good questions about the proposal, most of which are presently unanswered.

But the fact that a proposed $861 million raiding of public mental health funds is not being met with noisy protests from the agencies that rely on those funds is telling. It suggests that the proposal may have merit.

In the state’s current budget environment, we know lots of cuts will need to be made. Some of those cuts are likely to impact public mental health workers, including marriage and family therapists. Weathering the storm with a minimal amount of damage to public mental health, and even a potential long-term improvement to how it is funded, could be a very good outcome. Maybe.

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* Background on MHSA: As Governor Brown notes in his budget proposal,

To provide additional resources for county mental health services, voters passed the Mental Health Services Act (Proposition 63) in 2004. The intent of Proposition 63 was to reduce the long‑term adverse impact of untreated mental illness by developing services or expanding existing services at the local level. To fund these resources, Proposition 63 imposed a one‑percent surcharge on personal income over $1 million.

That tax brought in $2 billion more than expected in its first four years. (The budget proposal fails to mention that since then, the MHSA has brought in less than expected due to the worsening economy.) Counties have engaged in a long-term planning process for how they would use MHSA money to transform their mental health systems; by law, MHSA money was not to be used as simply a replacement funding stream for existing services. So while the MHSA currently has about $2 billion in reserves, counties have been planning for — indeed, counting on — that money to be available.

California CE providers routinely violate ad regulations

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A review of 15 advertisements for continuing education events for California MFTs and LCSWs finds that all of them violate state regulations by leaving out required information. If no one is complaining, do we need the regulations?                                                     

Forget-me-not2-croppedContinuing education providers in California are expected to offer some basic information about themselves and their events when advertising, just as licensed marriage and family therapists are expected to have our licensure information attached to any advertising we do. Ideally, these disclosure requirements prevent less-than-reputable folks from putting on less-than-worthwhile CE events to swindle therapists out of money.

But no one is following the requirements.

And that’s a literal “no one,” at least in our sample. Not one advertisement followed the letter of the law.

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We (my research assistant and I) reviewed ads from every issue in volume 21 (2009) of The Therapist magazine, published by the California Association of Marriage and Family Therapists every two months. We want to emphasize that CAMFT is not in any way responsible for policing outside ads; it is the CE providers who are solely responsible for their own advertising content. We found a total of 15 unique ads, many of which appeared in multiple issues; we did not count duplicates in our calculations.

Section 1887.9 of the California Code of Regulations (it can be viewed in the BBS laws & regulations booklet, page 142 by the on-page numbering, page 149 of the PDF) requires all CE providers to:

ensure that information publicizing a continuing education course is accurate and includes the following:

(a) the provider’s name;

(b) the provider number, if a board-approved provider;

(c) the statement “Course meets the qualifications for _______ hours of continuing education credit for MFTs and/or LCSWs as required by the California Board of Behavioral Sciences”;

(d) the provider’s policy on refunds in cases of non-attendance by the registrant; and

(e) a clear, concise description of the course content and objectives.

Providers seem to be simply ignoring this. We found a total of 15 unique ads for in-person CE events. We ignored ads for online or mail-in courses; they usually were advertising the provider, and not a specific course, and thus they are probably not subject to the above requirements.

We found that among the 15 ads we reviewed, providers routinely ignored all of the required information except the provider’s name:

Item Ads
containing		 Ads
missing		 % of ads
containing
1. Provider name 14 1 93%
2. Provider number 7 8 47%
3. “Meets qualifications”
statement		 0 15 0%
4. Refund policy 2 13 13%
5. Course description 8 7 53%

Another way to look at this is to see what proportion of ads had 2, 3, 4, or all 5 of the required pieces of information:

Items present Ads % of all ads
One or more 15 100%
Two or more 11 73%
Three or more 3 20%
Four or more 2 13%
All five 0 0%

The requirements exist to ensure that when licensees hand over their money to CE providers, the licensee knows what they are signing up for and those hours will legitimately count toward the licensee’s continuing education requirement. But the BBS does not enforce those requirements unless they receive a complaint, and such complaints are rare: in a 7-month span reported here, the BBS received just three complaints against continuing education providers. (And those were not likely to have been about advertising, judging by prior complaint data.) For comparison, there are more than 2,000 approved CE providers in the state.

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The relative rarity with which the requirements are followed, combined with the relative lack of complaints against continuing education providers, raises an important question: Are these regulations really helping anybody?

Certainly the BBS has better things to do with its enforcement unit than go after such minor omissions. Maybe it would be better to take the requirements off the books entirely.

Or, maybe the current landscape is just fine. After all, it allows licensees who feel they have been duped by unscrupulous CE providers to complain, and gives the BBS leverage to act against the provider who failed to advertise appropriately. It’s the CE-advertising equivalent of jaywalking: we all want the cops to focus their work on more important things, and it’s really only a problem when somebody gets hurt.

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If you’re wondering, the flowers in the picture are forget-me-nots. Seemed appropriate.

Wyoming bill would require counseling before marriage or divorce

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With some exceptions, three hours of premarital or pre-divorce counseling would be required. For divorcing couples, it’s good policy, even though it is unlikely to reduce divorce rates. It is much harder to justify the premarital requirement, on either a clinical or policy level.

Boutonniere-whitesuitA bill introduced in this year’s session of the Wyoming state legislature, HB0065, would require couples to attend three hours of premarital counseling before obtaining a marriage license, and three hours of marriage counseling before obtaining a divorce.

While there is little data to suggest that any three-hour process for couples already planning to split up will make much of a dent in the state’s divorce rate, requiring divorce counseling is a good idea for other reasons. Divorce education reduces conflict in the divorce process, particularly where custody is concerned (see this summary of several studies on divorce education for parents), and saves the divorcing couple as well as the public a significant amount of money in the process. Three hours is not an unduly burdensome amount, and the a judge can waive the requirement if the court finds there is “clear and convincing evidence that marital counseling will not lead to a reconciliation of the parties” — an important consideration for victims of relationship violence. Several states have adopted such programs, often similar to one called “Children in the Middle,” with good results.

The premarital counseling requirement is harder to support, either on a policy or scientific level — and this is coming from a guy who specializes in couples work (San Diego marriage counseling) and loves premarital counseling.

There is ample evidence that these relationship education programs improve communication, but it is unclear whether premarital education actually improves relationship satisfaction or stability, and there is virtually no evidence to suggest they actually have a long-term impact on divorce. (That’s primarily due to a lack of data, not studies showing failure.) A recent, thorough review in the journal Family Relations described current research on the very basic question of whether these programs work as “not as settled as program developers and practitioners might assume or like it to be.” There are at least three large-scale, federally-funded demonstration projects of premarital education (Appendix 2) underway now that should provide clearer answers.

In the meantime, these programs continue to grow because they are, in the words of one report, “popular and valued.” And there is some evidence to suggest they have a greater impact on low-income families, who do suffer from higher long-term divorce rates.

But here’s the catch. In the studies that have been done, as well as the large studies underway now, few have suggested that just three hours of education would be enough to even expect an impact. The federally-funded studies use programs of at least 24 hours of education. Most programs utilize at least 12 hours. Anything under eight hours was considered in the Family Relations review to be a “low-dosage” program.

This is why it’s so hard to get behind the premarital requirement in the proposed Wyoming law. I could see requiring 12 hours, and I can certainly understand requiring none. But three hours? It adds a hurdle to marriage, without sufficient reason to believe it will have a lasting positive impact. And while I believe quite strongly that premarital education can be effective, I cannot support requiring an amount of it that is too low to have any likely effect. Wyoming and other states should either require enough premarital education to make a lasting difference, or none at all.

Update: The bill died in its first committee in February 2011.