licensing

State differences in license requirements are small and serve no meaningful purpose. Considering mental health care as interstate commerce would improve access to care for those in need.
                                                                                                                                                                                                                                                                                                           

Marriage and family therapy students and interns today see similar steps on their career path no matter where they live in the US. Most states require a masters degree based on COAMFTE requirements, roughly 3,000 hours of supervised experience, and a passing score on the National MFT Exam to be licensed. The rules from state to state are not identical, though: As just a quick sampling, Delaware requires 3,200 hours. New Jersey separates out requirements for general counseling experience and MFT experience. And California doesn’t recognize the national exam. (It’s now a few years out of date, but go to page 258 of this PDF for a very well-done table of 2007 state MFT licensure requirements around the country, put together by California’s Board of Behavioral Sciences.)

There is no real need for these differences. In theory, having states determine their own licensure standards should ensure that each state is preparing professionals to meet the unique needs of that state’s population; in practice, though, that isn’t what happens. The development and refining of licensure laws has been about balancing national standards with political compromise. Neither the public nor the professions are demonstrably better-served by an MFT who passed the California exams as opposed to the National MFT Exam (or by 3,200 hours of experience versus 3,000, or any of the other minute differences between states). The state differences in mental health licensing do little more than create headaches for those professionals trying to move from one state to another.

The time has come for national licensing laws, for family therapists as well as the rest of the mental health professions.

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The professions understand that license portability is a problem. Each of the national mental health organizations has a model licensure law that they use as an ideal example for state legislatures around the country. (The American Psychological Association recently amended theirs to allow states to forgo a postdoctoral internship requirement.) These model acts promote the standardization of requirements from one state to the next, easing license portability for professionals and helping ensure to the public that the meaning of a professional title will not dramatically change when one crosses a state line. Those are both worthy aims. Unfortunately, they have not been especially successful.

National licensure has not been pursued in mental health because of concerns about the U.S. Constitution, which leaves to the states any powers not expressly given to the federal government. Since the licensing of professions is not a federal power in the Constitution, the states have needed to take it on themselves. The result has been our patchwork of state laws for each profession.

Two things have changed in the past decade to create the right conditions for national licensure to emerge. One has been the completion of a nation of licensure for MFTs and LPCs. The other has been the rapid growth of telemedicine.

1. A nation of licensure. In 2009, Montana became the 50th state to license MFTs and my great state of California became the 50th state to license counselors. This fact alone does not justify a single, national standard for licensure, but it is vital to the context of the discussion.

2. Growth of telemedicine. The internet has hastened the development of remote services, but did not create it. Therapists have been working with clients by phone since the early days of psychotherapy. Today, through secure videoconference connections, a therapist in his or her office in a major city could easily work with clients anywhere in the world where the technological means exist for such a connection. The American Counseling Association’s Code of Ethics has outlined clear and specific guidelines for therapists providing services by phone or internet. While there is limited data on the effectiveness of technology-assisted therapy, for many people who are in rural communities, have specific language needs, or simply lack the means to go to a therapist’s office, the alternative to phone- or internet-based treatment is no treatment at all. This point is where the Constitutional argument would seem to shift: The internet can make psychotherapy a form of interstate commerce. Regulating interstate commerce is squarely within the federal government’s powers under the Commerce Clause.

It has been repeatedly well-documented that rural areas face a severe shortage of mental health providers. At the same time, early-career practitioners in mental health — often living in urban areas — regularly fret about whether they can make a living in their chosen fields. A national licensure standard would go a great distance toward easing both concerns.

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Of course, I am a family therapist, not a constitutional lawyer. So I could be way, way off-base here in my reasoning when it comes to the law. If so, please say so in the comments! As the old quotation goes, I never learned anything from anyone who agreed with me. So send your disagreeable emails to ben[at]bencaldwell[dot]com, post in the comments below, or be pithy with a message to my Twitter feed.