Why don't current psychotherapy licensing regulations work?

A review and suggestions for change

John M. Grohol, Psy.D.
March 1998; Reviewed: February 2004

Licensing of professionals who provide psychotherapy services in their community is often hailed as a necessary requirement for ensuring a minimum standard of quality care and accountability that would otherwise be lacking in a professional field such as behavioral healthcare. Consider that licensing requirements for one type of behavioral healthcare professional -- psychologists -- have been around for decades in most states. The rationale is that the licensure requirements protects you, the consumer, from fraudulent professionals and maintains a certain minimum standard in the field. But how well does licensure succeed in meeting these goals?

Getting a license as a psychologist in any given state is a time-consuming, often costly task. It usually involves a minimum set of supervised hours doing therapy, at the expense of the unlicensed psychologist. If the unlicensed psychologist isn't working in some type of agency setting, this means paying another, licensed psychologist for their supervisory time. This already brings up an ethical dilemma of a dual relationship for psychologists, which is often ignored. The unlicensed psychologist is paying the supervisor for services rendered (supervision), while at the same time acting as a mentor/teacher and often times, friend. In an agency setting, the unlicensed psychologist is often an employee overseen by the same supervisor (boss/employee relationship). All of these issues make for a murky ethical situation, one where the supervisory relationship boundaries are often gray.

The second aspect of a psychologist's licensure is taking two examinations. One examination, a national test which is the same for every psychologist in every state each year, tests the unlicensed psychologist's knowledge in every area of psychology. No matter that the unlicensed psychologist already has his or her doctoral degree! Apparently all those years of schooling don't ensure any type of quality... or knowledgebase. Ideally, the assumption is this test will weed out psychologists who didn't learn anything from all of those years of schooling. The reality is that most psychologists who sit for this test purchase test preparation materials. The examination just doesn't test clinical knowledge, but all aspects of psychology. This includes areas such as industrial-organizational psychology, experimental psychology, and a host of other sub-fields not often the focus of a clinical psychologist's training or education. Most psychologists re-learn this material (or learn it for the first time) through the test preparation materials (often costing hundreds of dollars). How really useful is this test, then?

The second test is a local examination on the specific state laws governing mental health care in the state. This is the most vital aspect of licensure, because it does ensure the professional knows and understands all the legal statutes which dictate how that professional can practice psychotherapy in their state.

Since one of the main strengths of psychology is in designing and assessing the usefulness of psychological tests, one would expect the research literature to be brimming with information about the validity and reliability of licensure examinations. After all, a part of psychologists' ethical code is to ensure that psychologists know that a test they use is psychometrically sound (see the APA Ethical Principles, specifically sections 2.02-2.04). So how do these licensing exams fare? Poorly, with little research which validates their usefulness. Diane Novy, Kenneth Kopel, and Paul Swank in 1996 reported that "published evidence justifying the effectiveness and fairness of oral examinations for licensure as a psychologist is sparse across jurisdictions that exercise the power to implement these examinations." David Johnson and Dan Huff (1987) discovered that for social workers, "the factor that most strongly correlated with performance on the licensing examination was undergraduate grade point average [emphasis added]. Results indicate that few people fail the licensure examination and that education and work experience have little impact on test scores..." Clinical social workers go through a similar licensing process are the most heavily used behavioral healthcare professional amongst the majority of managed care organizations today. What does it say about licensing examinations in general if the most predictive indicator of doing well on it is simply one's undergraduate GPA? Not very reassuring. Most licensing examinations in most states do not directly test a clinician's therapeutic skills in any empirically-validated, systematic, and scientific manner.

Even if the process is so flawed, does it actually do what it purports to do --protect consumers and ensure a minimum quality standard for professionals? W.E. Goodrich, Ph.D., a Colorado psychotherapist, argues that it doesn't in its current form in most states (Goodrich, 1998). Dr. Goodrich states, "Historically, the purpose of licensing (of professions, as opposed to driving cars, etc.) has been 'turf protection.' Especially in the medical and mental health fields. In fact, it goes back to the Charters and Guilds of the 15th century." Goodrich's statements seem to be supported by the research literature in this area. Although David Lambert and Thomas McGuire (1991) found that consumers wanted licensure protection, they also confirmed that psychology licensure is "a product of the self-interest of providers." Kenneth Thomas (1993) argues that "that the primary purpose of professional credentialing is not to protect the weak but to increase the power, authority, and incomes of the strong." Other behavioral healthcare professions fare little better. Steven Segal and Sung-Dong Hwang (1994) in a California study found "that although licensure occurred with greater frequency among facilities serving the most disabled population, licensure neither predicts nor has as its apparent consequence the development of higher-quality [sheltered care] facilities."

Daniel Hogan (1985) makes a strong argument with the drawbacks to current licensing laws as they exist in most states today:

It is suggested that licensing may not only fail to accomplish its intended purpose but may be counter-productive. Licensing may not improve the quality of professional services, licensing boards often fail to discipline unethical or incompetent practitioners, and actions taken against the unlicensed are more often aimed at eliminating competition, not incompetence. In addition, licensing laws may have negative side effects, including an increase in the cost of professional services, the creation of shortages and maldistributions in supply, ineffective use of paraprofessionals, and impediments to needed reforms in education, training, and services. It is concluded that equally effective alternatives may be available that are less expensive and have less negative impact, and a system of registration is advocated for all practitioners.

Goodrich (1998) reports on the effectiveness of licensing laws in Colorado:

A recent multi-year study (commissioned by the State Legislature) found that there was no evidence [emphasis added] that licensing provided any degree of consumer protection overall. In one recent year, the Board issued several times more disciplinary actions (per capita) against each of the licensed groups than against the nonlicensed group. In fact, the Licensed Psychiatrists (who the non-licensed group outnumbered by about 4 to 1) drew more total disciplinary actions -- and more serious disciplinary actions -- than the unlicensed group that year. Not just more per capita, more overall.

Licensing examinations don't appear to be all that useful, based upon the sparse research available, and licensure in its current form doesn't appear to protect anybody other than the professionals who are already licensed from "outsiders". So what can be done to improve this situation? Getting rid of licensing isn't the answer; reforming it is, however.

Goodrich (1998) suggests a sensible, four-step outline based upon his experiences with the Colorado model. These steps include:

    1) Recognition and appropriate regulation of nonlicensed psychotherapists.

    2) Consolidation of the regulatory and disciplinary functions into a single multidisciplinary "grievance board" consisting of representatives of each form of Licensed Psychotherapists (LMFT, LPC, LPsychologist, LCSW, etc.), nonlicensed psychotherapists, and general-public "consumer representatives". An exception might be made for psychiatrists, who would be answerable to the relevant Medical Board for their actions (as physicians).

    3) A consistent set of functional and ethical regulations for all forms of psychotherapists.

    4) A central registry for all types of psychotherapists.

These steps seem very reasonable in light of the fragmentation of the current psychotherapy field, with no less than a half-dozen different professions providing forms of psychotherapeutic services in most states. Why should one profession be held to a higher or lesser standard than another profession, when both are doing the same thing -- psychotherapy? It simply doesn't make sense. It provides a byzantine structure consumers must navigate through to bring a grievance against each different type of mental health professional. A central registry and consolidated regulatory board overseeing all psychotherapy professions appears to directly benefit the consumer -- which is, after all, the original purpose of licensing laws in the first place.

Goodrich (1998) also suggests further changes which again would mainly benefit the consumer, reducing the confusion of trying to understand the differences between behavioral healthcare professions:

    1) Elimination of categorical licensure (except for psychiatrists) for such groups as psychologists, clinical social workers, marriage and family counselors, and the like. Categorical recognition can be handled on a discipline-based Certification process, for purposes of third-party evaluation and interstate/international recognition.

    2) Competency-based licensure for certain specific functions, such as psychometry, forensic psychology, legally-binding diagnosis, etc. without categorical qualifications. For example, "Psychologist" certification (or lack thereof) would have no bearing on Psychometry Licensure...which would be based on demonstrated ability to properly conduct and interpret major categories of psychometric tests.

    3) Optional competency-based Certification for specific categories of therapeutic practice, independent of the discipline-based certification in 1) above. These would include techniques, such as hypnotherapy, NLP, EMDR, etc., and functional areas such as grief resolution, trauma/PTSD, addiction/compulsion, substance abuse, severe dysfunction (such as schizophrenia or schizoaffective disorder), etc.

Goodrich (1998) summarizes his suggested changes this way, "The overall effect would be to provide consumers with a wide variety of choices and reasonable ways to make those choices, and create an effective and relatively 'nondenominational' mechanism for regulation and discipline of psychotherapists (and therefore some degree of protection for consumers and affected others), while limiting the scope and effect of organizational 'turf wars.'" Only time would tell whether Goodrich is right or not as to the likely effect of the implementation of his proposals. But the proposals are more consumer-oriented than current licensure regulations, and less protective of any specific behavioral healthcare profession. This suggests that bad professionals, no matter what their degree, could be held more easily to answer for their unethical or illegal behaviors in psychotherapy than currently possible under most states' arcane systems of licensure.

Goodrich's call for states to adopt more open, inclusive licensing laws such as those currently found in Colorado is unlikely to gain much support in the short-term. National professional organizations don't like the idea of partnering and unification with other professions. In fact, they often are antagonistic toward one another, in the increasingly competitive psychotherapy marketplace. For example, the American Psychiatric Association withdrew in late 1997 from a partnership with the American Psychological Association to publish a new journal entitled Treatment out of fear that the psychological association would use the journal as support for helping psychologists gain prescription privileges (impinging on psychiatrist's domain). If professions can't even agree to publish a scientific journal together, it is unlikely they will join hands to help fix the licensing practices found in most states and help consumers. In fact, the American Psychological Association lobbied for over a decade to get the types of restrictive licensing laws currently in place in most states. They would likely view the elimination of categorical licensing as something to fight against, despite the lack of research evidence which supports their point of view (see, for instance, Garfield & Bergin's [1994] review of the literature which still shows little strong empirical evidence supporting that differences in degree make any significant difference in client outcomes).

Currently licensing of psychotherapy is a delusion most behavioral healthcare professionals quickly and easily learn to buy into at an early point in their therapy careers. It ensures the continuity of the profession and gives an illusion of consumer protection, while offering very little actual protection to consumers in most states. Bringing a complaint against a psychologist is likely to be a completely different process than bringing a complaint against a psychiatric nurse or a clinical social worker, although all three can provide essentially the same psychotherapeutic services. Consumers have to muddle through a maze of different bureaucracies currently, each with their own unique set of arcane rules, regulations, and forms to fill out. Worse yet, each profession has their own set of ethical guidelines, confusing the consumer even more about what is a legitimate professional activity and what is actionable.

Simplifying licensing regulations, providing a registration system for unlicensed psychotherapists, developing one set of cohesive, sensible ethical guidelines, and consolidating all regulatory and disciplinary functions in one board makes a lot of sense for consumers. As a voter, you have the power to call your state representative in your legislature to ask them to look into the current system and make these changes. Licensure should work to protect you, as it was always intended to do. Help make it so.

References

Garfield, S.L. & Bergin, A.E. (1994). Handbook of psychotherapy and behavior change (Fourth edition). John Wiley & Sons: New York.

Goodrich, W.E. (February, 1998). Personal communication.

Hogan, Daniel B. (1983). The effectiveness of licensing: History, evidence, and recommendations. Law & Human Behavior, 7, 117-138.

Johnson, David A.; Huff, Dan. (1987). Licensing exams: How valid are they? Social Work, 32, 159-161.

Lambert, David A.; McGuire, Thomas G. (1991). Determinants of stringency of psychologist licensure. Special Issue: Law, psychiatry, and mental health policy. International Journal of Law & Psychiatry, 14, 315-329.

Novy, Diane M.; Kopel, Kenneth F.; Swank, Paul R. (1996). Psychometrics of oral examinations for psychology licensure: The Texas examination as an example. Professional Psychology: Research & Practice, 27, 415-417.

Segal, Steven P.; Hwang, Sung-Dong. (1994). Licensure of sheltered-care facilities: Does it assure quality? Social Work, 39, 124-131.

Thomas, Kenneth R. (1993). Professional credentialing: A doomsday machine without a failsafe. Rehabilitation Counseling Bulletin, 37, 187-193.

Reference
Grohol, J.M. (Mar 1998). Why don't current psychotherapy licensing regulations work? A review and suggestions for change. [Online]. .

Last reviewed: By John M. Grohol, Psy.D. on 27 Jan 2007
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