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Provision of Mental Health Counseling Services Under TRICARE (2010)

Chapter: 3 Requirements Related to the Practice of Counseling

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Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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3
Requirements Related to the Practice of Counseling

This chapter addresses several elements of the committee’s task that pertain to how mental health counselors are trained and how they practice. It begins with a brief history of the profession of counseling and an overview of the education and training requirements for mental health professionals. It then provides details on how counselors are trained and on the accreditation of their educational institutions. Next, it introduces the primary means of professional recognition—licensing, credentialing, and privileging. Licensing requirements, including licensure examinations, are addressed, as are third-party certifications of professional standing. The chapter concludes with an examination of credentialing and privileging of counselors in TRICARE’s direct-care and purchased-care systems and in the private sector. Box 3.1 at the end of the chapter contains a compilation of the abbreviations and acronyms used to denote the accrediting bodies, professional associations, certifications, and examinations referenced below.

Little has been published on the licensing, credentialing, and privileging of counselors; for that reason, the chapter provides detailed information on these topics.

THE PROFESSION OF COUNSELING

A number of authors have published work on the history of the counseling profession (Bradley and Cox, 2001; Gibson and Mitchell,

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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2008; Hershenson and Berger, 2001; Remley and Herlihy, 2010; Sweeney, 2001). That information is summarized here.

In the 1950s, the psychology profession was establishing the doctoral level as the requirement for professional status, and counseling psychology was developing as a specialty within psychology. Historical events were leading to the rapid development of school counseling programs and vocational-rehabilitation counseling. Eventually, changes in counseling psychology, the school-counseling movement, and federal funding of vocational-rehabilitation counseling led to the emergence of the new profession of counseling.

At the beginning of its effort to become a profession, psychology recognized people who had master’s degrees as professional psychologists. The American Psychological Association (APA) declared in the 1950s that in the future only psychologists who held doctoral degrees would be recognized as professionals. The profession decided to continue to recognize all current psychologists who held master’s degrees and allow them to practice but in the future to allow into the profession only those who held doctoral degrees in psychology. Licensure laws in psychology throughout the United States were changed to reflect the new position.

In 1957, when the Soviet Union successfully orbited the first spacecraft, Sputnik, politicians in the United States feared that, inasmuch as the Soviet Union had exceeded American technology and beaten the United States in the “race to space,” it might overpower the United States politically as well. In response to that fear, Congress created substantial programs to encourage young people to seek careers in technical and scientific fields. The effort included placing counselors in high schools to channel students into mathematics and science courses. Throughout the United States, universities created summer institutes in which high-school teachers were given basic courses that led to their placement in high schools as guidance counselors. In most instances, high-school teachers were given two or three courses in guidance or counseling, which allowed them to be certified as school counselors and to assume guidance-counselor positions in schools. Because the primary purpose of the effort was to encourage students to take mathematics and science courses, it did not seem necessary for counselors to be prepared beyond the training provided in the summer institutes.

School-accreditation groups were soon requiring high schools to have guidance counselors if they were to receive or continue their accred-

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

itation. Today, middle-school and high-school accreditation requires that schools have counselors, and in some areas elementary schools are required to have them. For school counselors to be certified, almost all states now require them to have received master’s degrees and to have completed specified courses and an internship.

An emphasis on rehabilitation of wounded soldiers began as early as the Revolutionary War. However, the modern era of rehabilitation began between 1900 and 1930 with increasing concern about the wellbeing of industrially disabled persons and the establishment of state and federal rehabilitation services. After increased concern about veterans of World War II and other people who had disabilities by the 1950s, there was recognition in the United States that citizens who had physical or mental disabilities were not being given the help that they needed to become productive members of society in that they were not receiving services by specifically trained rehabilitation counselors. As a result, legislation was passed in 1954 that established master’s-level rehabilitation counseling programs and provided counseling and educational resources that were meant to help persons who had disabilities to function more autonomously (Sales, 2007).

A major component of the legislation was funding to prepare counselors to help people to evaluate their disabilities, to make plans to work, and to find satisfactory employment. As a result of the funding, new master’s degree programs in rehabilitation counseling were developed, and existing programs were expanded. State rehabilitation agencies created positions in rehabilitation case management and counseling for the graduates of the programs.

The dynamics of the creation of the specialty of counseling psychology, the decision in the psychology profession to recognize professionals only at the doctoral level, the emergence of school counseling, and the funding of vocational-rehabilitation counseling programs led to the creation of counseling as a separate master’s degree–level profession. The origins of the profession were in the convergence of several disparate forces rather than in a single event.

Changes that have taken place in the last 20–30 years in the field of counseling include the lengthening of most educational programs from 30 to 48 to 60 semester hours in some specialties, professionalization of counseling through credentialing and legislation, the passage of laws granting privileged communication to interactions between counselors and their clients, and increases in the body of knowledge specific

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

to counseling, as distinguished from other mental health professions, through scholarly writing.

Counseling has made progress toward recognition as a profession at a rate comparable with that of professionalization efforts in other mental health disciplines, such as psychology. Connecticut became the first state to pass a law licensing psychologists in 1945, and licensing laws for psychologists had been enacted in all 50 states when Missouri passed its law in 1977, 32 years later (Benjamin, 2006). In comparison, the first counselor-licensure bill was passed in Virginia in 1976, and all 50 states had passed licensure bills for counselors by 2009, 33 years later.

Distinctions Between Counselors and Other Mental Health Professionals

Table 3.1 summarizes the similarities and differences in educational and training requirements among the mental health professions recognized by TRICARE. It was adapted from a summary by Remley and Herlihy (2010) that was based on information provided by the organizations that accredit the listed professions: for counseling, the Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2008); for pastoral counselors, the American Association of Pastoral Counselors (AAPC, 2009); for marriage and family therapy, the American Association for Marriage and Family Therapy (AAMFT, 2004); for social work, the Council on Social Work Education (CSWE, 2008); for nursing, the Commission on Collegiate Nursing Education (CCNE, 2009); for psychology, the APA Commission on Accreditation (APA CoA, 2008); and for psychiatry, the Liaison Committee on Medical Education (LCME, 2008) and the Accreditation Council for Graduate Medical Education (ACGME, 2007).

The 2006 IOM report Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series addresses the education of mental health professionals in far greater detail, and offers recommendations for increasing workforce capacity.

How Counselors Are Trained and Practice

The evolution of counseling began with the development of counseling specialties that were formed to meet the needs of particular employment settings, types of client populations, or even techniques

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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TABLE 3.1 Comparison of Preparation Requirements for the Mental Health Professions

Profession and Graduate Education Required

Summary of Required Courses and Required Supervised Field Experience

Counseling

48–60 graduate credits required for master’s degree

Graduate coursework required in professional identity; social, cultural diversity; human growth, development; career development; helping relationships; group work; assessment; research, program evaluation; specialty (mental health counseling, community counseling, school counseling, career counseling, marriage and family counseling and therapy, college counseling, gerontologic counseling, student affairs)

 

100-hour practicum, 600-hour internship required

Pastoral Counseling

Field of pastoral counseling does not accredit academic preparation programs; people may become certified as pastoral counselors by American Association of Pastoral Counselors, but academic preparation programs not accredited

Marriage and Family Therapy

Minimum number of graduate credits not specified

Graduate coursework required that covers 128 competencies in six domains: admission to treatment; clinical assessment, diagnosis; treatment planning, case management; therapeutic interventions; legal issues, ethics, standards; research, program evaluation

 

Number of hours of practicum, internship not specified

Social Work

60 graduate credits required for master’s degree

Coursework required in professional social worker identity; ethical principles; critical thinking; diversity, difference; advancing human rights, social and economic justice; research-informed practice, practice-informed research; human behavior, social environment; policy practice; contexts that shape practice; engaging, assessing, intervening, evaluating individuals, families, groups, organizations, communities

 

Minimum of 900 hours of field experience required

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Profession and Graduate Education Required

Summary of Required Courses and Required Supervised Field Experience

Nursing

Minimum number of graduate credits not specified

Graduate nursing coursework in research; policy, organization, financing of health care; ethics; professional role development; theoretical foundations of nursing practice; human diversity, social issues; health promotion, disease prevention; advanced health, physical assessment; advanced physiology, pathophysiology; advanced pharmacology; psychiatric nursing

 

Minimum of 500 hours of direct clinical practice

 

(Additional requirements are placed on persons practicing in psychiatric nurse specialties)

Psychology

3 full-time years of graduate study required for doctoral degree

Graduate coursework required in biological aspects of behavior; cognitive, affective aspects of behavior; social aspects of behavior; history, systems of psychology; psychological measurement; research methodology; techniques of data analysis; individual differences in behavior; human development; dysfunctional behavior or psychopathology; professional standards, ethics; theories, methods of assessment, diagnosis; effective intervention; consultation, supervision; evaluating efficacy of interventions; cultural, individual diversity; attitudes essential for life-long learning, scholarly inquiry, professional problem solving

 

1 full-time year of residency required

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Profession and Graduate Education Required

Summary of Required Courses and Required Supervised Field Experience

Psychiatry

130 weeks required for medical degree (usually 4 years)

MD requires coursework in anatomy; biochemistry; genetics; physiology; microbiology, immunology; pathology; pharmacology, therapeutics; preventive medicine; scientific method; accurate observation of biomedical phenomena; critical analysis of data; organ systems; preventive, acute, chronic, continuing, rehabilitative, end-of-life care; clinical experiences in primary care, family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, surgery in outpatient, inpatient settings; multidisciplinary content, such as emergency medicine, geriatrics; disciplines that support general medical practice, such as diagnostic imaging, clinical pathology; clinical, translational research, including how such research is conducted, evaluated, explained to patients, applied to patient care; communication skills as related to physician responsibilities, including communication with patients, families, colleagues, other health professionals; addressing medical consequences of common societal problems, for example, providing instruction in diagnosis, prevention, appropriate reporting, treatment of people for violence, abuse; how people of diverse cultures, belief systems perceive health, illness and respond to various symptoms, diseases, treatments; sex, cultural biases; medical ethics, human values

 

Psychiatry residency curriculum must include patient care; medical knowledge; practice-based patient learning, improvement; interpersonal, communication skills; professionalism; systems-based practice; research; required topics include supervised practice in providing psychiatric services to diverse populations

 

48-month residency in psychiatry is required, which includes 12-month internship in primary-care clinical setting

SOURCE: Adapted from Remley and Herlihy (2010).

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

rather than with the establishment of a general strong central profession with a logical metastructure before specialties were elaborated (Hosie, 1995; Myers, 1995; Sweeney, 1995). That historical pattern heavily influenced the structure of counselor education, training, and practice (Myers, 1995). As a result, there is a need to understand and differentiate between the various types of specialty education and practice so that they may be clearly related to the specific practice of mental health counseling at the independently licensed level. Academic degrees in counseling indicate a graduate’s specialty and need to be related to the graduate’s field of practice (Schweiger et al., 2008).

Training and Education

Overview People enter the profession of counseling through obtaining a master’s or doctoral degree in counseling from a counselor educational program or a related program (such as a rehabilitation counseling program). There are no standard requirements for a specific type of undergraduate degree, and undergraduate preparation requirements depend on the educational institution. Master’s degree preparation includes a practicum and internship in the specialty. Two bodies recognized by the American Counseling Association (ACA) accredit counselor educational programs: CACREP, which provides accreditation in a variety of counseling specialties other than rehabilitation counseling, and the Council on Rehabilitation Education (CORE), which accredits only rehabilitation counselor educational programs. Both bodies are recognized by the Council for Higher Education Accreditation (CHEA).

Because the two groups are substantially similar in their goals, objectives, and core knowledge and competence, they engaged in serious discussions about a possible merger in the mid-2000s but decided not to continue active pursuit of a merger at the time. The two organizations accredit most of the counselor educational programs, but some related specialties, such as pastoral counseling, are not accredited by them.

Not all counselor educational programs are accredited, but the proportion of such programs that are accredited continues to increase. Programs that are not accredited generally have patterned their curriculum requirements after the CACREP core curriculum requirements because many states that license counselors require curricula that are

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

based on the CACREP standards even if they do not specifically require CACREP accreditation (ACA, 2008).

As noted previously, the profession of counseling evolved in its early years through interdisciplinary influences and in response to the needs of clients in various employment settings. The overall definition of the profession has thus developed emphases both on personal growth and a wellness perspective and on providing counseling to people who have mental disorders. Those emphases permit practitioners in counseling to understand and work with problems as diverse as vocational decision-making for people in the ordinary course of their lives and interpretation and diagnosis of substantial symptoms and treatment options for people who have mental disorders (Gladding, 2009). The different emphases can be said to be reflected in the differences between the 2001 CACREP standards in community counseling that emphasized preventive development and the mental health counseling specialty accreditation that emphasized diagnosis of and treatment for mental health disorders (Chronister et al., 2009). Those two specialties have long been seen as closely related since their inception and were originally thought to assist in differentiating preparation needed by counselors who would work in community-based agencies (Community Counseling) from that needed by those who would work in private-practice settings (Mental Health Counseling).

The profession has moved toward a more consolidated view of how elements of the specialties are related to one another, and the 2009 CACREP accreditation standards consolidated the two specialties most closely related to the practice of mental health counseling—Community Counseling and Mental Health Counseling—into the singular category of Clinical Mental Health Counseling (CACREP, 2009a). In practice, it has been possible for graduates of the programs to apply for licensure and work in either type of setting because of the similarity of the types of work. That was the case even though counselors educated in Community Counseling programs typically took the mental health courses either as pregraduation electives or after graduation and then fulfilled the additional types and hours of supervised practice required (Neukrug, 2003).

Since the consolidated standards for Clinical Mental Health Counseling went into effect on July 1, 2009, all programs that were accredited in Community Counseling or Mental Health Counseling before then have had to renew their accreditation in the new category when

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

reaccreditation became necessary. That change standardized accreditation requirements in many ways, including moving all programs in the category to a minimum of 60 semester hours and requiring clinical coursework for most accredited counseling programs. The Clinical Mental Health Counseling curriculum has a heavy emphasis on clinical counseling and requires demonstration of skills and practices in the foundations of counseling, counseling, prevention and intervention, diversity and advocacy, assessment, research and evaluation, and diagnosis (CACREP, 2009a).


Number and types of programs As of August 2009, CACREP accredited 569 master’s and doctoral level counseling programs in 239 institutions in the following fields: 164 in Community Counseling; 55 in Counselor Education and Supervision; 19 in College Counseling; 9 in Career Counseling; 2 in Gerontologic Counseling; 32 in Marital, Couple, and Family Counseling and Therapy; 63 in Mental Health Counseling; 22 in Student Affairs; 2 in Student Affairs Practice in Higher Education with emphasis on College Counseling; and 201 in School Counseling (CACREP, 2009c). About 100 other master’s programs for rehabilitation counselors are accredited by CORE (2009c).

In an April 2009 presentation to the committee, CACREP Executive Director Carol Bobby (2009) noted that CACREP’s expectation is that most existing Community and Mental Health Counseling programs will make the transition to the new single standard on the basis of two recent surveys that the organization undertook to assess preparedness to meet the 60-semester-hours requirement. If that expectation is realized, there will be over 200 accredited Clinical Mental Health Counseling Programs (Bobby, 2009); this number would exceed the number of school counseling.

A number of non–CACREP-accredited programs also offer Community Counseling and Mental Health Counseling degrees. In 2001, Altekruse et al. reported that 84 out of 205 Community Counseling and 58 out of 79 Mental Health Counseling programs were not CACREP accredited; it is not known how many of the programs remain unaccredited by that organization.


Admission and graduation requirements Schools vary in the requirements placed on entrants into their graduate educational programs in counseling. Admission requirements include a bachelor’s

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

degree and some combination of minimum grade-point average and standardized test scores, successful completion of relevant preparatory coursework (typically in psychology), letters of recommendation, personal interviews, and evidence of interest in the field as evinced by volunteer work and the like (Schweiger et al., 2008). ACA notes that “majors in education, sociology, psychology, or any of the social sciences can be very helpful in graduate study,” but no specific undergraduate degree is required (ACA, 2009). Institutions set their own policies regarding whether, or the conditions under which, they recognize undergraduate coursework for completion of graduate-degree requirements.

Entry-level master’s programs are typically 2 years long. Graduation requirements typically mirror the requirements to apply for licensure as a mental health counselor in the state where the school is. They include successful completion of core curricula and a minimum course, practicum, and related training and experience hours. Depending on the institution, students may also need to pass comprehensive written or oral examinations, complete a thesis, or turn in a portfolio (Schweiger et al., 2008).

Similar statements could be made about master’s-level professional programs in the other mental health disciplines.


Location of programs As a result of the historically strong connections between guidance counseling and education in traditions and institutions, most counselor educational programs are in colleges and schools of education (Sweeney, 2001).


Curricular content The two credentialing bodies in counseling (CACREP and CORE) and the two major certification bodies for counselors (the National Board for Certified Counselors [NBCC] and the Commission on Rehabilitation Counselor Certification [CRCC]) have identified the same eight categories of core knowledge for professional counselors: professional identity, social and cultural diversity, human growth and development, career development, helping relationships, group work, assessment, and research and program evaluation (Chronister et al., 2009). These categories are supplemented in each specialty with additional categories of knowledge as established by the program accreditation body. In its 2009 standards, CACREP added demonstration of skills and practices specifically in each of the

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

knowledge categories, thus requiring a competence-based approach to evaluating programs (CACREP, 2009a). CACREP and CORE also impose the same clinical training and internship requirements; these are specified below.

Practice

Overview According to the US Department of Labor (DOL) Occupational Outlook Handbook, counselors held about 638,100 jobs in the United States in 2008. They worked in the following specialties: 275,800 educational, vocational, and school counseling; 129,500 rehabilitation counseling; 113,300 mental health counseling; 86,100 substance-abuse and behavioral-disorder counseling; and 33,400 counseling in other fields (BLS, 2009-10).

Bureau of Labor Statistics projections show the employment market for counselors growing at an above-average rate of 18% from 2008 to 2018. Although the specialties of counseling are projected to grow at various rates, the employment growth rate for mental health counselors is projected to be 24%. DOL attributes the latter rate to increases in the staffing, the increasing approval of counselors for reimbursement by insurance and managed-care companies, and increased demand as persons become more willing to seek help for mental health issues (BLS, 2009-10).


Job settings after graduation All graduates of counselor education have the core identity of and education in counseling, but most counselors find employment that is consistent with the specialization in which they were trained. Schweiger et al. (2008) found that master’s-level graduates of counselor educational programs found employment as follows: 67% of community-counseling and 65% of the mental health– counseling graduates in agencies, 94% of school-counseling graduates in schools, and 69% of college-counseling graduates in higher-education and student-affairs settings. Private practice as an employment setting occurs at lower rates: 10% of college counselors, 11% of community counselors, 8% of school counselors, and 12% of mental health counselors (Schweiger et al., 2008).

In 2004, the US Department of Health and Human Services reported the main primary work settings of 100,533 professional mental health counselors on whom information was available: academic setting,

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

33.4% (universities, colleges, and elementary and secondary schools); clinic, 22.5% (mental health and other health clinics); other and not specified, 16.0%; and individual practice, 15.1%. Those four categories account for 87% of the work environments reported by the clinically trained counselors (Manderscheid and Berry, 2004).

ACCREDITATION OF COUNSELOR EDUCATIONAL INSTITUTIONS

Voluntary accreditation in higher education is a collegial process of self-assessment and peer review for improvement of academic quality and public accountability of institutions and programs. CHEA characterizes accreditation as “the primary means of assuring and improving the quality of higher education institutions and programs in the United States” (CHEA, 2009). This quality-review process occurs on a periodic basis, usually every 3–10 years. Typically, it involves three major activities:

  1. Self-study by an institution or program using the standards or criteria of an accrediting organization.

  2. Peer review of an institution or program to gather evidence and validate what has been provided in documents, observation of activities, and inspection of records that could not be accomplished in the document review.

  3. Decision or judgment by an accrediting organization to accredit, accredit with conditions, or not accredit an institution or program.

Generally speaking, there are two types of higher-education accreditation: institutional and specialized. Institutional accreditation is granted by regional and national accrediting commissions; these accrediting bodies are recognized by the US Department of Education (ED)—for institutions that have a “federal purpose”—or through a voluntary recognition process administered by CHEA. Specialized accreditation is awarded to professional academic programs in institutions or to occupational schools that offer specific training and knowledge; these accrediting bodies are also recognized by ED or CHEA.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Council for Accreditation of Counseling and Related Educational Programs

CACREP is an independent accrediting agency created by ACA. It was incorporated in 1981. Institutional, curricular, and other requirements for CACREP accreditation of educational programs are described below.

For a program to be eligible for CACREP accreditation review, the institution that houses the program must be accredited by one of the regional or national institutional accrediting bodies recognized by CHEA. The institution and the program must also have appropriate institutional and faculty support; the academic unit overseeing the program must have at least three core faculty members whose academic appointments are in counselor education.

The CACREP accreditation cycle is for 8 years unless there are some minor deficiencies. A 2-year accreditation is granted to programs that substantially meet the requirements for accredited status but that need to address relatively minor standards-related deficiencies (CACREP, 2009b).

Academic-hours requirements vary by specialty. Those for Clinical Mental Health Counseling were established in 2009 and reflect a transition period for programs that were previously accredited in Community Counseling, which required 48 graduate semester hours. As of July 1, 2009, 54 graduate semester credit hours or 81 quarter credit hours were required. As of July 1, 2013, 60 graduate semester credit hours or 90 quarter credit hours—the standard already in place for accredited Mental Health Counseling programs—will be required (CACREP, 2009a).

Students must complete 100 clock hours over a minimum 10-week academic term. The 100 clock hours must include 40 clock hours of direct service with actual clients that contribute to the development of counseling skills. Specific individual and group supervision is required. One hour a week is required for individual or triadic supervision by a program faculty member. An average of 1½ hours per week is required for group supervision by a program faculty member or a student supervisor.

The supervised internship program requires completion of 600 clock hours in the student’s designated program field. The internship is begun after successful completion of a practicum. At least 240 clock hours of direct service, which must include leading groups, is required. Individual and triadic supervision is usually performed by the onsite clinical supervisor. Group supervision is performed by a program faculty member.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

CACREP also specifies standards for persons serving as individual or group practicum or internship supervisors.

According to the 12th edition of Counselor Preparation, a reference text on educational programs, “the goal of most [internship] programs is to provide an in-depth experience at a site that has working conditions similar to the student’s career goals.” However, there is no requirement for students to have experiences in specific mental health diagnostic categories (Schweiger et al., 2008).

Clinical Mental Health Counseling

Clinical Mental Health Counseling curricula have the following sections: foundations; counseling, prevention, and intervention; diversity and advocacy; assessment; research and evaluation; and diagnosis. Each section is supported by learning outcomes related to knowledge, skills, and practices. There is also a set of “common core curricular experiences and demonstrated knowledge” requirements shared by all the counseling specialties that CACREP accredits. The following is a sample of relevant skills and practices associated with Clinical Mental Health Counseling (CACREP, 2009b):

Counseling, Prevention, and Intervention

  • Uses the principles and practices of diagnosis, treatment, referral, and prevention of mental and emotional disorders to initiate, maintain, and terminate counseling.

  • Demonstrates the ability to use procedures for assessing and managing suicide risk.

  • Knows the disease concept and etiology of addiction and co-occurring disorders.

  • Provides appropriate counseling strategies when working with clients with addiction and co-occurring disorders.

  • Demonstrates the ability to recognize his or her own limitations as a clinical mental health counselor and to seek supervision or refer clients when appropriate.

Diversity and Advocacy

  • Understands how living in a multicultural society affects clients who are seeking clinical mental health counseling services.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
  • Demonstrates the ability to modify counseling systems, theories, techniques, and interventions to make them culturally appropriate for diverse populations.

Assessment

  • Selects appropriate comprehensive assessment interventions to assist in diagnosis and treatment planning, with an awareness of cultural bias in the implementation and interpretation of assessment protocols.

  • Demonstrates skill in conducting an intake interview, a mental status evaluation, a biopsychosocial history, a mental health history, and a psychological assessment for treatment planning and caseload management.

  • Screens for addiction, aggression, and danger to self and/or others, as well as co-occurring mental disorders.

  • Understands basic classifications, indications, and contra-indications of commonly prescribed psychopharmacological medications so that appropriate referrals can be made for medication evaluations and so that the side effects of such medications can be identified.

  • Applies the assessment of a client’s stage of dependence, change, or recovery to determine the appropriate treatment modality and placement criteria within the continuum of care.

Diagnosis

  • Demonstrates appropriate use of diagnostic tools, including the current edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders) to describe the symptoms and clinical presentation of clients with mental and emotional impairments.

  • Is able to conceptualize an accurate multiaxial diagnosis of disorders presented by a client and discuss the differential diagnosis with collaborating professionals.

  • Differentiates between diagnosis and developmentally appropriate reactions during crises, disasters, and other traumacausing events.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

The language used to express the learning outcomes calls into question whether the skills and practices would support some of the knowledge and skills to practice independently in circumstances that would include diagnosis of complex clinical conditions. The lack of specificity of the learning outcomes and the use of such words as “assist,” “screen,” and “collaborate” give the impression that the preparation may not by itself be adequate to support independent practice. It should be noted, however, that these are learning outcomes on graduation from an accredited CACREP academic program and before the generally required 2-year clinical experience that precedes licensing. That is consistent with patterns noted among the mental health professions. The Annapolis Coalition on the Behavioral Health Workforce has observed that graduate education and training for all mental health professionals lack specificity in a number of knowledge and competence elements that are essential for professional contemporary mental health practice (Hoge et al., 2002). The presence of the terms “assist” and “collaborating” can also been seen as being consistent with the calls for preparation to engage in collaborative approaches to practice (Hoge et al., 2002).

Council on Rehabilitation Education

The mission of CORE is the accreditation of rehabilitation-counselor education (RCE) programs to promote the effective delivery of rehabilitation services to people who have disabilities by promoting and fostering continuing review and improvement of master’s degree– level RCE programs. It is an independent accrediting agency that was incorporated in 1972 by a group of rehabilitation professionals.

CORE accredits graduate master’s degree programs that provide academic preparation for professional RCE. It also maintains a registry of programs that meet curriculum and outcome standards or guidelines for undergraduate programs in rehabilitation.

CORE has two commissions: the Commission on Standards and Accreditation and the Commission on Undergraduate Education. The Commission on Standards and Accreditation is the evaluation component of CORE. It has the responsibility of evaluating programs for compliance with CORE standards and recommending the type of accreditation recognition. There are two types of recognition. Candidacy for accreditation is granted to academic programs that are in the early stages but comply with all the standards except performance of gradu-

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

ates. Full accreditation provides evidence that a program complies with all standards and is able to maintain that level of compliance through the duration of the recognition. The latter recognition includes objective assessment of the professional performance of graduates. As of October 2009, there were 97 fully accredited programs and 11 programs that were candidates for accreditation (CORE, 2010).

The Commission on Undergraduate Education is responsible for recommendation to CORE of standards and criteria required for the undergraduate registry.

The eligibility criteria for any academic program to be considered for either type of recognition are as follows:

  • The educational institution is accredited by the appropriate regional accreditation body and offers graduate degrees in fields other than that being evaluated.

  • The program provides for 2 years of full-time graduate study.

  • The program has institutional approval for courses and degrees offered.

  • The program has a person designated as coordinator, or the equivalent, who is a Certified Rehabilitation Counselor.

  • The program has a written statement of its mission, objectives, curriculum, and criteria for student selection.

General Curriculum Requirements, Knowledge Domains, and Educational Outcomes

There are 10 knowledge domains with related outcomes:

  1. Professional identity.

  2. Social and cultural diversity.

  3. Human growth and development.

  4. Employment and career development.

  5. Counseling and consultation.

  6. Group work.

  7. Assessment.

  8. Research and program evaluation.

  9. Medical, functional, and environmental aspects of disability.

  10. Rehabilitation service and resources.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Specific selected outcomes in several knowledge domains are related to practice in mental health (CORE, 2008a):

Counseling and Consultation

  • Conduct individual counseling sessions with consumers.

  • Establish in collaboration with the consumer, individual counseling goals and objectives.

  • Assist the consumer with crisis resolution.

  • Recommend strategies to assist the consumer in solving identified problems that may impede the rehabilitation process.

  • Explain the implications of assessment/evaluation results on planning and decision making.

  • Assist the consumer in developing acceptable work behavior.

  • Adjust counseling approaches or styles to meet the needs of individual consumers.

  • Terminate counseling relationships with consumers in a manner that enhances their ability to function independently.

  • Recognize consumers who demonstrate psychological problems (e.g., depression, suicidal ideation) and refer when appropriate.

  • Interpret diagnostic information (e.g., vocational and educational tests, records, and medical data) to the consumer.

  • Assist consumers to successfully deal with situations involving conflict resolution and behavior management.

Group Work

  • Articulate the principles of group dynamics with persons with disabilities including group process components, developmental state theories, group members’ roles and behaviors, and therapeutic factors of group work.

  • Facilitate the group process with the individual’s family/ significant others, including advocates.

  • Apply approaches used for other types of group work with persons with disabilities including skill groups, psychoeducational groups, and group counseling.

  • Apply theories of group counseling when working with persons with disabilities including commonalities, distinguishing characteristics, and pertinent research and literature.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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  • Apply group counseling methods including group counselor orientation and behaviors, appropriate referral and selection criteria, and methods of evaluation and effectiveness.

Assessment

  • Determine an individual’s eligibility for rehabilitation services and/or programs.

  • Utilize assessment information to determine appropriate services.

  • Assess the unique strengths, resources, and experiences of an individual, including career knowledge and interests.

  • Assess an individual’s vocational or independent living skills, aptitudes, interests, and preferences.

  • Use behavioral observations to make inferences about work personality, characteristics, and adjustment.

Medical, Functional, and Environmental Aspects of Disability

  • Explain basic medical aspects of the human body system and disabilities.

  • Explain functional capacity implications of medical and psychosocial information.

  • Apply working knowledge of the impact of disability on the individual, the family, and the environment.

  • Consult with medical professionals regarding functional capacities, prognosis, and treatment for consumers.

Educational and Clinical-Experience Requirements

The 2008 CORE program standards require a minimum of 48 semester hours for RCE programs, but if the state in which the program exists requires 60 semester hours for licensure, the program must identify and provide the additional 12 semester hours required for licensure (CORE, 2008b).

Students are required to have a minimum of 100 hours of supervised rehabilitation counseling practicum with at least 40 hours of direct service to persons who have disabilities. The supervised rehabilitation-counseling internship involves 600 hours of applied experience in an agency or programs, including at least 240 hours of direct service to people who have disabilities. Both the practicum and the internship

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

require 1 hour per week of individual supervision or 1½ hours per week of group (no more than 10 students/group) supervision by a program faculty member or another qualified person who works in cooperation with a program faculty member. There is no requirement for students to have experience with specific mental health diagnostic categories.

The academic preparation for a Rehabilitation Counselor does not, in the committee’s view, support diagnostic and treatment ability in mental health associated with specific psychopathologic conditions unless additional coursework and clinical experiences are obtained, as would be the case when rehabilitation counselors become licensed as mental health counselors in states that require such additional courses and postgraduate clinical practice.

The Concept of “CACREP Equivalence”

“CACREP-equivalent” is a designation used by educational institutions and agencies, such as state licensure boards,1 to denote an academic or training program that ostensibly meets the student-outcome accreditation requirements of CACREP but that does not have formal recognition from CACREP.

The concept of CACREP equivalence appears to be based on substantially equivalent numbers of semester hours or quarter hours in an accredited institution. An unknown proportion of applicants who present coursework to be evaluated for CACREP equivalence are rehabilitation counselors who have graduated from one of the roughly 100 CORE-accredited programs.

Most licensure bodies that provide for equivalent coursework require specific course content in designated program areas that are consistent with the CACREP core curriculum. There appears to be little attempt to evaluate learning outcomes, and there is no specific documented evidence to indicate how equivalence is determined. In addition, because of the wide variation among courses, course titles,

1

For example, the Code of Alabama § 34-8A-7(4) (“Qualifications of applicants for professional counselor license”) states “the applicant has received a master’s degree from a regionally accredited institution of higher learning which is primarily professional counseling in content based on national standards or the substantial equivalent in both subject matter and extent of training. The board shall use the standards of nationally recognized professional counseling associations as guides in establishing the standards for counselor licensure” (emphasis added).

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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and qualifications of instructors, there is no empirical evidence that other accepted courses of study by licensure bodies have the same learning outcomes as accredited CACREP Clinical Mental Health Counseling programs.

MEANS OF PROFESSIONAL RECOGNITION

Recognition as a qualified mental health practitioner and the ability to provide mental health services in the US health-care system typically has three tiers. The first tier is licensure in one’s discipline in the state in which one practices, the second is credentialing, and the third is the granting of appropriate clinical privileges to diagnose mental health disorders or treat those who are experiencing them. Credentialing and privileging are considered critical elements in ensuring the delivery of high-quality mental health care because they involve verification of completed licensure requirements and assessment of a provider’s competence to deliver high-quality care to beneficiaries.

Licensure is granted by a state; it takes the form of a license, certification, or registration and refers to official or legal permission to practice in the state. Credentialing is the systematic process of screening and evaluating qualifications and other forms of professional recognition, such as licensure, education, training, and clinical experience to ensure that specific requirements are met. Overall, the credentialing process aims to ensure that a person is able to perform according to specified standards (Department of Veterans Affairs, 2008). Privileging is the process by which the scope and content of patient-care services are defined for an individual provider. Privileging by a health-care organization is based on an evaluation of a person’s credentials and performance in delivering services, and it authorizes a person to perform the duties outlined in his or her professional scope of practice.

Clinical privileging is the process by which a licensed independent practitioner is granted permission by law and a health-care facility to practice independently and to provide specific services within the scope of practice defined by the practitioner’s license. It is based on individual competence to provide services and is both facility-specific and provider-specific (HHS, 1996). Department of Defense Directive 6025.13 states that clinical privileges are to be “based on the capability of the healthcare facility, licensure, relevant training and experience, current competence,

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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health status, judgment, and peer and department head recommendations” (DOD, 1995).

The Military Health System also uses the term current competence in reference to the capabilities of health-care providers. It defines the term as follows (DOD, 2004):

DL1.1.10. Current Competence. The state of having adequate ability to perform the functions of a practitioner in a particular discipline as measured by meeting the following:

DL1.1.10.1. Authorized to practice a specified scope of care under a written plan of supervision at any time within the past 2 years; or, completed formal graduate professional education in a specified clinical specialty at any time within the past 2 years; or, privileged to practice a specified scope of care at any time within the past 2 years.

DL1.1.10.2. Actively pursued the practice of his or her discipline within the past 2 years by having encountered a sufficient number of clinical cases to represent a broad spectrum of the privileges requested; and,

DL1.1.10.3. Satisfactorily practiced the discipline as determined by the results of professional staff monitoring and evaluation of the quality and appropriateness of patient care.

LICENSING

Overview

All states, the District of Columbia, Puerto Rico, and Guam license mental health counselors. Several states used a tiered licensure system that includes an associate-counselor level and a general-counselor level. Other states differentiate between standard professional counselors and clinical professional counselors; scopes of practice are delineated according to the licensure level.

Typically, in states that have multiple levels of licensure, independent diagnosis and treatment can be performed only by those at the higher level. For example, licensure in Arkansas includes a level for associate counselors and a level for professional counselors. Only licensed professional counselors are allowed to diagnose and to treat patients. In Kansas, licensed professional counselors may practice only under the supervision of a licensed clinical professional counselor. Illinois’s

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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licensure of clinical professional counselors authorizes the independent private practice of clinical professional counseling whereas licensure of professional counselors authorizes only the general practice of professional counseling.

Further information on the various licenses granted by states and on the scope of practice associated with each license can be found in Appendix G. In response to elements of the statement of task, the table that makes up that appendix includes data on license names and associated educational, clinical-experience, and other licensing requirements; on licensure renewal and continuing education requirements; on independent-practice strictures; and on coverage of care by health insurance.

License Requirements

Education

Most states require master’s level–licensed counselors to complete a minimum of 48 semester hours of coursework in an accredited program in addition to various numbers of hours in a practicum and internship. There is no single accepted standard, but most states use or adapt CACREP requirements. State licensing bodies accept applicants from academic programs that are not accredited by either CACREP or CORE, but these programs must be offered in academic institutions that are accredited by regional accrediting bodies and are recognized by the Department of Education (ACA, 2008b). Most states do not require that people graduate from counseling programs that specialize in mental health to become licensed as mental health counselors. Table 3.2 outlines the variation in training standards that are accepted by states for licensure of professional counselors.

Clinical and Face-to-Face Supervision Experience

Clinical and face-to-face supervision experience varies widely among state licensure standards, as shown in Table 3.3. Requirements range from zero to 4,500 hours of supervised clinical experience and zero to 200 hours of face-to-face supervision.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 3.2 State Educational and Clinical Practicum or Internship Requirements, 2009

Training Standard

Required Educational Credits for Master’s Degree

Required Clinical Practicum or Internship

No. States Using Standarda

Council for the Accreditation of Counseling and Related Educational Programs

  • 48 semester hours

  • 60 semester hours for mental health– counseling specialty

  • 700 hours for standard counseling degree (no required experience in mental health setting)

  • 1,000 hours for mental health– counseling specialty (including 360 direct service hours in mental health setting)

18

Commission on Rehabilitation Education

Master’s in Rehabilitation Counseling

700 hours (including 280 hours of direct service to people who have disabilities)

2

Regional or other state accreditation

Program-dependent; generally, 48–60 semester hours

Program-dependent; no specified standard for practicum or internship length unless specified by state

10

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Training Standard

Required Educational Credits for Master’s Degree

Required Clinical Practicum or Internship

No. States Using Standarda

  1. Master’s in counseling

  2. Graduate degree in allied mental health or related field

  3. Graduate degree, including advanced counseling

  • Program-dependent; 42–60 semester hours of graduate work, may include specific counseling coursework

  • Some states permit “master’s in a related field” with board determining whether program is equivalent to counseling; only specialty mental health–counseling programs require specific skill in diagnosis and treatment of persons who have mental disorders

Program-dependent; generally, internship of at least 600 hours; programs tend to gear requirements to ensure that graduates qualify to sit for credentialing examinations

18

aNumber of states that use the standard as their least rigorously defined requirement. Several states permit more than one education or training standard for licensure.

SOURCE: Adapted and updated from DOD (2006).

Examinations

Licensing examinations vary by state, but the most common examinations required for licensure are the National Counselor Examination (NCE) and the National Clinical Mental Health Counselor Examination (NCMHCE)—both administered by NBCC—and the Certified Rehabilitation Counselor Examination (CRCE), administered by CORE. For their higher or highest level of licensure, 15 states and Puerto Rico require the NCE, 15 states require the NCMHCE,2 4 states require the NCE and NCMHCE, 7 states require either the NCE or the NCMHCE, 3 states require either the NCE or the CRCE, and 5 states

2

One of these, Minnesota, requires the NCMHCE, but will alternatively accept the NCE and Examination of Clinical Counseling Practice, a discontinued NBCC examination.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 3.3 State Requirements for Supervised Clinical Experience and Face-to-Face Supervision, 2009

Supervised Clinical Experience

Face-to-Face Supervision

Hours

States

Hours

States

<2,000

2: ID, SC

None required

26: AL, AR, AZ, CO, CT, DC, GA, IL, KS, MA, ME, MI, MN, MS, MT, NE, NJ, NY, OH, OR, PA, RI, TN, TX, WA, WV

2,000–2,999

7: CO, GA, ME, MN, OR, RI, SD

100

19: AK, DE, FL, HI, IA, IN, KY, LA, MD, NC, ND, NH, NM, NV, SC, SD, UT, VT, WY

3,000–3,499

30: AK, AL, AR, AZ, CA, CT, DE, HI, IL, IN, LA, MA, MD, MI, MO, MT, ND, NE, NH, NV, NY, OH, OK, TN, TX, VT, WA, WI, WV, WY

200

1: VA

3,500–3,999

3: DC, MS, PA

1–2 hours per week

5: CA, ID, MO, OK, WI

>4,000

5: KS, KY, NJ, UT, VA

0

2 years of post–master’s degree supervised experience

4: IA, FL, NC, NM

0

SOURCE: Adapted and updated from DOD (2006).

and the District of Columbia accept any of the three examinations for licensure, as of late 2009.3 Some states also allow additional or alternative examinations; others require additional examinations created by state licensing boards. Details regarding which states accept each examination are listed in Appendix G.

3

California had yet to set its final examination requirements for licensure at the time this report was completed.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

The National Counselor Examination The NCE is generic with respect to counseling. It covers the knowledge of counseling and counseling skills that should be known to all professional counselors regardless of field of practice. The NCE content outline has five content domains that consist of 130 tasks. The five domains and a sample of their tasks are listed in Table 3.4.

There are 200 multiple-choice items on the examination. They are based on the eight categories of core knowledge for professional counselors and the empirically determined five domains of professional-counselor work behaviors.


The National Clinical Mental Health Counseling Examination The NCMHCE is designed specifically for counselors who work in mental health. It is administered by NBCC.

The NCMHCE is a clinical-simulation examination that consists of 10 clinical mental health–counseling cases. Each case is divided into five to eight sections that are classified as information gathering or decision making. The cases cover the domains shown in Table 3.5.

A typical NCMHCE examination will include (NBCC, 2009d):

  1. One simulation involving an adolescent client(s) with at least one primary clinical issue and at least one secondary clinical issue.

  2. Three simulations with young adult clients with at least one primary clinical issue and at least one secondary clinical issue.

  3. Four simulations with middle-aged clients with at least one primary clinical issue and at least one secondary clinical issue.

  4. Two simulations with older adults clients with at least one primary clinical issue and at least one secondary clinical issue.

Primary clinical features on the examination would include such subjects as emotional abuse, suicidal issues, grief and loss, posttraumatic stress, depressive disorders, bipolar disorders, and adjustment disorders. Secondary clinical features would include such subjects as physical disabilities; homicidal, chronic medical, disaster-reaction, and substance-use–related issues; and schizophrenia and other psychoses, antisocial personality, and obsessive-compulsive disorder (NBCC, 2009c).

The committee notes that the use of simulations seems to be an appropriate strategy to test skills needed in a clinical mental health

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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TABLE 3.4 National Counselor Examination Content Domains and Sample Tasks

I. Fundamentals of Counseling

III. Group Counseling

  1. Assess client’s progress toward counseling goals

  2. Assess client’s psychological functioning

  3. Conduct diagnostic interview

  4. Assess need for client referral

  5. Diagnose on the basis of DSM-IV-TR criteria

  1. Facilitate group process

  2. Assist group members in providing feedback to each other

  3. Conduct postgroup follow-up procedures

  4. Identify behaviors that disrupt group process

  5. Assess progress toward group goals

II. Assessment and Career Counseling

IV. Programmatic and Clinical Interventions

  1. Use test results for client decision making

  2. Select and administer assessment instruments for counseling

  3. Provide career counseling for persons who have disabilities

  4. Administer and interpret achievement tests

  5. Assess client’s educational preparation

  1. Participate as member of multidisciplinary team

  2. Provide crisis counseling to victims of disaster

  3. Assess programmatic needs

  4. Conduct community outreach

  5. Administer and manage counseling program

 

V. Professional-Practice Issues

 

  1. Evaluate the performance of other counselors

  2. Provide diversity training

  3. Provide clinical supervision for professionals

  4. Engage in data analysis

  5. Conduct community needs assessment

SOURCE: NBCC (2009c).

practitioner, but it is not necessarily comprehensive enough to cover the breadth of diagnoses seen in the TRICARE system. It should be noted that the primary and secondary clinical features could lead to confusion if the DSM-IV is used for diagnosing purposes. Furthermore, although the content of the examination appears to be comprehensive, the use of such terms as coordinate and function as a member of a multidisciplinary team/network in the activities outline (NBCC, 2009c) content does not necessarily support independent practice. Task statements are not specific

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 3.5 National Clinical Mental Health Counseling Examination Case Domains and Sample Tasks

Case Domain

Sample Items

I. Evaluation and Assessment

  • Identify precipitating problems or symptoms

  • Conduct mental-status examination

  • Identify individual and relationship functioning

  • Conduct mental-status examination

    • Cognitive functioning

    • Affective functioning

    • Suicidal and homicidal ideations

    • Reality contact

    • Alcohol and other drug use

  • Conduct comprehensive biopsychosocial assessment histories

    • Educational

    • Addiction

    • Sexual

    • Psychiatric

    • Trauma

    • Psychiatric, medical, and addiction history of family system

    • Current medications and diagnosed medical problems

  • Interpret appraisal instruments and techniques

    • Personality

    • Intelligence

II. Clinical Diagnosis and Treatment Planning

  • Integrate client assessment and observational data with clinical judgment to formulate differential diagnosis

  • Coordinate treatment plan with other service providers

  • Monitor client progress toward goal attainment

  • Formulate DSM-IV classification (axes I–V)

  • Formulate ICD-9-CM classification

  • Develop treatment plan in collaboration with client

  • Establish goals that are relevant to diagnosis and client’s needs

  • Establish intervention strategies related to treatment objectives

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Case Domain

Sample Items

III. Clinical Practice

  • Determine whether services meet client’s needs

  • Understand scope of practice parameters

  • Provide prevention interventions

  • Implement counseling in relation to specific treatment plan

  • Function as member of multidisciplinary team

  • Educate client in need, effects, and impact of psychotropic medications

  • Understand scope of practice parameters

    • Liability issues

    • Ethics

Abbreviations: DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification.

SOURCE: NBCC (2009c).

regarding testing for the ability to determine a “diagnosis” independently. Treatment is used in relation to “counseling” of a patient or client and not in a “medical model” sense of treatment for a diagnostic category. However, the term counseling appears to be used interchangeably with psychotherapy in the literature of the counseling profession.4 In that sense, the use of treatment in relation to counseling would not be inconsistent. In addition, the terms coordinate and function as a member of a multidisciplinary team/network could also be interpreted as supporting the model of collaborative mental health care that is increasingly the standard of care in working with persons who have serious mental illness (Hoge et al., 2002). More specific task statements would be needed regarding specific treatment interventions to determine the body of knowledge that is being examined. The examination does seem to be aligned with the standard for an accredited academic program under CACREP.

Given those caveats, the NCMHCE’s focus on clinical mental health counseling and on the evaluation of candidates’ ability to apply knowledge to patient care led the committee to conclude that the examination is a more relevant test of the ability of counselors to serve

4

In the mental health field, psychotherapy is generally defined as a practice that aims to remediate conflicts or symptoms related to psychopathology while facilitating growth. Counseling aims to enhance growth and facilitate adaptive functioning.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

as independent providers of care than the NCEs. State licensure boards apparently share that view and use the NCMHCE as the examination applied to the more, or most rigorous, clinical level of licensure in many jurisdictions.


The Certified Rehabilitation Counselor Examination The CRCE is administered by CRCC (CRCC, 2009b). Requirements for sitting for the examination vary according to the applicant’s level of education (master’s versus doctoral degree) and the accreditation (if any) of the institution that granted the degree. They may include internship hours, employment experience, or specific coursework (CRCC, 2009a).

Twelve general knowledge domains underlie the examination. They are listed below, with additional detail in some aspects that are relevant to the practice of mental health counseling:

  1. Career counseling and assessment.

  2. Job development and placement services.

  3. Vocational consultation and services for employers.

  4. Case and caseload management.

  5. Individual counseling, including individual counseling, behavior, and personality theories and multicultural counseling theories and practices.

  6. Group and family counseling, including family and group counseling theories and multicultural counseling theories and practice.

  7. Mental health counseling, including the DSM, rehabilitation techniques for individuals with psychiatric disabilities, multicultural counseling theories and practices, medications as they apply to individuals with psychiatric disabilities, dual diagnosis, substance abuse, treatment planning, and wellness and illness prevention concepts and strategies.

  8. Psychosocial and cultural issues in counseling.

  9. Medical, functional, and environmental aspects of disabilities, including medical aspects and implications of various disabilities, medications as they relate to vocational goals and outcomes, and functional capacities of individuals with physical, psychiatric, and/or cognitive disabilities.

  10. Foundations, ethics, and professional issues.

  11. Rehabilitation services and resources.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×
  1. Health-care and disability systems, including managed-care concepts and insurance programs.

The test is administered electronically and comprises 150 scored and 25 field-test multiple-choice questions that span the domains listed above.

Ethical Standards

Generally, the licensure of professionals has been presented to legislators and the general public in terms that make the argument that professional practitioners are skilled in assisting people in the fields of their expertise and must be granted licenses to protect the public from those who offer the same services without having specific training and credentials. Licensure boards adopt ethical and disciplinary standards and processes with the intent of ensuring competent practice. Thus, the ethical standards and disciplinary processes constitute the mechanisms through which incompetent or unethical practitioners will be regulated and removed from practice if their infractions are serious enough. Some questions have arisen concerning the degree to which professional licensure boards aggressively prosecute ethical infractions and whether individual practitioners do what they are licensed to do with competence and ethically (Corey et al., 2006; Duncan et al., 2004; Gross, 1979). The licensure mechanism is structured in such a manner that licensure boards adjudicate complaints brought to them and do not attempt to monitor the practices of behavioral health professionals to ensure the quality of care for clients. It is estimated that fewer than 1% of licensed counselors have ever been subjects of ethics complaints to state boards (Neukrug et al., 2001). That rate appears to be roughly the same as the rates reported by other professions. For example, the field of psychology experienced a rate of disciplinary complaints that was about 2% of licensed psychologists during 1996–2001 (Van Horne, 2004). Despite the concerns raised, licensure boards constitute a powerful part of the credentialing system and prevent harmful or unethical practitioners from continuing in practice in their jurisdictions.

In general, licensure boards adopt in whole or in part the codes of ethics of the professional discipline they are related to, which typically are set forth by the major professional associations. Beyond that, other standards in administrative rules may supplement those ethical

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

codes, such as the requirement to pay annual licensing fees in a timely manner. Apart from administrative rules, sexual misconduct with clients is thought to be so serious that it is subject to criminal legal sanctions in an increasing number of states, including California, Colorado, Florida, Georgia, Idaho, Maine, Michigan, Minnesota, Washington, and Wisconsin. Other states are working toward passage of such legislation to supplant licensure boards’ governance related to this most serious of ethical infractions (Reaves, 2003).

The profession of licensed mental health counseling has followed the same general pattern as the other behavioral health disciplines. ACA reports that as of December 2009, 17 jurisdictions had adopted the ACA Code of Ethics into their rules and regulations: Alaska, Arizona, Arkansas, District of Columbia, Idaho, Illinois, Iowa, Louisiana, Massachusetts, Mississippi, North Carolina, North Dakota, South Dakota, Tennessee, Utah, West Virginia, and Wyoming (ACA, 2010). It notes that three states (Colorado, Ohio, and South Carolina) refer to the ACA code for advice on ethical guidelines or to use as an aid in resolving ambiguities in disciplinary rules. Delaware has adopted the NBCC Code of Ethics (State of Delaware, 2010). Some other states—Minnesota, for example—enforce their own codes of ethics (Minnesota Administrative Rules 2150.7500 CONDUCT).

The ACA code has a number of strictures regarding counselors’ ethical obligations to provide services only within their competence and scope of practice, to diagnose properly, to educate themselves in and apply scientifically based treatment modalities, and to appropriately refer patients who present with problems outside their competence and scope of practice. Relevant clauses are listed in Table 3.6. NBCC has similar requirements.

A nonscientific, annual survey of its member licensure boards conducted by the American Association of State Counseling Boards documents that ethical standards are being used by licensure boards to discipline their licensees (AASCB, 2008). For 2008, the survey of member boards reported that 395 licensees were disciplined in connection with 1,065 complaints received in the 27 states that reported data. There were a total of 81,309 licensees in the reporting jurisdictions. The 1.3% complaint rate in this informal survey is consistent with the rates of complaints to licensure boards reported in the literature. Among the 395 licensees disciplined, there were 33 revocations, 33 suspensions, 83 disciplinary letters, 3 criminal prosecutions, and 305 other actions reported.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

TABLE 3.6 Excerpts from ACA Code of Ethics Related to Professional Competence

A.11. Termination and Referral

A.11.b. Inability to Assist Clients

If counselors determine an inability to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives. If clients decline the suggested referrals, counselors should discontinue the relationship.

A.11.c. Appropriate Termination

Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling….

C.2. Professional Competence

C.2.a. Boundaries of Competence

Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse client population.

C.2.b. New Specialty Areas of Practice

Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and to protect others from possible harm.

C.2.c. Qualified for Employment

Counselors accept employment only for positions for which they are qualified by education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors hire for professional counseling positions only individuals who are qualified and competent for those positions.

C.2.d. Monitor Effectiveness

Counselors continually monitor their effectiveness as professionals and take steps to improve when necessary. Counselors in private practice take reasonable steps to seek peer supervision as needed to evaluate their efficacy as counselors.

C.2.f. Continuing Education

Counselors recognize the need for continuing education to acquire and maintain a reasonable level of awareness of current scientific and professional information in their fields of activity. They take steps to maintain competence in the skills they use, are open to new procedures, and keep current with the diverse populations and specific populations with whom they work.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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C.6.e. Scientific Bases for Treatment Modalities

Counselors use techniques/procedures/modalities that are grounded in theory and/or have an empirical or scientific foundation. Counselors who do not must define the techniques/procedures as “unproven” or “developing” and explain the potential risks and ethical considerations of using such techniques/procedures and take steps to protect clients from possible harm.

D.1.c. Interdisciplinary Teamwork

Counselors who are members of interdisciplinary teams delivering multifaceted services to clients keep the focus on how to best serve the clients. They participate in and contribute to decisions that affect the well-being of clients by drawing on the perspectives, values, and experiences of the counseling profession and those of colleagues from other disciplines.

D.2.a. Consultant Competency

Counselors take reasonable steps to ensure that they have the appropriate resources and competencies when providing consultation services. Counselors provide appropriate referral resources when requested or needed.

E.5. Diagnosis of Mental Disorders

E.2.a. Limits of Competence

Counselors utilize only those testing and assessment services for which they have been trained and are competent. Counselors using technology-assisted test interpretations are trained in the construct being measured and the specific instrument being used prior to using its technology-based application. Counselors take reasonable measures to ensure the proper use of psychological and career assessment techniques by persons under their supervision.

E.5.a. Proper Diagnosis

Counselors take special care to provide proper diagnosis of mental disorders. Assessment techniques (including personal interview) used to determine client care (e.g., locus of treatment, type of treatment, or recommended follow-up) are carefully selected and appropriately used.

F.2. Counselor Supervision Competence

F.2.a. Supervisor Preparation

Prior to offering clinical supervision services, counselors are trained in supervision methods and techniques. Counselors who offer clinical supervision services regularly pursue continuing education activities including both counseling and supervision topics and skills.

SOURCE: ACA (2005).

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Adherence to such codes helps to ensure that practitioners provide services within their expertise and results in specific disciplinary actions by counseling licensure boards that protect the public.

Criteria for Maintaining Licensure

Criteria for maintaining licensure vary but may include continuing education hours and maintenance of a “clean” record of adherence to ethical standards or other standards of professional or personal conduct.

The number of required continuing education hours for maintaining licensure varies by state from zero to 55 hours every 2 years. Licensure renewal is required by all states; the frequency of renewal ranges from once a year to once every 3 years. A complete list of continuing education and license renewal requirements is provided in Appendix G.

CERTIFICATION BY STANDARDS ASSOCIATIONS

Licensure and certification are viewed as complementary mechanisms; certification is thought to help in standardizing licensure requirements across states in that national certification examinations are often used as prerequisites for licensure. In the field of counseling, both require master’s level or higher degrees, a practicum or internship experience, supervised counseling experience, direct supervision, and passage of a counselor examination administered at the state or national level (Clawson, 2009).

Voluntary professional certification involves a systematic process and action by a duly authorized independent third party that determines, verifies, and attests in writing to the competences of people in a profession in accordance with applicable requirements associated with that profession. Major components of a certification process typically include the following:

  • A specified scope of the certification.

  • A well-defined code of ethics.

  • A job or practice analysis to identify competencies.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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  • Translation of the results of the job or practice analysis into a test blueprint that includes knowledge statements and task statements.

  • Examinations that are constructed to have psychometric rigor of fairness, validity, and reliability.

  • Scientific methods to determine the passing score.

  • A recertification program that demonstrates continued competence.

  • Processes to remove certification from a person.

The organization responsible for certifying mental health counselors at the national level is NBCC. CRCC performs an analogous function for rehabilitation counselors. The certifications granted by those organizations are discussed in the following sections. Other counseling specialties have their own governing bodies and certifications.

National Certified Counselor Certification

NBCC is an independent not-for-profit credentialing body for counselors. It was incorporated in 1982 to establish and monitor a national certification system, identify counselors who have sought and obtained certification, and maintain a register of certified counselors (NBCC, 2009a). NBCC’s primary focus is on promoting high-quality counseling. National certification by NBCC is a voluntary extra step taken by professionals in addition to required state counselor credentialing.

The basic educational requirements for the national certified counselor (NCC) credential are based on the CACREP accreditation standards and include a master’s degree in a counseling-related field from a regionally accredited institution, 48 semester hours of graduate study in the practice of counseling and closely related fields, and a counseling course in each of eight content categories. The categories are human growth and development, social and cultural foundations, helping relationships, group work, career and lifestyle development, appraisal, research and program evaluation, and professional orientation and ethics. In addition to those educational requirements, required clinical experience includes two academic terms of graduate-level, supervised field experience in a counseling setting; 2 years of post-master’s counseling experience (not necessary if the counselor graduated from a CACREP-accredited institu-

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

tion), 3,000 hours of client contact and 100 hours of face-to-face supervision, and passage of the NCE (NBCC, 2010).

Certified Clinical Mental Health Counselor Certification

The Certified Clinical Mental Health Counselor (CCMHC) certification was launched in 1979 under the National Academy for Certified Clinical Mental Health Counselors (NACCMHC), an organization formed by the American Mental Health Counselors Association. In 1993, NACCMHC and NBCC came to an agreement whereby NBCC would administer the CCMHC credential beginning July 1, 1993. The credential is sometimes used as an alternative method for meeting the requirements for becoming licensed in a state and may be one of the requirements for independent practice in a state.

Certification eligibility requirements are (NBCC, 2009b)

  • The NCC credential.

  • A passing score on the NCMHCE.

  • 60 semester hours or 90 quarter hours of graduate coursework, including a separate course of at least 2 semester hours or 3 quarter hours in

    • Theories of counseling psychotherapy and personality, including studies of basic theories, principles and techniques of counseling, and their application to professional counseling settings.

    • Counseling and psychotherapy skills, including training in basic counseling skills, consultation, and crisis intervention.

    • Abnormal psychotherapy and psychopathology, including training in diagnosis (DSM-III-R or DSM-IV), psycho-pharmacology, and treatment methods for mental and emotional disorders.

    • Human growth and development.

    • Group counseling and psychotherapy, including coursework in group dynamics and development, group counseling and psychotherapy theory, and group methods and techniques.

    • Career development.

    • Professional orientation to counseling.

    • Research.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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  • Testing and appraisal, including individual and group approaches to assessment and evaluation and interview assessment procedures.

  • Social and cultural foundations.

  • Clinical training:

    • 9–15 semester hours or 14–23 quarter hours.

    • Counseling supervisors must have at least a master’s degree in an allied mental health field and 5 years of post-master’s work experience or a doctorate in an allied mental health field and 3 years of postdoctoral work experience. (Additional requirements are also imposed on supervisors.)

The committee notes that the diversity of academic preparation and clinical internship experiences among the different types of approved supervision may lead to different outcomes. That may raise concern about the consistency and standardization that are needed to ensure common outcomes of students among academic programs or even within an academic program. Again, however, it is a generic issue and not one peculiar to mental health–counseling certifications.

Certified Rehabilitation Counselor Certification

The Certified Rehabilitation Counselor credential is administered by CRCC (CRCC, 2009b). Certification is granted on successful completion of the CRCE. CRCC requires that counselors renew their certification every 5 years by documenting the accrual of at least 100 clock hours of continuing education or by reexamination. Certificants are also obliged to conform to the commission’s Code of Professional Ethics for Rehabilitation Counselors as overseen by an ethics committee.

This certification is recognized by the National Commission for Certifying Agencies. Nine states require the CRCE to become licensed as a professional counselor (ACA, 2008b). The 12 general knowledge domains that underlie the CRCE are listed above.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

RECOGNITION OF THIRD-PARTY CERTIFICATIONS BY THE DEPARTMENT OF DEFENSE

The committee’s statement of task called for it to examine Department of Defense (DOD) recognition of third-party certification for members of the mental health professions. The department routinely relies on such certification on the basis of authority in the Code of Federal Regulations. Title 32 of Section 199.6 (excerpted in Appendix D) states that clinical psychologists, certified clinical social workers, certified psychiatric nurse specialists, certified marriage and family therapists, pastoral counselors, and mental health counselors must be licensed or certified by the jurisdiction where they wish to practice. For jurisdictions that do not offer licensure or certification, providers must be “certified by or eligible for full clinical membership in the appropriate national professional association that sets standards for the specific profession.” For counselors, the TRICARE Policy Manual (6010.54-M, Chapter 11, Section 3.10) sets the following standard:

In jurisdictions that do not offer licensure, the mental health counselor must be (or must meet all of the requirements to become) a Certified Clinical Mental Health Counselor (CCMHC) as determined by the Clinical Academy of the National Board of Certified Counselors (NBCC).

Other organizations recognized by TRICARE for certification of practitioners or their educational institutions include the National Register of Health Service Providers in Psychology for clinical psychologists, the CSWE for certified clinical social workers, and the American Association of Pastor Counselors.

A “qualified accreditation organization” is defined in 32 CFR § 199.2 as a not-for-profit corporation or foundation that develops knowledge and skill standards for health-care–professional certification testing, creates measurable criteria, publishes the standards and evaluation processes, provides national testing of people, provides written certification of compliance to people, publishes the outcomes for the general public, and “has been found by the Director, OCHAMPUS, or designee, to apply standards, criteria, and certification processes which reinforce CHAMPUS provider authorization requirements and promote efficient delivery of CHAMPUS benefits.”

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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CREDENTIALING AND PRIVILEGING

Health-care organizations (HCOs) ensure high-quality health care for their beneficiaries in part by ascertaining that their health-care providers meet established professional standards of education, training, and ethical conduct as demonstrated and validated by appropriate diplomas, licenses, and certificates. Credentialing involves the review and usually primary source verification of each practitioner’s professional document portfolio. Privileging—the authorization of a variety, scope, and content of professional activities for each practitioner by an HCO—is based not only on careful review and evaluation of each practitioner’s credentials and performance but on the mission, scope, and specific needs of the organization.

In the TRICARE system, both the direct-care system (military health-care facilities) and the contracted-out (purchased-care) system have specific credentialing and privileging requirements. These and practices in the private sector are discussed below.

Credentialing and Privileging in TRICARE

TRICARE Direct-Care System

Overview Credentialing and privileging requirements in the direct-care system are outlined in the appropriate service regulations or instructions, specifically Army Regulation 40-68; Navy BUMEDINST 6320.66E; and Air Force Instruction 44-119. The policies apply not only to active-duty people and others employed by each service but to other providers (e.g., volunteers and members of other services) who are not classified as employees of the particular service but are providing patient care under the auspices of the military or based on guidelines articulated in a US or foreign memoranda of understanding or memoranda of agreement.5

Credentialing and privileging policies are the responsibility of each service’s medical department, ultimately the service’s surgeon general. Specific privileges of each credentialed practitioner are delineated in each clinical department by the appropriate department chief; this

5

A memorandum of understanding or memorandum of agreement would be used, for example, for non-US health-care personnel deployed in a theater of operations.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

delineation must be approved by the medical treatment facility (MTF) commander—or, in the Navy, by a higher headquarters commander—who is the sole approval authority for each MTF in the Military Health System.

Providers are granted only clinical privileges that are appropriate for the settings in which they practice. A cardiothoracic surgeon practicing in an outpatient cardiology clinic, for example, will not be granted privileges to perform bypass surgery in the clinic; and a psychiatrist trained in electroconvulsive therapy (ECT) will not be granted privileges to perform ECT in a community mental health facility that is not equipped or staffed to support the procedure.

US Army, Navy, and Air Force requirements relevant to mental health–care providers are outlined below.


Army Army Regulation 40–68—Clinical Quality Management—delineates the service’s general policies on licensure, certification, and registration of health-care professionals. Appendix E excerpts several sections of the regulation that are relevant to the discussion below.

Section 4-4 of Regulation 40–68 provides a “not all inclusive” list of the professional disciplines requiring license, certification, or registration to practice in the Army. The list specifically mentions clinical psychologists, clinical social workers, counseling psychologists, physicians, psychological associates, substance-abuse counselors, and “behavioral health practitioners.”

Guidance regarding the scope of practice and other specific professional requirements for privileged providers is in Section 7. Section 7-6 addresses “behavioral health practitioners.” These are defined as persons who “are trained in behavioral science, counseling theories, and practical applications of behavior change principles” and “may manage numerous behavioral and emotional problems, in both general and particular specialty practice levels, providing a variety of behavioral health services, including screening, treatment, and consultation.” The regulation adds that “the behavioral health practitioner may develop additional expertise in psychometrics, industrial psychology, substance abuse rehabilitation, geriatric care, school or health psychology, neuropsychology, pediatric or adolescent psychology, aeromedical psychology, and combat stress reactions.”

Section 7-6b describes a three-tier privileging system for behavioral health practitioners. A Category I practitioner “performs specialty

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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counseling services and works under the supervision of a psychologist, psychiatrist, or clinical social worker licensed in his/her discipline” and is required to have a master’s degree in counseling psychology, including “a minimum of 12 supervised practicum hours in the major specialty” and “either the Licensed Professional Counselor (LPC) license or a master’s level psychology license, such as psychological associate license, from a State licensing board.” The regulation notes that “some States use a different title for their LPC-equivalent license” and “the education and experience requirements for licensure are the basis for determining equivalency.” Category II requires in addition “a minimum of 2 years’ full-time experience in the specialty in which services are performed under the supervision of a higher level privileged provider with a license in social work, psychology, or psychiatry.” Category III is for practitioners who provide “a wide range of services in the designated specialty and may supervise category II or I counselors in their provision of services in the specialty” but still need to “be supervised by a psychologist, psychiatrist, or a social worker who is licensed in their respective disciplines and privileged at a higher level (category).”

Section 7-6c states that practitioners will “practice within the guidelines of their respective State licensing boards as LPCs (or equivalent) or, if offered by their State, a license for master’s-level psychology graduates such as psychological associate or licensed mental health provider.” Specific clinical privileges are “granted based upon training, experience, and competency.” Five general privileges are delineated:

  1. Conduct screening evaluations, utilizing information from clinical interviews, nonpsychometric tests, and collateral sources, as appropriate.

  2. Determine a provisional diagnosis according to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.

  3. Provide individual and group behavioral health treatment within the scope of practice/privileges granted.

  4. Manage the behavioral health care of patients and refer those having needs beyond their scope of practice.

  5. Serve as collaborator in human behavioral issues with, and consultant to, community agencies, health care providers, and organizational leaders.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Two companion forms are used to document the delineation and evaluation of clinical privileges for behavioral health practitioners for specific providers: Department of the Army (DA) Forms 5440-34 and 5441-34. These include checkoffs for various types of assessment (psychological, substance abuse, adult, adolescent, and family), treatment planning (inpatient and outpatient), and categories of patients and therapy (adult, adolescent, family, marital, individual, group, crisis, inpatient, and outpatient). No specific therapies are listed, but the delineation of clinical privileges for “substance abuse rehabilitation”6 (DA Form 5440–58) offers insight into how this is accomplished in the Army. The form lists eight kinds of therapy for which practice privileges may be requested and approved (cognitive-behavioral and rational-emotive, reality, brief, gestalt, psychodynamic, group, and transactional analysis) with blanks for additions.


Navy General Navy and Marine Corps policies on licensure, certification, and registration of health-care professionals are articulated in Bureau of Medicine and Surgery Instruction (BUMEDINST) 6320.66E, Credentials Review and Privileging Program. They are quite similar to the Army instructions reviewed above except that in the latest (“E” ) version of Instruction 6320.66, authority for privileging providers in fixed medical and dental facilities is delegated by the chief of BUMED to higher headquarters commanders (medical regional commanders) rather than to facility commanders directly. Guidelines for clinical privileging and credentials review of “Clinical Practitioners/Providers in Department of the Navy Fleet and Family Support Program and Marine Corps Community Services” are provided in SECNAV Instruction 1754.7 (November 2005).

Section 8a(2), BUMEDINST 6320.66E, states that “Chief, BUMED shall: Establish, in coordination with chiefs of the appropriate corps and the specialty leaders, standardized clinical privilege sheets, which prescribe both core and supplemental privileges reflecting the currently recognized scope of care for each health care specialty.” Section 10d adds:

6

Professionals who practice substance-abuse rehabilitation have educational and licensing requirements similar to those of behavioral health practitioners.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Privileging authorities shall grant clinical privileges to health care practitioners using standardized, specialty specific privilege sheets contained in this instruction. These privilege sheets reflect the currently recognized scope of care appropriate to each health care specialty. Commanding officers shall ensure health care practitioners provide care consistent with their approved clinical privileges.

Appendix G (pages G-1–G-38) of BUMEDINST 6320.66E contains clinical-privilege sheets for the allied-health professions and outlines the educational requirements for each specialty. Clinical psychologists, clinical social workers, and marriage and family therapists are all addressed, but behavioral health practitioners and mental health counselors are not mentioned on this list or elsewhere in the instruction. A reasonable inference is that licensed counselors are not used in Navy health care facilities.

Counselors are, however, used in the Navy Fleet and Family Support Program (FFSP) and Marine Corps Community Services (MCCS) as documented in SECNAV Instruction 1754.7. The procedures outlined in the instruction are similar to those in other military facilities. Section 9a(1) states that “clinical practitioners include, but are not limited to, privileged psychologists, social workers, and marriage and family therapists”; and the instruction focuses on these behavioral health providers.

SECNAV Instruction 1754.7A, Process of Credentials Review and Privileging, sets up a three-tier privileging system similar to the Army’s. Tier I “includes entry-level providers who are collecting their supervised clinical hours to be applied toward licensure” and who are expected to complete their licensure/certification within a 36-month period. Tier II “includes providers who are State licensed or State certified or were granted a license or a certificate by a U.S. territory to provide independent clinical care.” Tier III “includes providers who are State licensed or State certified or were granted a license or a certificate by a U.S. territory, have been granted clinical privileges to function as an independent practitioner, and have attained specified additional clinical experience.”

Section 3 of SECNAV Instruction 1754.7A, which addresses the “minimum qualifications and capabilities of providers functioning within this three-tier system,” lists a master’s or doctoral degree in counseling from a program accredited by CACREP or an equivalent degree as meeting the requirement for Tier I privileging only. In addition to other

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

requirements, providers privileged at Tier II or III are required to have at least a master’s degree in marital and family therapy, psychology, or social work. Similarly, the list of core privileges provided in Enclosure 3 addresses privileges for those three disciplines but does not mention counselors. A reasonable conclusion is that the Navy uses counselors in the FFSP and MCCS but privileges them only at the Tier I level.


Air Force General policies on licensure, certification, and registration of health-care professionals are articulated in Chapters 4, 5, and 6 of Air Force Instruction 44-119, Medical Quality Operations. These are consistent with and similar to those in the Army and the Navy. Section 5.3 refers to the Centralized Credentials and Quality Assurance System (CCQAS), a DOD-mandated Web-based secure credentials and risk-management application used in the provider credentialing and privileging process, and it lists the categories of providers that according to DOD must be included in CCQAS. The list is similar to that of allied health professions included in Appendix G of Navy BUMEDINST 6320.66E in that it lists clinical psychologists, marriage and family therapists, and social workers; but it also mentions mental health counselors (to include certified alcohol and drug-abuse counselors) and professional counselors.

Chapter 7 of the instruction addresses the professional scope of practice for allied health. Section 7A presents an allied health provider list. It includes psychiatric and mental health nurse practitioners, psychologists, and social workers but does not mention mental health or other counselors or marriage and family therapists. Another list, “non-privileged Allied Health Professionals,” in Section 7B, specifically mentions certified alcohol and drug-abuse counselors. This suggests that, although counselors are mentioned in the categories of providers that are to be included in CCQAS if used by the services, they are probably not currently used by the Air Force.

TRICARE Purchased-Care System

As mentioned in Chapter 1, the purchased-care contractors in 2009 were MHN/HealthNet for TRICARE North, Humana for TRICARE South, and TriWest for TRICARE West. In July 2009, it was announced that new contracts had been awarded to Aetna Government Health

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Plans for the north region, UnitedHealth Military & Veterans Services for the south region, and TriWest for the west region. The information below addresses the contractors serving in 2009.

Purchased-care contractors must conform to the policies articulated in TRICARE Policy Manual 6010.54 (August 2002). Although policies dictate that counselors be credentialed, the details are left to the contractor. In a presentation to the committee in July 2009, a representative of MHN/HealthNet indicated that the following criteria—which largely overlap the regulatory requirements—were applied by his firm (Shaffer, 2009):

  • A degree from a US professional school that includes education and training commensurate with state requirements for licensure. A waiver can be applied for if the applicant graduated from a non-US school.

  • A current, independent license or certification in the state where practice will occur.

  • Professional liability insurance $1 million per occurrence/ $1 million aggregate, with lower limits possible when such are the community standard or when the MHN level of insurance is not available.

  • Two years of post-master’s experience which includes 3,000 hours of clinical work and 100 hours of face-to-face supervision.

MHN/HealthNet’s credentialing application process included primary source verification of education, license, and insurance; a review of the applicant’s history of insurance actions and license investigations; and a criminal-background check. That information needed to be examined and approved by the Credential Committee before a contract with the applicant was completed. MHN/HealthNet did not engage in case-specific or treatment-specific privileging but did ask providers to identify subjects of specific expertise in client subpopulations (children and adolescents, for example), in diagnosis, and in treatment modalities (such as dialectical behavioral therapy) (Shaffer, 2009).

TriWest provides specific credentialing forms for each behavioral discipline; the form for counselors conforms to TRICARE requirements regarding referral and supervision by a physician. Humana’s Provider Handbook does not address privileging and scope of practice beyond claim and billing considerations.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

The committee did not identify any circumstance in which the contractor defined the scope of practice for any particular discipline beyond the boundaries prescribed by each practitioner’s professional license and in anything other than general terms.

Supervisory policies are similarly vague. MHN/HealthNet indicated that it does not set specific criteria for the form and manner of physicians’ supervision of counselors beyond that specified in 32 CFR § 199.6 (Appendix D). Physicians are simply reminded that they have a responsibility to supervise (Shaffer, 2009).

Private Sector

Provider credentialing in private-sector HCOs is heavily shaped by the accreditation standards established by the National Committee for Quality Assurance (NCQA) and URAC.7 All contracted providers must be credentialed and, for most managed-care behavioral health organizations (MBHOs), must be licensed. Accreditation standards require MBHOs to verify from the primary source (directly contacting the source that has issued the training, certification, and so on) the training, licensure, certification, malpractice filing history (only available for MDs), report of “good standing” in the community (absence of an important criminal record or complaints to licensing boards and existence of references from colleagues) of each independent practitioner. MBHOs also collect signed attestation statements at the time of credentialing and recredentialing to disclose any criminal action, substance abuse, or mental impairment. Providers who practice in clinics or facilities that are not accredited are treated and must be credentialed as independent providers. Providers who practice in facilities or clinics that are accredited—by the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities (CARF)—are credentialed by hiring entities that follow the standards of the Joint Commission and CARF. MBHOs have the option to accept an accredited clinic or facility credentialing process and not duplicate the process. MBHOs are required to recredential providers every 3 years, updating such information as licensure status, attestations, complaints, sentinel events, and, in some MBHOs, patient satisfaction.

7

URAC is the formal name of the accreditation organization originally incorporated as the Utilization Review Accreditation Commission (URAC, 2009).

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

Other than conforming to state law, there is no consistent pattern or single set of rules applied to determine whether or under what circumstances a particular class of providers may have their services eligible for reimbursement or subject to referral or supervision requirements. Indeed, a class of providers that may be covered under one plan offered by an insurer might not be covered under a different plan offered by the same insurer. Decisions in such cases are driven by cost considerations and by the preferences of the organization that contracts with the insurer. For example, a religious organization may require that its plan cover the services of pastoral counselors.

The scope of practice for all contracted providers is dictated by their professional licensure, certifications where they exist, fellowships, and special training. Scopes of practice linked to formal certifications or fellowships are verified and included in the scopes of practice of a provider. Most behavioral health diagnoses and treatments do not have recognized designations of competency that are consistent and reliable, such as board certifications or subspecialty fellowships that are accredited. Complex conditions, such as eating disorders and traumatic brain injury, that require expertise do not have recognized certifications or accredited fellowships.

In the absence of those formal designations, other forms of information are collected by self-reporting to identify providers who have experience or expertise, such as the percentage of practice devoted to a specific diagnostic category or population type and postgraduate continuing education courses. In many MBHOs, providers are given a list of diagnoses and evidence-based treatments at the time of credentialing and recredentialing and are asked to indicate the scope of diagnosis and treatment in which they have experience or expertise.

Communication of provider expertise to patients is not addressed by accreditation standards. There is great variability in how providers’ experience is communicated when patients are selecting providers. All MBHOs list providers’ professional training credentials (such as MD, PhD, LPC, MFT, and CSW) and certifications. Beyond those designations, self-reported experience varies. CIGNA HealthCare, for example, displays on its Web site not only a provider’s credentials and experience but a photograph (if submitted by the provider) and a brief paragraph written by the provider to give a more personal introduction and description of her or his fields of practice and clinical approach.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
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Monitoring of the performance of independent providers, facilities, and clinics in the network of an MBHO generally follows accreditation standards. The standard monitoring touch points are as follows:

  • Patient safety (all items are recorded by individual provider, facility, or clinic):

    • Complaints registered with the MBHO (ongoing and real-time review).

    • Reported sentinel events such as suicide and assault (ongoing and real-time review).

    • Complaints collected through licensing board (every 3 years).

    • Site-visit review of environment and office procedures (record storage, onsite medication storage, and the like) (randomly selected or focused on high-volume providers).

  • Quality reporting:

    • Compliance with practice guidelines.

    • Patient satisfaction.

    • Utilization patterns.

    • Standardized Healthcare Effectiveness Data and Information Set (HEDIS)8 performance measures:

      • Measurement of postdischarge outpatient care.

      • Measurement of antidepressant-medication management for depression.

      • Measurement of ADHD-medication management.

      • Measurement of alcohol-use and substance-use screening and treatment engagement.

    • Other nonstandard measurements as designated by the MBHO.

Patient-safety data collection and review is ongoing for complaints and sentinel events reported to the MBHO. The MBHO must investigate, review, and resolve all complaints and sentinel events typically within 30 days. Members involved in the complaints and sentinel events are notified of the outcomes when that is appropriate. When unsafe practices are identified, the MBHO takes action with the provider, facil-

8

HEDIS is a tool administered by NCQA and “used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service” (NCQA, 2009).

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

ity, or clinic. Typical actions include creation of corrective-action plans with oversight until conclusion, removal from the network, and reporting to licensing and certification boards or accreditation bodies.

Most quality reporting is at the institutional level; it is seldom by individual providers. Resource limitations, technology limitations, and insufficient volume for an accurate measurement are the major factors that keep MBHOs from reporting on a provider level. Because MBHOs have such large networks and providers are selected by patients, it is difficult to accumulate a sufficient volume of patients being treated by a specific provider and belonging to the MBHO. Most MBHOs, if provider-level performance measures are collected and reported, focus on high-volume providers (generally 10–15 patients per provider during the measurement period) to obtain results that have a degree of validity.

Monitoring of compliance with stated scopes of practice by providers, including licensed counselors is not done in a formal or direct way in MBHOs. The lack of clear designation of scope of practice from subspecialty training programs and the lack of national criteria for setting standards for designating scope of practice pose a problem in determining with any validity a provider’s scope of practice beyond certifications and self-reporting. Technology and data-collection systems required to address that task would be expensive and labor-intensive. If there are complaints and sentinel events regarding the quality of service of specific providers, MBHOs review patient-safety trends at the time of recredentialing or each time an event is reported. During the investigation of a complaint or sentinel event, whatever scope-of-practice issues arise are addressed.

Some MBHOs have initiated the measurement of treatment outcomes for their providers. For example, OptumHealth Behavioral Solutions (OHBS)—through its ALERT program—requires the use of a valid global distress measurement for adults and children at baseline and during therapy by all contracted providers. The trend of outcome measurements is observed for high-volume providers (10 or more patients each with two data points), effect size and (a benchmarked measurement of clinical effectiveness) is reported. OHBS has started to tier providers on the basis of their scores—specifically, the ability to achieve clinical effectiveness with all their OHBS patients—and to make the tiering status available to members who seek care.

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

BOX 3.1

Abbreviations and Acronyms

Accrediting bodies and professional associations

ACA

American Counseling Association

ACGME

Accreditation Council for Graduate Medical Education

AMHCA

American Mental Health Counselors Association

APA

American Psychological Association

APA CoA

APA Commission on Accreditation

CACREP

Council for Accreditation of Counseling and Related Educational Programs

CARF

Commission on Accreditation of Rehabilitation Facilities

CCNE

Commission on Collegiate Nursing Education

CHEA

Council on Higher Education Accreditation

CORE

Council on Rehabilitation Education

CRCC

Commission on Rehabilitation Counselor Certification

CSWE

Council on Social Work Education

LCME

Liaison Committee on Medical Education

NACCMHC

National Academy for Certified Clinical Mental Health Counselors

NBCC

National Board for Certified Counselors

NCCA

National Commission for Certifying Agencies

NCQA

National Committee for Quality Assurance

The Joint Commission

formerly, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

URAC

the current name of the organization originally incorporated as the “Utilization Review Accreditation Commission”

Certifications in the field of counseling

CCMHC

Certified Clinical Mental Health Counselor

CRC

Certified Rehabilitation Counselor

NCC

National Certified Counselor

Counseling examinations

CRCE

Certified Rehabilitation Counselor Examination

NCE

National Counselor Examination

NCMHCE

National Clinical Mental Health Counselor Examination

Suggested Citation:"3 Requirements Related to the Practice of Counseling." Institute of Medicine. 2010. Provision of Mental Health Counseling Services Under TRICARE. Washington, DC: The National Academies Press. doi: 10.17226/12813.
×

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In this book, the IOM makes recommendations for permitting independent practice for mental health counselors treating patients within TRICARE--the DOD's health care benefits program. This would change current policy, which requires all counselors to practice under a physician's supervision without regard to their education, training, licensure or experience.

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