Head Games

This summer, a new law will establish mandatory licensing for mental-health professionals--but some fear it could end up hurting many of those it's designed to protect

Rachel is turning 26, and she's finishing up her master's degree. She's bright, confident and already secure in a job she loves. She looks forward to finishing school and a 40-hour work week.

"But I haven't always been optimistic about the future," she says, tapping the side of the ice tea she's been sipping, visibly uneasy that the conversation has turned to her past. "Four years ago, I wouldn't be recognizable from who I am now."

On a Thursday night nearly three years ago, Rachel--not her real name--checked herself into Palo Verde Hospital, afraid of what she might do to herself. She'd already made two attempts to kill herself.

"It was a complete nightmare," she says, describing the four days she spent at Palo Verde. "They take away your shoes. They take away your clothes. They put you in a room with plastic sheets with something like a cookie sheet for a mirror. I met my doctor for maybe five minutes that Friday, and that's it. The rest of the time, I spent in front of a TV with all the other patients, scared."

It was a bad experience, but Rachel admits it probably saved her life.

"It was really the worst thing I could have done to myself," she says. "But it did make me realize that I did need help ... a different kind of help than they were trying to give me."

When Rachel left the hospital that Monday morning, she went to see a family member who gave her the name of a private-practice counselor.

"I met (my counselor) when I was in a very bad place," she says. "I was suicidal. On top of that, I was cutting myself. And I really didn't have any idea why I was doing that, why I was depressed."

Before ending up in the hospital, Rachel had tried to go through her insurance company for help, first seeing her general practitioner--who got her started on Paxil--then visiting a psychiatrist. The medication just made things worse, she says. She describes the visits to the psychiatrist as cold and ineffective.

Today, after 2 1/2 years of therapy, Rachel has finally turned her life around. And she gives credit to her counselor.

"I know she cares about me," Rachel says. "And I know she cares what happens in my life. My gut feeling is that, if I hadn't found her, I'd be dead now."

But on July 1--if the state has its way--her counselor, along with many others, will be forced out of practice, leaving perhaps thousands of Arizona's most vulnerable citizens without the guidance they've come to rely upon. All this in the name of public safety.

"The intent is to bring all of the psychotherapy professions under one umbrella," says Rep. Deb Gullet, R-Phoenix, explaining why she sponsored the law that will establish a mandatory licensing procedure for mental-health professionals this summer. "The idea is to have some ability to regulate."

Arizona is one of only three states in the country that currently doesn't have mandatory certification for psychotherapists. That will end on July 1, when licensure becomes law. It's something that's long overdue, says Gullet.

"We had instances where somebody had been kicked out of practice in Michigan, and was no longer able to practice in California, and was moving to Arizona because of our incredibly low standards," Gullet says.

In 1989, the Legislature voted to create a voluntary certification process for counselors as part of its first attempt to regulate the field. The law established the Board of Behavioral Health Examiners and charged it with ensuring that candidates for certification met minimum academic and professional standards. The board also hears any complaints from the public levied against counselors.

But the voluntary process hasn't worked as well as some would have liked. Tim Hofmann is co-chair of the Arizona Behavioral Health Professionals Coalition, a collection of mental-health professional groups that pushed hard for licensure. Though certification is better than nothing, he says, the voluntary nature of the program has always meant that the board's hands are often tied in cases of obvious abuse.

"The goal here was to stop the abuse of clients. There were some people who were clearly abusing and taking advantage of their positions as counselors. And people were really getting hurt in the process," he says. "Nearly a third of those cases were getting dismissed as non-jurisdictional. Which means that this is not a certified person, so there's really nothing we can do."

Even when a case of abuse involved a state-certified counselor, the maximum penalty the board could impose was a revocation of the state-issued certification, which--since it's voluntary anyway--didn't stop rogue counselors from continuing to see clients.

Arizona needed a binding credential to protect the public and enforce standards within the field of counseling.

Licensure is meant to do just that.

When the new law goes into effect in July, anyone wishing to practice any form of psychotherapy in Arizona will have to hold a state-issued license. Practicing without one will be a Class Two misdemeanor, punishable by a daily fine of up to $500, and continuing to practice could result in jail time.

Until now, the lack of any real regulation has meant that the national reputation of the counseling profession in Arizona has been one big question mark. So, when the process designed to change that was approved by the Legislature in April 2003, an overwhelming majority of counselors applauded the move.

That is, until their rejections started coming.

The licensure law contains only one explicit grandfather clause, which states that only those counselors who hold or receive the current voluntary certification before the end of June will automatically receive licenses. Like many in her position, Jane Martin went ahead and submitted her application when the new law was passed last year.

Since then, she has amassed an impressive archive of documents related to her application for certification.

There's the application itself; the subpoena the board issued for records related to her work at the University of Arizona; the letter informing her of her rejection; the independent legal opinion she had drafted by a lawyer in Phoenix; and, finally, the letter she recently sent out to her 75 clients informing them that the state is shutting down her practice.

The experience has left her exhausted, confused and more than a little bitter.

"It's really traumatic to think that all my work, 17 years of work, doesn't mean anything after all," says Martin, who is now desperately trying to find other counselors to take on her clients.

"This is not just 'give people three names, and it's over.' My job has been my longest love affair. And now it's all going to end."

Martin holds a bachelor's degree in psychology and a master's in counseling and psychology. She spent six years at the UA, eventually becoming a staff member in the Department of Physiology and co-authoring 17 scientific papers. She has been in private practice for more than 17 years, and has reportedly never been the subject of a complaint. If anything, she appears overqualified for a license that is meant to reflect minimum requisite standards for her field.

But the board's counselor credentialing committee saw things differently. Though Martin had completed some 7,000 hours of supervised work during her time at the UA--nearly double what the state requires--those hours, the board ruled, didn't count. Nor did the tens of thousands of hours she'd worked in private practice.

"I felt sick to my stomach," Martin says, recalling the moment she learned from a colleague at the UA that the board had subpoenaed her records. "I'd never been in any trouble in my whole life."

The problem had to do with how the new licensure law was drafted, overturning a certification standard that clearly defines supervised work experience and replacing it with a clause that allows the board's counselor credentialing committee to define it however it wants.

Martin's work would probably have qualified under the old standard, but what is now approved by the board as "supervised experience" is limited to work in a board-approved agency. And the University of Arizona--one of the few institutions in the state offering a degree in counseling--doesn't make the grade in the eyes of the credentialing committee.

To qualify, Martin would have to go back and redo a minimum of two years of work in order to qualify and be allowed to operate a private practice.

Martin's is far from an isolated case, and Rep. Marian McClure, R-Tucson, who proposed drafting an amendment to the law, doesn't think that's fair.

"Some of these people have been practicing 20 years," says McClure. "What I find a little funny is that they've had their own private practice, but now, if they want to be certified, they have to go into someone's practice and work for $9 or $10 an hour for two years in order to be supervised. I believe that's an injustice. I truly do."

In the end, however, an amendment was never drafted. When McClure took her idea to the chair of the House Health Committee, she was told she could write the amendment, but it would never be brought to the table.

In December, representatives from Tim Hofmann's coalition, which helped draft the bill, got involved. They came before the board to ask for more leniency when evaluating the clinical supervision experience of veteran counselors. The board's answer was a flat no.

No member of The Arizona Board of Behavioral Health Examiners is allowed to speak publicly about board-related matters unless the board first votes to allow them to do so. Because the board only meets once a month, no comment was available from board members in relation to this article.

Anne Parker has never seen anything like it. For eight years, she served on various national credentialing organizations, eventually becoming chair of the National Commission for Certifying Agencies, a group that accredits credentialing boards.

"The biggest problem is that they haven't made any provisions for a true grandfathering or transitional licensure program," she says. "The standard is that when you start a program, you have an open period when anyone who's practicing at the time can get in. In this transfer from certification to licensure, they're not doing that."

According to Parker, the idea is to create a four to six month window, with a liberalized set of standards that would allow qualified and highly experienced counselors to remain in practice.

Gullet claims this would defeat the purpose of the law.

"What we set out to do is to make sure Arizona is not a safe haven that harbors quacks," she says, explaining why she's against the kind of grandfather clauses proposed by McClure and Parker. "It would eliminate licensure for anybody that's practicing, even though they represent half of the complaints the board gets. A handful of people just don't want to have standards."

But, though the board may very well be doing its job to keep out the grossly incompetent, many of the state's most well respected counselors may end up being excluded along with them.

Professor Carl Ridley holds a doctorate in marriage and family therapy and has been teaching counseling and psychology at the UA for 27 years. He also takes private clients from time to time. Many of the board's critics see his case as indicative of everything that's wrong with how the credentialing committees are choosing to implement the new law.

When Ridley recently applied for certification, he was denied on the grounds that he was academically deficient. It didn't seem to matter to the board that the course he was missing was one he'd been teaching for five years.

"It was a ridiculous situation," Ridley says. "In order to qualify, I would have to be in two roles. I would be the instructor in the class, and also I would be a student. And if I could do that, then I would meet their criteria. It's really kind of incredible."

For the students he's taught, however, there's no problem.

"A student could be in my class and get a D," says Ridley. "They could apply and list that on their application. They would get credit for that. Whereas, as the instructor in the class, having to know the material on that level, I can't."

Applicants with older degrees--those who've been in the field the longest--are especially hard hit by what is seen by many as an overall lack of flexibility on the part of the credentialing committee.

Psychology and psychotherapy are notoriously dynamic fields. What may for a time be seen as standard theory is often refined or discredited only a few years later. For this reason, there has been, until relatively recently, no nationwide standardization of curricula.

Because of this, the board has taken it upon itself to evaluate the individual classes taken by applicants who graduated before the '90s, requesting not only transcripts, but often syllabi and even the title pages of textbooks that in some cases have been out of print for 30 years or more.

In the case of Ridley, the course in question, "Theories of Counseling," is comprised of material covered in a class entitled "Principles of Counseling" that he took in the '60s. This still wasn't enough for the credentialing committee--something else Parker finds strange.

"As detailed an investigation as the credentialing committee is doing into course work," she says, "I worry that they are getting into a realm that is really the universities' responsibility. I've never heard of any credentialing committee evaluating a course the university said was appropriate, gave the person a grade, and graduated them in, just to come back and say that course wasn't good enough. In my experience on the national level, that's completely out of the realm of what a credentialing committee should be doing."

Coming up with a solid figure for just how many counselors are being left out isn't easy. According to the Arizona Board of Behavioral Health Examiners' Sunrise Report, which the state itself used to determine the need for a licensing scheme, nearly 18,000 Arizonans will require some sort of mandatory certification under the new law. When that report was published two years ago, less than a third were certified under the voluntary program.

Since then, not nearly enough people have come forward in time to beat the July 1 cutoff. And of those that have, a significant number are being turned down.

In the nine months since the beginning of the fiscal year, the board has received more than 1,500 applications from mental health professionals seeking certification. During that same time period, the four credentialing committees have granted only 844.

If you include the untold numbers that haven't even applied for one reason or another, the situation begins to look grave.

Catherine Penn is a Tucson counselor who helped form Arizona Professional Counselors for Fair Licensure, a group that is pushing for a review of the new law and how it's being implemented. She has a theory about why many counselors haven't sent in their applications.

"Quite frankly," she says, "people are afraid of the board. And I think they're afraid with some good reason, because of the stories people are telling them about some of their experiences there. The board isn't fostering any stance saying, 'Come on in. Let's talk to you. Let's make it work.' When we complain to legislators about this, they go to the board, and the board says, 'Don't worry about it. We're working with them.' And that's not exactly what's happening."

Instead, she says, many counselors worry their client records will be subpoenaed. Some, because the law has received so little publicity, still don't know a licensing scheme has been created. Still others, knowing they won't qualify, are trying not to draw attention to themselves.

Richard Poppy runs a methadone clinic in downtown Tucson. When he began the application process, he was told that since the counseling program he'd graduated from was based on a system of three-hour classes, he wouldn't qualify. The credentialing committee demands four-hour classes for a professional counselor's license.

It didn't matter that he'd taken more than the required number of classes; that Seattle University, where he'd done his master's degree, has one of the most prestigious counseling degrees in the Pacific Northwest; or that he'd been among only 20 applicants accepted into the program that year from a pool of more than 200.

"I am in that category of people that knows they don't meet the requirements. So there's really no reason for me to spend $250 just so I can get rejected," says Poppy.

Penn claims this is a fairly common sentiment among counselors she's talked with.

"At this point," she says, "the board is really trying to make everyone look the same. And that just isn't going to happen. There are a number of people, especially in the field of counseling, that simply don't fit the requirements."

Of course, the biggest losers in all of this will almost certainly be many of those the law is intended to protect: people like Rachel.

"You need to understand how lost this makes me feel," she says. "To have to completely start over after 2 1/2 years, it almost doesn't feel worth it to me. And if this had happened early on in the relationship, I would have taken it as just another sign that there is something wrong with me. Part of the point of forming that kind of relationship with a counselor is to have that security, to feel that they're there for you. I don't think people realize how important it is to form that relationship."

She blames the board's handling of the situation for creating what she believes could become a statewide disaster.

"In its current form, I think the law is hurting the people of Arizona more than helping them," Rachel says. "It's amazing to me that they haven't researched this. That they haven't looked into how this is going to affect people."

Many counselors, too, are concerned by what might happen when masses of clients are forced to make the often-traumatic transfer to a new counselor. Jane Martin worries that many of the people she works with could regress or even abandon therapy altogether.

"It could get really bad," she says. "People could attempt suicide. They could return to substance abuse. If they're overeaters, they could eat more. They could behave in inappropriate or mean ways toward their children, because they just don't have the support of someone they can call up and say 'My kids are driving me crazy, Jane. What should I do?' It triggers all sorts of things."

In March, Arizona Professional Counselors for Fair Licensure filed a lawsuit seeking an injunction against the new law, partly on the grounds that it violates the state Constitution's promise of equal protection under the law.

They are arguing that, as uncertified counselors, they have been practicing legally in Arizona for years, making it an established right that the state cannot take away. The lawsuit contests that excluding them, while granting voluntarily certified counselors automatic licensure, violates this right.

"The point is that certification was a voluntary process," says Catherine Penn. "No one now practicing without certification has been doing anything illegal or unprofessional. And no one I know is against licensure. The problem that is occurring now is that, in the transition from voluntary certification to mandatory licensure, there was no provision created to allow into licensure anyone who didn't go through that voluntary certification."

The fact that the board is using the new standards for licensure to evaluate applications for certification also causes a legal problem. Since the law lets the board make those standards whatever they want, Arizona Professional Counselors for Fair Licensure claims the law itself is unconstitutionally vague.

The state's Attorney General's office has already responded to the lawsuit, moving for a summary dismissal.

The upcoming weeks could very well determine the fate of thousands of Arizona's mental health professionals, as the case goes before a judge who will determine if the suit should go any further. He has the option of throwing the complaint out or of granting a preliminary injunction, allowing both sides the time to argue their cases.

In the best-case scenario for counselors fighting for changes to the law, the whole process could take years. But for some who've already begun the transition to the agency jobs that will allow them to continue practicing, it is probably already too late.

Martin will shut down her private practice in late June, having already accepted an entry-level position at an agency in Douglas on the Mexican border. Late in her career, and with three children in college, she will earn less than a third of what she had been making in private practice. At the end of two years, she will be able to resubmit her application for licensure. She's still not sure she will ever return to private practice.

Despite the fact that she'll now have to operate within the clinical confines of an agency, she'll be able to carry on, at least in some way, what's come to be her life's work.

"I may not be doing what I love," she says, "but I'll find a way to love what I'm doing."

Laurel Allen contributed to this article.

Comments (0)

Add a comment

Add a Comment

Tucson Weekly

Best of Tucson Weekly

Tucson Weekly