Trying to summarize state licensure laws for psychologists: Burial by

Trying to summarize state licensure laws for psychologists: Burial by grains of salt Mollie Herman Nathan Sharer Presented by Mollie Herman at the annual ACCTA conference, Baltimore, 2012

Special thanks to: Sarah Armstrong, Cheryl Blank, Cyndy Boyd, Cindy Bruns, Daniela Burnworth, Brigid Cahill, Maria CarrubaWhetstone, Paul Castelino, Jane Clement, Rhandi Clow, Julie Corkery, Kathlyn Dailey, Kristen Davis-Johnson, Harriet Dickey-Chasins, Glade Ellingson, Pamela Epps, Betty Fletcher, Mark Forest, Tricia Hanley, Bruce Herman, Chris Hogan, Merris Hollingsworth, Karen Lese-Fowler, Peter Liggett, Jenny Lybeck-Brown, Keith Magnus, Joan Mizrahi, Rosemary Nicolosi, Jennifer Petro, Julia Phillips, Jeanne Piette, Emil Rodolfa, Felix Savino, Daniel Schulte, Andrew Shea, Meredith Shefferman, Tawa Sina, Joy Stephens, Karen Taylor, Jod Taywaditep, and Brett Vicario

The Tenth Amendment to the US Constitution (part of the Bill of Rights) Ratified December 15, 1791 The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people. Licensing state power

Licensure laws vary on numerous dimensions: Number of hours of experience required for licensure What proportion of those hours must be predoctoral versus postdoctoral (with some states requiring no predoctoral hours, others requiring no postdoctoral hours, and still others requiring 2000 hours of each), Whether internship and / or postdoctoral supervisors need to have been licensed for a specified amount of time Whether interns or postdocs need a certain number of direct service hours If and how direct service is defined

Other professions Lawyers: 28 states do not have reciprocity agreements (Black, 1994) Doctors: frustration about licensure mobility, esp with new technologies like telemedicine (Silverman, 2000)

Psychology’s efforts to ease mobility: The EPPP ASPPB developed the EPPP – first used in 1965 General agreement that licensure requirements should include: two years of supervised experience doctoral degree pass the EPPP

But the EPPP does not solve the problem of . Differences in state laws regarding education and experience requirements for licensure eligibility

Other efforts by ASPPB: Agreement of Reciprocity State accepts another state’s determination of licensure eligibility regardless of different requirements In the 15 years of the Agreement of Reciprocity’s existence, only 12 jurisdictions have joined

Other efforts by ASPPB: The CPQ Certificate of Professional Qualification (1998) 1998 (ASPPB, 2010a) Meet certain educational and experience qualifications Licensed in the US or Canada In practice for at least five years No history of disciplinary action they can apply for a CPQ Can apply for CPQ which facilitates licensure in states that accept the CPQ (so far 52 of ASPPB’s 63 jurisdictions) Not universally accepted Need 5 years experience

Other efforts by ASPPB: Inter-Jurisdictional Practice Certificate (IPC) temporary care across state lines But doesn’t address issue of non face-to-face treatment made possible by technological advances

Problems still persist Example: Maryland allows immediate licensure Pennsylvania requires 1 year of postdoctoral experience BUT Pennsylvania will not count supervision that has been paid for

Even ASPPB and APA disagree In their respective model licensing acts: APA recommends 2 full time years of professional supervised experience, both of which can occur before degree is granted ASPPB recommends that 1 year occur after degree is granted

How the project got started

Phase I Procedure Recruited ACCTOIDS from the listserv 35 people from numerous states (including this paper’s authors) investigated 50 states plus DC Each researcher was provided with a questionnaire and was asked to look at the Handbook of Specific Licensure Requirements by State hosted on the ASPPB website and state psychology licensure websites contact the state licensing boards for clarification of discrepancies or to provide information that was omitted email the completed questionnaire to the authors. Complete a brief Survey Monkey survey

Phase I Questionnaire State: Total hours required for licensure: Minimum / maximum years permitted to accrue hours: Is internship required by law: Is there a specific number of hours required from INTERNSHIP? (Yes / No) If yes, total required from internship: APA-accreditation requirements for internship? (Yes/No) Are there a specific number of POSTDOCTORAL hours required? (Yes / No) If so, total required from postdoctoral experience: Can you count non-internship predoctoral hours: Specific percent of internship experience required to be direct service? Definition of direct service (If applicable): Supervisor requirements (e.g. must supervisor be licensed in the state in which the activity occurs; must the supervisor have been licensed for a specified period of time; etc.): Any other particular requirements or important facts:

Enter Phase II As completed questionnaires came in and authors compared them to ASPPB Handbook and state websites, quickly became clear that everything was UNCLEAR Many of the regulations were confusing and could be interpreted in different ways Also, some items from the Phase I questionnaire were open to interpretation

Phase II Procedure Additional volunteers recruited from ACCTA (and one extremely dedicated member stayed on from phase I! – thanks, Sarah!) Also invited TUCC staff to help out Ten researchers investigated 50 states plus DC Repeated the first two steps in phase one and then checked their findings against phase one findings Tried to rectify discrepancies with further research Completed Survey Monkey survey for each state researched

Phase II Questionnaire: State: Total hours required for licensure: Can you count predoctoral hours (including internship)toward the licensure hours requirement? (Yes/No) What are the minimum number of hours required for internship? (Total/None/Not-specified) How many internship hours can you count toward licensure requirements? (Total/None/Not-specified) How many NON-INTERNSHIP, PREDOCTORAL hours (e.g. externship, practica) can you count toward licensure hours? (Total/None/Not-specified) Is there a time limit specified in which to accrue predoctoral hours for licensure? [Yes (Min/Max)/No] Is internship required by law: (Yes/No) Does internship have to be APA or CPA-accredited? (Yes/No) If no, are other specifications listed? (e.g. meet APPIC standards, meet standards of state board; be acceptable to doctoral program): Internship supervisor must be licensed in jurisdiction in which supervision takes place? (Yes/No) Internship supervisor must have been licensed for a specified amount of time?[Yes (how long)/No] Specific percent of internship experience required tobe direct service? Definition of direct service (If applicable): Are there a specific number of POSTDOCTORAL hours required? (Yes/No) Postdoctoral experience supervisor must be licensed in jurisdiction in which supervision takes place? Postdoctoral experience supervisor must have been licensed for a specified amount of time? What percentage of postdoctoral experience must be supervised by a psychologist meeting the requirements stated above? (Percent) Specific percent of postdoctoral experience required to be direct service? Definition of direct service (if applicable)

Where the direction changed One author (me) double-checked all submissions for consistency with ASPPB Handbook and state laws. About 10 states into this process, I gave up Endless loop: doing research, becoming confused, seeking clarification, making a decision, and then, upon doublechecking, becoming confused again.

Mission Impossible This was the point at which the authors decided that gathering truly accurate information about state licensure requirements for psychologists was impossible. Mission changed: tell the story

Summary of licensure laws Sent around on ACCTA Mistakes found within minutes of sharing Mixed feelings about sharing – so many inaccuracies

Results: Responsiveness of licensing boards 35% in Phase I and 14% in Phase II attempted to contact the state board Mostly, licensing boards responded quickly; but in phase one, 19% never heard back from the board in phase two, 19% had to wait over two weeks for a response, and another 19% never heard back Some difficulties reaching the board: broken links on ASPPB website, wrong contact provided

Results: Helpfulness of licensing boards In phase one, 21% , and in phase two, 72% of researchers remained confused after communicating with the board Comments about contact with boards: quick responses, patient listening, thorough feedback “vague”, “confusing”, and “inconsistent” responses My experiences with Maryland

Results: Discrepancies between ASPPB Handbook and state websites Something weird Approximately 50% of the researchers in Phase one found discrepancies. Approximately 30% of the researchers in Phase two found discrepancies They were all looking at the same information There were discrepancies in identifying discrepancies!

Results: More discrepancies Nearly 50% of phase two researchers found discrepancies between their own findings and those of the phase one research. What this means: Two professionals (many with licenses in the states they were researching) were presented with the same licensure law data and half the time came to different conclusions about what the law stated.

Places where discrepancies were most frequently found between phases I and II Number of hours required for licensure Whether pre-doctoral hours count toward licensure Whether an internship is required State law changes not reflected on ASPBB’s website Whether a supervisor needs to be licensed (as well as where and for how long) Time limits to accrue hours.

Respondent comments about doing this research. 60 responses overwhelmingly negative most frequent words: “difficult” “frustrating” “time consuming” Other words: “tedious” “unclear” “uncertain”

But not universally bad Approximately 30% of the respondents who left feedback reported that the process for their state was not very taxing and that resources were helpful There are clearly differences between states regarding accuracy and accessibility of information

Implications of this mess Costs to the public Restricts availability of mental health services – even if you live on the border of a state, can’t necessarily seek help from someone a few miles away Difficulty with emergency resources in case of disasters Obstacles to telepsychology and other new technologies Costs to professionals Trainees can go crazy trying to figure this stuff out Training programs can go crazy trying to figure this stuff out Psychologists who wish to relocate or expand their practices can encounter bureaucratic obstacles Seemingly arbitrary differences can have enormous impact on the ability of professional psychologists to practice where they want to practice

Recommendations: 3 levels Ascend in realism, descend in degree of solving the problems 1. Dream: would solve the problems, but unlikely to happen 2. Improvements: could be within reach, but not without a lot of work 3. Coping: manages the current problem

The DREAM . Nationally accepted standard for psychology licensure. all states agreed to adopt a common standard for psychology licensure (with each state having option of state jurisdictional exam) Use evidence to establish this national standard Research regarding the number of hours and what types of experiences are needed for minimum competency. (e.g. currently: Iowa requires 1500 hours of experience; Florida requires 4000; any differences in their outcomes?)

The Improvement Level State boards provide thorough, accurate, and up-to-date information about their licensure laws Consistent and easily navigated design for state board websites ASPPB Handbook is also accurate and up-to-date and expands to include: Restrictions on eligible supervisors based on their years of licensure Whether a state has particular requirements for the proportion of experience that is direct service State board representatives be better informed of the issues related to psychologist licensure in their state Allows them to accurately complete ASPPB questionnaires for handbook Allows them to respond effectively to direct inquiries

The Coping Level Maintain healthy skepticism about licensure information; get information in writing Trainees make conservative choices regarding how and when they gain professional experiences Whenever possible, choose internship supervisors who have been licensed for at least three years Obtain similar postdoctoral supervision Doctoral training programs and internship sites provide informed consent about licensure issues to potential students and interns

FROM 2012 ACCTA SURVEY: Supervisors Required to be Licensed for

FROM 2012 ACCTA SURVEY: If there are no restrictions on how long supervisors must have been licensed 64% provide advance warning to interns about potential complications related to licensure eligibility 36% do not

Discussion Reactions? How do people handle this at their sites? Has anyone had any problems with interns getting licensed elsewhere? Any other strategies come to mind to address the problems?

References American Psychological Association (2010). Model Act for State Licensure of Psychologists Adopted by Council as APA Policy 2/20/2010. Retrieved from http://www.apa.org/about/policy/model-act-2010.pdf Association of State and Provincial Psychology Boards (2010a). ASPPB Model Act for Licensure and Registration of Psychologists. Retrieved from http://www.asppb.net/files/Final Approved MLRA November 2010.pdf Association of State and Provincial Psychology Boards (2010b). Obtaining a License. Retrieved from http://www.asppb.net/i4a/pages/index.cfm?pageid 3390 Association of State and Provincial Psychology Boards (2010c). The Association of State and Provincial Psychology Boards (ASPPB) Handbook of Licensing and Certification Requirements. Retrieved from http://www.asppb.org/HandbookPublic/HandbookReview.aspx Black, A. (1994). Canadian lawyer mobility and law society conflict of interest. Fordham International Law Journal, 18, 1. Commonwealth of Pennsylvania (2012). Supervisor requirements. Retrieved from http://www.pacode.com/secure/data/049/chapter41/s41.33.html DeMers, S. T., Van Horne, B. A., & Rodolfa, E. R. (2008). Changes in training and practice of psychologists: Current challenges for licensing boards. Professional Psychology: Research And Practice, 39(5), 473-479. doi:10.1037/0735-7028.39.5.47 Hess, H. F. (1977). Entry requirements for professional practice of psychology. American Psychologist, 32(5), 365-368. doi:10.1037/0003-066X.32.5.365

Marques, T. (2012). Europe overhauls physician mobility regulations. Canadian Medical Association Journal , 184(3), E169-E170. Missouri General Assembly. (2011). Missouri Revised Statutes Chapter 337 Psychologists— Professional Counselors--Social Workers Section 337.025. Retrieved from http://www.moga.mo.gov/statutes/C300-399/3370000025.htm National Council of State Boards of Nursing. (2012). Nurse Licensure Compact. Retrieved from https://www.ncsbn.org/nlc.htm New York State Education Department. (2009). Regulations of the Commissioner. Retrievedfrom http://www.op.nysed.gov/prof/psych/part72.htm Reaves, R. P. (2006). The History of Licensure of Psychologists in the United States and Canada. In T. J. Vaughn (Ed.), Psychology licensure and certification: What students need to know (pp. 17-26). Washington, DC US: American Psychological Association. doi:10.1037/11477-002 Rodolfa, E., Ko, S. F., & Petersen, L. (2004). Psychology Training Directors' Views of Trainees' Readiness to Practice Independently. Professional Psychology: Research And Practice, 35(4), 397-404. doi:10.1037/0735-7028.35.4.397 Schaffer, J.B. & Rodolfa, E.R. (2011). Intended and unintended consequences of state practicum licensure regulation. Training and Education in Professional Psychology, 5(4), 222228. Silverman, R. (2000). Regulating medical practice in the cyber age: Issues and challenges for state medical boards. American Journal of Law & Medicine, 26(2-3), 255-276. Tracy, E.N., bucchianeri, M., & Rodolfa, E.R. (2011). Internship hours revisited: Further evidence for a national standard. Training and Education in Professional Psychology, 5(2), 97101.