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,



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3 Requirements Related to the Practice of Counseling T his 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 coun- seling 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, includ- ing 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, 

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE 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 doc- toral 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 pro- grams 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 psycholo- gists. 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 con- tinue 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, inas- much 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 cre- ated 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-

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 REQUIREMEnTS RELATED To THE PRACTICE oF CoUnSELInG 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 well- being 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, leg- islation 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 coun- selors 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 cre- ated positions in rehabilitation case management and counseling for the graduates of the programs. The dynamics of the creation of the specialty of counseling psychol- ogy, 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, professionaliza- tion of counseling through credentialing and legislation, the passage of laws granting privileged communication to interactions between coun- selors and their clients, and increases in the body of knowledge specific

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE 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 recog- nized by TRICARE. It was adapted from a summary by Remley and Herlihy (2010) that was based on information provided by the organi- zations 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 Accredita- tion (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

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 REQUIREMEnTS RELATED To THE PRACTICE oF CoUnSELInG TABLE 3.1 Comparison of Preparation Requirements for the Mental Health Professions Profession and Graduate Summary of Required Courses and Required Supervised Education Required Field Experience Counseling Graduate coursework required in professional identity; 48–60 graduate credits social, cultural diversity; human growth, development; required for master’s career development; helping relationships; group work; degree 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 Graduate coursework required that covers 128 Therapy competencies in six domains: admission to treatment; Minimum number of clinical assessment, diagnosis; treatment planning, case graduate credits not management; therapeutic interventions; legal issues, specified ethics, standards; research, program evaluation Number of hours of practicum, internship not specified Social Work Coursework required in professional social worker 60 graduate credits identity; ethical principles; critical thinking; diversity, required for master’s difference; advancing human rights, social and economic degree 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 continued

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE TABLE 3.1 Continued Profession and Graduate Summary of Required Courses and Required Supervised Education Required Field Experience Nursing Graduate nursing coursework in research; policy, Minimum number of organization, financing of health care; ethics; professional graduate credits not role development; theoretical foundations of nursing specified 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 Graduate coursework required in biological aspects of 3 full-time years of behavior; cognitive, affective aspects of behavior; social graduate study required aspects of behavior; history, systems of psychology; for doctoral degree 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

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 REQUIREMEnTS RELATED To THE PRACTICE oF CoUnSELInG TABLE 3.1 Continued Profession and Graduate Summary of Required Courses and Required Supervised Education Required Field Experience Psychiatry MD requires coursework in anatomy; biochemistry; 130 weeks required for genetics; physiology; microbiology, immunology; medical degree (usually pathology; pharmacology, therapeutics; preventive 4 years) 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).

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE 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 counsel- ing 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 obtain- ing a master’s or doctoral degree in counseling from a counselor educa- tional 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 recog- nized by the American Counseling Association (ACA) accredit coun- selor educational programs: CACREP, which provides accreditation in a variety of counseling specialties other than rehabilitation counseling, and the Council on Rehabilitation Education (CORE), which accred- its 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 cur- riculum requirements after the CACREP core curriculum requirements because many states that license counselors require curricula that are

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 REQUIREMEnTS RELATED To THE PRACTICE oF CoUnSELInG 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 devel- opment 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 Com- munity 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 Coun- seling went into effect on July 1, 2009, all programs that were accred- ited in Community Counseling or Mental Health Counseling before then have had to renew their accreditation in the new category when

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00 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE reaccreditation became necessary. That change standardized accredita- tion 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 clini- cal 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 diag- nosis (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 pro- grams for rehabilitation counselors are accredited by CORE (2009c). In an April 2009 presentation to the committee, CACREP Execu- tive 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 Com- munity Counseling and Mental Health Counseling degrees. In 2001, Altekruse et al. reported that 84 out of 205 Community Counsel- ing 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 pro- grams in counseling. Admission requirements include a bachelor’s

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0 REQUIREMEnTS RELATED To THE PRACTICE oF CoUnSELInG degree and some combination of minimum grade-point average and standardized test scores, successful completion of relevant prepara - tory 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 under- graduate degree is required (ACA, 2009). Institutions set their own policies regarding whether, or the conditions under which, they rec- ognize 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 institu- tions, 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 profes- sional counselors: professional identity, social and cultural diversity, human growth and development, career development, helping rela- tionships, group work, assessment, and research and program evalu- ation (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

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE 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 contrac- tor. 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 pri- mary 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.

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 REQUIREMEnTS RELATED To THE PRACTICE oF CoUnSELInG The committee did not identify any circumstance in which the con- tractor 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 indi- cated 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 contact- ing the source that has issued the training, certification, and so on) the training, licensure, certification, malpractice filing history (only avail- able 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 practitio- ner. MBHOs also collect signed attestation statements at the time of credentialing and recredentialing to disclose any criminal action, sub- stance 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 facil- ity credentialing process and not duplicate the process. MBHOs are required to recredential providers every 3 years, updating such informa- tion as licensure status, attestations, complaints, sentinel events, and, in some MBHOs, patient satisfaction. URAC is the formal name of the accreditation organization originally incorporated as 7 the Utilization Review Accreditation Commission (URAC, 2009).

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE Other than conforming to state law, there is no consistent pattern or single set of rules applied to determine whether or under what cir- cumstances 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 consider- ations 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 accred- ited. 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 infor- mation 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 credential- ing 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 designa- tions, 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.

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 REQUIREMEnTS RELATED To THE PRACTICE oF CoUnSELInG 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 inves- tigate, 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- HEDIS is a tool administered by NCQA and “used by more than 90 percent of 8 America’s health plans to measure performance on important dimensions of care and service” (NCQA, 2009).

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE ity, or clinic. Typical actions include creation of corrective-action plans with oversight until conclusion, removal from the network, and report- ing 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 dur- ing the measurement period) to obtain results that have a degree of validity. Monitoring of compliance with stated scopes of practice by pro- viders, 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 investiga- tion of a complaint or sentinel event, whatever scope-of-practice issues arise are addressed. Some MBHOs have initiated the measurement of treatment out- comes for their providers. For example, OptumHealth Behavioral Solu- tions (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 mea- surements 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.

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 REQUIREMEnTS RELATED To THE PRACTICE oF CoUnSELInG 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 formerly, the Joint Commission on Accreditation of The Joint Healthcare organizations (JCAHo) Commission the current name of the organization originally URAC 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

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