Ben Caldwell, PsyD, recently published a blog article on the shortage of therapists in California. He discussed the “supply-demand disconnect” and why it’s so difficult to meet the needs of clients across the state. Toward the end of the article, he remarked that due to this shortage, “more of our functions will be turned over to substance abuse counselors, peer counselors, and other professionals and para-professionals.”
What did he mean by that? How can therapists possibly be replaced by individuals who haven’t earned a master’s degree, aren’t registered with the Board of Behavioral Sciences, and aren’t supervised by a qualified mental health professional? Unfortunately, I can cite examples from my own personal experiences in the workforce that support Ben’s claim.
As I discussed in my blog article on starting salaries for prelicensed MFTs, there are many types of work settings in our field. In my region, it’s common for non-profit organizations’ programs to rely on contracts issued by the County of San Diego. These contracts can be very specific about how much money will be allotted to a program each year, how many clients need to be served, and so on. Depending on how a contract is worded, mental health professionals may or may not be required for certain positions. Furthermore, contracts may specify whether or not a mental health professional needs to be licensed, registered, and/or able to become licensed or registered within a certain time frame.
My first experience with a county-funded organization took place at an adult, outpatient mental health clinic. A variety of professionals and para-professionals worked there, including therapists, case managers, employment specialists, peer support specialists, nurses, and psychiatrists. Each employee was expected to meet a productivity requirement (meaning a certain percentage of your total work time had to be “billable” or “reimbursable” under the county contract). As you can probably imagine, this put an immense amount of pressure on everyone to make the numbers look favorable; otherwise, they could be let go by the program manager.
There was no shortage of potential clients at this clinic. In fact, there was a waitlist for therapists! So you would think the threat of being replaced by other professionals and para-professionals would be low, right? Wrong. Remember, everyone had to meet the productivity requirement, so everyone had to find a reason to meet with clients, whether it be for therapy or something else.
During multi-disciplinary team meetings, I began to notice that the case managers, employment specialists, and peer support specialists frequently ventured into “therapy territory.” Instead of sticking to education about section 8 housing, or assisting with job applications, or providing emotional support after a difficult week, they would attempt to educate clients on their mental health diagnoses, explore their families-of-origin, and even teach them coping skills from CBT or DBT workbooks. If you were to look at progress notes from any of these professionals or para-professionals, they would look eerily similar to progress notes from therapists. At this particular clinic, the only clear difference was that therapists were the ones who conducted the mental health assessments.
To the program manager’s credit, they would remind these other professionals and para-professionals to stick to their job duties. Chart audits would lead to conversations about how to avoid “duplicating” the mental health services provided by therapists. However, this didn’t stop other professionals and para-professionals from regularly crossing into areas that were beyond their scopes of practice.
My second experience with a county-funded organization involved working in the juvenile justice system. This particular program employed therapists and AOD counselors, with the idea that therapists would address mental health issues, while the AOD counselors would address substance use issues. This sounded good – in theory. The reality was that, once again, AOD counselors would venture into “therapy territory.” Unfortunately, the end result was that clients often became confused about who was truly their “therapist.” Clients would attend court and tell the judge they didn’t see the point in meeting with both a therapist and an AOD counselor, because “I talk about the same things with them.”
To make matters worse, judges would routinely order clients to undergo evaluations with psychologists who were separate from the program itself. This was often done in order to determine what a client’s mental health and substance use diagnoses were. Time and time again, therapists would explain that the clients already had diagnoses listed in their charts (as therapists had been meeting with them and were required to complete a mental health assessment at the beginning of treatment); however, the judges failed to comprehend the unnecessarily repetitive nature of their orders.
The bad news is that therapists are replaceable, in the sense that employers, clients, and other individuals may fail to see the necessity for their services when other professionals and para-professionals can (seemingly) perform the same job duties in certain work settings.
The good news is that therapists can do something about this.
When I noticed colleagues venturing into “therapy territory,” I would attempt to learn more about their own scopes of practice. For case managers, employment specialists, and peer support specialists, this was essentially determined by their job descriptions. For AOD counselors, this was also determined by their job descriptions, as well as their certifications or registrations (such as CADC or CATC). Having a better understanding of the differences between our scopes of practice allowed me to have more persuasive conversations with colleagues when I noticed they were overstepping their limits with clients we were both supporting.
If the thought of having this conversation makes you uncomfortable, consider section 3.10 of CAMFT’s Code of Ethics, which states “Marriage and family therapists do not generally provide professional services to a person receiving treatment or therapy from another psychotherapist, except by agreement with such other psychotherapist or after the termination of the patient’s relationship with the other psychotherapist.” The way I see it, we have an obligation to talk to another professional or para-professional when we notice they are stepping into the role of a therapist (or pseudo-therapist) with a mutual client!
When it became clear this was a systemic issue at both organizations, I addressed my concerns with the program managers. One of my other blog articles talks about “speaking the language” of employers, which can be helpful in situations like this one. For example, an employer may not be overly concerned about each employee’s scope of practice; however, they may worry if you bring up the idea of losing a contract due to an ongoing issue with “duplication of services.” (The county doesn’t like it when they’re billed by two different employees for essentially providing the same service to the same client. This could become a serious problem during an audit, and even lead to a program losing their contract with the county!)
If you’re not comfortable bringing up concerns directly with your employer, then there may be another individual who can advocate on your behalf. Depending on how a program is structured, the program manager and clinical supervisor may be two separate individuals. While the program manager is typically concerned with administrative tasks, the clinical supervisor is usually concerned with the well-being of clients and your development as a therapist. The clinical supervisor may be in a better position to address systemic problems with your employer, and if the program manager isn’t receptive to feedback, they may even be willing to go to the “higher-ups” (e.g., the program director or vice-president of the organization).
When meeting with clients for the first time, I would expand upon my standard introduction. I started off by explaining what I do (and don’t do) as a therapist. I would then go on to explain how I was different from the other professionals and para-professionals my clients met with on a regular basis. This was especially important in the juvenile justice system, where it was common for clients to withhold information because they didn’t want me disclosing personal details to their judges, probation officers, and parents. My clients had negative (and sometimes harmful) experiences with other professionals and para-professionals who didn’t maintain the same level of confidentiality that I was required to.
Once your clients understand the difference between a therapist and another professional or para-professional, they can begin to appreciate how the work you’re doing with them is unique and separate from case management, substance use counseling, or peer support. When your client is clear about who is providing them with mental health services (and they can articulate that to someone in management or a position of authority), it makes the therapist appear more relevant in the eyes of an employer. If a client doesn’t see the need for your services (because any other staff member can do the exact same thing), your value within the program diminishes from the employer’s point-of-view.
When we begin to see trends like the one Ben Caldwell noted, we need to talk to everyone we can about our concerns. Some simple steps you can take today include:
I recently joined CAMFT’s Pre-Licensed Committee and will be addressing concerns that affect associate marriage and family therapists, trainees, and students in the years to come. Please share your thoughts about the issue discussed in this blog article, as well as thoughts about any other concerning issues, in the comments section below!
This is a great article Robin! Thank you for all you do for the community.
-Tyra Butler, LMFT