State legislatures address key issues for psychology

Lawmakers consider master's-level practice, prescription privileges, practice definition and parity for mental health.

By Kathryn Foxhall
Monitor staff

It's already been an important year in several state legislatures for issues key to psychology practice.
Oklahoma and Kansas have instituted new laws that preserve the title "psychologist" for doctoral-level professionals, but allow independent practice by individuals who hold masters degrees in psychology, despite misgivings by the state psychological associations.

Louisiana and Georgia have apparently moved closer to getting prescription privileges for psychologists, and similar bills are also on the docket in Illinois and Alaska.

In New York, psychologists are closer to having a law that for the first time defines the scope of psychology practice in the state.

And in a tale still unfolding, California, with its 12 percent of the U.S. population, is moving to join a growing number of states in requiring parity between insurance benefits for physical health and those for mental health.

"The mix of activity at the state level illustrates the paradox the field of psychology finds itself in. On the one hand, it faces challenges to protecting its existing practice. At the same time, considerable effort is targeted toward expanding the field's activities."

Master's-level practice

In Oklahoma and Kansas, the state psychological associations have won hard-fought battles to retain the title of "psychologist" for doctoral-level professionals only. The laws permit people with master's degrees in psychology to be licensed for independent practice if they complete a credentialling process more rigorous than currently required. However, these practitioners cannot call themselves psychologists.

"The development is significant in that in both states the doctoral standard for the independent practice of psychology has withstood challenges and has been preserved," says Michael Sullivan, PhD, APA's assistant executive director for state advocacy.

Under the Kansas law, master's-level psychology practitioners, marriage and family therapists, and professional counselors who attain a new and more demanding "clinical level" of credentialling will be authorized to diagnose and treat mental disorders listed in the Diagnostic and Statistical Manual. Master's-level psychology practitioners who earn those credentials will have the title "licensed clinical psychotherapist."

Those credentials will require candidates to complete a 60-hour master's psychology program; 15 additional credit hours in diagnosis and treatment; a graduate-level supervised clinical practicum; 4,000 hours postgraduate supervised professional experience; and at least the minimum percentage required in the national exam known as the EPPP (Examination for Professional Practice Psychology). Their minimum passing score will be the same as for licensed psychologists.

Master's-level professionals who do not attain the "clinical level" must continue to practice under the direction of an independent professional. That supervisor may be a physician or psychologist, but also may be a master's-level professional who holds the clinical-level credentials.

Kansas Psychological Association (KPA) Executive Director Susan Linn said the association had decided it could not successfully oppose the coordinated push of these three master's-level professions to win authority for independent practice and diagnosis. Thus, she said, KPA concentrated its efforts on preserving the "psychologist" title for the doctoral level.

The political impetus for the independent-practice legislation was triggered last year when the state's insurance carrier for Medicare stopped reimbursing master's-level psychology practitioners for services "incident to psychotherapy." That was a considerable problem given that, for example, most of the state's mental health center directors are master's-level practitioners, says Linn.

Although some master's-level psychology practitioners plan to move to independent practice, most say they will stay in their current situation, Linn says. Many work under direction in mental health centers or hospitals, she says.

Neighboring Oklahoma also passed legislation that allows graduates of master's-level psychology programs to practice independently. They will be called "Licensed Behavioral Practitioners" and as of 2005 will be required to have 60 graduate semester hours of behavioral science-related work and three years of supervised full-time experience. They will be licensed, among other things, "to prevent, diagnose or treat mental, emotional, or behavioral disorders or associated distress which interfere with mental health."

Arlis G. Wood, PhD, legislative chair of the Oklahoma Psychological Association, said the association's major victory with the legislation was to remove the title "psychologist" and references to the practice of psychology. However, he says, it's still uncertain what the work of these professionals will consist of and how close it will be to psychology practice.

Prescription privileges

On another legislative front, Louisiana had been moving toward becoming the first state to give psychologists prescription privileges when a sudden national controversy slowed the momentum, according to John F. Bolter, PhD, who spearheaded the effort for the Louisiana Psychological Association.

In the state's legislative session, a bill to grant those privileges passed House and Senate committees and was headed to the floor in both bodies. But the push lost ground over publicity about an APA journal study on pedophilia (see article, July/August, APA Monitor, page 47), despite the lack of a connection to the prescription issue.

The state took no action on the prescription privileges bill, but passed a resolution condemning the study.

Bolter praised APA's work in the state to clarify the association's--and the profession's--position on pedophilia. However, he said, with the time lost in defensive work and with extensive opposition from the state medical society, the opportunity for passage waned as the legislature's three-month session drew to its end.

Psychologists will return with the prescription privileges proposal in 2001, the next time the legislature will meet on legislative matters. On alternative years the body works on fiscal matters.

(In the meantime, the first class of 35 psychologists graduated in July from the state's new postdoctoral master's-degree program in psychopharmacology. After a year of supervised work, the graduates would be ready to prescribe independently if the proposed legislation is enacted.)

In Georgia, another state where psychologists are fighting for prescription privileges, the initiative stalled in the state legislature after other health legislation took precedence. The Georgia Psychological Association (GPA) has decided to spend another year educating politicians and the public about the issue before they attempt to push the bill through the legislature.

Causes for optimism for next year, says GPA, include bipartisan support for the bill and support from both the new governor and the lieutenant governor. In addition, by next year, the first class of GPA's postgraduate psychopharmacology master's-degree program will be certified and ready to prescribe. GPA President Michael Sessions says the struggle is still up hill, but the past year has been very productive in raising legislators' awareness of psychologists' roles and quality of training.

Bills for prescription privileges were also introduced in Alaska and Illinois this year, and as of press time, were before committees in the legislatures, although neither bill is expected to pass this year. APA's Committee for the Advancement of Professional Psychology (CAPP) Subcommittee for Prescription Privileges and the Practice Directorate staff provide technical guidance on the issue.

New York's scope of practice

In another struggle to strengthen laws on psychology practice, New York has come closer than ever to passing a bill to define psychology practitioners' scope of practice--the first time it would be written into law for the nation's third most populous state.

New York psychologists are now guided by definitions that appear in state regulations. John Northman, PhD, chair of the New York State Psychological Association (NYSPA) Legislative Committee, says this situation allows untrained practitioners, or even psychologists who have lost their licenses, to offer services by calling themselves psychotherapists or other titles. It also makes it more difficult for psychologists to face managed-care challenges, he says, and leaves open the possibility that the regulatory scope of practice could be overturned in a court action.

The legislation cleared Assembly and Senate committees this spring and NYSPA pushed to have it brought to the floor in both houses. However, odds for passage this year declined as the legislature recessed in June, announcing plans to come back for only a short session with a limited agenda that must include the state budget.

Nevertheless, Northman is heartened by the progress made this year and says psychologists will be pushing for the bill again next year.

The scope of practice provisions are part of an omnibus bill that would also define a scope of practice for social work and allow licensing for mental health practitioners in creative arts therapy, marriage and family therapy, mental health counseling and psychoanalysis. The proposal has faced continuous opposition from the state medical society, which says the scopes of practice for all the professions in the bill are not well defined.

Mental health parity

In a continuing trend, more states are passing laws requiring parity for mental health in insurance coverage. (See on page 22.)

Among the most compelling developments in parity is a competition playing out in California. The state Senate has passed a bill to require insurance companies to cover all types of mental illnesses, but the state assembly has approved legislation for coverage of serious mental illness only.

At press time, legislators had the choices of working out the differences, passing only one of the bills or putting two bills on new Governor Gray Davis's desk so he could decide which to support. Carl London, lobbyist for the California Psychological Association, is optimistic that the more comprehensive bill will prevail. It garnered bipartisan support in the Senate, with 29 out of the possible 40 votes. Support has also been generated by President Clinton's work on the issue and by personal stories of mental illnesses from legislators.

One major task for advocates, says London, will be convincing the governor that the cost, even for comprehensive coverage, is not a major factor. Due in part to managed care, says London, a recent study estimates the difference between covering all mental disorders and only serious mental illness is only 9 cents per month.

Passage of comprehensive benefits in California, the most populous state and a huge part of the U.S. economy, could have major implications for other states and for national policy, London points out. Much the same choice is being considered in the U.S. Congress, which also is looking at rival bills.

Flood of new states mandate mental health parity

The trend toward state mandates for equity for mental health in insurance coverage became a tidal wave this year as 10 new states passed laws requiring "parity" for the general population.

They join 13 others that have passed such laws over the past five years. However, most states--15 out of the 23 total--continue to require equal treatment only for serious mental illness (SMI), not for all mental conditions
or disorders (broad-based parity), as advocated by APA. States typically define SMI as schizophrenia, bipolar disorder and a few other diagnoses. The actual formulation varies from state to state.

In addition, two states now require parity for state employees only: North Carolina's plan is broad-based and Texas covers SMI only.

Russ Newman, PhD, JD, APA executive director for practice, pointed out that the spread of the SMI laws could be a mixed blessing for mental health.

"We've seen that when the insurance industry is mandated to cover only certain areas, it looks for other areas to cut back on," he explains. "Thus the SMI legislation could actually put at risk the coverage for other significant mental health disorders."

The association pointed out that SMI laws most often do not cover many severe emotional disorders of youth or disorders more common in women such as anorexia nervosa or post traumatic stress disorder, which can be a consequence of rape. Nor do they cover other anxiety and depression disorders that do not rise to the level of serious mental illness. In addition, only five states have included substance-abuse benefits under the parity package.
APA recently applauded Connecticut for becoming the first state to change an SMI mental health parity law into a broad-based law.

In another development, on June 7 President Clinton announced a requirement for broad-based parity in the health-benefit program of federal employees, which covers nine million people (see July/August Monitor).

At APA Monitor press time, California was considering both a broad-based and an SMI bill.

--K. Foxhall



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