Psychology Licensure and Credentialing in the United States and Canada
Abstract and Keywords
The history of licensing and credentialing in psychology and its relationship to education and training are reviewed. The purposes, processes, and methods that licensing boards utilize are discussed in both the credentialing of entry-level licensees and in the responsibility to monitor and investigate complaints from the public. Finally, current challenges facing licensing boards, particularly the use of technology in the education of psychologists and in provision of psychological services and the inconsistency in licensure requirements across jurisdictions, are explored.
Psychology Licensure and Credentialing In the United States and Canada
This chapter seeks to increase awareness of both the historical development of regulatory mechanisms in psychology and the current status and future concerns related to licensing and credentialing of psychologists in the United States and Canada. Regardless of the profession under discussion, professional regulation is a process designed to limit entry into the profession to qualified practitioners and to monitor the professional conduct of these recognized practitioners.
According to Merriam-Webster’s Dictionary On-line (2012), a profession is described as a “calling” or vocation involving specialized knowledge and long and intensive preparation. Numerous authors (e.g., Gross, 1978; Weissman, 1984) list the hallmarks of a profession that distinguish it from a trade or other commercial activity. These hallmarks include: (a) academic training programs that prepare individuals to practice the profession, (b) recognized societies or organizations composed of members of the profession that develop standards for training and promote the acquisition of new knowledge, (c) a code of ethics or standards of professional conduct that represent the shared commitment to provide competent and ethical professional services, and (d) a process of professional regulation that restricts entry to the profession to those meeting the acceptable standards of training and that monitors the professional conduct of recognized members of the profession to ensure adherence to ethics codes and other recognized standards. Clearly, the link between psychology’s licensing and credentialing community and its academic and training community is an important one; and this link is a shared responsibility for setting standards that is necessary for our profession to thrive. Psychology regulators use the standards created by professional organizations as a basis for the laws and rules governing entry to practice and professional conduct; concomitantly, educators and trainers must devise training programs that meet the specific criteria needed for entry to practice that regulators devise. A collaborative and mutually respectful relationship between regulators and educators/trainers is optimal, not only for entry into the profession of new generations of psychologists, but also for efforts (p. 202) aimed at maintaining the competence of already licensed psychologists.
In this chapter, we present the history and purpose of psychology licensure laws and the common standards and processes that licensing boards employ to control entry into the profession. Next, we describe the methods that licensing boards use to monitor and control the professional conduct of credentialed practitioners, including the relationship between codes of ethics and legally enforceable codes of professional conduct. Finally, we address some of the challenges limiting effective professional regulation in psychology. These challenges currently include an enduring inconsistency in licensure standards across jurisdictions, and inadequate provisions for the recognition of new modalities of psychology training and practice. Throughout this chapter, we tie the issues critical to regulation to the education and training of psychologists and highlight where there has been good collaboration, as well as where more consistency and communication are needed.
Historical Perspective on Psychology Licensure
In the United States and Canada, professional regulation began with the passage of medical practice acts in the late 1800s designed to protect the public from charlatans offering useless or harmful remedies. The U.S. Supreme Court issued an important decision in the case of Dent v. West Virginia (1889) that recognized the legitimate interests of states to monitor and control the behavior of physicians in order to protect the health and safety of their citizens (Schaffer, DeMers & Rodolfa, 2011). This decision by the highest court in the United States led to the passage of medical practice acts in almost every state legislature by 1912. These medical practice acts created regulatory boards that set minimum standards for academic training as a physician, issued licenses to those individuals who met those minimum standards, and made it illegal for others to claim to be physicians or to engage in any of the healing arts listed in the law as part of the scope of medical practice. These early medical practice acts were typically sweeping in their scope, essentially describing medical practice as providing for the health and well-being of all citizens (Schaffer, DeMers & Rodolfa, 2011).
Although medical licensing laws set the foundation for the psychology licensing acts that were to follow, they also impeded the passage of such laws. Often physicians and medical associations strongly opposed early attempts to pass psychology licensing acts in state legislatures. This opposition reflected their belief that mental health fell within the broad definition of the medical scope of practice and, therefore, physicians should provide or supervise all mental health services. Psychologists, however, believed that psychology had become sufficiently distinct from routine medical practice, and thus was an independent and autonomous profession worthy of a separate licensing act for psychology in order to adequately protect the public (DeMers and Schaffer, 2012).
Professional regulation in psychology is accomplished through an interplay between professional societies, like the American Psychological Association (APA) or the Canadian Psychological Association (CPA), and legislatively mandated or sanctioned regulatory bodies, such as psychology licensing boards or colleges. The APA was founded in the late 1800s as a scientific society focused on the study of human behavior. However, the development of psychological theories and measurement instruments that could be applied to the treatment or resolution of human problems led to early concerns about who was qualified to use such methods. In 1938, APA established the first Committee on Scientific and Professional Ethics to address these and other concerns about the application of psychological methods and tools to the real life problems of individuals (Ford, 2001). In the mid- to late-1940s the issues of standards and controls in professional psychology were explored directly by the Conference of State Psychology Associations (Carlson, 1978). It is likely that the emergence of medical practice acts, combined with the increased use of psychological methods and principles to evaluate developmental delays in children, screen military recruits, and treat patients in mental hospitals, led to the need for both a formal system of professional regulation in psychology and standardized training that would adequately prepare individuals for licensure. The first licensing act for psychology was passed in Connecticut in 1945 (DeMers, 1998; Reaves, 1996). Like most early psychology laws, the Connecticut law protected the title of “psychologist,” but did not preclude others (particularly physicians) from using psychological methods. In 1960, Ontario passed the first licensing law for psychology in Canada. By 1977, all states had passed some form of psychology regulation, and in 1990, Prince Edward Island was the last Canadian province to enact a psychology licensing law. Currently there are 64 psychology regulatory boards throughout the U.S. and Canada, including the 50 states, 10 (p. 203) provinces, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands (ASPPB, 2012a).
The purpose of all licensure laws is to protect the public from professionals who practice incompetently or unethically. According to the Association of State and Provincial Psychology Board’s (ASPPB) website,
...(licensing) laws are intended to protect the public by limiting licensure to persons who are qualified to practice psychology as defined by state or provincial law. The legal basis for licensure lies in the right of a jurisdiction to enact legislation to protect its citizens. The concept of caveat emptor, or buyer beware, is considered an unsound maxim when the consumer of services cannot be sufficiently informed to beware. Hence, jurisdictions have established regulatory boards to license qualified practitioners.
Like any profession, psychology requires specialized knowledge and skill, acquired through advanced and extensive training and practice. The average citizen is not equipped to judge whether the psychological services received are appropriate and meet the standard of care accepted within the profession. Consequently, state legislatures and other governing bodies agree to limit who may legally identify themselves as psychologists and who may provide services defined as psychological in exchange for the professional’s agreement to operate in the best interests of the public by following recognized standards of care and professional conduct. Licensing boards and colleges enforce and regulate this contract between the profession and society.
One implication of this contract between society and the profession is that licensing boards and colleges have a statutorily defined purpose that differs from that of state/provincial and national psychological associations. Licensing boards focus on the protection of the public, while professional societies focus on promoting the profession and the welfare of their members. These purposes often overlap, however, because professional societies generally recognize that increasing public knowledge about the profession and adopting rigorous standards for education and professional conduct also result in better protection of the public. Typically, professional societies have established standards for education and training of students, in order to insure that those individuals have the competencies necessary for entry into the profession. Licensing boards view the standards and quality-control mechanisms developed by professional societies to promote and advance the profession (e.g., accreditation of training programs) as important tools in their efforts to protect the public, and so these standard curricula typically form the basis for licensing boards to develop regulations regarding the training necessary for entry-level practice and licensure. As the ASPPB (2010b) website notes: “By ensuring high standards for those who practice, the board serves the best interests of both the public and the profession.”
As more states developed separate psychology licensing boards, it became evident that there was a growing need, not only for a common standard of training, but also for a common examination to aid in the identification of competent psychological practitioners. This need for a common examination was the impetus for the creation of the American Association of State Psychology Boards (AASPB) in 1961 (Carlson, 1978). The organization’s name was later changed to the ASPPB to accurately reflect the Canadian as well as U.S. participation in the organization from its inception. ASPPB started with representatives from 21 member jurisdictions from both the United States and Canada. (This chapter uses the term jurisdiction when referencing the governmental entity responsible for regulating professional practice, whether that entity is a state in the United States, a province in Canada, or a territory of either country. Similarly, this chapter uses the term licensing board to refer to the legally appointed, elected, or recognized agency within a jurisdiction with the authority to regulate the profession of psychology. Such regulatory bodies are called by different names in different jurisdictions, most typically, Board of Psychology in the United States, or College, Register, or Order of Psychologists in Canada.)
As noted earlier, ASPPB’s early focus was on the development of a common examination. In 1964, the Association administered the first version of the Examination for Professional Practice in Psychology (EPPP) to one candidate in Virginia. By June 1968, multiple forms of the EPPP had been developed and the exam had been administered in 28 states and provinces to hundreds of applicants for a license in psychology (Reaves, 2004). For many years, the EPPP was administered as a proctored paper-and-pencil exam given only twice a year on a specified date in April and October. In 2001, the EPPP transitioned to computer delivery and it now is administered continuously through local computer-based testing centers to approximately 5,700 candidates annually in 64 member jurisdictions across the United States and Canada. It is currently offered in English, with a French version available because of legal requirements in Canada (p. 204) that examinations be offered in French. A Spanish exam currently is being prepared for use in Puerto Rico because of regulations in that country that require such a version.
The EPPP has always been a multiple-choice test with items written by a group of content experts across various specialties and research areas in psychology. Although the specific number of items contained on the EPPP has changed during its more than 50-year history, the structure and purpose of the EPPP as an assessment of essential foundational and practice specific knowledge has remained unchanged (DeMers, 2009). The EPPP assesses knowledge deemed essential for practice in psychology (DeMers, 2009). It has been validated through a series of practice analyses (Rosen, Reaves, & Hill, 1989; Rehm & Lipkins, 2006, the most recent of which was completed in 2010. These practice analyses have involved surveys or focus groups of practicing psychologists who are asked to rate specific knowledge statements within the field on their importance for entry-level practice and for protection of the public. These strategies follow the recommended procedures for validating a licensure examination (AERA, APA & NCME, 1999). The passing score on the EPPP is largely uniform across jurisdictions with almost all adopting the ASPPB recommended pass point.
ASPPB has expanded its mission over the years beyond the Examination Program to include the development and creation of model licensing laws and an ASPPB Code of Conduct (ASPPB, 2005); a disciplinary data system (DeMers & Schaffer, 2012; an ongoing educational program, including an annual convention and midwinter meeting; guidelines relevant to certain regulatory matters (e.g., practicum training leading to licensure) (ASPPB, 2009); publications and other training materials and programs for members of regulatory bodies; and a mobility program that promotes efforts to standardize psychological training throughout the United States and Canada, in part to help make it easier for psychologists to relocate to other jurisdictions (DeMers, Van Horne, & Rodolfa, 2008). Many of the various programs and publications available through ASPPB have been developed through collaborative efforts with other psychological associations and the training councils involved in the psychology education and training community.
Mission and Scope of Psychology Licensing Laws
As noted earlier, the main purpose of psychology licensing laws is to protect the public from unqualified, incompetent, impaired, or unethical individuals who seek to provide psychological services. Consumer groups and many psychologists themselves misperceive the mission of psychology regulatory boards as focused on protecting the profession. But the mission, and the activities pursued by boards to accomplish that mission, is clearly focused on protection of the public. Psychology licensing laws and the regulatory boards they create accomplish this mission through several main activities,,namely, defining the practice of psychology, issuing credentials to qualified and competent practitioners, and investigating complaints against practitioners who are already credentialed. Each of these main activities involves several aspects that are described in the sections that follow.
Defining the Nature and Scope of the Practice of Psychology
Licensing laws define the practice of psychology and the scope of practice for psychologists. Such statutory language serves two purposes. First, it defines what constitutes psychological services, such as assessment and intervention, as recognized activities under the statute. Second, defining the scope of psychological practice stipulates that boards of psychology have jurisdiction over certain activities of licensed psychologists, so that if harm or potential harm to the public occurs, or if a psychologist acts in an unethical manner, disciplinary and remedial action can be taken (Retfalvi & Simon, 1996).
The recently revised APA Model Licensing Act states the following:
Practice of psychology is defined as the observation, description, evaluation, interpretation, and modification of human behavior by the application of psychological principles, methods, and procedures, for the purposes of (a) preventing, eliminating, evaluating, assessing, or predicting symptomatic, maladaptive, or undesired behavior; (b) evaluating, assessing, and/or facilitating the enhancement of individual, group, and/or organizational effectiveness—including personal effectiveness, adaptive behavior, interpersonal relationships, work and life adjustment, health, and individual, group, and/or organizational performance, or (c) assisting in legal decision-making.
The practice of psychology includes, but is not limited to, (a) psychological testing and the evaluation or assessment of personal characteristics, such as intelligence; personality; cognitive, physical, and/or emotional abilities; skills; interests; aptitudes; (p. 205) and neuropsychological functioning; (b) counseling, psychoanalysis, psychotherapy, hypnosis, biofeedback, and behavior analysis and therapy; (c) diagnosis, treatment, and management of mental and emotional disorder or disability, substance use disorders, disorders of habit or conduct, as well as of the psychological aspects of physical illness, accident, injury, or disability; (d) psychoeducational evaluation, therapy, and remediation; (e) consultation with physicians, other health care professionals, and patients regarding all available treatment options, including medication, with respect to provision of care for a specific patient or client; (f) provision of direct services to individuals and/or groups for the purpose of enhancing individual and thereby organizational effectiveness, using psychological principles, methods, and/or procedures to assess and evaluate individuals on personal characteristics for individual development and/or behavior change or for making decisions about the individual, such as selection; and (g) the supervision of any of the above
(APA, 2011, p. 215).
In over a dozen states, the psychology licensing law separates licensees into health service providers and general applied practice providers based on their training and experience. Only health service providers are legally allowed to offer health-related services including diagnosis, treatment, and intervention for health related disorders. General applied practice providers may provide psychological services in other areas such as industrial/organizational psychology or consultation. Most jurisdictions have laws that employ a generic model using the broad definition of the practice of psychology found in the APA Model Act and then require that practitioners follow their ethical responsibility to limit their activities to their demonstrated areas of training and competence.
Although the main purpose of defining psychological practice is to require licensure in psychology in order for individuals to lawfully engage in these activities, most laws also exempt from licensure certain other categories of individuals who may be trained in psychology. Individuals with advanced degrees in psychology who teach in institutions of higher education, or who work in settings like federal institutions (e.g., Veteran’s hospitals, military installations, federal prisons) or some state agencies, are typically exempt from state licensure laws. Many federal agencies require such personnel to be licensed in at least one state or province, but not necessarily where they are assigned. Federal agencies have their own mechanisms for professional regulation. Many U.S. states have eliminated the previously common exemption for state employees based on the principle that professionals providing services in public agencies should meet the same standards as individuals practicing in nonpublic settings. Many states have also placed limits on exemptions for university teachers and researchers, requiring those university employees also be licensed who are involved in the delivery or supervision of services to the public through such venues as training clinics or research involving clinical trials of new techniques, since the potential for harm still exists. Thus, most psychologists involved in training and education in clinical or health services related programs must themselves be licensed in order to provide supervision for their students.
Finally, most psychology licensing laws in the United States exempt both school psychologists, who fall under the authority of a Department of Education, and licensed individuals from other regulated professions who provide services within their own legislatively recognized scope of practice. Thus, psychiatrists, psychiatric nurses, clinical social workers, and licensed professional counselors may all engage in some of the services that are part of the defined practice of psychology, but those services are also recognized as part of the legitimate scope of practice of those other groups.
Credentialing Qualified Practitioners
Psychology licensing acts are designed to protect the public by identifying and credentialing only those individuals who are qualified and competent to practice psychology safely and ethically. Psychology regulatory boards accomplish this goal by establishing strict standards for educational preparation and supervised experience and by administering examinations to measure the professional knowledge and skills of the applicant for licensure. Each jurisdiction establishes specific educational requirements for licensure as a psychologist, including degree level and type (e.g., PhD, EdD, PsyD, MS, MA, MEd), institutional accreditation (e.g., university must be regionally accredited in the U.S. or recognized by Royal Charter in Canada), and completion of an approved program of study. All jurisdictions require applicants to obtain their training as psychologists from a program that provides an organized sequence of study in the field of psychology. For jurisdictions requiring a doctoral degree in psychology for licensure, adequacy of the doctoral training program is (p. 206) demonstrated by accreditation of the program by the APA or CPA or by designation as a psychology doctoral program by the ASPPB/National Register Joint Designation System (for psychology doctoral programs that fall outside the scope of APA or CPA accreditation).
Two states, West Virginia and Vermont, allow the independent practice of psychology based on receipt of an acceptable master’s degree in psychology. Another 12 states have statutes that permit practice at the master’s degree level provided the individual is supervised by a licensed doctoral psychologist, either permanently or for an initial period of some years, after which they may be granted the ability to practice autonomously. In those states authorizing supervised practice with a master’s degree in psychology, such practitioners typically are not referred to as “psychologists” but are allowed to use a variety of titles, including “psychological associate” or “psychological examiner.”
In Canada, four provinces require the doctoral degree in psychology for independent practice (British Columbia, Manitoba, Ontario, and Quebec), whereas two other provinces (Nova Scotia and New Brunswick) are amending their regulations to require the doctoral degree. Four provinces (Alberta, Newfoundland and Labrador, Prince Edward Island and Saskatchewan) and one territory (Northwest Territories) allow independent practice with either the master’s or doctoral degree in psychology. In Canada, all psychology degree granting programs must reside in a provincially approved and recognized institution of higher education.
In addition to setting degree requirements and assessing adequacy of the training program, each jurisdiction through its psychology licensing law adopts specific requirements for supervised professional experiences necessary for licensure eligibility. Most jurisdictions require two years of full-time supervised experience, one year of which must be postdoctoral (ASPPB, 2012a). Recently, about a dozen U.S. states have amended their laws to require the two years of supervised experience, but allow more flexibility regarding whether there must be a postdoctoral year of experience. The APA Model Act for Licensure of Psychologists (2011) embraces this flexibility in an attempt to lower student debt and recognize practicum training that occurs during the doctoral program. However, removing the postdoctoral requirement may have had the unintended consequence of limiting professional mobility by making those licensed without a postdoctoral year of supervised experience ineligible for licensure in states that still require such a year (Schaffer & Rodolfa, 2011).
Finally, each jurisdiction also adopts one or more examinations that applicants for licensure must pass at specified levels. All psychology regulatory boards in the United States and most in Canada (Quebec is the single exception) require passing the EPPP. Some jurisdictions also give oral or written examinations focused on their mental health laws, ethics, practice competence or some combination of these. These “complementary” or “supplementary” exams typically are locally developed, normed or standardized, and scored.
Currently, the profession of psychology (including professional societies, councils of academic faculty, groups representing field supervisors, and groups involved with regulation, accreditation and credentialing) is exploring the feasibility of moving toward the assessment of competence to evaluate outcomes of training or readiness for entry to practice (Fouad et al., 2009; Kaslow et al., 2009; Roberts, Borden, Christiansen, & Lopez, 2005). Roberts et al. (2005) have framed these efforts to consider assessment of competence as a shift away from the traditional practice of educators and regulators who viewed competence as merely the accumulation of graduate credits or hours of supervised experience. Kaslow, et al. (2009) provide a comprehensive review of a range of competency assessment methods for professional psychology, including using standardized patients, portfolios, structured rating systems, consumer satisfaction surveys, and other tools. They also discuss the methodological strengths and weaknesses of each method for assessing the practice competence of professional psychologists. Rodolfa, Schaffer, and Webb (2010) argue that the “culture of competence must be paired with the culture of competence assessment” (p. 296). DeMers & Schaffer (2012) suggest that if some reliable and valid methods to assess practitioner competence can be developed and adopted across the training sequence leading to licensure, then regulatory bodies may be able to incorporate these new strategies of assessment in determining eligibility for licensure. (Wise, 2010). In addition, adoption of a defensible system of competency assessment by licensing boards could then create an environment in which the EPPP may be given earlier in the sequence of training (e.g., at completion of coursework) followed by administration of these new competency assessment examinations upon completion of all required supervised experience (DeMers, 2009). Wise (2010) has also suggested (p. 207) that assessment of competency could bolster efforts to improve ongoing assessment of continuing professional competence at the time of licensure renewal.
The increased interest in developing new methods to assess competence should not mislead one to assume that there are no means of assessing professional competence currently in place. At present, most academic training programs and licensing boards rely on ratings of trainees completed by practicum, internship, and postdoctoral residency supervisors (ASPPB, 2012a; DeMers, 2009). It is appropriate that supervisor ratings serve as one important measure of competence, because supervisors often directly observe the behaviors of students in the practice setting.
However, there are also problems with relying on supervisors’ evaluations. Both supervisors and faculty are in dual roles with students that can be problematic for the objectivity of the evaluation (Johnson et al., 2008). Faculty and supervisors have a vested interest in the success of their students, because outcomes, such as licensure rates and the attainment of employment, reflect on the training the student received. As a result, graduate programs and supervisors may have incentives to evaluate students positively, even if they exhibit inadequate competence (Johnson et al, 2008). Clearly then, more objective and valid measures of competence are needed (Fouad et al, 2009; Kaslow et al, 2009). Likewise it would be useful for regulators to understand the process of supervisor evaluation, including whatever training supervisors have received to insure that the evaluations are both reliable and valid. It may be that the education and training community will need to develop methods for supervisor training that promote reliability and validity so that regulators can rely more consistently on the supervisor evaluations they receive.
The upshot is, then, that there is no consistently applied standard of education, supervised experience or examination that is uniform across the United States or Canada. Although the major professional associations like APA, CPA and ASPPB certainly exert considerable influence over members of the profession who serve on licensing boards, the ultimate decisions about setting the educational, supervised experience or examination standards often rest with the legislative body (e.g. state or provincial government) that created and oversees the psychology regulatory board (DeMers & Schaffer, 2012; Retfalvi & Simon, 1996; Wand, 1993). Regulatory boards have the authority and duty to suggest changes in the standards they use, but any party can seek to amend the standards. The final decision about changes to these standards is typically made by a political entity, such as a state legislature or provincial ministry, and is subject to the political forces at work in any locality.
For example, the Canadian government adopted an Agreement on Internal Trade in 1995 that required all trades and professions with certified or licensed practitioners to remove any “unjustified” barriers to labor mobility within Canada. Given the diversity of education requirements for psychology, licensure across the provinces, psychology regulatory boards, or colleges as they are commonly known, worked together to develop a mutual recognition agreement based on attainment of a set of prescribed competencies rather than academic degrees. However, the issue of who may use the title “psychologist” in provinces that formerly restricted that title to individuals with doctoral degrees has remained controversial. In 2009, the provincial ministers in Canada amended the 1995 Agreement in a way that has the potential to require all provinces to award the title “psychologist” to any individual so credentialed in another province regardless of academic degree.
Such diverse and fluctuating requirements for entry into the profession of psychology, both within and across jurisdictions, have resulted in great hardship for licensed psychologists who seek to relocate. They may find that differences in licensing laws across jurisdictions make them suddenly unacceptable for licensure in a new jurisdiction (DeMers, Van Horne & Rodolfa, 2008). This same patchwork quilt of licensure standards in psychology has seemed to confuse the public about the training that psychologists receive prior to being credentialed to practice, or indeed, who or what psychologists are (DeMers & Schaffer, 2012). As previously mentioned, one of the long-standing missions of ASPPB has been to bring greater uniformity across jurisdictions in the standards for licensure so that the public is less confused, and so that practitioners can move more freely across jurisdictions without fear of being denied a license in the new jurisdiction simply because of idiosyncrasies in jurisdictions’ licensing laws (DeMers, Van Horne, & Rodolfa, 2008).
Another major activity undertaken by psychology regulatory boards to fulfill their mission is investigating complaints of incompetent or unethical practice made against currently licensed (p. 208) practitioners. Each psychology licensing act specifies the grounds for which someone licensed as a psychologist may be disciplined, and the process by which such a charge is to be investigated and adjudicated (DeMers & Schaffer, 2011; Reaves, 1996).
Because a license to practice one’s profession is clearly a property right of some value and consequence, a governmentally sanctioned process to deny, restrict, or rescind such a license must be conducted with adequate attention to the individual’s rights of due process and appeal (DeMers & Schaffer, 2012). In the United States, most psychology licensing boards operate within the legal realm of administrative law and the process must comply with the Administrative Procedures Act that governs such action by the state (Stromberg et al., 1988). In Canada, the regulatory bodies operate according to a set of rules or governing bylaws that are typically submitted to the provincial government for approval.
According to Stromberg et al. (1988), most state and provincial laws provide some form of the following due process rights: adequate notice of the charges, right to a fair and impartial hearing, an opportunity to present evidence and confront witnesses, a decision based solely on the evidence, a record of the proceedings, and a process for appealing the decision. Similar legal protections and processes exist in federal and provincial law in Canada (Reaves, 1996).
Although some complaints are dismissed and others are settled through a negotiated agreement of stipulated conditions of remedy (e.g., mandatory supervision, additional training in ethics), complaints involving charges of significant misconduct or those charges that are contested are resolved through a hearing process. Before a hearing is scheduled, most jurisdictions in the United States and Canada require that the psychology board must have received a signed, written complaint, conducted an initial investigation of the merits of the charges, notified the psychologist of the specific charges, identified witnesses and subpoenaed documents, and taken any necessary depositions. The hearing itself is conducted in a variety of formats across jurisdictions depending on local law and the resources available to the regulatory board. In some jurisdictions the hearing is conducted before the regulatory board with the board serving as a panel of inquiry and a decision-making body. In other situations, regulatory boards are assisted in this process by hearing officers, who rule on motions and arbitrate disputes. In still other arrangements, a hearing officer alone hears cases, and recommendations and transcripts of the proceedings are made available to the board, which later renders its decision. Following an adverse decision, a psychologist may appeal to a separate legal tribunal (e.g., a circuit court in a state) if he or she believes there had not been a fair and impartial hearing of the complaint.
As a result of the hearing, the regulatory board issues its findings of fact and conclusions of law; that is, its findings of what it believes happened and whether such facts constitute a violation of the licensing law. Where a violation is found, the regulatory board may impose an appropriate sanction ranging from a reprimand to a permanent revocation of one’s license to practice. Other common sanctions imposed, either alone or in combination, include suspension of the license for a certain time, restriction in the type of clients or problem areas addressed, a return to supervised practice, additional training or education, therapy, restitution of assets, reimbursement of fees, and administrative fines (Reaves, 1996).
Despite the common misperception among licensed psychologists that complaints are rampant (Williams, 2001), a survey of all licensing boards conducted by Van Horne (2004) found that the number of complaints filed against psychologists was relatively low. Van Horne reported that the number of complaints reported to ASPPB equaled only 2% of the number of all licensees in each year from 1996 to 2001 when these numbers were averaged across all jurisdictions reporting. Van Horne cautions that this should not be interpreted as 2% of all licensed psychologists receive complaints each year, since some individuals receive multiple complaints, some individuals hold licenses in multiple jurisdictions, and one complaint can be acted upon by more than one jurisdiction.
Since 1983, ASPPB has maintained a Disciplinary Data System (DDS) that collects and disseminates summaries of disciplinary actions from its member psychology regulatory boards throughout the United States and Canada. Until 1996, the summary reports of disciplinary actions were disseminated in printed form, first annually and then quarterly, as the number of reports grew. Beginning in 1996, the ASPPB Disciplinary Data System was placed online whereby jurisdictions could report and retrieve information about disciplinary actions against a specific individual via a secure searchable database, giving regulatory boards immediate and timely access to all disciplinary actions contained in the system.
The consequences of being found in violation of a psychology licensing act are not limited to the (p. 209) sanctions imposed by the regulatory board. Reports from the DDS are routinely distributed to other relevant psychology credentialing or professional associations, as well as to all regulatory boards (DeMers & Schaffer, 2012). The current distribution list of the ASPPB Disciplinary Data System includes the ethics committees of the APA and the CPA, the American Board of Professional Psychology (ABPP), the National and Canadian Registers of Health Service Providers in Psychology, and the U.S. Department of Health and Human Services National Practitioner Data Bank. Given recent government initiatives, media attention and consumer activism, it is quite possible that information from the DDS soon may be made available to the general public through the ASPPB website as a means for helping boards to discharge their responsibility to protect the public using modern methods of information dissemination.
As a result of such broad distribution, individuals sanctioned by their home jurisdiction may find sanctions imposed by other regulatory boards where they hold additional licenses, by professional association ethics committees, by other credentialing bodies like ABPP, or even by insurance companies and managed health-care providers.
Since psychology regulatory boards are composed of psychologist as well as public members, many psychologists notified of charges lodged against them expect or hope to receive “friendly” treatment from their psychologist peers on the board. However, psychologists serving on regulatory boards learn and understand that the role entrusted to them by the legislative act creating the board of psychology requires them to protect the public and not show blind allegiance to the profession. Furthermore, the rules established to protect the rights of psychologists who are accused of violations necessitates a formal and complete investigation of all complaints, making informal resolution unlikely. However, since boards of psychology typically decide the issues raised in a complaint, a psychologist unjustly accused can be assured that the panel of individuals who will decide the merits of the complaint is likely composed of other psychologists who will understand the conduct of the professional probably better than the average citizen who serves on a civil or criminal jury panel.
Current and Future Issues
Like any profession, psychology is constantly progressing in its science and practice. Although such innovations demonstrate that psychology is an evolving discipline, such professional evolution often presents a number of challenges to psychology regulatory mechanisms that were established at an earlier stage in the development of the profession. Although there are many regulatory challenges, we will focus on two topics of particular relevance to the education and training community, namely, the lack of consistency across jurisdictions in the educational and training standards required to call oneself a psychologist and to practice independently, and the need to develop effective methods to regulate new models of service delivery.
Education and Training Standards for Independent Practice
Since the Boulder Conference in 1949 (Raimy, 1950), organized psychology in the United States has espoused the doctoral degree as the entry level for independent practice in psychology. Most licensing laws for psychology passed in the United States and Canada have required this standard since Connecticut first law adopted it as the required level of training for independent practice (Retfalvi & Simon, 1996). As noted earlier, a handful of states and provinces adopted a master’s degree standard rather than the doctorate, sometimes due to the lack of availability of doctoral level psychologists to fill positions; sometimes due to political forces at work; and sometimes due to concerns about cost, access to care in rural areas or other factors. Many colleges and universities continued to prepare individuals at the master’s degree level and many early licensing laws contained exemptions from the doctoral standard for state and local government, allowing publicly funded mental health agencies to employ individuals who did not meet the educational requirements for independent practice in that jurisdiction. Also, departments of education in the United States began credentialing school psychologists for practice in the nation’s public schools, and most of these state departments of education adopted a nondoctoral educational standard for independent practice as school psychologists (Fagan & Wise, 2007). All these factors created a situation in which controversy was likely to emerge over the standard for independent practice in psychology.
Such controversy has emerged in several different ways. Exemption from licensure requirements for publicly employed psychologists has been challenged by patient advocates and by professional associations resulting in the virtual elimination of such exemptions. Individuals with master’s degrees credentialed as psychological associates and working (p. 210) under mandatory supervision in jurisdictions allowing for such practice are now seeking to extricate themselves from the supervision requirement by changing psychology licensing laws to allow independent practice with a master’s degree or by seeking licensure in another mental health profession that does not require the doctorate for independent practice. In a few U.S. states, school psychologists with nondoctoral credentials from state departments of education have sought and obtained the right to practice independently outside the purview of the public school system. In Canada, although some provinces have replaced a previous master’s degree standard for independent practice with a new doctoral standard, the federal initiative to promote labor mobility has resulted in provinces with a doctoral standard being required to allow some form of independent practice for individuals trained to the master’s degree level.
Consequently, unlike medicine and law, the profession of psychology in the United States and Canada has never successfully advanced a universally accepted standard of educational preparation for its practitioners. The APA and CPA have promulgated standards of accreditation of training programs that adhere to the doctoral standard (APA, 2009). For many years, APA and ASPPB have disseminated model licensure acts for psychology in an attempt to promote greater consistency in licensing laws across the country. Despite these efforts, inconsistencies in standards remain. Recently, several emerging sources of divergence appear to further compromise professional coherence and mobility.
The increased use of online delivery of graduate education courses, and even entire degree programs, has raised the question of whether physical presence within a training environment is a necessary condition for professional preparation in psychology. The rapid expansion of online or distance education training programs requires educators to redefine quality assurance measures and requires regulators to determine the appropriate use of online instruction in professional preparation (DeMers et al., 2008). Recognizing the diversity of web-based instruction and its constant evolution, regulations specifying educational requirements for psychology licensure in terms of distance education seem challenging at best (Murphy, Levant, Hall, & Glueckauf, 2007).
This movement away from reliance on a physical campus to a virtual campus where students are linked via the Internet with professors, other students, and the resources necessary for learning, presents huge benefits in terms of greater access to instruction; but this instructional approach also leads to questions about on-campus residency requirements. The APA Accreditation Guidelines and Principles (Section A.4.) requires of each student “a minimum of 3 full-time academic years of graduate study—at least 2 of which must be at the institution from which the doctoral degree is granted and at least 1 year of which must be in full-time residence or the equivalent thereof” (APA, 2012). One of the stated purposes of the one-year, full-time minimum residence requirement is to permit faculty, training staff, supervisors, and administrators to assess student competence. Given growing concerns about lack of communication between practicum supervisors, internship sites and graduate programs, offering greater flexibility in meeting residency requirements could call into question the integrity of doctoral training (Johnson, et al, 2008). Another challenge for accreditation panels as well as regulators is the likelihood that transcripts do not necessarily accurately or completely reflect either the manner or quality of instruction, thus making review of credentials more difficult.
Most psychology licensing laws never anticipated completion of a doctoral degree in psychology without regular direct physical contact for a sustained period of time with program faculty and a training cohort. Consequently some states are revising their licensure laws to define residency requirements in such a way as to require some minimal period of time (typically at least one year) of physical presence on the regionally accredited campus awarding the doctoral degree. The ASPPB Model Act for Licensure and Registration of Psychologists (ASPPB, 2010) includes such a requirement and a definition of residency. The APA Commission on Accreditation has issued an implementing regulation (APA, 2012) that also describes the goal and desired outcomes that come from physical presence on campus. This accreditation regulation also states that programs that are predominately or substantially delivered online are not in compliance with its residency standard.
Today, many licensed psychologists and other providers of mental health services are either providing or are considering providing psychological services across jurisdictional boundaries due to client mobility, their own mobility, or innovative practice opportunities. Such practice across jurisdictional boundaries involving use of the Internet or other electronic communication methods presents unique (p. 211) challenges as yet unaddressed by most psychology licensing laws (APAPO, 2010). Most current psychology licensing laws presume that psychological services are delivered in a particular jurisdiction by an individual who is licensed to practice in that jurisdiction. What happens to professional regulation when psychological services are delivered to clients via the Web or other telecommunications systems across state, provincial, or even national boundaries? If a client feels harmed, to whom do they complain: the board of psychology where they reside, which may have no jurisdiction over an out-of-jurisdiction provider, or the jurisdiction where the provider resides, which may feel the activity did not occur in that jurisdiction?
Beyond the significant complexities and legalities of filing complaints, the use of technology to deliver psychological services raises new questions about the limits of what constitutes acceptable practice in this medium (Reed, McLaughlin, & Milholland, 2000). Although one can easily think of examples of national or international experts who could and should be available for consultation about rare or specialized cases or topics (Glueckauf, Pickett, Ketterman, Loomis & Rozensky, 2003), should more routine psychotherapy be conducted using online messaging platforms or Web-based communications vehicles for the convenience or benefit of the practitioner or the client? In the absence of any system of national or international licensing, the regulation of psychological services delivered via electronic means is tenuous at best, and perhaps nonexistent (DeMers & Schaffer, 2012).
Nevertheless, the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, and information across distance is a reality (Maheu & Gordon, 2000). Whether called telepractice or telepsychology, such use of innovative service delivery methods generally does not refer to occasional phone conversations or emergency phone contacts with an ongoing client with whom one has regular meetings. Instead, the controversy focuses on using telepractice as the primary or even sole means of delivering services, or the issue of frequently using electronically based media such as the Internet for clinical communications with clients or patients.
The reality of telepractice is that a psychologist can provide services without physically entering another jurisdiction and possibly without knowing the actual location of the consumer receiving services (Reed, McLaughlin, & Milholland, 2000). Such innovations in service provision challenge traditional regulatory mechanisms and thus require creative approaches to consumer protection (APAPO, 2010).
Although this rapidly evolving method of professional practice raises significant risks to consumers from misconduct, security breaches or the inability to deal effectively with emergency situations, it also allows for significant improvements in access to care when delivered competently and appropriately. Licensing boards have no desire to impede the delivery of effective services, but the board does have a legal responsibility to ensure that these innovative service delivery methods are performed in a manner that protects the public from harm. In this developing area of practice, psychologists will need to be aware not only of their ethical, regulatory and legal obligations, but also about newly emerging standards of care for such practice (APAPO, 2010; Glueckauf et al., 2003).
A recent article from the APA Practice Organization (2010) raises a number of persistent questions, as yet mostly unanswered, with regard to the complexities of telepsychology practice. What part of the practice of psychology can be competently and ethically delivered via largely electronic means? Should the jurisdictional board where the psychologist is practicing, or the jurisdictional board where the client receives services, or both, regulate the practice? What records are kept, by whom, and for how long? How is accurate and secure identification of the client and the professional established? How will an emergency be handled? What are the limits of confidentiality? Will professional liability insurance cover practice across jurisdictional lines?
The questions are many for the education and training community, the practicing psychologist, and the licensing entity. The challenges of effectively regulating such electronic practice seem to be almost insurmountable without requiring licensure in every jurisdiction where services are being provided. However, requiring full licensure in every jurisdiction where a psychologist may have a temporary contact with a client seems unlikely to be an effective regulatory approach. New structures or systems that offer a means to better regulate temporary, electronic practice by a provider licensed in another jurisdiction seems like a more fruitful path to pursue. The profession, including the educators, trainers, accreditors, and the regulators will need to develop and then embrace these new structures, as well as consistent regulations for telepractice services, if practitioners can be reasonably expected to comply (DeMers et al., 2008). (p. 212)
In 2011, APA, ASPPB and the APA Insurance Trust (APAIT) created a joint task force to develop guidelines for the practice of telepsychology. These guidelines have now been completed and approved by the three organizations supporting this task force. The guidelines address both the types of psychological services that can be ethically and competently delivered using these innovative technologies, and the regulatory issues created by providing services across jurisdictional boundaries. Now that these guidelines have been approved, training programs may need to offer specific instruction on “best practices” in using telepsychology approaches, and licensing laws will need to be changed to recognize any new rules or structures that offer better regulation of such service delivery models.
Credentialing and regulation of individuals to practice psychology in the United States and Canada is a complex and multifaceted process. It involves the interplay of professional associations, educators, and trainers, legislatively created regulatory bodies, state and provincial governments, and the public. The sole purpose for the passage and continuation of psychology licensing laws is to protect the public from incompetent or unethical practitioners. When the public (or at least their elected public representatives) loses confidence in the ability of the profession to regulate itself, then psychology licensing laws are either modified or rescinded. Although it may be tempting for the profession to feel that it knows best how to regulate the practice of psychology, the profession must be mindful to educate the public about the reasons underlying its preferred standards and policies or risk having them rejected by those representing the public’s interests. It is imperative that the education and training and the regulatory communities routinely collaborate with each other in order to develop consistent standards for training psychologists and to put forth a unified view of what training and educational experiences are necessary to produce competent entry-level psychologists. That understanding can then be used by legislative bodies as they consider and hopefully adopt those standards endorsed by both the training and regulatory communities. Such consistency in standards not only promotes the licensure of competent and ethical practitioners and promotes easier professional mobility across jurisdictions; it also reinforces the public’s view of psychology as a credible and unified profession.
As modern society changes through technological advances, marketplace forces, and government initiatives, it may be necessary to modify the standards and processes that have been created to both educate and regulate the profession of psychology to date. The United States and Canada have been world leaders in the development of education and credentialing mechanisms and fair and impartial disciplinary proceedings for psychologists. Despite the challenges outlined earlier, hopefully that leadership can continue for the benefit of the consumers of psychological services and the profession itself.
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