A number of states in the U.S., including Maine, Vermont, Washington and Colorado, have adopted some form of registration law.  Usually, these are in addition to more restrictive laws regulating psychology, social work and marriage and family counseling.  Below is a description of how two of these appear to be working.

The state of Vermont has adopted a registration law in the form of a “Roster of Psychotherapists Who Are Non-Certified and Non-Licensed” whose purpose is:

•    “To ensure that consumers of psychotherapy services are provided with the information relating to the training and qualification of nonlicensed and noncertified providers of psychotherapy necessary to enable them to make informed decisions concerning their choice of providers.

•      That psychotherapists who are nonlicensed and noncertified are entered on a roster and practice according to established standards of professional conduct and be subject to disciplinary procedures if they fail to adhere to those standards.

•      That the term psychotherapy as used in this chapter be narrowly interpreted to ensure that only those persons who provide services that clearly fall within the definition of psychotherapy are subject to the provisions of this chapter.”

This law has been in effect since 1994 and appears to have worked effectively, according to Board member Lauren Berrizbeitia. She states that the number and type of complaints received are similar to other professional groups, such as psychologists, based on a pro rata basis. The original law had been passed with some trepidation. When it came up for “sunset review,” the state legislature did not even bother with the review process since it concluded that the law was obviously effective and valuable.

The State of Colorado passed a statute establishing a Grievance Board for all psychotherapists who are not licensed by another profession, such as psychology or social work. This requires registration of all such practitioners and provides a vehicle for disciplining those who are errant or wayward.

The legislature conducted a multi-year study of the effectiveness of restrictive licensing and concluded that no demonstrable protection of the public could be found. According to William Goodrich, in a recent year psychiatrists were subject to a larger number of and more serious offenses than the registered group of therapists, despite the fact that the registered group outnumbered the psychiatrists by 4:1. This suggests that whatever the dangers posed by psychotherapeutic practice, protection is not being provided by traditional forms of licensing with its reliance on academic credentials. An active disciplinary board with a broad-based register seems a far better solution.

Regulation of output, not input

Regulation through licensure constitutes control of input, since it establishes standards and criteria governing entrance into a profession. Because current requirements have not been shown to be related to effective performance, alternatives should be considered such as competency-based measures which attempt to correlate particular skills with effective performance. Regulations that are based on output measure or correlated with them are strongly to be preferred. Registration laws (see box xxx) represent an output-based system, since they allow all practitioners in, and then regulate their practice through the disciplinary arm of the registration board.

Registration, not licensing or certification

Regulation through registration, in which practitioners are required to register with a government agency but are not required to meet any academic or other prerequisites, is the most desirable form of regulation. Where licensing laws have entrance requirements, only the unlicensed use of specific titles should be restricted, not the right to practice. Registration allows all people to practice so long as they provide certain information to the state. Practitioners can, however, be removed from the roles if they engage in incompetent, harmful or unethical activity. Registration has the advantage of bringing all people into the fold, ending the turf wars that currently exist.

Minimal use of restrictive licensing laws

Licensing laws that restrict practice to those who possess academic credentials should be avoided. Even if licensing laws do not restrict the right to practice, but prohibit only the unlicensed use of certain titles, they are inadvisable. Restrictive licensing should not be employed unless the following conditions are met:
•      The profession being regulated is mature and well-established.

•      The profession has a clearly defined field of practice.

•      The profession has a significant public impact

•      The net benefits of licensing outweigh any negative side effects by a substantial amount.

•      Less restrictive alternatives are unavailable.

•      The potential for harm from incompetent or unethical practitioners is significant, pervasive, and well documented.

•       Reliable and valid measures exist to determine whether practitioners are qualified to practice.

•       Adequate financial and human resources will be provided for the operation of the regulatory board or agency.

Full disclosure requirements

All licensing laws should require practitioners to disclose relevant information to clients and the public including the name, address and methods of contacting the government disciplinary agency, fee structure, and status of confidentiality. Clients should be given a copy of the rules and regulations of the board and what constitutes unethical or incompetent practice. Practitioner education, experience, supervision status, methods used, and techniques in which certification by an outside organisation has been achieved, are among the types of disclosure that would be valuable.

Increased education of the public

Although little used until now as a method of professional regulation, education has the potential as a powerful tool in protecting the public from harm. To be effective, however, considerable effort, money, time and commitment must be devoted to developing a sound program for public education and information dissemination. State agencies should undertake programmes to help educate potential clients as to what to look for in a therapist, what questions to ask, and what to do if dissatisfied with the service. State agencies should act as a conduit for information supplied by various professional groups to inform the public about the state of the art.

Encourage a proliferation of professional associations and accrediting organizations

Professional associations and accrediting organisations will and should continue to play a strong role in the regulation of psychotherapists. Because of the lack of consensus on standards of practice, methods of training, and methods of selection, however, it will be crucial to create a situation in which many such organisations coexist, each advocating different methods and theories for the training and certification of therapists. The goal should be a pluralistic system in which the public can choose any of a variety of therapists. By carefully monitoring the effectiveness of therapists certified by different associations, long-term research might begin to establish which methods of training and selection produced the most competent or least dangerous therapists. In the US a national certifying agency has been put into place to certify accreditation organisations in the health field

Exploration of the value of client evaluations

Because at least some aspects of a professional’s practice are subject to direct evaluation by a client, such as client satisfaction and what the therapist actually said and did, the use of such evaluations should be explored by licensing bodies. The idea would be to have these evaluations available to the board and perhaps to the public.

Special laws for specific problems and the use of existing criminal law

Where special dangers are identified in the psychotherapeutic process, and where traditional avenues of dealing with them are ineffective, special laws should be enacted. Existing fraud and sexual harassment laws should be strengthened and used to prevent some of the abuses that currently occur in professional practice. This alone would obviate much of the need for licensing.

Balanced representation of interests, not professional control

The basic policies of the regulatory board or agency should not be set by a board composed solely of professionals, but should have a balanced representation of appropriate constituencies, including the public, clients, and government officials. Licensing boards or agencies should be administered by personnel skilled at their task. Thus, discipline should be carried out by trained investigatory staff. The board or agency should have adequate financing and should not rely on registration fees for its continued operation.

Narrow definitions of practice

Definitions of practice should be carefully and narrowly drawn. The more a regulation restricts practice to a limited few, the more rigidly this guideline needs to be applied.

Competency-based standards and criteria

Licensing requirements should be competency-based and related to actual performance. Academic credentials should only be used if they have a demonstrable relationship to performance.

Focus on definitions of minimal competence

Licensing requirements should be aimed at a minimal level of competence, not high quality.

Legitimacy of alternative paths

Whether academic credentials are used or not, licensing laws should allow persons to be licensed on the basis of proficiency examinations, educational equivalency measures, apprenticeships or certification by an appropriate professional association.

Maximum delegation of functions to paraprofessionals

Restrictive licensing laws should allow licensed persons to delegate any and all functions to para-professionals, unless demonstrated danger would result. Delegation provisions should only require direct, over-the-shoulder supervision where absolutely necessary.

Accreditation

Where academic credentials are a requirement of licensing laws, the further requirement that the degree must be from an accredited institution or program should only exist if accreditation is determined by truly competency-based measures. Otherwise, the encouragement of multiple accrediting agencies should take place, with accompanying research on their impact and effectiveness.

Avoidance of standardised national examinations

The use of standardised national examinations by licensing boards should be avoided unless evidence exists that these examinations have a demonstrable relationship to competent practice. In other words, they must have predictive as well as content validity. Further, even with demonstrable validity, it still may be worthwhile to avoid standardisation to allow the possibility of even better measures or alternative examinations that are equally predictive.

Use of a Wide Variety of Selection Methods

Since little agreement exists about what selection methods are best for determining professional competence, licensing boards should experiment with the use of supervisor evaluation, evaluations of role-playing and taped samples of actual performance, acceptance of certification by appropriate professional associations, and other selection procedures.

Performance-based relicensure and continuing competence

Although demonstration of continuing competence should be an essential feature of all licensing laws, no evidence exists that continuing education requirements are a good measure of this. Instead, licensing boards should require a demonstration based on a proficiency examination or direct evidence of competent performance. A quick perusal of the offerings of continuing education programs shows how absurd most such requirements are. Most courses have a marginal relationship to protecting the public and one will find few courses that focus on ethics or the dangers of the therapeutic process.

Generous use of exemptions

All licensing laws should contain specific exemptions for professionals certified by recognised professional associations in the psychotherapy and counselling field. The criteria for determining whether a professional association is recognised should be based on whether the association has a membership of reasonable size, standards and criteria for admission that are based on competent practice, a method for disciplining incompetent or unethical members, and methods for periodically reviewing members’ continuing competence.

Generous grandparent clauses

When a new licensing law is enacted, adequate provision must be made to protect the rights of those who do not meet the education (or other) requirements of the law, but who have been practicing prior to the law’s enactment.