The Mental Health Workforce: A Primer

The Mental Health Workforce: A Primer
The Mental Health Workforce: A Primer
Elayne J. Heisler
Specialist in Health Services
Erin Bagalman
Analyst in Health Policy
April 16, 2015
Congressional Research Service
7-5700
www.crs.gov
R43255
The Mental Health Workforce: A Primer
Summary
Congress has held hearings and introduced legislation addressing the interrelated topics of the
quality of mental health care, access to mental health care, and the cost of mental health care. The
mental health workforce is a key component of each of these topics. The quality of mental health
care depends partially on the skills of the people providing the care. Access to mental health care
relies on, among other things, the number of appropriately skilled providers available to provide
care. The cost of mental health care depends in part on the wages of the people providing care.
Thus an understanding of the mental health workforce may be helpful in crafting policy and
conducting oversight. This report aims to provide such an understanding as a foundation for
further discussion of mental health policy.
No consensus exists on which provider types make up the mental health workforce. This report
focuses on the five provider types identified by the Health Resources and Services Administration
(HRSA) within the Department of Health and Human Services (HHS) as “core mental health
professionals”: clinical social workers, clinical psychologists, marriage and family therapists,
psychiatrists, and advanced practice psychiatric nurses. The HRSA definition of the mental health
workforce is limited to highly trained (e.g., graduate degree) professionals; however, this
workforce may be defined more broadly elsewhere.
An understanding of typical licensure requirements and scopes of practice may help policymakers
determine how to focus policy initiatives aimed at increasing the quality of the mental health
workforce. Most of the regulation of the mental health workforce occurs at the state level because
states are responsible for licensing providers and defining their scope of practice. Although state
licensure requirements vary widely across provider types, the scopes of practice converge into
provider types that generally can prescribe medication (psychiatrists and advanced practice
psychiatric nurses) and provider types that generally cannot prescribe medication (clinical
psychologists, clinical social workers, and marriage and family therapists). The core mental
health provider types can all provide psychosocial interventions (e.g., talk therapy).
Administration and interpretation of psychological tests is generally the province of clinical
psychologists.
Access to mental health care depends in part on the number of mental health providers overall
and the number of specific types of providers. Clinical social workers are generally the most
plentiful core mental health provider type, followed by clinical psychologists, who substantially
outnumber marriage and family therapists. While less abundant than the three aforementioned
provider types, psychiatrists outnumber advanced practice psychiatric nurses. Policymakers may
influence the size of the mental health workforce through a number of health workforce training
programs.
Policymakers may assess the relative wages of different provider types, particularly when
addressing policy areas where the federal government employs mental health providers.
Psychiatrists are typically the highest earners, followed by advanced practice psychiatric nurses
and clinical psychologists. Marriage and family therapists earn more than clinical social workers.
The relative costs of employing different provider types may be a consideration for federal
agencies that employ mental health providers.
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The Mental Health Workforce: A Primer
Contents
Introduction...................................................................................................................................... 1
Mental Health Workforce Definition: No Consensus ...................................................................... 2
Mental Health Workforce Overview ................................................................................................ 3
Licensure Requirements ............................................................................................................ 3
Degree ................................................................................................................................. 3
Supervised Practice ............................................................................................................. 4
Exam ................................................................................................................................... 4
Scope of Practice ....................................................................................................................... 4
Mental Health Workforce Size......................................................................................................... 8
Mental Health Workforce Annual Wages....................................................................................... 13
Concluding Comments .................................................................................................................. 14
Figures
Figure 1. Workforce Size Estimates, by Mental Health Provider Type ........................................... 9
Tables
Table 1. Licensure Requirements and Scope of Practice, by Mental Health Provider Type............ 5
Table 2. Workforce Size Estimates, by Mental Health Provider Type ........................................... 11
Table 3. Mean and Median Annual Wages, by Mental Health Provider Type ............................... 13
Appendixes
Appendix A. Mental Health Professional Shortage Areas (MHPSA) Definition .......................... 16
Appendix B. Additional Resources ................................................................................................ 20
Contacts
Author Contact Information........................................................................................................... 21
Acknowledgments ......................................................................................................................... 21
Congressional Research Service
The Mental Health Workforce: A Primer
Introduction
The federal government is involved in mental health care in various ways, including direct
provision of services, payment for services, and indirect support for services (e.g., grant funding,
dissemination of best practices, and technical assistance).1 Policymakers have demonstrated
interest in the federal government’s broad role in mental health care. They have done so primarily
by holding hearings2 and introducing legislation3 addressing the interrelated topics of quality of
mental health care, access to mental health care, and the cost of mental health care.
The mental health workforce is a key component of mental health care quality, access, and cost.
The quality of mental health care, for example, is influenced by the skills of the people providing
the care. Access to mental health care depends on the number of appropriately skilled providers
available to provide care, among other things. The cost of mental health care is affected in part by
the wages of the people providing care. Thus an understanding of the mental health workforce
may be helpful in crafting legislation and conducting oversight for overall mental health care
policy.
It is important to note that, while the federal government has an interest in the mental health
workforce, and federal initiatives may affect the training of mental health care providers, for
instance, most of the regulation of the mental health workforce occurs at the state level. State
boards determine licensing requirements for mental health professionals, and state laws establish
their scopes of practice.
This report begins with a working definition of the mental health workforce and a brief discussion
of alternative definitions. It then describes three dimensions of the mental health workforce that
may influence quality of care, access to care, and costs of care: (1) licensure requirements and
scope of practice for each provider type in the mental health workforce, (2) estimated numbers of
each provider type in the mental health workforce, and (3) average annual wages for each
provider type in the mental health workforce. The report then briefly discusses how these
dimensions of the mental health workforce might inform certain policy discussions.
1
For example, federal agencies such as the Veterans Health Administration (within the Department of Veterans
Affairs) provide mental health care directly; federal programs such as Medicare pay for mental health care; and federal
agencies such as the Substance Abuse and Mental Health Services Administration (within the Department of Health
and Human Services) support mental health care through grant funding, dissemination of best practices, technical
assistance, and other means.
2
See, for example, U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Oversight and
Investigations, Federal Efforts on Mental Health: Why Greater HHS Leadership is Needed, 114th Cong., 1st sess.,
February 11, 2015; U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Oversight and
Investigations, Where Have All the Patients Gone? Examining the Psychiatric Bed Shortage, 113th Cong., 2nd sess.,
March 26, 2014; and U.S. Congress, Senate Committee on Health, Education, Labor, and Pensions, Examining Mental
Health: Treatment Options and Trends, 113th Cong., 2nd sess., February 25, 2014.
3
For example, in the 113th Congress, bills were introduced intended to improve mental health care overall (e.g., H.R.
1263, H.R. 3717, S. 264, and S. 689), and for specific populations such as veterans (e.g., H.R. 1725 and H.R. 2540),
school children (e.g., H.R. 320 and H.R. 628), and Medicare beneficiaries (e.g., H.R. 794 and S. 562), among others.
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The Mental Health Workforce: A Primer
Mental Health Workforce Definition: No Consensus
No consensus exists on which provider types make up the mental health workforce. While some
define the workforce as a broad range of provider types, others take a more narrow approach. For
example, the Institute of Medicine (IOM)—a private, nonprofit organization that aims to provide
evidence-based health policy advice to decision makers, often through congressionally mandated
studies—has conceptualized the mental health workforce broadly, including primary care
physicians, nurses, physician assistants, peer support specialists, and family caregivers, among
others.4 The Substance Abuse and Mental Health Services Administration (SAMHSA)—the
public health agency within the Department of Health and Human Services (HHS) that leads
efforts to improve the nation’s mental health—has in recent years defined the mental health
workforce to include psychiatry, clinical psychology, clinical social work, advanced practice
psychiatric nursing, marriage and family therapy, substance abuse counseling, and counseling.5
Previously, SAMSHA’s definition also included psychosocial rehabilitation, school psychology,
and pastoral counseling and excluded substance abuse counseling.6
The Health Resources and Services Administration (HRSA)—the public health agency within
HHS with primary responsibility for increasing access to health care (including mental health
care) for vulnerable populations7—provides a more narrow definition of the mental health
workforce that is tied to existing federal programs aimed at alleviating provider shortages (e.g.,
Medicare bonus payments and health workforce recruitment programs). Eligibility for such
programs is determined in part by the designation of a Mental Health Professional Shortage Area
(MHPSA).8 The MHPSA designation is based on a limited number of core provider types because
it is intended to identify the most extreme workforce shortages in order to target federal
investments. For purposes of designating MHPSAs, HRSA identifies “[c]ore mental health
professionals [as] psychiatrists, clinical psychologists, clinical social workers, [advanced practice
psychiatric nurses],9 and marriage and family therapists” who meet specified training and
licensing criteria (as detailed in Appendix A). Notably, this definition is limited to highly trained
mental health professionals.
4
IOM (Institute of Medicine). 2012. The Mental Health and Substance Use Workforce for Older Adults: In Whose
Hands? Washington, DC: The National Academies Press. Hereinafter, IOM Workforce Report. The IOM definition
also includes all fields in the SAMHSA definitions.
5
SAMHSA. (2013). Behavioral Health, United States, 2012. HHS Publication No. (SMA) 13-4797. Rockville, MD:
SAMHSA.
6
SAMHSA. (2006) Mental Health, United States, 2004. HHS Publication No. (SMA) 06-4195. Rockville, MD:
SAMHSA. The IOM definition includes all fields in the SAMHSA definitions.
7
HRSA, About HRSA, http://www.hrsa.gov/about/.
8
Health professional shortage areas (HPSAs) are defined in 42 U.S.C. §254e. HRSA developed operational definitions
of HPSAs and of MHPSAs specifically, available at http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/
designationcriteria.html and http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsaoverview.html.
HRSA designates MHPSAs based on the ratio of mental health providers to population. As of January 2015, HRSA had
designated 4,071 MHPSAs. See U.S. Department of Health and Human Services, Health Resources and Services
Administration, “Health Professional Shortage Areas (HPSA) and Medically Underserved Areas/Populations
(MUA/P),” http://datawarehouse.hrsa.gov/topics/shortageAreas.aspx#chart. For a larger discussion of HPSAs, of which
MHPSAs are a specific type, see CRS Report R42029, Physician Supply and the Affordable Care Act.
9
This report uses the term “advanced practice psychiatric nurse,” which is more common than the term “psychiatric
nurse specialists” used in HRSA’s MHPSA designation criteria. See U.S. Department of Health and Human Services,
Health Resources and Services Administration, “Mental Health HPSA Designation Overview,” http://bhpr.hrsa.gov/
shortage/hpsas/designationcriteria/mentalhealthhpsaoverview.html.
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The Mental Health Workforce: A Primer
Mental Health Workforce Overview
In conceptualizing and outlining the mental health workforce, this report relies on the HRSA
definition of “core mental health professionals,” including clinical social workers, clinical
psychologists, marriage and family therapists, psychiatrists, and advanced practice psychiatric
nurses.10 For each of the five core mental health professions, Table 1 summarizes licensure
requirements (including degree, supervised practice, and exam) and scope of practice; each of
these terms is explained briefly below. Although the licensure requirements vary widely across
provider types, the scopes of practice converge into provider types that generally can prescribe
medication (psychiatrists and advanced practice psychiatric nurses) and provider types that
generally cannot prescribe medication (clinical psychologists, clinical social workers, and
marriage and family therapists). All provider types in this report can provide psychosocial
interventions (e.g., talk therapy). Administration and interpretation of psychological tests is
generally the province of clinical psychologists.
Licensure Requirements
Licensure requirements are the minimum qualifications needed to obtain and maintain a license in
a specific health profession. These requirements are generally defined by state licensing boards—
independent entities to which state governments have delegated the authority to set licensure
requirements for specified professions. State licensing boards generally have responsibility for
verifying that requirements to obtain (and maintain) a license have been met, issuing initial and
renewed licenses, and tracking licensure violations, among other activities.11
Table 1 focuses on licensure requirements that are common across many states; it generally does
not address state variation. Across all provider types, the table addresses licensure for
independent clinical practice,12 although some disciplines offer licensing at lower practice levels
or provisional licensing. The table describes requirements to obtain a license and does not include
requirements to maintain a license (e.g., continuing education).13
Degree
The degree noted in Table 1 indicates the minimum level of education generally required to be
licensed for independent practice.14 For the core mental health professionals outlined in this
report, licensure for independent practice requires the completion of graduate education.15 Table
10
The HRSA definition is used because of its relevance to federal workforce programs.
See, for example, “FSMB Mission and Goals,” Federation of State Medical Boards at http://www.fsmb.org/
mission.html.
12
In order for a health professional to “count” for MHPSA designation purposes, the health professional must be
licensed to practice independently.
13
As licensure requirements change over time, previously licensed providers may not be subject to new requirements.
14
Some disciplines offer degrees with the same title in both clinical and non-clinical tracks—for example, a Doctor of
Philosophy (PhD) in clinical psychology and a PhD in experimental psychology or a Masters of Social Work (MSW) in
clinical social work and an MSW social work administration—where graduates of the non-clinical track are not
qualified for clinical licensure.
15
Licensure generally requires a degree from a school or program that has been accredited; however, a discussion of
accreditation of educational institutions and programs is beyond the scope of this report.
11
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The Mental Health Workforce: A Primer
1 generally does not include degrees that are prerequisites for graduate education (e.g., a
bachelor’s degree) or degrees beyond those required for licensure (e.g., a doctoral degree
available in a discipline where a master’s degree is qualifying for licensure for independent
practice). Notably, in order to enroll in a graduate program to become an advanced practice
psychiatric nurse, an individual must first be a registered nurse with a bachelor’s degree in
nursing. The other provider types in this report do not have equivalent requirements for specific
undergraduate degrees or for prior licensing.
Table 1 provides a brief description of each graduate degree, including requirements such as a
field experience or a dissertation. The table also indicates the amount of time typically required to
complete the degree. In some cases, individuals may complete the degree in less time (e.g., by
participating in an accelerated program) or more time (e.g., by attending school part-time or
taking longer to complete a dissertation).
Supervised Practice
For most provider types discussed in this report, licensure for independent practice requires a
period of post-graduate supervised practice. This period of supervised practice is distinct from the
practicum or internship experiences required to obtain a degree. An example of such supervised
practice is the residency required for physicians to become psychiatrists.
Exam
State licensing boards generally require a passing score on an exam offered by a national body
(e.g., the American Board of Psychiatry and Neurology), although some state licensing boards
may offer their own exams in addition to or in lieu of the national exam. In some cases,
individuals applying for licensure may have a choice of exams that meet the licensure
requirement. The timing of the exam may vary by state; that is, some states may allow individuals
to take the exam immediately upon completing the degree requirements, while other states may
require individuals to have completed a portion (or all) of the supervised practice requirement
prior to taking the exam.
Scope of Practice
The scope of practice for each provider type is established at the state level by state statute,
regulation, or guidance. Table 1 highlights elements within scope of practice that involve
diagnosing and treating mental illness. The scope of practice for most provider types includes
other activities, such as preventive care, case management, and consultation with other providers.
The scope of practice described in the table reflects what is generally true in most states. For
example, prescribing medication is included in the scope of practice for advanced practice
psychiatric nurses, a provider type that comprises both nurse practitioners (allowed to prescribe
medication in all states) and clinical nurse specialists (allowed to prescribe medication in only
some states).
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Table 1. Licensure Requirements and Scope of Practice, by Mental Health Provider Type
Licensure Requirements
Provider Typea
Degreec
Supervised Practice
Exam
Clinical Social
Worker
Master of Social Work (MSW),
which typically requires 2 years.
Coursework emphasizes human
and community well-being.
Requires a supervised field
practicum (internship).
Generally requires 3,200–3,400
post-degree supervised clinical
hours, which take approximately 2
years.
Generally requires a passing score on
the Clinical Exam of the Association of
Social Work Boards.
Doctoral degree in psychology or
a related field, which generally
takes between 5 and 7 years to
complete and requires academic
coursework, clinical training, a
dissertation, and an exam.
Generally requires 3,000 hours of
supervised clinical training, which
take approximately 2 years.d
Clinical
Psychologist
Marriage and
Family Therapist
(MFT)
CRS-5
Master’s degree (2-3 years),
doctoral degree (3-5 years), or
postgraduate clinical training (3-4
years) in marriage and family
therapy or a related field.g
Coursework emphasizes the
individual’s mental health in the
context of interpersonal
relationships (e.g., family and
peers). Generally requires a field
practicum or internship.
Generally requires 2 years of
post-degree supervised clinical
training.
Generally requires a passing score on
the Examination for Professional
Practice in Psychology (EPPP).e
Generally requires a passing score on
the Association of Marital and Family
Therapy Regulatory Board’s
Examination in Marriage and Family or
the equivalent California Exam.h
Scope of Practiceb
•
Diagnose mental disorders.
•
Provide psychosocial
treatment for individuals,
families, and groups.
•
Cannot prescribe medication.
•
Diagnose mental disorders.
•
Provide psychosocial
treatment for individuals,
families, and groups.
•
Administer and interpret
psychological tests.
•
Generally cannot prescribe
medication.f
•
Diagnose mental disorders.
•
Provide psychosocial
treatment for individuals,
families, and groups.
•
Cannot prescribe medication.
Licensure Requirements
Provider Typea
Degreec
Supervised Practice
Exam
Psychiatrist
Medical Doctorate (MD) or
Doctorate of Osteopathic
Medicine (DO), both of which
typically require 4 years to
complete (including 2 years of
clinical rotations). Coursework
emphasizes physical medicine.
Generally requires 3 or 4 years of
post-degree supervised clinical
training (residency) in the specialty
of psychiatry.
Generally requires a passing score on
the United States Medical Licensing
Examination (USMLE) for MDs or
DOs.i DOs can also elect to take the
Comprehensive Osteopathic Medical
Licensing Examination (COMLEX).
•
Diagnose mental disorders.
•
Provide psychosocial
treatment for individuals,
families, and groups.
•
Can prescribe medication.
To become board certified, an exam
administered by the American Board of
Psychiatry and Neurology.j
•
Can diagnose and treat
physical conditions as well.
Master of Science (MS) in nursing,
which generally requires 2 years
of coursework and clinical hours
(generally 500 or more).l
Coursework and clinical
experience focus on psychiatric
mental health nursing.
No separate post-graduate clinical
training is required.
Generally requires a passing score on
an exam offered by the American
Nurses Credentialing Center.m
•
Diagnose mental disorders.
•
Provide psychosocial
treatment for individuals,
families, and groups.
•
Generally can prescribe
medication.
•
Can diagnose and treat
physical conditions as well.n
Advanced
Practice
Psychiatric Nurse
(APPN)k
Scope of Practiceb
Sources: U.S. Department of Labor, Bureau of Labor Statistics; U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA);
and various professional associations. For more information on the professional organizations for each of five health professions, see Appendix B.
Notes: The degree, supervised practice, and exam indicated in the table are those generally required to obtain a license for independent practice. Licensure
requirements (defined by state boards) and scope of practice (defined by state laws) vary by state. Degree requirements may vary by program. In all cases, the
information provided in the table reflects what is generally true in most states and programs. Elaborating the exceptions is beyond the scope of this report.
a.
The provider type may not correspond to the name of the license (which may vary by state for some provider types). The provider types correspond to HRSA’s
“core mental health professionals” (with the exception of advanced practice psychiatric nurses, which HRSA calls “psychiatric nurse specialists”).
b.
The table focuses on the elements within scope of practice that involve diagnosing and treating mental illness. The scope of practice for most provider types includes
other activities, such as preventive care, case management, and consultation with other providers.
c.
The table focuses on graduate degree requirements (i.e., post-baccalaureate training requirements).
d.
Generally, states require that at least 1,500 hours (of the 3,000 hours required) be a post-doctoral experience. See Association of State and Provincial Psychology
Boards, “Entry Requirements for the Professional Practice of Psychology, 2008,” http://www.asppb.net/files/public/09_Entry_Requirements.pdf.
CRS-6
e.
A board certified psychologist is one who has completed training in a specific specialty and has passed an examination that assesses the basic knowledge and skills in
that particular area. As in psychiatry, board certification is not required, but some employers may require it. Board certification is conducted by the American Board
of Professional Psychology, see http://www.abpp.org/.
f.
In New Mexico, Louisiana, Guam, the U.S. Department of Defense (DOD) system, the Indian Health Service, and the U.S. Public Health Service, licensed
psychologists who obtain additional training can apply to have prescription writing privileges as part of their scope of practice. See Robert E. McGrath, “Prescriptive
Authority for Psychologists,” Annual Review of Clinical Psychology, vol. 6 (April 27, 2010), pp. 21-47.
g.
Related fields may include psychology, social work, nursing, education, or pastoral counseling. See American Association for Marriage and Family Therapy, About
AAMFT, Qualifications and FAQs, http://www.aamft.org/imis15/content/about_aamft/Qualifications.aspx.
h.
Marriage and Family Therapists (MFTs) who practice in California (representing more than half of all MFTs), must pass a separate California licensing exam.
i.
Graduates of certain foreign medical schools may also be eligible to take the USMLE.
j.
The term “board certified physician” means one who has completed the required training in a specific specialty and has passed an examination that assesses the basic
knowledge and skills in a particular area (in this case psychiatry or neurology). Board certification is not required to practice as a psychiatrist but may be a condition
of employment for some employers.
k.
This includes mental health/psychiatric nurse practitioners and clinical nurse specialists. This report uses the term “advanced practice psychiatric nurse,” which is
more common than the term “psychiatric nurse specialists” used by HRSA. The American Psychiatric Nurses Association (APNA) aims to bring uniformity to the
requirements for advanced practice psychiatric nurses by 2015, in accordance with the “Consensus Model for APRN Regulation: Licensure, Accreditation,
Certification & Education;” see American Psychiatric Nurses Association, APRN Consensus Model, http://www.apna.org/i4a/pages/index.cfm?pageID=4387.
l.
The nursing profession is moving towards requiring doctoral degrees in these fields, which requires an additional two years of training. See American Psychiatric
Nurses Association, “What is an Advanced Practice Psychiatric Nurse?” http://www.apna.org/i4a/pages/index.cfm?pageID=3866.
m.
Prior to January 1, 2014, the American Nurses Credentialing Center offered four different exams: two for Nurse Practitioners (in Adult or Family Psychiatry) and
two for Clinical Nurse Specialists (in Adult or Child/Adolescent Psychiatric Nursing). In order to become an advanced practice psychiatric nurse, an individual must
first be a registered nurse, which generally requires a passing score on the National Council Licensure Examination-RN (NCLEX-RN). See National Council of State
Boards of Nursing, NCLEX Examinations, https://www.ncsbn.org/nclex.htm.
n.
Some states may require that advanced practice psychiatric nurses be supervised by physicians.
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The Mental Health Workforce: A Primer
Mental Health Workforce Size
Access to mental health care depends in part on the overall number of practicing mental health
providers and the number of specific types of providers.16 As of January 2015, HRSA had
designated 4,071 Mental Health Professional Shortage Areas (MHPSAs), including one or more
in each state, the District of Columbia, and each of the territories.17 Although HRSA designates
MHPSAs, it does not collect parallel data on the size of the mental health workforce nationally.18
Figure 1 and Table 2 both present workforce size estimates for each core mental health provider
type from
•
The Mental Health and Substance Use Workforce for Older Adults: In Whose
Hands? by the IOM19 (supplemented with more recent data from the Bureau
Labor Statistics,20 one of the sources the IOM used);
•
Behavioral Health, United States, 2012 by SAMHSA;21 and
•
other sources, including professional associations and licensing boards.
Although the number of mental health providers in each profession varies across the three
sources,22 each source yields the same order of provider types from most plentiful to least
16
One of the primary challenges in assessing the overall size of the mental health workforce is that there is no uniform
definition; see “Mental Health Workforce Definition.” Using the HRSA definition of “core mental health
professionals,” a relatively narrow definition, yields a smaller estimate than would be found using a somewhat broader
definition such as the one used by SAMSHA or a much broader definition such as the one used by the IOM.
17
Health Resources and Services Administration, Data Warehouse, Health Professional Shortage Areas (HPSA) and
Medically Underserved Areas / Populations (MUA/P),” http://datawarehouse.hrsa.gov/topics/
shortageAreas.aspx#chart.
18
HRSA uses a variety of data sources when designating MHPSAs. Individual states apply to HRSA for MHPSA
designations. When doing so states must provide data on the ratio of health practitioners to population. States use a
variety of sources when providing these data including professional association data, state licensing data, and state
specific survey data. Source: E-mail from HHS Office of the Assistant Secretary for Legislation, August 1, 2013. In
November 2013, HRSA released a chartbook that included counts of certain behavioral health professions (e.g.,
psychologists and counselors); these data are not used in this CRS report because they do not include all professions
included in the MHPSA definition nor do they restrict counts to clinical practitioners. For more information, see U.S.
Department of Health and Human Services, Health Resources and Services Administration, National Center for Health
Workforce Analysis, The U.S. Health Workforce Chartbook, Part IV: Behavioral and Allied Health, Rockville, MD,
November 2013.
19
Institute of Medicine. (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?
Washington, DC: The National Academies Press. IOM is a private, nonprofit institution established in 1970 under the
congressional charter of the National Academy of Sciences to provide health policy advice. See National Academies,
Institute of Medicine, About the IOM, http://www.iom.edu/About-IOM.aspx. For information about the health
professions included in the IOM’s definition of the mental health workforce, see “Mental Health Workforce
Definition.” The IOM used data from the Bureau of Labor Statistics for 2011 in the IOM book. This CRS report uses
2013 data from the same source. IOM also used data for Advanced Practice Psychiatric Nurses (APPN) from the
National Sample Survey of Registered Nurses. This survey, commissioned by HRSA, was last conducted in 2008.
20
U.S. Department of Labor, Bureau of Labor Statistics, Occupational Employment Statistics, May 2013 Occupation
Profiles, http://www.bls.gov/oes/current/oes_stru.htm.
21
Substance Abuse and Mental Health Services Administration (SAMHSA). (2013). Behavioral Health, United States,
2012. HHS Publication No. (SMA) 13-4797. Rockville, MD: SAMHSA. SAMHSA is a public health agency
established within HHS by Congress in 1992 to advance mental health in the United States. See SAMHSA, About Us,
http://beta.samhsa.gov/about-us. For information about the health professions included in the SAMSHA’s definition of
the mental health workforce, see “Mental Health Workforce Definition: No Consensus.”
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plentiful, as illustrated in Figure 1. According to each data source, clinical social workers are
estimated to be the most plentiful, followed by clinical psychologists, who substantially
outnumber marriage and family therapists. While less abundant than the three aforementioned
provider types, psychiatrists outnumber advanced practice psychiatric nurses.
Figure 1. Workforce Size Estimates, by Mental Health Provider Type
Sources: CRS analysis of data from Institute of Medicine (IOM), The Mental Health and Substance use Workforce
for Older Adults: In Whose Hands? (Washington, DC: National Academies Press, 2012), supplemented with more
recent data from U.S. Department of Labor, Bureau of Labor Statistics, Occupational Employment Statistics, May
2013 Occupation Profiles, http://www.bls.gov/oes/current/oes_stru.htm.; Substance Abuse and Mental Health
Services Administration (SAMHSA), Behavioral Health, United States, 2012, Rockville, MD, 2013; and other
sources (i.e., professional associations and licensing boards).
Variation in the numbers from different sources reflects some of the difficulty in determining the
size of the workforce—and therefore also in determining the adequacy of the workforce to
provide access to mental health care. Along with workforce size estimates for each provider type,
Table 2 presents the original data sources (e.g., the IOM report relies on data from the Bureau of
Labor Statistics and the National Sample Survey of Registered Nurses for APPNs). Limitations of
each original data source may lead to overstating or understating the number of providers (e.g.,
(...continued)
22
The numbers obtained vary in part because these data sources rely on different methodologies including surveys,
state licensure data, and membership in professional associations.
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The Mental Health Workforce: A Primer
the Bureau of Labor Statistics data excludes self-employed workers). Major limitations are noted
in Table 2.
Even looking at the numbers in relative terms, the limitations of the original sources complicate
comparisons across professions. For example, the Bureau of Labor Statistics figures include
school psychologists and exclude school social workers, limiting their comparability.
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Table 2. Workforce Size Estimates, by Mental Health Provider Type
Provider
Type
Institute of Medicine (IOM) Reporta/
Bureau of Labor Statistics (BLS)
Other Sources
(Membership and Licensing)
Behavioral Health, United States, 2012b
Clinical
Social
Worker
110,010
BLS, May 2013, estimate of mental
health and substance abuse social
workers (SOC 21-1023). Excludes
the self-employed.
193,038
Psychlist Marketing, Inc. 2011.
Based on state licensure data with
duplicate addresses removed.
185,723
Association of Social Work
Boards, Inc., 2011, sum of statelevel numbers of MSWs with
experience. May double-count
those licensed in multiple states.
Excludes those from states that did
not report.
Clinical
Psychologist
104,480
BLS, May 2013, estimate of clinical,
counseling, and school
psychologists (SOC 19-3031).
Excludes the self-employed.
95,545
Psychlist Marketing, Inc. 2011.
Based on state licensure data with
duplicate addresses removed.
134,000
American Psychological
Association, 2013, members.
Includes members who are not
mental health providers (e.g.,
experimental psychologists).
Excludes non-members.
Marriage
and Family
Therapist
(MFT)
29,060
BLS, May 2013, estimate of
marriage and family therapists
(SOC 21-1013). Excludes the selfemployed.
62,316
Psychlist Marketing, Inc. 2011.
Based on state licensure data with
duplicate addresses removed.
58,007
American Association for Marriage
and Family Therapy, 2013, sum of
state-level numbers of fully
licensed MFTs from state boards.
May double-count those licensed in
multiple states. Excludes those
with provisional licenses.
Psychiatrist
25,040
BLS, May 2013, estimate of
psychiatrists (SOC 29-1066).
Excludes the self-employed.
33,727
American Medical Association
2011. Includes providers engaged
in patient care; excludes those in
training (e.g., residents and
fellows).
40,737
American Medical Association,
2013, Board Certified Psychiatrists.
Includes psychiatrists who are not
practicing (e.g., researchers or
retirees).
Advanced
Practice
Psychiatric
Nurse
(APPN)c
19,126
National Sample Survey of
Registered Nurses, 2008, estimates
of psychiatric advanced practice
registered nurses.
13,701
National Sample Survey of
Registered Nurses, 2008.
9,780
American Nurses Credentialing
Center, 2008, sum of state-level
numbers of APPNs.d May doublecount those licensed in multiple
states.
Notes: BLS = Bureau of Labor Statistics; SOC = Standard Occupational Classification (codes used by the Bureau of Labor Statistics).
CRS-11
a.
Institute of Medicine (IOM). (2012).The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC: The National Academies
Press. See Table 3-2 “Estimated Number of Mental Health/Substance Use (MH/SU) Specialists, 2011.” For all provider types other than advanced practice psychiatric
nurses, the IOM used data from the Bureau of Labor Statistics (BLS), Occupational Employment Statistics, Occupational Employment and Wages, May 2011. BLS
estimates are based on a survey that excludes self-employed workers. The data presented in this table are the 2013 data from the same source, U. S. Department of
Labor, Bureau of Labor Statistics, Occupational Employment Statistics, May 2013 Occupation Profiles, http://www.bls.gov/oes/current/oes_stru.htm.
b.
SAMHSA. (2013). Behavioral Health, United States, 2013. HHS Publication No. (SMA) 13-4797. Rockville, MD: SAMSHA. See Table 93 “Mental Health and Substance
Abuse Treatment Providers, by discipline and state: number, United States, 2008, 2009, and 2011.”
c.
The IOM and SAMHSA present different numbers, both attributed to the same source. The information provided was not sufficient to explain how this occurred.
d.
Cited in Hanrahan et al. (2010), “Health Care Reform and the Federal Transformation Initiatives: Capitalizing on the Potential of Advanced Practice Psychiatric
Nurses,” Policy, Politics, & Nursing Practice 11(3): 235-244.
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The Mental Health Workforce: A Primer
Mental Health Workforce Annual Wages
Just as access to mental health care providers depends partly on the size of the mental health
workforce, the cost of mental health care depends partly on the wages paid to mental health
providers. Table 3 presents mean and median annual wages from the Bureau of Labor Statistics
(BLS). These wage data are widely used because of their large sample size, broad geographic
reach, and the comparable methodology used to collect data across occupations.23 Information
from BLS is likely to either over- or under-state wages for some mental health providers; the data
are based on a survey that excludes self-employed workers (i.e., those in private practice), who
may have different incomes. For example, for both clinical psychologists and clinical social
workers, the categories used by the BLS include individuals who may earn substantially less than
those who meet the HRSA definition of the provider type. The wage estimates for clinical
psychologists are based on a category that includes school psychologists, who do not have to
meet the same licensure requirements as HRSA-defined clinical psychologists and thus might
receive lower wages. Similarly, the wage estimates for clinical social workers are based on a
category that includes individuals who are not licensed for independent practice and who also
might earn less.
Despite their limitations, the BLS data are able to illuminate the relative wages of each provider
type as outlined in Table 3. Psychiatrists are the relative highest earners, followed by advanced
practice psychiatric nurses and clinical psychologists. Marriage and family therapists generally
earn more than clinical social workers.
Table 3. Mean and Median Annual Wages, by Mental Health Provider Type
Annual Wage
Provider Type
Mean
Clinical Social Worker
$44,420
$40,970
Mental Health and Substance Abuse Social Workers
(SOC 21-1023). No distinction is made between
levels of education or licensure.
Clinical Psychologist
$72,710
$67,760
Clinical, Counseling, and School Psychologists (SOC
19-3031).
Marriage and Family
Therapist (MFT)
$51,690
Psychiatrist
Advanced Practice Psychiatric
Nurse (APPN)
Median
BLS Category Useda
$48.160
Marriage and Family Therapists (SOC 21-1013).
$182,660
$178,950
Psychiatrists (SOC 29-1066).
$95,070
$92,670
Nurse Practitioners (SOC 29-1171). No estimate is
provided for the psychiatric/mental health specialty.
Source: CRS summary of data from U.S. Department of Labor, Bureau of Labor Statistics, Occupational
Employment Statistics, May 2013 Occupation Profiles, http://www.bls.gov/oes/current/oes_stru.htm.
a.
BLS wage estimates do not include self-employed workers. SOC = Standard Occupational Classification
(codes used by the Bureau of Labor Statistics).
23
For example, the BLS Handbook of Methods, Chapter 3: Occupational Employment Statistics discusses the uses of
the OES data that include federal programs, state workforce agencies, and the Department of Labor Foreign Labor
Certification Program, see http://www.bls.gov/opub/hom/homch3.htm#uses.
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Concluding Comments
Understanding the mental health workforce may help policymakers address a range of potential
policy issues related to mental health care, including its quality, access, and cost.
An understanding of typical licensure requirements and scopes of practice may help policymakers
determine how to direct federal policy initiatives focused on enhancing the quality of mental
health care such as those related to training mental health providers. If, for example, training new
providers quickly is a priority, initiatives may focus on training additional providers who can be
licensed with a master’s degree, rather than a doctoral degree. Initiatives may focus on training
providers who can prescribe medication if the need is greater for medication than for
psychosocial interventions. Going beyond the provider types discussed in this report, if a priority
is to expand the breadth of the mental health workforce, policymakers might also consider federal
training directed toward initiatives that focus on paraprofessionals who do not require extensive
training or toward primary care professionals who do not specialize in mental health but may
provide care for individuals with mental illness. Increasing the breadth of the mental health
workforce may also increase its overall size.
Another way policymakers may influence the size of the mental health workforce (and thus
access to mental health services) is through the provision or expansion of federal programs.24 For
example, the federal government may provide grants to establish or expand training programs for
mental health providers. The federal government may also provide incentives such as loan
repayment or loan forgiveness to encourage individuals to enter mental health occupations, which
are projected to grow faster than the overall workforce.25 Policymakers may consider strategies to
direct people into these high growth fields as part of larger labor force policy considerations.
Initiatives may be targeted to certain provider types or to certain locations (e.g., MHPSAs).
Policymakers may also wish to consider the relative wages of different provider types,
particularly when addressing domains within which the federal government employs mental
health providers. For instance, agencies which employ these mental health professionals include
the Department of Defense, the Veterans Health Administration (within the Department of
Veterans Affairs), the Bureau of Prisons (within the Department of Justice), and the Indian Health
Service (within HHS), among other agencies. The federal government is the largest employer of
some provider types, such as clinical psychologists and social workers.26 As such, the cost of
24
CRS Report R42029, Physician Supply and the Affordable Care Act, discusses the interplay between the demand for
health services and the supply of a specific type of providers: physicians. Some of the discussion and some of the
policy levers used to affect physician supply could also be used to affect the mental health workforce. For a description
of health workforce programs, see CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in
ACA: Summary and Timeline; CRS Report R42029, Physician Supply and the Affordable Care Act, and U.S.
Government Accountability Office (GAO), Health Care Workforce: Federally Funded Training Programs in Fiscal
Year 2012, 13-709R, August 15, 2013, http://www.gao.gov/products/GAO-13-709R.
25
BLS projects the growth rate between 2012 and 2020 to be 11% among all occupations, 22% among health care
practitioners, and higher within some of the mental health professions (e.g., 31% among marriage and family therapists
and 23% among mental health and substance abuse social workers). Department of Labor, Bureau of Labor Statistics,
“Employment Projections, Employment by Occupation,” December 19, 2013, http://www.bls.gov/emp/
ep_table_102.htm.
26
See, for example, U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, Human
Resources Challenges with the Veterans Health Administration, committee print, prepared by Randy Phelps, Deputy
Executive Director for Professional Practice of the American Psychological Association, 110th Cong., May 22, 2008,
http://veterans.house.gov/witness-testimony/randy-phelps-phd; psychologist recruiting information from the Federal
(continued...)
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employing different provider types—as well as their scopes of practice—may be a consideration
not only in determining staffing priorities, but also in attempts to recruit and retain mental health
providers (e.g., by offering competitive compensation).
(...continued)
Bureau of Prisons at http://www.bop.gov/jobs/hsd/psychology_services.jspl; and social work recruiting information
from the Department of Veterans Affairs at http://www.vacareers.va.gov/resources/downloads/MHEI_Brochure.pdf.
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The Mental Health Workforce: A Primer
Appendix A. Mental Health Professional Shortage
Areas (MHPSA) Definition
This appendix excerpts the specific criteria that the Health Resources and Services Administration
(HRSA) uses to designate mental health professional shortage areas (MHPSAs). MHPSAs can be
geographic areas, population groups, or facilities. This designation is used to determine eligibility
for federal programs such as Medicare bonus payments and health professions recruitment
programs. HRSA bases the MHPSA designation on the availability (relative to population size) of
“core mental health professionals,” which include “psychiatrists, clinical psychologists, clinical
social workers, psychiatric nurse specialists, and marriage and family therapists.” The criteria for
designating a MHPSA are as follows:27
1. Geographic Areas must:
•
Be a rational area for the delivery of mental health services
•
Meet one of the following conditions:
•
•
•
A population-to-core-mental-health-professional ratio greater than or
equal to 6,000:1 and a population-to-psychiatrist ratio greater than or
equal to 20,000:1 or
•
A population-to-core professional ratio greater than or equal to 9,000:1
or
•
A population-to-psychiatrist ratio greater than or equal to 30,000:1
Have unusually high needs for mental health services, and
•
A population-to-core-mental-health-professional ratio greater than or
equal to 4,500:1 and a population-to-psychiatrist ratio greater than or
equal to 15,000:1, or
•
A population-to-core-professional ratio greater than or equal to 6,000:1,
or
•
A population-to-psychiatrist ratio greater than or equal to 20,000:1
Mental health professionals in contiguous areas are overutilized, excessively
distant or inaccessible to residents of the area under consideration.
2. Population Groups must:
•
Face access barriers that prevent the population group from use of the area’s
mental health providers
•
Meet one of the following criteria:
•
Have a ratio of the number of persons in the population group to the
number of FTE core mental health professionals serving the population
27
See U.S. Department of Health and Human Services, Health Resources and Services Administration, “Mental Health
HPSA Designation Overview,” http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsaoverview.html.
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group greater than or equal to 4,500:1 and the ratio of the number of
persons in the population group to the number of FTE psychiatrists
serving the population group greater than or equal to 15,000:1; or
•
Have a ratio of the number of persons in the population group to the
number of FTE core mental health professionals serving the population
group greater than or equal to 6,000:1; or
•
Have a ratio of the number of persons in the population group to the
number of FTE psychiatrists serving the population group are greater
than or equal to 20,000:1
3. Facilities must:
•
Be maximum or medium security facilities
•
Be either Federal and/or State correctional institutions, State/County mental
hospitals or public and/or non-profit mental health facilities
•
Federal or State Correctional facilities must:
•
•
•
Have at least 250 inmates and
•
Have a ratio of the number of internees per year to the number of FTE
[full-time equivalent] psychiatrists serving the institution of at least
2,000:1
State and county mental health hospitals must:
•
Have an average daily inpatient amount of at least 100; and
•
The number of workload units per FTE psychiatrists available at the
hospital exceeds 300, where workload units are calculated using the
following formula: Total workload units = average daily inpatient census
+ 2 x (number of inpatient admissions per year) + 0.5 x (number of
admissions to day care and outpatient services per year).
Community mental health centers and other public and non-profit facilities must:
•
Be providing (or responsible for providing) mental health services to an
area or population group designated as having a shortage of mental
health professionals and
•
Have insufficient capacity to meet the psychiatric needs of the area or
population group
B. Methodology.28
In determining whether an area meets the criteria... the following methodology will be used:
1. Rational Areas for the Delivery of Mental Health Services.
28
U.S. Department of Health and Human Services, Health Resources and Services Administration, “Mental Health
HPSA Designation Criteria,” http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsacriteria.html.
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The Mental Health Workforce: A Primer
(a) The following areas will be considered rational areas for the delivery of mental health
services:
(i) An established mental health catchment area, as designated in the State Mental Health
Plan under the general criteria set forth in section 238 of the Community Mental Health
Centers Act.
(ii) A portion of an established mental health catchment area whose population, because of
topography, market and/or transportation patterns or other factors, has limited access to
mental health resources in the rest of the catchment area, as measured generally by a travel
time of greater than 40 minutes to these resources.
(iii) A county or metropolitan area which contains more than one mental health catchment
area, where data are unavailable by individual catchment area.
(b) The following distances will be used as guidelines in determining distances corresponding
to 40 minutes travel time:
(i) Under normal conditions with primary roads available: 25 miles.
(ii) In mountainous terrain or in areas with only secondary roads available: 20 miles.
(iii) In flat terrain or in areas connected by interstate highways: 30 miles.
Within inner portions of metropolitan areas, information on the public transportation system
will be used to determine the distance corresponding to 40 minutes travel time.
2. Population Count.
The population count used will be the total permanent resident civilian population of the
area, excluding inmates of institutions.
3. Counting of mental health professionals.
(a) All non-Federal core mental health professionals (as defined below) providing mental
health patient care (direct or other, including consultation and supervision) in ambulatory or
other short-term care settings to residents of the area will be counted. Data on each type of
core professional should be presented separately, in terms of the number of full-timeequivalent (FTE) practitioners of each type represented.
(b) Definitions:
(i) Core mental health professionals or core professionals includes those psychiatrists,
clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage
and family therapists who meet the definitions below.
(ii) Psychiatrist means a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who
(A) Is certified as a psychiatrist or child psychiatrist by the American Medical Specialties
Board of Psychiatry and Neurology or by the American Osteopathic Board of Neurology and
Psychiatry, or, if not certified, is “board-eligible” (i.e., has successfully completed an
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The Mental Health Workforce: A Primer
accredited program of graduate medical or osteopathic education in psychiatry or child
psychiatry); and
(B) Practices patient care psychiatry or child psychiatry, and is licensed to do so, if required
by the State of practice.
(iii) Clinical psychologist means an individual (normally with a doctorate in psychology) who
is practicing as a clinical or counseling psychologist and is licensed or certified to do so by
the State of practice; or, if licensure or certification is not required in the State of practice, an
individual with a doctorate in psychology and two years of supervised clinical or counseling
experience. (School psychologists are not included.)
Clinical social worker means an individual who—
(A) Is certified as a clinical social worker by the American Board of Examiners in Clinical
Social Work, or is listed on the National Association of Social Workers’ Clinical Register, or
has a master’s degree in social work and two years of supervised clinical experience; and
(B) Is licensed to practice as a social worker, if required by the State of practice.
(v) Psychiatric nurse specialist means a registered nurse (R.N.) who—
(A) Is certified by the American Nurses Association as a psychiatric and mental health
clinical nurse specialist, or has a master’s degree in nursing with a specialization in
psychiatric/mental health and two years of supervised clinical experience; and
(B) Is licensed to practice as a psychiatric or mental health nurse specialist, if required by the
State of practice.
(vi) Marriage and family therapist means an individual (normally with a master’s or doctoral
degree in marital and family therapy and at least two years of supervised clinical experience)
who is practicing as a marital and family therapist and is licensed or certified to do so by the
State of practice; or, if licensure or certification is not required by the State of practice, is
eligible for clinical membership in the American Association for Marriage and Family
Therapy.
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Appendix B. Additional Resources
Below are resources for additional information about each mental health provider type, including
national associations of state boards, professional associations, accrediting organizations for
educational programs, and other relevant organizations. In some cases, a single organization may
serve multiple roles (e.g., a professional association may also accredit educational programs).
Psychiatrists
American Academy of Addiction Psychiatry (AAAP): http://www2.aaap.org
American Academy of Child & Adolescent Psychiatry (AACAP): http://www.aacap.org
American Academy of Clinical Psychiatrists (AACP): https://www.aacp.com
American Board of Medical Specialties (ABMS): http://www.abms.org
American Board of Psychiatry and Neurology (ABPN): http://www.abpn.com
American Psychiatric Association (APA): http://www.psych.org
National Board of Osteopathic Examiners: http://www.nbome.org
Psychologists
American Psychological Association (APA): http://www.apa.org
Association of State and Provincial Psychology Boards (ASPPB): http://www.asppb.net
Social Workers
Association of Social Work Boards (ASWB): http://www.aswb.org
Council on Social Work Education (CSWE): http://www.cswe.org
National Association of Social Workers (NASW): http://www.socialworkers.org
Social Work Policy Institute (SWPI): http://www.socialworkpolicy.org
Advanced Practice Psychiatric Nurses
American Academy of Nurse Practitioners (AANP): http://www.aanp.org
American Nurses Credentialing Center (ANCC): http://www.nursecredentialing.org
American Psychiatric Nurses Association (APNA): http://www.apna.org
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National Association of Clinical Nurse Specialists (NACNS): http://www.nacns.org
National Council of State Boards of Nursing (NCSBN): https://www.ncsbn.org
Marriage and Family Therapists
American Association for Marriage and Family Therapy (AAMFT): http://www.aamft.org
Association of Marital and Family Therapy Regulatory Boards (AMFTRB):
http://www.amftrb.org
Author Contact Information
Elayne J. Heisler
Specialist in Health Services
[email protected], 7-4453
Erin Bagalman
Analyst in Health Policy
[email protected], 7-5345
Acknowledgments
Jimmylee Gutierrez conducted background research for this report during an internship with CRS. Adam
Salazar, Research Assistant, provided valuable assistance in updating this report.
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