Kristi McCaskill, M.Ed., NCC, NCSC
INTRODUCTION AND EXECUTIVE SUMMARY
Mr. Chairman and Honorable Members of the Veterans Affairs Committee, I thank you for the opportunity to present testimony regarding the need for additional mental health care providers in the Department of Veteran’s Affairs (VA). As a representative of the National Board for Certified Counselors (NBCC), I believe that counselors play an important role in assisting the VA with health care recruitment and retention.
By way of background, I am the Counseling Advocacy Coordinator at the NBCC. For the past two years, I have worked with certificants as they explain their certification and qualifications to prospective employers, to the public, and to legislators. As a certificant of NBCC, I understand the value of counseling and counseling credentials. I was trained as a school counselor at the University of North Carolina at Chapel Hill. Shortly after graduation and beginning work as a counselor in the schools, I completed my certification as a National Certified Counselor (NCC). The NCC is the flagship certification offered by the NBCC. I also possess the NBCC specialty certification for school counseling, the National Certified School Counselor (NCSC).
NBCC is the nation’s premiere professional certification board devoted to credentialing counselors who meet standards for the general and specialty practices of professional counseling. Founded in 1982 as an independent, non-profit credentialing body, NBCC provides a national certification system for professional counselors, identifies those counselors who have obtained certification, and maintains a registry of those counselors.
NBCC is the largest certification agency for professional counselors in the United States, certifying more than 42,000 practitioners, living and working in the U.S. and over 40 countries. We also create and distribute all licensure examinations for 49 states, District of Columbia and Puerto Rico. NBCC works closely with over 300 universities offering master’s level education in counseling throughout the United States as well as around the world.
The practice of professional counseling involves the application of mental health, psychological, and human development principles, through cognitive, affective, behavioral or systematic strategies, that address wellness, personal growth, or career development, as well as pathology. Working with individuals, groups, families and organizations in a variety of settings, professional counselors are trained to address a wide range of issues including anxiety, depression, bereavement, addiction, coping with illness and disability, adjustments in living situations, family and relationship issues and job stress. Professional counselors also provide emergency services in times of catastrophic events, such as acts of terror and natural disasters, which can severely traumatize survivors. NBCC has established an enforceable Code of Ethics to foster ethical practices for all clients of NBCC credentialed counselors.
Counselors certified by NBCC meet predetermined standards in education, training, and experience. For 25 years, NBCC has offered the NCC, the first general practice counseling credential with nationwide recognition. NBCC also offers specialty credentials for mental health counselors, addictions counselors, and school counselors. These specialized credentials require advanced knowledge and experience in these respective counseling fields.
As a non-profit 501 (C) (3) organization, NBCC continues to promote leadership, accountability and quality assurance within the counseling profession.
NBCC and licensed professional counselors are pleased with the passage of the Veterans Benefits, Health Care, and Information Technology Act of 2006 (Public Law 109-461), which was signed into law on December 22, 2006, and we thank this Committee for working so hard to pass this legislation during the last session of Congress. This groundbreaking legislation paved the way for licensed counselors to utilize their training and skills to meet the increasing needs of veterans.
This legislation explicitly recognizes licensed professional counselors as health care providers within the Veterans Healthcare Administration (VHA) (including licensed marriage and family therapists). It also delineates the qualifications mental health counselors need to be appointed to a position in the VA. This legislation is the result of years of work by the counseling profession and Congress to gain recognition of licensed counselors within the VA. Although rehabilitation counselors are recognized within the VA, licensed professional counselors have had only a limited role as mental health providers. Prior to passage of this law, the VA could not hire counselors for mental health professional positions at the same pay grade as clinical social workers, nor could licensed professional counselors apply for supervisory positions open to clinical social workers and others.
Passage of this law will allow counselors access to better paying jobs as mental health specialists, with the potential for promotion into supervisory positions. This will increase the pool of mental health specialists the VA is able to draw upon in attempting to meet the growing health care needs of veterans. With enactment of the provision, the federal Office of Personnel Management (OPM) will be required to create a General Schedule (GS) occupational classification for mental health counselors, which is necessary for a counselor to be employed by the U.S. Government.
In my position with NBCC, I understand the frustration that some counselors have experienced in their attempts to work within the VA health system. In the past, licensed professional counselors faced significant employment obstacles within the Veterans Health Administration (VHA) and its hospitals, clinics, and programs across the country. While some counselors have found positions within the agency, either on a contract or full-time basis, there continue to be barriers to independent practice, advancement, and hiring.
While licensed clinical social workers were able to practice independently and serve as clinical supervisors in the VA, counselors found themselves struggling to achieve similar recognition. The VA remains the largest employer of clinical social workers in the country, and the VA employs very few counselors on a full-time basis. According to the VHA, most supervisory positions at Department hospitals and clinics are filled by psychiatrists, psychologists, and social workers. Many VHA positions in mental health services are developed by social workers on staff, and therefore the agency is most likely to hire social workers first. Psychiatrists, psychologists, and clinical social workers are specifically named in VA statutes. While VHA says there is no formal policy excluding licensed professional counselors from being hired, some have found that the VA does not recognize their licensure, and therefore refuses to hire them or relegates them to non-clinical positions. The lack of recognition of licensed professional counselors by OPM exacerbates this problem.
We commend the United States Congress for recognizing the need for mental health counseling within the VA and thank you for passing such meaningful legislation. The inclusion of licensed counselors by the VA and the quality of the services they provide will make it easier for those who served our nation and in need of mental health services to get the health care they need. This issue is especially important given the increasing number of veterans returning from Iraq and Afghanistan with symptoms of mental illness.
I believe we are all familiar with the mental health needs of our returning service men and women and veterans from Iraq and Afghanistan. According to a report by the United Press (UP) in June of 2005, the Army’s first study of the mental health of our troops who fought in Iraq, found that about one in eight reported symptoms of post-traumatic stress disorder (PTSD), which can cause flashbacks of traumatic combat experiences and other severe reactions. By mid-2006, more than one in three soldiers and Marines returning from the wars in Iraq, Afghanistan and other locations later sought help for mental health problems. About 35 percent of soldiers are seeking some kind of mental health treatment a year after returning home under a program that screens returning troops for physical and mental health. I need not elaborate more to convey the immense impact PTSD and other mental health issues has on our soldiers, especially those with repeated and extended deployment to battle zones. PTSD and other effects of war linger and will require ongoing care for many years to come.
The VA and the Pentagon have acknowledged a need to improve access to mental health treatment. NBCC is encouraged by the recent announcements of VA’s intention of hiring suicide prevention counselors at VA medical centers, providing readjustment counseling at VA community based Vets Centers, and increasing outreach and advocacy efforts for veterans of the Global War on Terror. However, NBCC is concerned that little has been accomplished in the 10 months that have passed since legislation was signed into law recognizing licensed professional counselors as health care providers within the VHA. VA now has the statutory authority to make these changes, and we are concerned that licensed professional counselors are not being utilized to serve in the VA health system.
There is a practical solution to the shortage of mental health care professionals available to veterans. By fully implementing Public Law 109-461 and creating a counselor job classification within the GS schedule, more than 100,000 clinically trained counselors would be added to the pool of possible candidates to these positions.
THE NATIONAL BOARD FOR CERTIFIED COUNSELORS (NBCC)
NBCC has created and maintained standards for professional counselors for 25 years. These standards include specifications regarding education, experience, and required examinations for initial certification. Continuing education in the mental health field and adherence to NBCC’s Code of Ethics are required in order to maintain certification. Any applicant or certificant violating the Code of Ethics is subject to sanctions determined by a well-developed adjudication process.
The initial, fundamental designation awarded by the NBCC is the National Certified Counselor (NCC) certification. To become certified as a NCC, the applicant must document graduation from (at least) a master’s-level CACREP-accredited program (or an equivalent curriculum), complete a specified minimum number of hours of supervised experience as a counselor, and pass a national counselor examination. Qualified NCCs who work as school counselors, clinical mental health counselors, or addictions counselors may apply for specialized credentials through NBCC. In order to obtain a specialized credential, additional education, experience, and assessment requirements must be met. NBCC also creates and distributes the licensure examinations for the 49 states that regulate the practice of counseling, District of Columbia and Puerto Rico.
NBCC’s educational requirement and assessments are based on educational standards developed by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP). In addition, NBCC adheres to the Standards for Educational and Psychological Testing (1999) and the U.S Federal Uniform Guidelines on Employee Selection Procedures (1978) in its commitment to providing assessments that test examinees’ ability to apply knowledge in ways that define safe and effective professional practice, with public protection as the ultimate goal. The Uniform Guidelines identify job analysis as the sine qua non of procedures for amassing content-related validity evidence for licensure testing. NBCC utilizes the job analysis framework, developing a detailed list of responsibilities that counselors routinely perform, as well as responsibilities that are essential to safe and effective practice of counseling. The validity of NBCC’s assessment development process, maintenance, and security processes is acknowledged nationwide as the standard for the counseling profession. Both the National Certified Counselor Certification and the Master’s Addiction Counselor Certification are accredited by the National Commission for Certifying Agencies (NCCA). Utilizing an assessment based on a national analysis of the work performed by professional counselors helps assure that NBCC’s certificants and the states’ licensees possess the knowledge essential to providing excellent service.
In June 2007, Nevada passed counselor licensure legislation bringing the total number of states regulating the practice of counseling to 49. The only state without such provision is California where similar legislation is pending. Nationwide, there is a growing body of about 100,000 professional counselors licensed to practice independently. Under state laws, credentialed counselors have the authority to practice independently and increasing numbers may bill insurance companies for reimbursement of services provided.
Professional counselors possess a master’s degree or higher from an accredited college or university. The degree program must cover specific coursework including counseling theories, group counseling, social/cultural foundations, human growth and development, appraisal/assessment techniques, etc. Additionally, professional counselors must document a supervised professional practice, pass a national counselor examination, submit a professional disclosure statement, and must keep current their professional education.
Licensed counselors are well qualified professionals that assist people of all ages and abilities to develop life-enhancing skills. They utilize their skills to identify and treat emotional, psychological or behavioral disorders which may interfere with daily activities. While counselors are trained to understand mental illnesses, counselors approach issues from a developmental perspective. This perspective of strength building encourages those who are struggling to seek help and reduces stigma.
THE NEED FOR INCREASED MENTAL HEALTH SERVICE PROVIDERS
In February 2007, a Presidential Task Force conducted an investigation on the psychological needs of U.S. Military Members and their families identified three main barriers to effective military mental health treatment:
- a shortage of professionals experienced in military life,
- the stigma of receiving mental health services, and
- difficulties assessing help due to long waiting lists, limited clinic hours, location, etc.
Other important statistics found in this study include:
- Over 23,000 have returned with physical wounds and permanent disabilities including traumatic brain injury.
- As many as one-fourth of returning servicemen and women are struggling with psychological injuries.
- There has been a 22% decrease of licensed clinical psychologists serving servicemen and women.
- There are approximately 1,839 psychologists employed by the VA to serve more than 24.3 million veterans from previous wars as well as the rapidly growing number from the current conflict.
The VA acknowledges the need for increased mental health providers. A tour of the VA website in the mental health section provides the following information:
- “Suicide is the 11th most frequent cause of death in the US: someone dies from suicide every 16 minutes.”
- “The newest patients to the VA have been returning combat soldiers, men and women who served in Operations Enduring Freedom and Iraqi Freedom (OEF/OIF).”
- “In a recent study, Dr. Karen Seal and colleagues at the San Francisco Veterans Affairs Medical Center and USC, reviewed records for over 100,000 veterans, who separated from active duty between 2001-2005 and sought care from VA medical facilities.”
- “The most common combination of diagnoses found was post traumatic stress disorder (PTSD) and depression.”
- “Young soldiers were three times as likely as those over 40 to be diagnosed with PTSD and/or another mental health disorder.”
- “VA is expanding counseling and mental health services to meet the needs of the returning veterans and provide early treatment.”
In recent testimony provided to the President’s Commission on the Care of Wounded Warriors, Dr. Thomas Clawson, the President and CEO of NBCC, illustrated the connection between PTSD and the witnessing of traumatic events. His testimony included information regarding the occurrence rates of other disorders within the military – anxiety disorder (24%), adjustment disorder (24%), depression (20%) and substance abuse disorder (20%). Despite these numbers, Dr. Clawson noted that less than half with problems sought help because they were worried that it would have an adverse affect n their status within the military. Dr. Clawson also referenced a report from the Office of the Surgeon General of the U.S. Army Medical Command which stated the conditions under which our service men and women currently serve are unprecedented and have a significant influence upon them.
This information is consistent with a statement by Vice Admiral Donald C. Arthur, MC, CSN, co-chairman of the Department of Defense Task Force on Mental Health. According to Admiral Arthur, “Not since Vietnam have we seen this level of combat. With this increase in psychological need, we now find that we have not enough providers in our system.”
Furthermore, in recent testimony, Dr. Antoinette Zeiss, Ph.D., Deputy Chief Consultant, Office of Mental Health Services, Department of Veterans Affairs, stated that the VA has seen many returning veterans with “injuries of the mind and spirit.” Recognizing the increasing need for mental health services, Dr. Zeiss’s testimony included a plan to expand the number of Vet Centers from 209 to 232 over the next two years. She elaborated that these centers are staffed by psychologists, nurses, and social workers. Dr. Zeiss projected that 686,306 service members have been discharged since the end of the first quarter of FY 2007, and that of those, nearly 33% have sought care. Of the group that sought care, she reports that mental health problems are the second most common.
The implementation of licensed counselors in the VA system is one method of helping to address this increasing and apparent need for providers. Implementation will increase access to returning veterans and address the issue of long wait times for care and treatment by veterans. Furthermore, it is cost-effective to utilize licensed professional counselors who work at different pay grades than to psychiatrists and psychologists.
THE DEPARTMENT OF VETERAN’S AFFAIRS (VA) AND P.L. 109-461
With the passage of PL 109-461in December 2006, licensed mental health counselors were recognized as mental health specialists by the Department of Veteran’s Affairs (VA). NBCC is concerned that in the ten months following the passage of PL 109-461, the VA has not made any visible progress and there still is not a General Schedule (GS) occupational classification for counselors, paving the way for licensed counselors to become recognized as service providers.
The VA website references the U.S. Office of Personnel Management (OPM) as the primary method of determining basic qualifications for every job within the federal government. VA vacancy announcements provide additional qualifications needed for specific positions. Potential applicants are encouraged not to apply if they do not meet both the required minimum qualifications and any selective factors described. Without a new GS schedule specifically designed for counselors, it is difficult, if not impossible, for counselors to become employed at the VA, despite the passage of PL 109-461.
NBCC would like to offer itself as a resource to military and government leaders, including the VA and the OPM, and we remain committed to developing long term solutions to the current and future mental health needs of our service members and their families. As an organization with over 25 years experience, NBCC maintains close associations with other professional counseling organizations including the American Association of State Counseling Boards (AASCB), the organization representing state licensure boards. We are prepared and capable of connecting licensed counselors with the VA so that together we can provide services for the increasing mental health needs of veterans. Licensed counselors are well qualified professionals with training and experience in helping those who are struggling with depression, post-traumatic stress disorder (PTSD), stress/anxiety, and other mental health issues. P.L. 109-461 was an important step in adding qualified mental health service providers. We are enthusiastically poised for the next steps which would allow counselors to work for the VA.
As a demonstration of our eagerness, we have compiled information which could be helpful to OPM in the creation of a job classification. By working together, NBCC and licensed counselors in the United States can help the VA in its mission to serve America’s veterans and their families with dignity and compassion and to help ensure that they receive appropriate services and support in recognition of their service to this Nation.
On behalf of NBCC, I want to again express my appreciation to the members of the Subcommittee on Heath of the U.S. House of Representatives Committee on Veteran’s Affairs for their dedication to the provision of quality mental health services to our veterans. It would be our pleasure and an honor to work with you to establish a mechanism to allow licensed counselors to serve veterans who not only have given of themselves to protect our country, but who now need our help.
NBCC stands ready, willing, and able to work cooperatively, effectively, and professionally with VA and Congressional leaders interested in developing a lasting solution to current and future mental health needs of our active duty servicemembers, veterans, and their families.