Executives Must Get a Grip on the Expansion of Unlicensed Counselors

Opportunities to coach and counsel others on behavioral issues have been growing. The roles are varied and share a lack of professional license for doing such work. Some get voluntary certifications and others work in treatment settings with quasi-supervisory arrangements. While not necessarily a cause for worry, it merits analysis due to the wide range of activities, steady growth, and potential for abuse.

Whatever their training or title, these counselors are having personal conversations with consumers. A life coach might be hired privately, while an unlicensed behavioral specialist might work in a primary care physician’s (PCP) office. How do we categorize this work? What standards should exist and how do we ensure quality? This needs debate, and in practical terms, any action to be taken falls to executives in healthcare.

Framing the Issue

Let’s start with well-defined roles that cause no worry. Treatment facilities hire unlicensed staff to work in their programs, and certified peer specialists use their lived experience with a mental health condition or substance use disorder (SUD) to support and mentor others in recovery. This is different from unlicensed counselors providing behavioral interventions in nearly autonomous roles, much like licensed counselors.

There can be no question that people lacking advanced credentials provide valuable patient care. Many can connect with very challenging individuals and make a profound difference. Outcomes research has long noted that credentials do not drive results. People without them can be natural healers who facilitate more change than some with advanced education and training.

Life coaches are a growing, unique group. This vague yet expansive role may be more inspirational than clinical in nature, but many see it as an alternative to psychotherapy. Coaching lacks the stigma of therapy, and it seems to leverage the personality of the coach more than using specific techniques. While it resembles therapy, it lacks therapy’s quality checks or consumer protections.

Our concern should focus on quasi-independent healthcare roles. Are these specialists safe because they use evidence-based approaches like cognitive behavioral therapy (CBT) or behavioral counseling interventions for unhealthy behaviors? Can validated techniques be delivered by anyone? Surely not, but where do unlicensed staff fit? Is this a separate category to be trusted?

Erosion of Professional Boundaries

Behavioral coaches and counselors are growing in the primary care setting based on concerns about psychiatric conditions like depression and behaviorally driven conditions like diabetes. PCPs handle every condition, and it is reasonable for them to expand their care teams with behavioral specialists. However, many specialists are unlicensed, and PCPs are leaders of a quasi-supervisory setting.

Psychotherapists are licensed. Behavioral visits are private when the door closes, and licensure is one of many quality assurance tools. The expansion of unlicensed counseling is not surprising because it is an appealing career choice for many. However, these are not professional roles with a clear scope of practice. While these roles were created with good intentions, they are open to misuse.

Any hope of having clear boundaries evaporates upon reading job descriptions. An online posting for behavioral specialist clearly crosses professional lines. This example from a national recruiter seeks candidates:

• With an unspecified degree “in mental health, psychology, or a related field” to develop and implement “treatment plans to address behavioral issues” and “conduct assessments” on treatment progress.
• Specialists will “treat individuals with emotional or behavioral problems and disorders such as depression, anxiety, addiction, autism, ADHD, OCD, etc.”

This does not fit an unlicensed role. We should reject placing sophisticated clinical demands on marginally trained people. Yet no licensing board has standing to hear complaints. Our best choice is to not hire them and encourage opposition to this trend.

For the Sake of Care Access?

This trend of pseudo-specialists should prompt debate on how far we go to solve our care access problem. Digital therapeutics raise a similar conundrum. They offer valuable self-help tools, but should we prioritize their wide dissemination as a strategy for improving care access? These scalable, lower cost solutions will be hard for many businesses to resist.

Business often seeks lower cost solutions. It is attractive to stay affordable while solving problems. If experts validate such solutions, investors will fund them. Yet executives can also stop trends by not funding them. This unlicensed trend rests with executives who should ask a simple question. Is this how you want family members to receive care?

An alternative medical approach bears consideration, though it brings complications. Lower tiered professions like nurse practitioners and physician assistants were created for basic medical care. Might a similar path be right here? Clients would get the added assurance of quality that comes with licensure, and some of today’s unlicensed counselors might still provide care. Turf battles would surely follow.

We should probably not settle on a solution now. A sense of urgency is more critical. These roles are gaining credibility as efficient ways to improve access and integrate behavioral with medical care. Only executives have the clout to pause this development.

Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.