health workers who are eligible for insurance reimbursement, many rural residents receive mental health services from their primary care practitioners, who may be ill-prepared to provide such services, and lack the time to provide counseling (Rost, Owen, Smith and Smith, 1998; Mechanic, 1990).
While reimbursement policies may have greater effect than licensure laws in determining what kinds of professionals choose to practice in rural areas, some third party payers, such as Medicare, look to licensure laws as an indication of which provider types they will allow to bill them directly. While details of such payment policies are beyond the scope of this paper, a thorough review of licensure laws is a logical starting point in examining differences among the mental health professions. This study examines state licensure laws and administrative rules for social workers, psychologists, professional counselors and marriage and family therapists in all states with at least ten percent of the population living in rural areas, for a total of 40 states.a Where licensure laws and rules have explicit implications for reimbursement for one or more of these professions, this is reported. b
To facilitate interpretation of these findings, this study also examines the history and professional culture of each of these professions. How the members of a profession see themselves and their role as providers has, in many respects, evolved in contrast to another profession. For example, psychologists may define their role in terms of psychiatry, while social workers may define their role in terms of psychology. Historically, professional counselors have reacted against each of these professions, viewing them as “disease-oriented,” and have preferred to emphasis mental wellness. These cultural factors may be useful in considering policy initiatives designed to improve the distribution of mental health providers. A summary description of each of these professions may be found in the appendix of this paper.
We began our analysis by identifying the core set of services that we deemed to be the central functions of a mental health professional: prescribing psychoactive medications, assessment, diagnosis, developing and implementing a treatment plan, providing individual and/or group counseling, and psychotherapy. At the time of our study, none of the professions could prescribe drugs, so this service was eliminated from our analysis. While the distinction
a The states excluded from this analysis were: CA, CT, FL, MD, MA, NJ, NY, OH, RI, and VA.
b While we also examined licensure laws and rules for advanced practice registered nurses (APRN’s) specializing in
mental health, this paper does not present data for this group of professionals because we found that licensure laws and rules for nurse practitioners and clinical nurse specialists rarely include information on mental health nursing specialties.