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Chapter 22

Mental Health Practitioners and Trainees

Psychiatry

Farifteh F. Duffy, Ph.D; Joshua Wilk, Ph.D.;
Joyce C. West, Ph.D., M.P.P.;
William E. Narrow, M.D., M.P.H;
Donald S. Rae, M.A.; Rebecca Hall, B.S.;
Darrel A. Regier, M.D., M.P.H.
American Psychiatric Association

Psychology

Social Work

Psychiatric Nursing

Counseling

Marriage and Family Therapy

Psychosocial Rehabilitation

School Psychologists

Applied and Clinical Sociology

Pastoral Counseling

Center for Mental Health Services

Introduction

Late in 1987, research staff from the American Psychiatric Association (APA), the American Psychological Association, the National Association of Social Workers (NASW), and representatives of professional psychiatric nursing formed a work group on human resources data with staff from the National Institute of Mental Health (NIMH). This work group had four major purposes:

1. To identify common, basic human resources data that could be reported on by these mental health disciplines (psychiatrists, psychologists, social workers, and psychiatric nurses).



2. To prepare a chapter for Mental Health, United States, 1990 (Dial et al., 1990) that presented and described these data.



3. To identify data gaps and plan steps by which these gaps might be corrected.



4. To improve survey comparability among the participating disciplines so that the essential pool of common core data could be expanded.

The work group has addressed each of these purposes: a common, basic data set was developed and published in Mental Health, United States, 1998 (Manderscheid & Sonnenschein, 1998); chapters were developed on human resources for the 1990, 1992, 1996, 1998, and 2000 editions of Mental Health, United States (Manderscheid & Sonnenschein, 1992, 1996; Manderscheid & Henderson, 1998, 2001); and a plan was developed to fill data gaps and to improve data comparability for the professions that provide mental health services. In addition to the four original disciplines, early in the 1990s, representatives of clinical mental health counseling, marriage and family therapy, and psychosocial rehabilitation were added to the work group. More recently, representatives of school psychology, sociology, and pastoral counseling have been added.

This chapter is designed to update information in similar chapters from the 1990, 1992, 1996, 1998, and 2000 editions of Mental Health, United States. It presents information on the size and characteristics for eight of ten disciplines (specific data are not available for sociology and only limited data for pastoral counseling). Results are restricted to data elements that are comparable across the disciplines. Exceptions to this general approach are noted in the footnotes and in the appendix to this chapter, and readers are encouraged to review this appendix for descriptions of the survey methodologies used to collect the data reported here. Clearly, a strong need exists in the mental health field for increased precision and comparability of human resources data. Because mental health is a very labor-intensive field, the preponderance of financial resources is spent in the area of human resources, so the policy and resource implications of human resource data are enormous. To plan adequately for future services, both the public and private sectors require access to such data. This chapter is another step along a path that is of potential benefit to the entire field. Mental Health United States 2002 (Manderscheid & Henderson, 2004) featured a separate chapter, Perspectives on the Future of Mental Health Disciplines (see Wilk et al., 2002, pp. 17-42). Changes since that time are integrated into this chapter.

At the outset, it is important to specify the scope and limitations of the data in this chapter. The reader needs to be sensitive to data coverage within and across disciplines, as well as over time.

The chapter addresses two types of human resources:

1. Clinically trained mental health personnel, who, because of recognized formal training or experience, could perform direct clinical mental health care, whether or not they are currently doing so.



2. Clinically active mental health personnel who are currently engaged in providing direct clinical mental health care (a subset of total mental health personnel).

The numbers of clinically trained mental health personnel and clinically active mental health personnel are specified only for professionals from the eight mental health disciplines with specific data. Clinical supervision of trainees is considered to be a direct clinical activity. When possible, coverage includes an entire discipline rather than the membership of a professional association. The analyses for each discipline specify the scope of coverage. Time frames for the statistical information vary somewhat from discipline to discipline. The reader should note the variability within and across disciplines (see appendix).

Psychiatry

This section describes the current workforce in psychiatry. Demographic and training characteristics, as well as professional activities and settings, are characterized. Data sources for this section include the American Medical Association (AMA) Physician Characteristics and Distribution in the United States (2004); the 2002 membership records of the APA; the 1990-91 through 2002-03 APA annual census of residents (1991, 1995, 1999, 2003); the AMA 2000-01 Graduate Medical Education Database; the 2001-02 joint Association of Medical Colleges (AAMC) and AMA — National Graduate Medical Education (GME) census; the 1988-89 APA Professional Activities Survey (PAS); the 2002 APA National Survey of Psychiatric Practice (NSPP); and the 1998 APA National Survey of Psychiatric Practice (NSPP).

The AMA Physician Characteristics and Distribution in the United States (2004) contains information on all physicians practicing in the United States who are self-designated or self-identified as psychiatrists. As a result, the AMA database may include some physicians with no specialty psychiatric training. In comparison, the APA data, which supplement the AMA estimates by providing data not otherwise available, include only APA members who have completed psychiatric residency or have board certification. The APA membership database does not represent the universe of psychiatrists; however, it represents the majority of psychiatrists in the United States.

Demographic and Training Characteristics

Although there has been a 38 percent increase in the number of clinically trained psychiatrists in the United States, from 1983 to 2002 (AMA, 2004), the rate of growth has slowed in recent years. In fact, the rate of growth from 2000 to 2002 was less than 1 percent (see table 22.1). According to APA membership records of U.S. members, membership is approximately 72 percent male and 28 percent female, a small increase in female members since 2000 (CMHS, 2004). In 2002, the median age of female and male APA member psychiatrists was 49 and 57, respectively. Approximately 53 percent of female APA members are under age 50, compared with 29 percent of male APA members.

White non-Hispanics are overrepresented in the APA membership (75 percent) compared to general population (69 percent), as are individuals of Asian origin (10 percent vs. 4 percent), while other racial/ethnic groups are underrepresented. Persons of Hispanic descent account for nearly 5 percent of the APA membership and 14 percent of the general population, African-Americans account for nearly 3 percent of the APA membership and 12 percent of the general population, and American Indians account for 0.1 percent of the APA membership and 0.9 percent of the general population.

As reported in table 22.3, there are approximately 14 clinically active, private sector non-Federal psychiatrists per 100,000 individuals in the U.S. population (AMA, 2004). The distribution of clinically active psychiatrists, however, varies across geographic regions, ranging from 6 per 100,000 in Idaho to 28 per 100,000 in New York, 32.3 per 100,000 in Massachusetts, and 57.6 per 100,000 in the District of Columbia.

Data indicate that the psychiatric workforce in general continues to age, with 64 percent of clinically trained psychiatrists having completed their highest professional degree more than 21 years ago (table 22.4; APA, 2002). Over the past decade, APA membership has declined, specifically for younger psychiatrists. For example, in 1990 psychiatrists under age 45 constituted 37 percent of the APA membership, but by 2002 that number had dropped to 21 percent. Other data corroborate the aging of the psychiatric workforce as well. According to the AMA (2004), psychiatrists under age 45 constituted 46 percent of the psychiatric workforce in 1990 and only 30 percent in 2002.

While during the 1980s, the number of medical students entering psychiatric residencies increased by almost 25 percent (Dial et al., 1990), data from the APA annual census of residents indicate that during the 1990s, this growth plateaued (see table 22.8). The 2002-03 data in table 22.8 indicate a decrease of about 8 percent in the total number of residents since the mid-1990s. However, a steady increase in the proportion of female residents continues. In 1998-99, 53 percent of psychiatric residents were male and 47 percent were female, compared with 56 percent and 43 percent, respectively, in 1990-91 (1 percent missing data). The 2002-03 GME track documented that 49 percent of psychiatric residents were male and 50 percent were female (less than 1 percent missing data). It is important to note that the 2002-03 training data were derived from the joint AMA and AAMC Graduate Medical Education track, rather than APA's annual census of resident, which was the source of data on residency training during the 1990s. The scope of the programs covered by the survey conducted by the 2002-03 AAMC/AMA GME track is restricted to American Council for Graduate Medical Education (ACGME)-accredited programs, whereas APA's annual census of residents traditionally surveyed ACGME-accredited as well as AOA-approved programs, consultation-liaison, research, and other postresidency programs. Although the 2002-03 data displayed in table 22.8 attempted to include programs not covered by the GME track and to follow up with nonresponding programs, methodological differences across data sources, as well as factors such as program mergers, closures, and downsizing in the late 1990s may account for some of the decline in 2002-03 numbers in psychiatric residency training. Furthermore, the 2002-03 data were based on an 84.2 percent response rate from training programs in the United States.

During the 1990s, there has been a 63 percent increase in the proportion of international medical graduates (IMGs) entering psychiatric residencies (APA, Census of Residents, 1990-1998). The greatest increase occurred during the early to mid 1990s, with the proportion of IMGs increasing 92 percent between 1990 and 1996. In recent years, however, this trend appears to have subsided, with a nearly 6 percent decrease in the proportion of IMGs between 2000 and 2002. Furthermore, in the past 2 years, the proportion of Hispanic, African-American, Asian, and Native American residents has increased, while the proportion of White residents has decreased considerably, from 62.5 percent in 2000 to 55.7 percent in 2002.

Professional Activities

It is important to note some methodological differences in collecting data on professional activities from 1988 to 2002, in that questions were asked in different ways in some cases. However, both surveys used the AMA 2002 Physician Masterfile, which includes all U.S. physicians self-identified as psychiatrists as a sampling frame, and both were weighted to provide national estimates.

Findings from the 2002 NSPP indicate a decrease in the number of psychiatrists working in more than one setting, with 45 percent of psychiatrists working in more than one setting during the course of a week compared to 76 percent in 1988. Among psychiatrists working full time (35 hours or more per week) in the United States in 2002, 50 percent worked in two or more settings (table 22.5), whereas 22 percent of psychiatrists working part time (less than 35 hours per week) practiced in two or more settings. In 1988, 79 percent of psychiatrists who worked full time and 59 percent of psychiatrists who worked part time worked in multiple settings. Consequently, the mean number of settings in which psychiatrists work per week decreased slightly between 1988 and 2002 (from 2.3 to 1.6). Overall, the mean number of hours psychiatrists work per week fell from 48 hours in 1988 to 43 in 2002. However, the proportion of psychiatrists working full time has increased slightly from 74 percent in 1988 to 76 percent in 2002.

In 2002, active psychiatrists reported spending 45 percent of their patient care time in either an individual or group practice (2002 APA NSPP). Previously, hospitals have been one of the major work settings for psychiatrists, but substantial changes in the health care delivery system may have resulted in a decline in the proportion of psychiatrists primarily working in hospitals. Of active psychiatrists responding to the 2002 APA NSPP, 11 percent reported a hospital as their primary work setting—down from 28 percent in 1988. The number of psychiatrists working in outpatient clinics increased during this period: 30 percent of psychiatrists in 2002 reported outpatient clinics as their primary work setting (see table 22.6), compared with 10 percent in 1988. Furthermore, in 2002, psychiatrists reported that nearly 16 percent of psychiatric patient care time was spent either in a general or psychiatric hospital compared to 28 percent of psychiatric patient care time in outpatient facilities, including private, public, and health maintenance organization (HMO) clinics.

In addition to working in more than one setting, psychiatrists usually are involved in several work activities. As shown in table 22.7, in 2002, 94 percent of psychiatrists were involved in patient care, 85 percent in administration, and 20 percent in research. Psychiatrists spent a mean of 26.1 hours per week or 60 percent of their work week in direct patient care in 2002, compared to 67 percent in 1988. In addition, psychiatrists appear to have spent 8.7 hours per week in administrative activities in 2002, up from 5.8 hours per week in 1988. The decrease in direct patient care hours and increase in administrative hours during this period may be due to changes in the organization and financing of the Nation's health care system.

Conclusion

Over the past two decades, the number of clinically trained psychiatrists has increased slightly; however, the rate of growth in the number of clinically trained psychiatrists has decreased. The number of female psychiatrists entering the field has increased, and the median age of psychiatrists has increased since 1988 (Manderscheid & Henderson, 2001, 2004). The number of psychiatric residents has decreased slightly during the past decade. There has, however, been significant growth in the number of IMGs entering psychiatric residencies during the 1990s, although this trend has subsided since 2001. Stricter visa laws as a result of the events of September 11 may continue to decrease the number of IMGs entering U.S. residencies (Manderscheid & Henderson, 2004).

One major change over the past decade has been the decrease in time psychiatrists are spending in direct patient care, with more of their time being devoted to administrative activities. This change is of particular concern, given its impact in decreasing the available psychiatric workforce for direct patient care, especially in light of the increased demand for psychiatric services. Nearly two out of every five psychiatrists work in more than one setting. In the past 20 years, hospitals have declined as a primary work setting for psychiatrists. The number of psychiatrists working in other organized care settings (e.g., HMOs), on the other hand, has increased. Psychiatrists continue to be involved in many types of work activities, including direct patient care, research, administration, and teaching (Zarin et al., 1998).

Research has shown that psychiatrists treat a patient population with more severe and complex problems than other general medical and mental health providers (Olfson & Pincus, 1996; Pincus et al., 1999). Analyses of the National Medical Expenditure Survey data indicate that compared with psychologists, psychiatrists tend to see a larger proportion of persons who are socially disadvantaged, who report that their health interferes with their work, and who have higher utilization of nonhospital outpatient mental health care. In addition, psychiatrists provided significantly more visits than psychologists for schizophrenia, bipolar disorder, substance abuse, and depression, but fewer visits for anxiety disorders and isolated symptoms.

As the U.S. health delivery system evolves and the demand for psychiatric services rises, it will be increasingly important to track and understand the characteristics of psychiatric workforce as well as the populations it serves.

Psychology

Prior to World War II, psychologists were primarily employed in traditional academic settings. A small proportion actively engaged in mental health service delivery worked outside universities. This picture began to change in the mid-1970s, with statutory recognition of the profession by State regulatory agencies (DeLeon, Vanden Bos, & Kraut, 1984). In 1975, the United States had an estimated 20,000 licensed psychologists. This number doubled to 46,000 by 1986, and reached at least 85,000 by 2004 (see table 22.1).

Coupled with the dramatic growth in the number of practitioners was a significant increase in the role of psychologists as direct mental health service providers. Today psychologists are involved in every type of mental health setting, including those that are research or treatment oriented and general primary health care or specialty focused (e.g., sports and other injuries, elderly, seriously mentally ill). Given these more diversified workplaces, the roles of psychologists also have diversified and become more complex. In addition to the assessment and treatment of individual clients, psychologists now are involved in prevention, intervention at the community level, assessment of service delivery systems (outcomes), and client advocacy.

Demographic and Training Characteristics

The past two decades have been ones of growth and challenge for doctoral-level psychologists trained to provide mental health services. As noted above, in 1983, Stapp, Tucker, and VandenBos (1985) estimated the number of doctoral level psychologists at 44,600. Twenty years later that number had risen to at least 85,000. This growth was fueled early on by a surge in degree production. The number of new doctorates awarded in the practice specialties in psychology rose from 1,571 in 1979 to nearly 2,400 in 1989 and to about 3,615 in 2004 (APA, 2005; Pion, 1991; Syverson, 1980; Thurgood & Weinman, 1990). The training system also has expanded during the past two decades, with a doubling in the number of doctoral psychology programs in clinical, counseling, and school psychology accredited by the APA. There were 134 such doctoral programs in 1979, 234 in 1989, and 369 in 2004. These counts do not include the programs that do not seek APA accreditation but do award doctoral degrees in psychology, which further expand the ranks of the clinically trained. The total number of graduate students enrolled in accredited doctoral programs has risen from 14,586 in 1984-85 to at least 26,151 in 2004-05 (data tables compiled by the APA Research Office from 2005 information). The number of enrollees has leveled off in recent years.

Despite this growth in the number of psychologists trained to provide direct services, these services continue to be relatively inaccessible in many areas of the country, and shortages of mental health personnel exist for certain target populations. These populations include seriously emotionally disturbed children and adolescents, adults with serious mental disorders, rural residents with mental health needs, and the elderly, to name a few.

Table 22.2 presents basic information on the demographic characteristics of psychologists who could provide mental health services (the clinically trained pool). In many ways this group reflects the changing demographic characteristics of psychologists as a whole. For example, women made up 51 percent of all clinically trained psychologists in 2002, up from 38 percent in 1989 (Dial et al., 1990). This growth is not surprising given that the participation of women in psychology as a whole has grown significantly over the past two decades (Pion et al., 1996). In 2003, 68 percent of all doctorates in psychology were awarded to women, compared with 49 percent in 1985 and 32 percent in 1975 (Henderson, 1996; National Science Foundation, 2004). The representation of women among new doctorates in clinical psychology was even higher than among new doctorates in psychology as a whole, at 71 percent, and in 2002, women accounted for almost 73 percent of all full-time graduate students in doctorate-granting departments of psychology (Coyle, 1986; Gilford, 1976; Oliver & Rivers, 2005).

Although psychology attracts a higher percentage of racial and ethnic minorities than many other disciplines, their representation remains relatively small at under 7 percent. This figure is lower than their representation in the U.S. adult population (at least 29 percent in 2003). As reported by the National Science Foundation (NSF), the proportion of doctorates in science and engineering fields earned by racial and ethnic minorities was 21 percent in 2003 (Burrelli, 2004). As table 22.2 indicates, in 2004, the population of clinically trained women was slightly more racially and ethnically diverse than that of men. The pool of clinically trained psychologists, like psychiatrists, continues to age. The mean age in 2004 was 52.7, compared with 44.2 in 1989. Similarly, the median years since receiving the doctorate increased from 12 years in 1989 to 19 years in 2004 (analyses are drawn from the APA membership profiles as well as tables 22.2 and 22.4). Results reveal that women are generally about 6 to 7 years younger than men (49.5 for women vs. 56.3 for men) and have earned their doctorates more recently (15 years for women vs. 23.5 for men) These findings are to be expected, given the trends in degree production noted earlier.

Professional Activities

Table 22.1 indicates that most of the psychologists who are actively providing services are working full time (almost 76 percent), and table 22.6 shows that 46 percent are doing so by filling a combination of two or more positions. It is more common for those who are working part time to be occupying one position.

Table 22.6 presents the primary and secondary employment settings of active health service providers in psychology. Half of the health service providers indicated that their primary setting was independent practice, with most having a solo practice (38 percent) rather than working in a group or medical/psychological group setting. The next most frequent setting, a far second, was the academic setting, including university/college counseling centers (13 percent), followed by nonpsychiatric hospitals (6 percent), clinics (6 percent), elementary and secondary schools (4 percent), and mental health hospitals (3 percent). About 14 percent were employed in other settings, such as government or business.

Forty-six percent, or about 23,638 of all clinically active psychologists, worked in more than one setting in 2002 (see table 22.6). Again, the most frequent setting was independent practice (individual and group) at 39 percent, followed by academic and other settings (23 and 26 percent, respectively). Much smaller percentages worked in other settings.

Table 22.7 reveals that almost 90 percent of those who are trained to provide direct services do, in fact, report this as an activity in which they are involved. But the table also demonstrates the wide variety of activities reported by clinically trained psychologists. About one-fourth conduct research; almost 39 percent provide some type of education (usually in higher education); more than one-third reported managerial or administrative responsibilities; and about 39 percent mentioned other employment activities (such as publishing or writing) not captured by these categories.

Social Work

The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. A historic and defining feature of social work is the profession's focus on individual well-being in a social context and the well-being of society. Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living (NASW, 2000c, p. 1).

Founded on these core principles, social work evolved as a profession in the midst of the rampant social poverty during the tide of industrialization, urbanization, and immigration in the late 19th century. Three movements formed the basis of the profession: the charitable organizations, the settlement houses, and the societies founded to address child welfare issues at that time. The charitable organization movement, however, is credited as the originator of the social work profession with its ambitious and organized goals to provide assistance, as well as understanding and solutions, to widespread poverty and family disruption (Popple, 1995).

By the end of the 19th century, the complexity of social problems clearly demanded professionals with more formal training grounded in science. In 1898, the first classes in social work were offered at Columbia University in New York City. Today, there are more than 200 accredited graduate social work programs (master of social work [MSW] or doctoral) as well as 430 accredited undergraduate social work programs (Lennon, 2001). Rigorous education standards at the bachelor's, master's, and doctoral levels ensure that social workers are prepared for professional practice through formal course work combined with fieldwork from an accredited social work degree program, professional supervision, adherence to the NASW professional Code of Ethics (2000a), and licensure or certification at the State level. In addition, the NASW offers professional practice credentials and standards as well as specialty certifications in case management; school social work; alcohol, tobacco, and other drugs; health care; and children, family and youth.

In the early 1900s, the profession gained increasing credibility and integration into the workplace. By 1905, Massachusetts General Hospital in Boston had established a hospital based social services department, followed in 1906 by a division designated to serve patients struggling with mental illness. In that same year, school social workers were introduced into the public school system. In 1912 the U.S. Children's Bureau was created, and by 1926, the U.S. Veterans' Bureau was hiring social workers in its hospitals (Popple, 1995). These early developments mirrored the continuing diversity of social work practice settings and skills.

In the decade following the Great Depression, the number of social work positions doubled from 40,000 to 80,000 as social services expanded in the pubic sector to address financial assistance, public health, and child welfare issues (Popple, 1995). Jane Addams, known for her leadership roles in the settlement house and peace movements, was awarded the Nobel Peace Prize in 1931 (Quam, 1995a). Frances Perkins, a social worker and Secretary of Labor under President Franklin D. Roosevelt, was instrumental in developing the New Deal Legislation in the 1940s. During her tenure as Secretary of Labor, she advocated for improved workers' conditions, including minimum wages, maximum hours, child labor legislation, and unemployment compensation (Quam, 1995b). As the Depression drew to an end, social workers could be found providing services in both the public and private sectors.

The 1960s brought a renewed commitment to public welfare as society again focused on issues of poverty. During that decade, the profession's historical commitment to social welfare issues continued and the scope of practice expanded to include not only casework and counseling, but also policy, planning, program administration, and research.

Today, social workers are employed in a wide range of settings, serving as therapists, administrators, advocates, case managers, consultants, researchers, policy makers, teachers, and supervisors. Social workers use their skills and knowledge to provide social services and counseling; increase the capacity and problem solving skills of clients, family members, and communities; connect people to resources; and influence social policies (Barker, 1999). Clinical social work is identified as one of the five core mental health professions by the National Institute of Mental Health (NIMH) and the Health Research and Services Administration (HRSA). In addition, all 50 States regulate the profession of social work through licensure, certification, or registration, as well as through the use of professional titles.

NASW is the largest professional association of social workers. Formed in 1957 through the merger of seven affiliated social work organizations, it now serves 153,000 members in the United States and abroad. NASW seeks to advance the profession of social work as well as to enhance the effective functioning and well-being of individuals, families, and communities through its work and its advocacy.

Demographic and Training Characteristics

The number of clinically trained social workers continues to grow as the largest professional group of mental health and therapy services providers. According to NASW membership data, there were 103,128 clinically trained social workers in 2004 (see table 22.1). Since 1989-90, there has been a steady increase in the number of MSW degrees awarded—up by nearly 50 percent. The number of doctoral degrees awarded since 1989-90 has fluctuated. The 1998-99 numbers reflect an 8 percent increase in doctoral degrees awarded since 1989-90. Clinically trained social workers or those with master's degrees are qualified to provide a wide range of social work services—therapy, case management, advocacy, education, teaching and are eligible for licensure or registration in every State. According to the NASW 2004 Practice Research Network (PRN) survey, 94 percent of all regular NASW members (bachelor's, master's, or doctorate in social work) hold some form of State social work license, certification, or registration. Formal training in social work occurs primarily in accredited undergraduate programs that offer baccalaureate social work (BSW) programs or in accredited professional schools of social work offering MSW, DSW, Ph.D., or other doctoral programs (Barker, 1999). Training entails a combination of formal course work and direct supervised work with clients. For the purposes of this section, clinically trained social workers were defined as those holding a master's or doctoral degree from an accredited graduate level social work program. The numbers in parentheses reflect an estimate of the number of clinically trained social workers in the United States, because not all clinically trained social workers are members of NASW. We arrived at this estimate by using data from the Bureau of Labor Statistics that suggest that NASW membership accounts for approximately a quarter of the total social work labor force. Tables 22.2 through 22.7 present data on clinically trained social workers who are NASW members and may not represent all the social workers in the United States.

The data for this section and its tables were drawn from membership information and informed by the two NASW PRN surveys (2000b; 2005). Conducted in 2000 and 2004, the NASW PRN surveys captured demographic and practice data from two random samples of 2,000 regular members each. On the basis of the sampling techniques and the high rate of responses (81 percent and 70 percent, respectively), which minimized potential for selectivity and nonresponse bias, these results are highly representative of the membership.

The social work field continues to be predominantly White (87 percent) and female (82 percent; see table 22.2). The schools of social work report a similar gender distribution for MSW enrollees and degree recipients in 1997-98, averaging about 84 percent female and 16 percent male (Lennon, 2001). There has been a slight increase in the percentage of clinically trained social workers who are people of color, from 8 percent in 1998 to 11 percent in 2000 (table 22.2). However, nearly one-fourth (24.2 percent) of students awarded MSW degrees in 1998-99 were people of color (Lennon, 2001). This figure is more consistent with the 2000 U.S. Census findings that people of color represent 25 percent of the U.S. population. Thus, the percentages in table 22.2 may underrepresent the ethnic/racial diversity among social workers. Both the schools of social work data and NASW data indicate that the majority of people of color among social workers (about 5 percent) are African-Americans. Given the ethnic and racial diversity of the U.S. population, culturally competent practice is a critical model/focus for social work practice (NASW, 2001), as is the recruitment and retention of people of color within the profession.

Table 22.3 shows both the geographic distribution of social workers and the concentration of social workers by region and State. Consistent with earlier findings, New York and California have the highest numbers of social workers, 15,905 and 8,267, respectively. On average, there are 30.73 social workers for every 100,000 people, a decrease since 2000. Yet table 22.3 also shows the wide variance in the concentration across the United States, ranging from more than 200 social workers per 100,000 citizens in the District of Columbia to 12 per 100,000 in North Dakota. In fact, 12 States have fewer than 20 social workers per 100,000 residents—Alabama, Arkansas, Georgia, Mississippi, Nebraska, Nevada, North Dakota, Oklahoma, South Carolina, South Dakota, Texas, and West Virginia—all States with significant rural populations. California averages 23 social workers per 100,000—a relatively low ratio. Conversely, Washington, DC, Massachusetts, New York, Rhode Island, Maine, and Connecticut all report high concentrations of social workers—ranging from 77 to 227 per 100,000 people.

Clinical social workers, as reflected by NASW membership, are highly experienced. Nearly three quarters (72 percent) of social workers have 10 or more years of experience since completing their first degree, with a significant number (33 percent) having 20 or more years of experience. Slightly more than 10 percent of members had 4 years or less of experience. Data for table 22.4 were drawn from the PRN survey (NASW, 2000b), which captures different interval levels based on completion of the first professional degree, and thus are not comparable to other disciplines or earlier years. The Council on Social Work Education reports a steady influx of newly degreed professionals into the field, although after 10 years of increasing enrollments, the number of students enrolled in MSW degree programs was fairly constant between 1996-97 and 1998-99 (see table 22.8). Although it appears that newly degreed social workers are less likely to join NASW as regular members, given that fewer than 2 percent of members had fewer than 2 years of experience, some may take advantage of transitional membership categories for newly degreed social workers, which could influence that small number. The extent to which workforce retention/loss issues may influence this number is not clear.

Professional Activities

The majority of social workers are employed in either full time (54 percent) or in a combination of full-time and part-time employment (23 percent). Just under one-fourth of social workers report part-time employment only. Table 22.5 does not include data on the number of employment settings for social workers because the NASW PRN (2005) survey did not capture those data.

Outpatient mental health is the predominant employment setting for social workers, whether as independent practitioners or employees in outpatient mental health clinics. Slightly more than 18 percent of social workers identified independent practice as their primary employment setting, a nominal increase since 1998. Clinics continued to be the primary employment setting for social workers, with an overall rate (23 percent) only slightly higher than in 1998. However, the majority in this category (17.6 percent) worked specifically in mental health clinics. Individual practice remains the predominant setting for secondary employment (28 percent), despite a significant decline from 1998 (22 percent). Nearly 21 percent held secondary employment in an outpatient clinic, again, primarily in mental health (12.9 percent).

The largest increases since 1998 for secondary employment were in social service agencies—from 4.7 percent to 11.9 percent. A large percentage (15.9) identified "other" settings for secondary employment. This category reflects not only those who checked "other" or did not specify but also those employed in employee assistance programs, government or military agencies, managed care settings, and criminal justice settings. The NASW PRN survey (2000b) indicates that nearly 6 percent were employed primarily by government or military agencies.

As table 22.7 shows, direct service is still the primary work activity for clinical social workers; more than 61 percent identified patient care/direct service as their principal role in their primary area of practice. Administration was the second highest area at 13 percent. Teaching and research represent 2.69 percent and 0.3 percent, respectively. Seeing such a high percentage in direct service is not surprising, because the social worker profession has a strong tradition in clinical and casework and comprises the majority of the mental health professional groups. The NASW PRN survey (2005) gathered data only about the principal role in the social worker's primary practice setting and thus does not reflect the multiple work activities of social workers in their primary and secondary employment. Twenty-two percent of social workers have both full-time and part-time jobs. The social work data in table 22.7 are not comparable to the other disciplines.

Psychiatric Registered Nurses and Advanced Practice Psychiatric Nurses

The current psychiatric nurse workforce practices in a variety of roles and is a core discipline in mental health care delivery systems across all levels of care. The workforce includes registered nurses with basic nursing education who are working in psychiatric mental health settings, referred to in this section as psychiatric registered nurses (PRNs); and registered nurses with master's and/or doctoral degrees with graduate education in psychiatric mental health conditions, referred to as psychiatric mental health advanced practice registered nurses (PMH-APRNs). To remain comparable to other mental health disciplines, the tables refer only to board certified PMH-APRNs.

Various sources of data are used to capture a rich description of the demographics, training characteristics, professional activities, and settings of the psychiatric nursing workforce. Data sources include the 2000 National Nurse Survey of Registered Nurses (The Registered Nurse Population, 2001), the National League for Nursing (NLN, 1994), American Nurses Credentialing Center (ANCC, 2003), and the American Association of Colleges of Nursing (Berlin, Stennett, & Bednash, 2004).

Psychiatric Registered Nurses (PRNs)

Approximately 80,000 PRNs are employees of hospitals and agencies providing mental health services (Manderscheid & Henderson, 2002). Nearly half of PRNs work in private, nonfederal psychiatric hospitals and general hospital psychiatric units; the other PRNs are community based (Manderscheid & Henderson, 2002). Compared with the general registered nurse (RN) population working in acute care hospitals, PRNs are older, with fewer younger RNs choosing to specialize in psychiatry (Hanrahan & Gerolamo, 2004). The average age of PRNs is 47 years, versus 44 years for RNs. Only 16.7 percent of PRNs are younger than 39 years, where 27.7 percent of RNs are 39 or younger. These data suggests that the workforce shortage of PRNs is more urgent than the national shortage of general RNs.

Compared with general RNs, a greater proportion of PRNs are males (6.7 percent vs. 16.2 percent, respectively). The PRN workforce has a better racial mix than general RNs, with a lower proportion of Whites (82.4 percent vs. 87.6 percent, respectively) and a higher proportion of Blacks (11.8 percent vs. 5.3 percent, respectively). More than half of PRNs have an associate degree in nursing, and 24 percent report a baccalaureate degree (Hanrahan & Gerolamo, 2004). The majority of PRNs are employed full time (73 percent) in direct patient care, supervisory, and administration functions, suggesting that PRNs play a large role in the direct management and coordination of acute inpatient psychiatric care (Hanrahan, 2004). Job turnover is higher for PRNs than general RNs. Most PRNs who changed jobs reported that they were attracted by a more interesting job or better opportunities. In sum, acute care PRNs are aging out of the workforce faster than general RNs. One implication of this finding is that there may not be enough registered nurses to staff environments that serve the most acutely ill clients. In addition, aging out will negatively affect recruitment into the advanced practice psychiatric nurse role.

Advanced Practice Psychiatric Mental Health Nurses (PMH-APRNs)

A PMH-APRN is a registered nurse with advanced academic and clinical experience, which enables him or her to diagnose and manage most common and many chronic mental and physical illnesses, either independently or as part of a health care team. A PMH-APRN focuses clinical practice on individuals, families, or populations at risk for developing and/or having a diagnosis of psychiatric disorders or mental health problems across the life span. PMH-APRNs are educated through programs that grant a minimum of a master's degree. An intensive clinical practicum and preceptorship are key components of most PMH-APRN programs. Competencies of the PMH-APRN include continuous and comprehensive services necessary for the promotion of optimal mental and physical health, prevention and treatment of psychiatric disorders, and health maintenance (Bjorklund, 2003). These competencies includes the assessment, diagnosis, and management of mental health problems and psychiatric disorders (National Panel for Psychiatric Mental Health NP Competencies, 2003). In most States, PMH-APRNs may prescribe medication (Haber et al., 2004). There are 140 graduate programs in nursing offering psychiatric mental health specialty preparation (Berlin, Stennett, & Bednash, 2004).

It is estimated that more than 20,000 graduate trained advanced practice psychiatric nurses were in the 2004 workforce (AACN, 2003). Of these nurses, 8,751 are board certified by the American Nurses Credentialing Center (ANCC, 2003). Three-quarters of board certified PMH-APRNs are employed full time. Ninety-six percent of employed nurses are employed in nursing, which is a decrease from 99 percent in 1996. Table 22.2 shows that 94.6 percent of psychiatric nurses are female, and 80.5 percent of the females are White. Less than 3 percent of female graduate prepared nurses are under age 35; in 1988, 18 percent were under age 35. This trend continues with the decline in percentages of nurses in the 35 to 39 and 40 to 44 age groups. The average age of female graduate-prepared psychiatric nurses was 55 years in 2003, up from 48 years in 1996. Four percent of male graduate-prepared nurses are under age 35, with an average age of 44 years in 2003.

Regional distributions of board certified PMH-APRNs are presented in table 22.3. Most of these nurses reside in the New England, Middle Atlantic, or the South Atlantic regions, with the fewest in the West South Central region and the Mountain States. Geographic densities and shortages are affected by variability in state regulations on privileges and titling. Massachusetts, one of the first states to grant prescriptive privileges to advanced practice nurses, shows the highest proportion of certified advanced practice psychiatric nurses. States such as Illinois have only recently granted titling and prescriptive privileges and have relatively small numbers of certified APRNs. Low numbers of PMH-APRNs in particular States may be a result of population density and the fact that many of these States have few graduate nursing programs (e.g., North Dakota, South Dakota, Wyoming).

A difference in health status between residents in rural and urban regions has prompted attention to the challenges facing rural health care and health care systems. One major issue is poor access to mental health services and a severe shortage in the mental health workforce associated with rural areas. According to a recent study of the rural mental health workforce, significant numbers of advanced practice psychiatric nurses choose to work in rural areas (Hartley, Hart, Hanrahan, & Lioux, 2004). Twenty states have at least 20 percent of their advanced practice psychiatric nurses in rural practice. Using a system for classifying rural areas based on census tract geography, population size, and commuting relationships, there are 3.11 advanced practice psychiatric nurses per 100,000 in the United States. However, in rural Maine, rural New Hampshire, and rural Vermont, estimate ratios of rural practicing advanced psychiatric nurses per 100,000 are 9.6, 8.7, and 10.4, respectively (Hartley et al., 2004).

Table 22.4 shows PMH-APRNs by number of years since completion of highest professional degree. Two-thirds of these nurses received their highest degree in nursing more than 10 years ago, indicating that PMH-APRN is a discipline with career longevity and experience. PMH-APRNs are required by certification and most State regulations to document continuing education. The percentage of PMH-APRNs receiving their highest degrees in recent years may be influenced by master's prepared psychiatric nurses returning for doctoral education.

Table 22.5 shows that most full and part-time employed PMH-APRNs hold one position in nursing. Fewer than 20 percent of full-time employed nurses hold a second position. A similar pattern holds true for part-time employed nurses. PMH-APRNs work primarily in hospitals, private practice, and mental health clinics (see table 22.6). Fewer than 2 percent of the nurses noted academia as a work site, which reflects the reality of nursing faculty shortage (AACN, 2003). There are no significant changes from 1996 and 2000 in the distribution of nurses in various work areas except for a rising number of nurses in the "other" category, which may be due to an increase in employment opportunities in the managed care sector.

Table 22.7 shows that more than 80 percent of PMH-APRNs report their dominant function as direct patient care, followed by "other activities" (12.6 percent), administration (3.7 percent), teaching (1.7 percent), and research (1.3 percent). Other functions are proportionally similar to previous years with administration, teaching, and research ranked respectively.

Table 22.6. Percentage of clinically trained mental health personnel, by discipline and primary and secondary employment setting, for specified years.

As of 2003, there were 1,550 enrollees in psychiatric mental health graduate programs, with only 35 percent (537) enrolled full time and 65 percent (1,012) enrolled part time (see table 22.8). The number of graduates increased from 426 in 1997-98 to 460 in 2003. About 71 percent of graduates are prepared as psychiatric nurse practitioners (NP), which includes those educated in combined NP/clinical nurse specialist (CNS) roles, with 29 percent being prepared as CNSs. This is a slight undercount since five psychiatric mental health nursing graduate programs are broadly categorized as dual programs (preparing graduates to sit for more than one certification) and those numbers are not entered into the total graduation figure. The recent proliferation of psychiatric nurse practitioner educational programs is producing a different nursing workforce than previously existed and may address the current shortage, as the number of nurses enrolled in these graduate programs is rising. In 1991, few nurse practitioner students (only 89) specialized in psychiatric nursing (NLN, 1994). In 2003, there were 941 enrollees of such programs, with 287 graduates (Berlin, Stennett, & Bednash, 2004).

A critical workforce shortage area is child psychiatry. Four out of five children who need mental health services are not receiving them (U.S. Department of Health and Human Services, 1999). PMH-APRNs are trained to provide the full range of assessment and treatment services, including medications, to seriously emotionally disturbed youngsters. Currently, 1,200 PMH-APRNs are certified to treat children and adolescents. The current workforce of PMH-NPs trained in child/family is expected to increase as a result of the recent opening of 15 new graduate programs.

Conclusion

For more than a century, psychiatric nurses have been an integral part of caring for the physical and mental health of individuals and families across the life span. Over the past 20 years, educational preparation of psychiatric nurses has naturally evolved to include advances in brain-behavior science and the growing use of pharmacologic treatment. Because of this training, psychiatric nurses often manage mental illness complicated by comorbid physical illnesses such as diabetes, heart disease, HIV, or other health problems. Owing to their broad base of preparation and grounding in neuroscience, the demand for psychiatric nurses is growing. However, the aging out of the psychiatric nurse workforce threatens an adequate supply of these nurses. Addressing the shortage requires focused attention on recruitment and retention strategies, which should include educational grants and modification of State regulation to promote uniform and full scope of practice for advanced practice psychiatric nurses.

Counseling

The American Counseling Association (ACA) and the National Board for Certified Counselors (NBCC) define professional counseling as the application of mental health, psychological, or human developmental principles through cognitive, affective, behavioral, or systemic intervention strategies that address wellness, personal growth, or career development, as well as pathology. Patterson and Welfel (1994) note that the primary purpose of counseling is to empower the client to deal adequately with life situations, reduce stress, experience personal growth, and make well-informed, rational decisions.

Counselors work in a wide array of settings, including community counseling centers, government agencies, hospitals, rehabilitation centers, schools and colleges, businesses, and private practice. In addition to the traditional roles of individual counseling and supervision, counselors perform a variety of other functions related to preventing problems and promoting healthy development, including consultation, outreach, psycho-education, and other forms of indirect service.

The beginnings of counseling can be traced back to six distinct origins: (1) laboratory psychology, with its roots in Europe; (2) psychoanalysis; (3) the mental hygiene movement; (4) the vocational guidance movement; (5) the mental testing movement; and (6) Carl Rogers and the humanistic psychology movement. All these movements coalesced in the 20th century with the shift from an agrarian to an industrial society. This shift was accompanied by both bureaucratization of organizations and specialization of the workforce. Thus, the first organized counseling activities came out of the Vocational Guidance movement, which resulted from a need to adapt to these major lifestyle changes. Over time, all the early antecedents to modern-day counseling have had an influence as counseling has broadened its role.

Since the beginning of the 20th century, when Frank Parsons began what we think of as professional counseling, one of counseling's most important characteristics has been how much it is connected to the current socioeconomic and political context. Commonly referred to as the father of guidance and counseling, Frank Parsons established the Vocational Bureau of Boston in 1908 (Gibson & Mitchell, 1995). Parsons was an advocate for youth, women, the poor, and the disadvantaged (O'Brien, 1999). His book, Choosing a Vocation, was published in 1909, shortly after his death. It outlined his model of career guidance, which provided a basis for the career counseling of the time. Although career guidance initially took place in community agencies, it soon became popular in school settings as well.

As noted earlier, the mental testing movement influenced the establishment of counseling. Alfred Binet developed the first individual intelligence test in 1908 (Kimble & Wertheimer, 1998). Binet believed that guidance toward a career should be based on the measurement of aptitudes. Many others followed, developing testing into the major social force it is today. Another important force was the development of an emphasis on conscious and unconscious thoughts, feelings, and emotions, which began with Freud. As more individuals have taken advantage of developments in psychotherapy to seek to improve their mental health, professional counselors have met the need. Thus counseling, which at first focused on vocational guidance, soon came to emphasize assessment and testing. Later, counseling expanded to include work with individuals in emotional distress.

National legislation influenced the evolution of the counseling profession. Following World War II, the Federal Government developed and funded a variety of mental health services. For example, the National Mental Health Act of 1946 established the National Institute of Mental Health, which marked the beginning of publicly funded mental health services. At this point, the Veterans Administration began to see the need to help returning veterans readjust to civilian life, both vocationally and personally, and employed professionals to assist them in this process.

The passage of the National Defense Education Act (NDEA) in the late 1950s made it possible for graduate schools of education to establish funded programs to train school guidance counselors. This decision became a landmark, linking personal needs and education with the Nation's well-being. The NDEA provided grants to States for stimulating the establishment and maintenance of local guidance programs and to institutions of higher education for training guidance counselors to staff local programs (Gibson & Mitchell, 1995). The intent of the school counseling addressed in the act was to establish a national cadre of counselors adept in helping students plan for post high school education. Specifically, Congress wanted talented math and science students to be encouraged to further their education.

In an indirect but significant manner, the Soviet space and arms race gave rise to the establishment of counselor education programs across the Nation. Although school counselors began to serve a much broader role than envisioned by the NDEA, there is no question that the act provided a base from which counseling could grow. By the mid-1960s, notable contributions achieved by the act could be easily identified. These contributions included supporting 480 institutes designed to improve counseling capabilities and granting 8,500 graduate fellowships, which was a step toward meeting the need for more college teachers. By the end of the 1960s, more than 300 academic units housed postgraduate counselor education programs.

Another piece of legislation that had a great impact on the counseling profession was the Community Mental Health Centers Act of 1963. This act resulted in a substantial increase in employment opportunities for professional counselors across the country. Community mental health centers have traditionally employed a significant number of professional counselors, and many counselors who worked in this environment went on to establish independent private counseling practices.

Valuable information regarding counselor preparation is provided in the book Counselor Preparation Programs, Faculty, Trends (Clawson, Henderson, Schweiger, & Collins, 2004), which is the eleventh edition in a longitudinal study of counselor training. According to Clawson et al., the United States has 618 entry-level counselor training programs, of which approximately 31 percent are accredited by the Council for Accreditation of Counseling and Related Education Programs (CACREP). As shown in table 22.8, there were 46,425 master's students in 2004. At the doctoral level, there are 118 programs, 40 percent of which are CACREP accredited. In 2004, 2,369 students were in these doctoral programs, for a total of 48,794 counselor trainees.

Early counseling activities tended to be directive and counselor focused. This approach was challenged by Rogers (1942) with the publication of his landmark book Counseling and Psychotherapy, which had a profound impact on the way counseling was viewed. Counseling's focus consequently shifted from education to psychology, social work, and humanism. Rogers' work implied that one person's solutions may not be suitable for another's morals, values, and goals and that being an effective helper entails being familiar with the client (Patterson & Welfel, 1994). Rogers emphasized a nondirective, client-centered approach to counseling. As Smith and Robinson (1995) noted, Rogers' client-centered theory also emphasized the client as a partner in the healing process, rather than as a patient to be healed by the therapist. Although other competing theories have emerged and gained acceptance, emphasis on the importance of the relationship continues to be a hallmark of much counseling theory and practice. With this foundation, counselors use an appropriate combination of theories, techniques, and assessment and testing instruments to help clients achieve co-constructed goals.

Although a considerable overlap exists among the helping professions, counseling can be distinguished by its relationship-building as well as its focus on the individual within an environmental context. One focus of counseling is to help each individual define his or her goals while reaching his or her fullest potential. Counseling thus takes a broad view of mental health care, emphasizing its developmental, preventative, and educational aspects in addition to the traditional focus on the remedial treatment of illnesses (Hinkle, 1994, 1998). "Simply stated, mental health counseling believes that a person does not have to be sick to get better" (Smith & Robinson, 1995, p. 158). Counseling results in unforced and accountable behavior and actions on the part of the client while also educating the client with the necessary skills to regulate his or her positive, as well as negative, thoughts, feelings, and emotions.

Formal recognition of counseling as a unique profession has been fostered by the establishment of a professional counseling organization, a national counselor certification organization, accreditation standards for counselor training programs, and state licensure for counselors. The National Vocational Guidance Association, founded in 1913, and the National Association of Deans of Women, established in 1914, were the first two organizations begun specifically for counselors.

The American Counseling Association (ACA), established in 1952 as the American Personnel and Guidance Association, resulted from the merger of the National Vocational Guidance Association, the American College Personnel Association, and the National Association of Guidance Supervisors and Counselor Trainers. These four organizations then became the founding divisions of the umbrella association, ACA. A number of counseling specialty areas have been added to the original founding divisions. The ACA divisions were formed with the idea of providing specific leadership, resources, and information for a particular specialty area. Two examples of specific divisions are the Association for Specialists in Group Work (ASGW) and the Association for Counselor Education and Supervision (ACES). While not all professional counselors are ACA members, its membership represents various specialty and interest areas in the field. The ACA currently has 44,000 members.

After many years of legislative activities, almost all the States (48) plus the District of Columbia and Guam have passed licensure or certification laws for master's level practitioners. Legislative activities in the remaining two States should soon see results. The number of States with these laws indicates the increased acceptance of professional counseling as a unique and legitimate profession in the panoply of mental health service providers. Additional hallmarks of professional maturity are the development of accreditation and certification bodies for counseling.

In addition to licensure and certification, counseling has an accrediting body for its training programs. Accreditation is a method of strengthening the profession by upholding a set standard to which accredited university programs must adhere. Accreditation standards are typically set by a professional organization. The ACA (then called the American Personnel and Guidance Association) established CACREP in 1981 to oversee the quality of counselor training programs seeking accreditation.

CACREP established educational standards for master's-and doctoral-level counselor training programs. Becoming an accredited program is a voluntary process; however, virtually every counseling program in the country uses the CACREP curriculum and clinical training guidelines, even if programs that have not sought formal accreditation. One reason is that the guidelines are widely used as standards for preparation by State counseling licensure boards. Use of these guidelines also is a qualification for those who seek to become certified by NBCC. Thus, the CACREP standards have helped to ensure uniformity in training across the field. The 2001 Standards are the most recent CACREP guidelines. Among other requirements, students in an accredited program must complete work in eight common core areas. Currently, there are 181 accredited institutions, each having one or more accredited programs, in the United States and the District of Columbia, and this number is growing yearly.

Another hallmark of the profession's maturity is the establishment and development of a national certification program as a complement to State licensure. NBCC, established in 1982, is the largest certification organization for the profession of counseling worldwide. It began credentialing National Certified Counselors (NCCs) in 1983. Along with CACREP, NBCC has had a significant impact on the counseling field and provides a registry of those who have met its national certification standards. These individuals must fulfill three components to become National Certified Counselors: receive a graduate counseling degree from a regionally accredited university; receive a specific amount of supervised experience; and pass the National Counselor Examination (NCE). They are then entitled to use the designation NCC.

NBCC also has a Code of Ethics that details a minimal level of ethical standards to which NCCs are to adhere. In keeping with the advanced technology used in today's society, NBCC also outlines standards for the ethical practice of Web-based counseling. In addition to serving as a national registry, the NCE is required by most States for licensure. NBCC has 38,000 certified counselors in the United States, the District of Columbia, and Guam, as well as in 44 other nations.

Demographic Characteristics

For the purpose of collecting data for this chapter, we have emphasized the number of clinically trained counselors. Clinical training was reflected by creating an unduplicated total of NCCs, and licensed counselors by State where licensure numbers were unavailable. In States without counseling licensure, we determined totals by using the number of NCCs with an estimated number of licensable counselors using data from similar States and regions. The total number of counselors reflected in table 22.1 is the sum of these State totals. The ratios and percentages in the remaining tables are based on NBCC database queries, ACA membership statistics, a 1999 NBCC National Job Analysis of the Professional Counselor, and Clawson et al. (2004).

Table 22.2 illustrates that as a population, counselors are aging. In 2002, the largest proportion of clinical counselors was between the ages of 55 and 59 (30 percent). The proportion of counselors between the ages of 30 and 40 is 44 percent. In 2004, more than 40,000 students were in training, the great majority in master's programs, which they complete in 2 years (see table 22.8). Anecdotal numbers from training programs indicate that their enrollments are increasing, which will help offset the current small decreases in the numbers of professional counselors. Thus, it appears that there will be ample replacements for those who retire from the field.

Counselors practice throughout the country geographically, with the largest numbers in the Middle Atlantic, the South Atlantic, and the East North Central States (see table 22.3). The overall numbers have decreased since 2002, possibly as a result of an earlier overestimation of counselors in States that did not yet have licensure as well as a significant number of counselors retiring from the field.

Looking Ahead

Today's counselors, like other mental health professionals, are faced with a world of rapid change. Managed care has changed the health care system dramatically for professional counselors. The emphasis now is on the shortest and least expensive mode of treatment. On the positive side, this emphasis on cost containment has led to an increased demand for master's level counselors. All NCCs hold master's level degrees, and 6 percent hold doctoral degrees. Likewise, all professional counselors who are members of ACA hold a minimum of a master's degree in counseling, which parallels the State licensure requirement for mental health counselors. Hence, the need for master's level counselors resulting from the managed care system is likely to be met in the future.

Currently, a much larger female than male population makes up the counseling profession. Combined data show that 78 percent of professional counselors are female and 22 percent are male (table 22.2).

Multiculturalism is an important issue facing today's counselors. The U.S. population continues to become more and more diverse. However, the counseling profession is not representative of the population. Approximately 81 percent of the counselors currently practicing are White, compared with 5 percent African-American, 2 percent Hispanic/Latino, 1 percent Asian, and less than 1 percent Native American counselors. There is a need for an increasing number of counselors of various ethnic, racial, and religious backgrounds. Training programs are meeting the need for diversity by including courses on multiculturalism and other modes of training to expose counselors and students of counseling to a wide array of cultures, customs, and traditions so as to maximize their appreciation for and service to different cultures.

The field is making use of electronic communication in a number of different ways. One of the early electronic developments was the use of listservs for communication among counseling professionals. Today, a number of listservs are devoted to counseling issues. These listservs can be general in nature or for specialty areas, such as group counseling, both in the United States and abroad.

Another mechanism that has grown rapidly is the use of the World Wide Web. Almost all university counseling departments have a departmental Web page. These Web pages typically describe the program and its requirements and provide access to course syllabuses as well as information about the faculty. In some cases, much of the application process to the program can be completed online. The ACA and several of its divisions and NBCC have informative Web sites. One of the features of a Web page is the enhanced ability to link to other information sources quickly and easily is enhanced enormously, and this trend will continue into the future.

The use of electronic communication in counseling has profound practical and ethical implications. Counseling organizations are attempting to come to terms with this fact in various ways. Both the ACA and NBCC have developed a code of ethics for Web based counseling. In addition, a variety of commissions and committees are studying these issues. Also, graduate counseling courses are being taught electronically, and entire degrees can be completed online. This fact raises the issues of accreditation, accountability, and quality. The use of real-time video for counseling sessions raises issues of confidentiality since the Internet still poses privacy questions.

Distance counseling is an approach that takes the best practices of traditional counseling as well as some of its own unique advantages and adapts them for delivery to clients via electronic means in order to maximize the use of technology assisted counseling techniques. The technology assisted methods may include telecounseling (telephone), secure e-mail communication, videoconferencing, or computerized stand-alone software programs. NBCC's new Distance Credentialed Counselor (DCC) credential is nationally recognized.

Distance counseling may be more convenient for some clients. While telecounseling takes place in real time and does depend on "making an appointment," it eliminates travel and related formalities. Telecounseling and various forms of e-mail or synchronous communication techniques demand special counseling and communication skills from the counselor, and in some ways, from the client as well.

Distance counseling methods can be used as part of the counseling process or as a stand alone mental health service component. Certain types of clients actually seek distance counseling services for both practical and logistical reasons, as well as because of personal preference. Therefore, distance counseling techniques can help counselors reach a greater number of clients who need help. Currently, NBCC has certified 145 Distance Certified Counselors.

NBCC's Approved Clinical Supervisor (ACS) credential attests to the educational background, knowledge, skills, and competencies of approved clinical supervisors in counseling as well as among other types of mental health therapists. Professional counselors and other therapists with the ACS credential are identified as mental health professionals who have met national professional supervision standards. The ACS certification also promotes professional identity, visibility, and accountability among approved clinical supervisors. NBCC has currently certified 428 Approved Clinical Supervisors among professional counselors as well as among other mental health service providers.

Even more current is the Nation's awareness of the potential for national catastrophe and the emotional distress that results after disasters, whether manmade or natural. The events of September 11 reinforced the Nation's need for professional counselors. Counselors, as well as numerous other individuals from various health care disciplines, were called upon to respond to the psychological needs of those directly and indirectly affected by the terrorist attacks. Crisis counseling and grief counseling was, and continues to be, an integral part of the healing process. Whereas counseling programs typically have offered training in crisis intervention and post traumatic stress counseling, the need to further develop these courses has resulted in university curriculum changes. Looking to the future, it is hard to predict the psychological impact these events have had or how many incidences of post traumatic stress disorder, along with other mental health difficulties, may result. What is certain is that professional counselors can help people acquire the behaviors, beliefs, decision-making skills, and abilities to cope with the aftermath of crises and mental illness.

Marriage and Family Therapy

Marriage and family therapists are mental health professionals with a minimum of a master's degree and 2 years of supervised clinical experience. Marriage and family therapists (commonly referred to as MFTs or family therapists) are trained and licensed to independently diagnose and treat mental health and substance abuse problems. Marriage and family therapy is one of the core mental health disciplines and is based on the research and theory that mental illness and family problems are best treated in a family context. Trained in psychotherapy and family systems, MFTs focus on understanding their clients' symptoms and interaction patterns within their existing environment. MFTs treat predominantly individuals, but also provide couples, family, and group therapy. MFTs treat all clients from a relationship perspective that incorporates family systems.

Marriage and family therapy grew out of the public's demand for professional assistance with marital difficulties and from the development of a family systems therapy orientation by psychotherapy professionals and others (Nichols, 1992). From their beginnings in the 1930s and 1940s, MFTs have developed into uniquely qualified and distinct health care professionals who are federally recognized as a core mental health discipline, along with psychiatry, psychology, social work, and psychiatric nursing (42 CFR Part 5, Appendix C).

Federal law defines an MFT as an individual with a master's or doctoral degree in marital and family therapy, and at least 2 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, who is eligible for clinical membership in the American Association for Marriage and Family Therapy (42 CFR Part 5, Appendix C). The Department of Labor defines MFT services as: "diagnose and treat mental and emotional disorders, whether cognitive, affective, or behavioral, within the context of marriage and family systems. Apply psychotherapeutic and family systems theories and techniques in the delivery of professional services to individuals, couples, and families for the purpose of treating such diagnosed nervous and mental disorders" (21-1013 Marriage and Family Therapists). Research has found the services provided by MFTs to be effective (often more than standard treatments) for many severe disorders and to result in improved outcomes in both the health and functioning of clients (Doherty & Simmons, 1996; Pinsof & Wynne, 1995).

The profession of marriage and family therapy has burgeoned since the 1970s, with the number of therapists increasing from an estimated 1,800 in 1966 to 7,000 in 1979 to more than 50,000 currently.

Demographic and Training Characteristics

An estimated 50,158 MFTs were clinically active in the United States in 2001 (see table 22.1). Females represent over two-thirds of practicing MFTs (see table 22.2), and the median age is 54 (Northey, 2004; Riemersma, 2004).

Consistently, African-Americans and those of Hispanic descent are underrepresented among MFTs, compared with their proportions in the U.S. population. As table 22.2 shows, the ratios of MFTs of Asian origin and Native Americans are more in line with their representation in the total population. As in the other mental health disciplines, Whites are significantly overrepresented, making up 92 percent of MFTs, compared with 75.1 percent of the U.S. population. Gender differences exist, however. Slightly more minorities are found among male than female MFTs (8.7 versus 7.5 percent). Increased representation of minorities among MFTs appears promising. Almost 21 percent of the students enrolled in 2003 in training programs accredited by the Commissions on Accreditation for Marriage and Family Therapy Education (COAMFTE) are from minority population groups.

Table 22.3 reveals that the distribution of marriage and family therapists varies considerably across the United States. These variations can be explained by the existence (or lack thereof) of State regulation of the practice of marriage and family therapy or the presence of accredited university/college training programs. MFTs have strong representation in rural areas, with 31.2 percent of rural counties having at least one MFT.

In 2004, an estimated 25,368 individuals were in training to be MFTs (see table 22.8). This 7.6 percent decrease from 2001 is due to an overestimation of students training in California. The 2004 estimates are based on a larger sample of MFT programs in California, which decreased the California trainees, but actually increased trainees from throughout the country. Another 11,289, MFTs have graduated but are not yet practicing independently.

The primary agency recognized by the U.S. Department of Education for the accreditation of clinical training programs in marriage and family therapy at the master's, doctoral, and postgraduate levels is COAMFTE of the American Association for Marriage and Family Therapy (AAMFT). COAMFTE accreditation is required for programs to establish eligibility to participate in Federal programs. COAMFTE also is recognized by the Council for Higher Education Accreditation (CHEA, formerly CORPA), a nonprofit organization of colleges and universities that coordinates and provides oversight of accrediting bodies. As of 2002, COAMFTE had accredited or in candidacy status 55 master's degree, 18 doctoral degree, and 14 postgraduate degree programs in 36 States.

Three-quarters of MFTs in clinical practice hold a master's degree (75 percent); another 25 percent have doctoral degrees (Northey, 2004; Riemersma, 2004). Almost half of MFTs received their degree in marriage and family therapy. Upwards of 92 percent of MFTs are licensed as marriage and family therapists in their States (Northey, 2004; Riemersma, 2004).

Three-quarters (75.42 percent) of the estimated 50,158 clinically active MFTs in 2004 completed their training more than 10 years ago (see table 22.4), making them highly experienced as a group.

Forty-four of the 46 States that regulate MFTs require some continuing education. Almost every MFT obtained at least 1 hour of continuing education per year; the average number of hours required was 35 per 2-year renewal cycle. The mean number of continuing education hours obtained by MFTs is approximately 27 per year (Northey & Harrington, 2004; Riemersma, 2004).

Professional Activities

In 2004, most clinically active MFTs (60.0 percent) worked full time (see table 22.1), usually in one setting (41.9 percent) (see table 22.5). In the past 10 years the number of MFTs working in multiple settings has doubled for full-time MFTs (58.1 percent) and almost tripled for part-time MFTs (52.3 percent). Further, the vast majority of MFTs work in a private individual or group clinical practice settings (90.3 percent) at least part time (see table 22.6). However, the number of MFTs who work exclusively in private practice settings (27.4 percent) continues to drop from a high of 65.2 percent in 1998 and 50 percent in 2002. There is a concomitant shift in the numbers of MFTs working in public sector jobs, with 72.8 percent of MFTs working in hospitals, academic settings, clinics, or social service settings (see table 22.6).

Almost all MFTs are involved in the provision of direct services; increasingly, however, as shown in table 22.7, MFTs are involved in roles other than direct treatment, such as administering human service and agency organizations (18.7 percent) and teaching (24.0 percent), as well as other activities, such as developing prevention programs, enhancing public welfare (especially child welfare through family preservation services), developing public policy, providing client advocacy, consulting to businesses, and, more recently, managing managed care cases (Northey & Harrington, 2004). On average, full-time MFTs work 41 hours per week and part-time MFTs work 12 hours, the latter seeing 20 clients per week (Northey, 2004).

Table 22.7. Percentage of clinically trained mental health personnel involved in each type of work activity, by discipline, for specified years¹

MFTs treat the full spectrum of American society. More than half the clients seen are female (58 percent); 20 percent are racial and ethnic minorities; the average age of clients is 35, and 20 percent of clients are children (Northey, 2004b). Most MFTs report treating ethnic and racial minority clients (83 percent) and feel competent to treat them (Doherty & Simmons, 1995; Northey & Harrington, 2004; Riemersma, 2004). About half of the adult clients of MFTs have a college or postgraduate degree, whereas the other half have a high school degree and some college. MFTs treat a wide range of individual, couple, and family problems. Mood disorders and depression, couple relationship problems, family relationship problems, anxiety disorders, and adjustment disorders are the most commonly cited presenting problems (Northey, 2004).

The presenting problems treated by MFTs tend to be severe. Nearly half (49 percent) of the problems are rated as severe or catastrophic; another 45 percent moderately severe; and 6 percent mild. The severity of client problems is further supported by the fact that 29.3 percent had been hospitalized in the past year, 6.1 percent of them while under treatment by the MFT (Doherty & Simmons, 1995).

Despite their focus on family systems, MFTs do not treat only couples and family units. Indeed, two-thirds of cases seen by MFTs are individuals (67 percent), 13 percent are couples, and 16 percent are families (Northey, 2002). A significant proportion of the clients are children (20 percent).

Clients report being highly satisfied with the services of MFTs. In a national survey of clients, 98.1 percent rated the services as good or excellent; 97.1 percent said they got the kind of help they wanted; and 91.2 percent said they were satisfied with the amount of help they received. Furthermore, 94.3 percent said they would recommend their therapist to a friend (Doherty & Simmons, 1995).

Clients also reported overwhelmingly positive changes in functioning: 83 percent reported that their therapy goals had been mostly or completely achieved. Nearly 9 out of 10 (88.8 percent) reported improvement in their emotional health; 63.4 percent reported improvement in their overall physical health; and 54.8 percent reported improvement in their functioning at work (Doherty & Simmons, 1995).

Treatment by MFTs is naturally brief and cost effective. The average length of treatment is 11.5 sessions for couples therapy, 9 sessions for family therapy, and 13 sessions for individual therapy. The average fee is $80 per hour, which makes the average cost per case $780 (Doherty & Simmons, 1995).

As of the end of 2004, 46 States and the District of Columbia regulate the practice of marriage and family therapy. The latest to pass a licensure bill was the District of Columbia, in November 2003. California was the first State to regulate the profession in 1963, followed by Michigan in 1966 and New Jersey in 1968. The most impressive growth in State regulation began in the 1980s, with the vast majority of State regulatory laws having been adopted since 1980.

All MFT licensure laws regulate the profession at the independent level of practice. The most common title for regulation is Licensed Marriage and Family Therapist, although a few States use Licensed Clinical Marriage and Family Therapist. Arizona was the last State to regulate the profession through certification rather than licensure, but that law was amended in 2003. Many States also provide an interim certification or license for postgraduates who are obtaining their 2 years of clinical experience for a license.

States' definitions of the practice of marriage and family therapy vary in the specific language used, but are consistent with AAMFT's Model Licensure Law, which states the following:

"Marriage and family therapy" means the diagnosis and treatment of mental and emotional disorders, whether cognitive, affective, or behavioral, within the context of marriage and family systems. Marriage and family therapy involves the professional application of psychotherapeutic and family system theories and techniques in the delivery of services to individuals, couples, and families for the purpose of treating such diagnosed nervous and mental disorders.

While the overwhelming majority (91.5 percent) of the 50,158 MFTs nationwide hold a State marriage and family therapy license, 44.0 percent hold additional professional licenses. The additional licenses that MFTs hold include psychologist (2.7 percent), social worker (6.6 percent), professional counselor (12.1 percent), and nurse (2.9 percent) (Northey, 2002). Over two-thirds (69.5 percent) of MFTs hold only a marriage and family therapy license. There has been a 31 percent increase since 1995 of licensees. Regardless of their training, most MFTs (75.0 percent) describe their primary professional identity as marriage and family therapist (Northey, 2004a).

Psychosocial Rehabilitation

Psychosocial rehabilitation (PSR) is a rapidly growing approach to working with individuals with severe mental illness in the community. PSR programs usually provide any combination of residential services, training in community living skills, socialization services, crisis services, residential treatment services, recreation services, vocational rehabilitation services, case management services, and educational services. In recent years, PSR has been identified as a necessary ingredient for maintaining persons with severe mental illness in the community. PSR services reduce hospitalization, increase employment, and increase the quality of life of persons served. Thus, PSR services are an important part of mental health care in the community, addressing practical, day-to-day needs, such as housing, income, work, friends, and coping skills.

The focus of PSR activities on in teaching individuals with severe mental illness the skills necessary to attain goals of their choice in the community and on developing innovative supports. In providing these services, PSR providers draw upon theories and practices of psychology, education, sociology, social work, and rehabilitation. In addition, PSR has been at the forefront of disability and rehabilitation movements, working toward the empowerment of individuals with severe mental illness through the delivery of services and the integration of the client and the services into the normal life of the community. PSR has been successfully used with individuals who have disabilities other than mental illness and those who have concurrent disabilities of substance abuse, mental retardation, and hopelessness as well as physical disabilities, such as deafness. Specialized programs have also been developed for individuals older than 65.

The importance and success of the field is evidenced by its rapid growth. In 1988, 965 facilities identified themselves as offering PSR services. In 1990, 2,200 facilities were identified as offering PSR services to persons with severe mental illness. By 1996, 7,000 facilities were identified. With an average agency staff size of 16, a conservative estimate of the PSR workforce is 100,000 (see table 22.1).

Demographic and Training Characteristics

Like other mental health workers, PSR workers, as shown in table 22.2, are predominantly female (65 percent) and White (70 percent); assuming that the distribution of female is similar to that of males, approximately 21 percent are African-American, 6 percent are Hispanic, 2 percent are Asian, and .04 percent are Native American. The average age of PSR workers is 38, and they have been in the field for an average of about 15 years (see table 22.4). Those with advanced degrees have been in the field for an average of 8 years. As shown in table 22.5, PSR workers can be found in 48 of the 50 States, the District of Columbia, and the Virgin Islands.

Two percent of all PSR workers have a doctoral degree, 24 percent have a master's degree, 38 percent have a bachelor's degree, 13 percent have some college or an associate degree, and 22 percent have only a high school degree. Twenty-five percent of PSR workers with bachelor's degrees are currently working to attain a master's degree. Among PSR workers with master's or doctoral degrees, 24 percent have degrees in psychology, 36 percent in social work, 4 percent in psychiatry, 3 percent in counseling, and 3 percent in education. Sixteen percent have licenses or certificates in social work; 8 percent are certified as counselors; 6 percent are certified as teachers; and 3 percent are certified as addiction counselors.

As the value of PSR has become recognized, academic programs have developed that specialize in PSR or include PSR as a specialized part of their curriculum. Currently, there are thirteen Ph.D. programs, three combined M.D. and Ph.D. programs, ten master's level programs, one bachelor's program, and one associate program in PSR. The number of programs is expanding rapidly as the field grows.

Because PSR encompasses an approach, a philosophy, and patterns of interpersonal interactions as well as didactic material, many agencies hire interested, caring people and train them on the job, through supervision, inservice training, and experience. Inservice training, which imparts various combinations of knowledge, attitudes, and skills, is provided in 19 States, by 7 county-level mental health authorities, 21 agencies, and 15 centers or institutes, 8 of which are affiliated with universities. These workshops and training sessions, which may last from 1 to 3 days, typically cover principles and values of PSR, functional assessment, choosing a rehabilitation goal, employment, case management, supported housing, teaching skills, stigma/discrimination issues, cultural diversity, clinical interviewing skills, program evaluation/research, supported employment, and career development. A practitioner typically emphasizes one of these fields over the others.

Professional Activities

Thirty-six percent of PSR workers are employed in residential programs; 32 percent in daytime facility-based programs; 15 percent in case management; 9 percent in vocational; and 6 percent in other areas. A majority are employed in a single setting (table 22.5).

PSR has taken a number of steps toward establishing itself as a distinct professional field, including developing a credentialing program called the Registry for Psychiatric Rehabilitation Practitioners. Many States are in the process of adopting the registry as a credential for this workforce. This program screens applicants for experience, education, training, and knowledge of psychosocial rehabilitation. Individuals who apply for the registry must meet certain educational requirements, have minimum levels of experience in the field, demonstrate written competence in the principles and practices of PSR, and provide evidence of ongoing training as well as references from three individuals familiar with their work.

Parallel to this process, competencies needed by PSR workers have been identified. These competencies have been derived from empirical literature that proves the efficacy of certain interventions and from experience in the field. They include knowledge and skills in the following areas: mental illness; specialized techniques of rehabilitation; establishing strong relationships with consumers; accessing community resources, such as families and self-help groups; cultural competency; and developing programs and relationships that promote recovery. The International Association of Psychosocial Rehabilitation Services (IAPSRS) has also developed standards for the implementation of psychiatric rehabilitation in the form of Practice Guidelines for the Psychiatric Rehabilitation of Persons with Severe and Persistent Mental Illness.

IAPSRS worked closely with the Commission on Accreditation of Rehabilitation Facilities (CARF), the Joint Commission for Accreditation of Health Care Organizations, the Council on Accreditation, and the Leadership Council in developing its guidelines. These guidelines were created by experts in the field on the basis of research and were validated by a field review by practitioners. The guidelines describe psychiatric rehabilitation approaches and interventions that are responsive to individual needs and desires and enhance recovery. Included are such areas as assessment, rehabilitation planning, skills teaching in all areas of functional limitations, facilitation of environmental supports, encouraging participation in community support and social activities, mental illness management, cognitive interventions, and methods of working with co-occurring disabilities. IAPSRS has also developed a code of ethics for its practitioners, with a process of adjudication for violations.

The body of research literature that supports the efficacy of PSR has been growing rapidly as its importance in the management of severe mental illness has become firmly established. Psychosocial interventions are reported in many different journals and books. IAPSRS has also taken the lead in developing a set of outcomes measures to be used by agencies in the field. These measures, which look at many domains of a person's life, have been incorporated into the data sets of other types of rehabilitation.

School Psychology

School psychologists are highly trained in both psychology and education to help children and adolescents succeed academically, socially, and emotionally. Their primary responsibilities lie in the application of psychological principles of mental health service delivery in educational settings and the assessment and planning of services for students with learning problems. Professional school psychology has grown significantly over the past 30 years, and in 2004 it is estimated that approximately 30,000 school psychologists certified by State boards of education or licensed by State boards of psychological services are practicing in the Nation's public schools (Charvat, 2004). Thousands more are primarily associated with the discipline as university instructors, as practitioners in private schools, as full-or part-time private practitioners, or in alternative settings. Most school psychologists serve in 15,000 local educational agencies and nearly 100,000 schools in all States and territories, as well as in Department of Defense schools nationally and internationally (National Association of School Psychologists, 2004).

School psychologists are involved in delivering a broad array of services related to mental health in the schools, including consulting with teachers and parents, developing and implementing educational programs, evaluating skills and development, and intervening directly with students and families. As part of the Individuals with Disabilities Education Improvement Act of 2004 (IDEA; P.L. 108-446), school psychological services are among the related services available to students with disabilities who need special education. School psychologists are also designated as pupil services personnel and among the providers of "pupil services" under the No Child Left Behind Act of 2001 (P.L. 107-63). Thus, by Federal statute and in practice, school psychologists provide services to all students in both general and special education.

Demographic and Training Characteristics

The preeminent professional association representing school psychologists in the United States is the National Association of School Psychologists (NASP), which has more than 22,000 members (NASP, 2004). The demographic information on school psychologists in this chapter is based on NASP membership surveys (Curtis, Chesno Grier, Walker Abshier, Sutton, & Hunley, 2002; Curtis, Chesno Grier, & Hunley, 2004), NASP membership data (NASP, 1997, 1998, 1999, 2000, 2004), NASP inquiries regarding the number of school psychologists in the United States (Charvat, 2004; Thomas, 2000), and data published by the U.S. Department of Education (USDOE, 2002). The base number of 37,893 clinically trained school psychologists in the tables is the most accurate figure available. Data on gender, ethnicity, years of experience, and other demographic variables are also presented in the tables.

School psychology is still a relatively young profession. Prior to 1975, about 5,000 school psychologists were reported as being employed in more progressive school systems in urban and suburban areas, primarily in California, New York, Pennsylvania, and Ohio (Fagan & Sachs-Wise, 1994). The recognition of the civil right to education of children with disabilities through passage of the Education of All Handicapped Children Act of 1975 (P.L. 94-142) increased the number of school psychologists to its present level and their distribution across urban, suburban, and rural communities in all the States. As the profession has grown, it has become increasingly female. While a survey conducted in the early 1970s revealed that approximately 40 percent of school psychologists were female (Farling & Hoedt, 1971), in 2004 it is estimated that approximately 70 percent of clinically trained school psychologists are female (Curtis et al., 2002). Illustrating this trend, a national survey of university training programs found that more than 80 percent of full- and part-time enrolled students were female (Thomas, 1998).

Survey data on ethnicity suggest that there are relatively few minorities in the profession. However, the approximately 7 percent minority representation presented in table 22.2 reveals a slight increase over the course of a decade, with the number of Hispanic school psychologists doubling from 1.5 to 3.1 percent (Curtis et al., 2002). It is important to note that NASP membership data may underestimate the percentage of minorities in school psychology, as evidenced by the fact that a survey of all graduate education programs indicated that 17 percent of students in training were minorities (Thomas, 1998).

The data in table 22.3 show that school psychologists are not evenly distributed across the Nation. Lund and Reschly (1998) also reported significant State and regional variations, with most States not meeting the NASP standard of one school psychologist for every 1,000 students. Survey data indicate that 35.7 percent of full-time practicing school psychologists work in settings that meet the recommended ratio, though 25.2 percent work in settings with ratios of 2,000 students or more per school psychologist (Curtis et al., 2002). It is important to note that there is considerable State-by-State variation in the ratios (Thomas, 2000).

All professional school psychologists are required to be certified or licensed by the State in which they provide services. Most States use certification and authorize the State education agency to certify school psychologists. Although requirements vary from State to State, NASP offers a national certification (Nationally Certified School Psychologist, or NCSP) that is recognized by 26 States. The requirements are a master's degree or higher specialist degree in school psychology with a minimum of 60 graduate semester hours, a 1,200-hour internship (600 hours of which must be in a school setting), a score of 660 on the National School Psychology Examination (ETS Praxis Series II), and course content to ensure substantial preparation in school psychology. NCSP renewal occurs on a 3-year cycle and is contingent upon completion of 75 hours of continuing professional development.

On average, about 1,900 students graduate from school psychology training programs each year. Most of them enter the field having completed a 60-credit master's or specialist degree. Approximately 30 percent hold doctorate degrees in school psychology, education, or related fields (Curtis, Grier, & Hunley, 2004). Although the percentage of school psychologists with a doctorate has remained relatively constant in recent years, the percentage meeting the requirements for national certification continues to increase. In 2004, there are 8,388 Nationally Certified School Psychologists (NASP, 2004). School psychologists who are members of NASP or hold the NCSP are required to abide by the Professional Conduct Manual for School Psychologists, which contains the Principles for Professional Ethics and the Standards for the Provision of School Psychological Services (NASP, 2000).

Nationally, 168 school psychology training programs are fully accredited by NASP/National Council for Accreditation of Teacher Education (NASP, 2004). Each year, approximately 1,750 school psychology students graduate from these and other institutions and become initially certified/licensed to practice in the Nation's schools (Curtis, Grier, & Hunley, 2004). The USDOE has reported that there are, on average, more than 600 unfilled, funded vacancies or additional certified personnel per year needed for the public schools (U.S. Department of Education, 1997a, b, 1998, 1999). A shortage of school psychologists is predicted in the immediate future in light of the increase in retirement rates among school psychologists and the proliferating need for mental health services in the schools. A recent study predicted a shortage of 9,000 school psychologists between 2000 and 2010 (Curtis, Grier, & Hunley, 2004).

Professional Activities

As shown in table 22.6, school psychologists are employed in a variety of settings, including public and private schools, universities, clinics, institutions, private practice, and community agencies. However, the majority (77.5 percent) practice in public schools, with significantly fewer (6.8 percent) practicing in private schools. Another 4.3 percent are in private practice. Some school psychologists are employed by mental health agencies that provide psychological services to the schools (Curtis et al., 2002). Although there are no officially recognized subspecialties within the profession, school psychologists' professional activities include a wide variety of services for diverse student populations. These services include consulting with teachers, parents, and school personnel about learning, social, emotional, and behavior problems; developing and implementing educational programs on classroom management strategies, parenting skills, substance abuse, anger management, teaching, and learning strategies; evaluating academic skills, social skills, self-help skills, personality, and emotional development; and intervening directly with students and families (including individual, group, and family psychological counseling), as well as helping solve conflicts related to learning and adjustment.

Demographic trends in the discipline suggest that the retirement of baby boomers in the next few years will contribute to a serious shortage of school psychologists that will peak in about 2010 (Curtis, Grier, & Hunley, 2004). Facing the possibility that the shortage will result in a reversal of the positive trends in the field, such as, for example, the decreasing student to school psychologist ratio, school psychologists and NASP are mobilizing to address the situation. Current efforts are focused on increasing awareness of the negative consequences of insufficient numbers of school psychologists, advocating for legislation that will strengthen the workforce, and considering potential new directions for the profession that will enhance school psychologists' contributions to the social, emotional, and academic learning of our Nation's students.

Sociology

The revival of the sociological practice movement can be traced back to the late 1970s (Friedman, 1987), a turbulent era in higher education, in which many academic institutions—particularly "small private liberal arts colleges, two-year private colleges, middle level private urban universities, and a spate of remote State colleges and universities" (Bingham, 1987; Smith & Cavusgil, 1984)—experienced three major challenges: (1) declining enrollments among aging baby boomers and increasing enrollments among nontraditional adult and minority students (Strang, 1986); (2) closures, cooperative arrangements with other institutions, and mergers (Bingham, 1987); and (3) reduced government funding amid rising education costs, necessitating relief from private funding sources such as alumni, foundations, and corporations (Bryant, 1983). These changes, not typically shared by their larger, private academic counterparts, necessitated a conceptual shift in sociology away from theory and statistical testing that characterized the discipline's post World War I efforts to legitimize itself and toward its original mission of social reform, based on application and intervention (Clark, 1990; Franklin, 1979; Huber, 1984, 1986; Kuklick, 1980; Parsons, 1959). New hands-on academic incentives—particularly workshops, supervised fieldwork, and—internships were designed to attract the changing student demographic and respond to economic constraints. Schools also integrated sociology departments into their respective communities and with their publics, balancing students' substantive disciplinary interests with more vocationally oriented courses (Ruggiero & Weston, 1986; see also Fleming & Francis, 1980; Olzak, 1981).

Sociology's theoretical and substantive contributions to mental and behavioral health care derive from its philosophical origins as a social science and practice profession in Europe and America.¹ More recently, sociologist Thomas J. Scheff (1966) broke new ground in his seminal work, Being Mentally Ill, which devoted attention to the social contexts of mental health and mental illness and conceptualized behavioral health care as a distinct social system. Drawing ideas from his contemporaries such as Edwin Lemert (1951), Kai T. Erikson (1957), and Erving Goffman (1961), Scheff's effort remains the cornerstone of modern mental health law in the United States. Interdisciplinary support for Scheff's position came from psychiatrist Thomas Szasz (1974) in The Myth of Mental Illness, which linked mental illness to specific socioeconomic, political, and cultural conditions in the social environment (cf. Hollingshead & Redlich, 1958). Current sociological contributions in mental and behavioral health care fields derive from the practical experiences and casework of clinical sociologists who specialize in individual, family, and other interventive group practice (see, e.g., Brabant, 1996; James & Gabe, 1996; Kemper, 1990).

Demographic and Training Characteristics

During the past two decades, the demand for qualified mental and behavioral health care professionals, coupled with stringent practice standards, has given academic departments in the social and behavioral sciences and allied health care occupations the incentive to accredit their practice programs and provide their graduates with association and State professional credentials (Witkin, Atay, Manderscheid, & DeLozier, 1998, pp. 153, 168). Sociologists seeking work as mental and behavioral health care providers, administrators, researchers, and educators found it increasingly necessary to qualify themselves with definitions of title and practice, educational qualifications, and State examination requirements from nonsociological practice legislation.² Extradisciplinary oversight, however, has not always represented and advanced sociologists' career interests and standing in mental and behavioral health care fields, nor has it fully exploited the application of sociology's distinct theories, methods, and approaches to everyday problems, particularly its capacity to "benefit society and social life through research action or administration" (Fleischer 1998; portion quoted is from Olsen, 1991, p. 6).³

In an era of managed care, sociologists' entry into the heavily regulated behavioral health care industry has led many to realize the value of acquiring supplemental association and State professional credentials, which serve as recognizable symbols of their competence to serve the public welfare, health, safety and to contribute to the quality of social life. Sociologists understand that without practice credentials, their opportunities to engage work as unregulated behavioral health care researchers, interventionists, caseworkers, and administrators will continue to decline. As a result, they have begun to organize and revise their accreditation and credential programs. The Commission on Applied and Clinical Sociology (CACS) was established in February 1995 as a joint initiative of the Society for Applied Sociology (SAS) and the Sociological Practice Association (SPA). SAS and SPA were founded in 1978—SPA as the Clinical Sociology Association (CSA). In 1997, CACS completed program accreditation standards and peer review guidelines at the baccalaureate level for sociology departments interested in complementing their traditional academic emphases with clinical and applied education and training components. Comparable standards and guidelines at the master's level were published in 1999. Doctoral equivalents are under consideration. These measures, sensitive to evolving training and administration standards in behavioral health care, permit practicing sociologists to apply their unique perspectives, skills, assessments, and interventions to the complex set of interactions that characterize social relations between and among sundry behavioral health care populations, providers, networks, sponsors, and members and their institutional environments. These concerns and practices have often been overlooked or underused in the allied health care marketplace. Sociologists' treatments will add significantly to the mix of existing approaches.

Following the implementation of its pilot accreditation program in fall 1997, CACS reviewed its first application for accreditation and self study from St. Cloud State University in St. Cloud, Minnesota, in February 1998. It conducted a site visit of St. Cloud's Applied Sociology Concentration in March 1998, and recommended full accreditation in August 1998. St. Cloud's program was reaccredited in August 2003. A second program, the Applied Sociology Program at Our Lady of the Lake University in San Antonio, Texas, was accredited in August 1999, and reaccredited in August 2004. CACS has since received several additional inquiries from sociology departments interested in having their applied or clinical programs accredited at the baccalaureate or master's level. CACS provided these programs with its published Accreditation Standards and Policies and Procedures. Three of these programs—Buffalo State College in New York, Valdosta University in Georgia, and Humboldt State University in Arcata, California—filed accreditation applications, presenting their self-study reports to separate Commission-sponsored Accreditation Review Committees (ARCs) in spring 2002. A site visit for Valdosta's undergraduate Concentration in Applied and Clinical Sociology was completed in spring 2003, and full accreditation was awarded in August 2003. Site visits for Valdosta's Master's Concentration in Applied Sociology and Humboldt's Master's Practicing Sociology Track were completed in fall 2003, and full accreditations were awarded in August 2004. The Sociology department at Buffalo State University withdrew its application of accreditation for its Bachelor of Science in Applied Sociology Program in April 2004.

CAC plans to replace its pilot accreditation program with an approved implementation, following its own accreditation by the Council on Higher Education Accreditation (CHEA) and/or recognition by the Association of Specialized Professional Accreditors (ASPA) or similar agencies. Sociological practice programs accredited by CACS are listed in its National Directory of Applied and Clinical Sociological Practice Programs. Program graduates are listed in its National Registry of Sociological Practitioners. Provisions will be made to "grandfather" qualified, nonprogram-accredited sociologists into the registry as well. The registry will be used to support graduates' candidacy for practice certification and their eligibility to enter and engage employment in interdisciplinary practice fields, including mental and behavioral health care. Later, it will be used to support their candidacy for State professional credentials through registration, certification, or licensure in compliance with State regulatory and jurisdictional requirements. Sociological practice legislation is currently under advisement by CACS. As in other professions, different classes of association and State professional credentials will be awarded on the basis of education and training. Core data will be incorporated into upcoming editions of Mental Health, United States.

SPA currently offers qualified candidates at the master's and doctoral levels two credentials. A Certified Sociological Practitioner (CSP) possesses the requisite knowledge and skills to apply sociology in one or more recognized subfields, such as organizational development, social policy assessment, conflict resolution, forensic counseling, and community intervention. A Certified Clinical Sociologist (CCS) specializes in providing evaluative, therapeutic, educational, and administrative services in the mental and behavioral health care fields.

SPA officials report that approximately 20 candidates were certified in 1998, adding to the association's base of 48 credentialed sociologists. Six additional applications for SPA certification were filed in 1999. By May 2002, the number of sociologists certified by SPA declined to 61 practitioners. No changes were reported through the end of 2004. Of the 61 practitioners, 22 (or 36 percent) have provided counseling and other mental and behavioral health care services to individuals, families, and small groups since their certification. This percentage increases to 45 percent (or 14 of 31 practitioners) with current SPA certification. Subspecialties include, but are not limited to, emotional therapy, grief work, sociotherapy, health education and family planning, individual and small group intervention, interpersonal and group conflict resolution, forensic counseling in the criminal justice system, clinical evaluation research, clinical administrative practice and consulting, and clinical training and supervision. Client populations include, but are not limited to, widows and other women, children, families, communities, law enforcement officers and firefighters, and public and private sector organizations. In short, SPA has certified 22 sociologists with clinical training in mental and behavioral health care fields. Only 14 (or 63.6 percent) are clinically active as of December 2004. Overall, male practitioners outnumber their female counterparts 12 to 10 (54.5 percent to 45.5 percent). This proportion evens to 50 percent, or seven males and females each, when the calculation is based on the subset of practitioners whose SPA certification is current.

Since 1983, the SPA certification program has served as a demonstration project to model and deploy a comprehensive national program, possibly in conjunction with the American Sociological Association. However, future plans in SPA include forming partnerships with other sociological, nonsociological, and professional associations, including SAS and the Society for the Scientific Study of Social Problems (SSSSP), to expand the pool of qualified candidates who are eligible to apply for SPA credentials. In October 2003, the SPA and SAS boards agreed to merge their associations and combine memberships. In 2004, negotiations still are in progress; the new entity will be named the Association of Applied and Clinical Sociology (AACS).

¹For European roots in epistemology and phenomenology, see Husserl (1960, 1999; cf. Kockelmans, 1994; also see Geiger, 1969; Mannheim, 1936; Scheler, 1962; Schutz, 1962; Stark, 1958); for an American treatment, see Blumer (1969; Garfinkel, 1967; Mead, 1934, 1938; Merton, 1957; Mills, 1959); see Blumer (1969) and Garfinkel (1967) for the strain in social psychology; and Weinstein and Platt (1973) for the strain in psychoanalytic sociology.
²In some instances, as in the case of Wisconsin Assembly Bill 125, in 1991, sponsored by social workers, psychologists, marriage and family therapists, professional counselors, alcohol and substance abuse counselors, and others, sociologists were asked to comply with its extradisciplinary requirements within a specified period of time or else cease practice as unregulated professionals. The bill failed (Onnie, 1992).
³Many practicing sociologists argue that extradisciplinary oversight results in an oblique use of sociological knowledge, generating fewer benefits to society than would be possible with direct implementation legitimated, sanctioned, and regulated by sociologists in conjunction with the State, as can be accomplished in independent sociological practice legislation (for a discussion, see Fleischer, 1998).

Professional Activities

Current data on applied and clinical sociologists, particularly those employed in mental and behavioral health care fields, other than those certified by SPA, are limited to disparate studies of independent researchers. To date, no discipline-wide or association sponsored sociology groups have generated exhaustive findings for the universe of postsecondary-educated, trained, and active practitioners, though CACS is considering such efforts.

Data from the Open System Practitioner Survey in 1998, a diagnostic administered by Mental Health Update coauthor Michael Fleischer, its principal investigator, canvassed a nonrepresentative sample of 217 sociologists, graduates at all degree levels of 10 of 37 postsecondary institutions in the tri-State, Chicago metropolitan area between 1977 and 1992. Of these sociology graduates, 69.5 percent reported current or previous employment in the academic and nonacademic workplace and professional marketplace. Fewer than one-third said they practiced sociology in academic settings, whereas more than two-thirds said they did so in nonacademic settings. A total of 21.8 percent worked in mental health care and allied medical health care fields, domains comprising the second largest industry for applied and clinical sociologists behind law, social policy, and community service, in which 23.1 percent said they worked.

Noteworthy is that 9.2 and 2.6 percent, respectively, of practicing sociologists reported single and multiple professional association credentials (all nonsociological), and 25.8 and 3.3 percent, respectively, reported single and multiple State professional credentials (all nonsociological by default). Generalizable only to the sample that confirmed residence and employment in the referenced region between August and November 1993, 42 percent of practicing sociologists, a plurality, obtained non-sociological professional association credentials in social service and mental healthcare fields, whereas 41 percent acquired State professional credentials as certified and licensed social workers or similarly credentialed clinical and school social workers. Others reported having State credentials in marriage and family therapy and professional counseling.

In a separate study of 12,211 Ph.D. sociologists polled in the 1995 Survey of Doctorate Recipients, sponsored by the National Science Foundation's (NSF's) Division of Science Resource Studies, independent researchers Koppel and Dotzler (1999) found that Ph.D. sociologists favor academic over nonacademic jobs by a margin greater than three to one. Their data, weighted on 36 "best principle job codes," indicate that 45.8 percent of all Ph.D. sociologists employed during the week of April 15, 1995, taught sociology at postsecondary institutions. In contrast, 1 percent of nonacademically employed Ph.D. sociologists coded their work as sociological, whereas 2.4 percent coded it as psychological, and 1.8 percent as social work. An additional 1.9 percent classified their work as "other health occupations," as distinguished from medical science (nonpracticing); registered nursing, pharmacology, diet, and therapy; and health technology.

A more robust and accurate picture of sociologists' employment in the mental health workforce in the United States may be possible with congressional or other support of the Core Data Set (CDS), developed by the Alliance of Mental Health Professions (AMHP), in response to current disparities in questionnaire construction, item selection, sampling methodologies, data collection, and reporting procedures in national mental health association membership surveys. Serving as the basis for the human resources data set in Decision Support 2000+ (see Henderson, Minden, & Manderscheid, 2001), CDS's sampling universe would be expanded to include all State-credentialed (registered, certified, and licensed) clinicians in addition to members of professional mental health associations. The benefits of this sampling frame are better accounting and control of providers who are cross credentialed in multiple mental health professions and States, an end to duplication and fragmentation in data collection and reporting across professions, better information to policy makers in behavioral health care issues and service delivery, and the identification of interdisciplinary, evidence based best practices.

Looking Ahead

The Directory of Programs in Applied Sociology and Practice, published biennially by the American Sociological Association, lists 35 baccalaureate, 102 master's, and 47 doctoral programs in sociological practice, all potential candidates for CACS accreditation (Fleischer, 1999). Specializations vary widely across interdisciplinary fields; however, many fall into mental and behavioral health care fields. These programs, responsive to the rapidly evolving standards of managed care education, training, administration, and intervention, will graduate candidates with the requisite clinical background to qualify them for SPA certification in mental and behavioral health care fields, and the acquisition of State professional credentials, once sociological practice legislation is enacted.

To date, the scarcity of clinically trained and active sociologists who practice in mental and behavioral health care fields yields insufficient data to project their composition and demographics over the next several years. Notwithstanding, CACS anticipates continued departmental interest in its postsecondary accreditation programs and expects that SPA credentialed graduates of its accredited clinical programs will soon augment those who currently provide educational, administrative, evaluative, and therapeutic services in mental and behavioral health care fields.

Since September 11, 2001, a few sociology departments have reported noticeable trends in the educational and career interests of their new enrollees. Others have reported no change. One department has tracked an increase in the number of declared majors among returning adult students&mdashparticularly pilots, flight attendants, and support personnel laid off by the airline industry. These enrollees have concentrated their studies in the subfield of criminology in order to pursue new careers in law enforcement. They cite safety and security issues as primary concerns. Other enrollees, such as one former flight attendant supervisor, plan to use their sociology degrees to counsel trauma survivors and people in crisis situations. Some sociology departments have begun to review their curricular requirements and the substantive content and frequency of their core and elective offerings. A few will implement changes. One department, for example, plans to add a new course on terrorism to its program, its coordinator commenting that it should be popular among traditional and returning adult students. When they become available, data on clinically trained and active sociologists will permit a fuller analysis of these patterns, as well as the demand for clinical sociologists in mental and behavioral health care fields.

Pastoral Counseling

Identity and Practice

Pastoral counseling is a unique mental health discipline that integrates behavioral science with the spiritual dimension of life, as lived out through values, belief systems, and religious practices. Pastoral counselors, as mental health professionals, are recognized and endorsed, through ordination or by other means, by an identified faith group.

For the past 40 years, the American Association of Pastoral Counselors (AAPC), the credentialing and professional body for pastoral counselors, has certified pastoral counselors as well as pastoral counseling centers and training programs (American Association of Pastoral Counselors, 2001).

A landmark development in the field of pastoral counseling occurred in 1937 when Smiley Blanton, M.D., a psychiatrist, teamed with the Rev. Norman Vincent Peale to form the American Foundation for Religion and Psychiatry. This program continues as the Blanton Peale Institute, an AAPC accredited pastoral counseling service and training center that is now one of the largest providers of outpatient mental health care in New York City. The Blanton-Peale Institute is one of a large network of pastoral counseling centers and training programs around the country. Famed psychiatrist Karl Menninger was among the pioneers in the integration of psychological and theological disciplines, believing in the "inseparable nature of psychological and spiritual health" (American Association of Pastoral Counselors, 2001).

Pastoral counseling is a highly specialized discipline that requires extensive graduate education, clinical training, and continuing education/consultation. This discipline is dynamic in nature, as are the other major recognized medical and psychological disciplines applying specific modalities of treatment.

The United States has approximately 85 accredited Pastoral Counseling Centers, which provide a wide range of mental health services and work in close collaboration with other mental health professionals, including psychiatrists, clinical psychologists, clinical social workers, and other credentialed counselors. The Samaritan Institute, based in Denver, represents the largest network of Pastoral Counseling Centers operating throughout the country. In addition, there are many independent, nonprofit centers in almost all States. Pastoral counselors, certified by AAPC, are employed in these Pastoral Counseling Centers, in private practice, or in community mental health agencies and religious institutions.

Certified Pastoral Counselors have become major providers of mental health services, offering individual, couple, family, child, adolescent, and group therapy. AAPC represents approximately 3,000 individual members and more than 100 faith groups.

Traditionally, religious communities have been a principle gateway for those seeking relief from a wide variety of problems, including mental and emotional illness, family conflict, substance abuse, depression and suicide, child and spousal abuse, violence, and other societal problems. Spirituality and religious affiliation have demonstrated their value as a resource for promoting recovery from illness, not just prevention of morbidity.

AAPC is a nationally recognized mental health organization which works cooperatively with other mental health provider and consumer groups, such as the Mental Health Liaison Group, the National Mental Health Association, the National Alliance for the Mentally Ill, the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. Increasingly, health care providers recognize the therapeutic benefits of spiritual sensitivity in their practices. They are recognizing the effectiveness of creatively using spirituality in the healing process. However, a lack of training and skill sets impose limitations on the ability of other health care providers to apply the spiritual dimension to behavioral science. Clinically, the spiritual dimension translates into using the patient's belief and value systems to effect mental, emotional, and spiritual healing. Pastoral counselors, consistent with the AAPC Code of Ethics, do not use proselytizing or religious conversion methods in the psychotherapy.

There is increasing scientific evidence that spirituality and religion are also beneficial in preventing and healing physical disease. Many physical symptoms and diseases have their etiology in mental and emotional problems. The elderly have an affinity for the spiritual dimension because they become more aware of their mortality and suffer more serious and chronic illness than other age groups. In a recent poll (American Association of Pastoral Counselors, 2001), the elderly represented higher levels of support for seeking the assistance of pastoral counselors over the assistance of family physicians and psychiatrists. Seventy-five percent of those polled from all groups stated that it would be important for elderly parents or relatives in need of treatment to receive assistance from a mental health professional that knew and understood their spiritual values and beliefs.

Pastoral counseling offers a modality of treatment that maintains the natural connection between the physical, mental, and spiritual realities of life and fosters a sound and lasting foundation for the prevention and treatment of mental and emotional illness. The wider use of pastoral counseling is consistent with the present administration's Faith Based Initiative, an initiative which recognizes the merits of close collaboration with the Nation's faith groups in alleviating a variety of social and health related problems.

Pastoral Counselor Training

Certified Pastoral Counselors are among the best trained mental health professionals. Through graduate study in theology as well as psychology, pastoral counselors are trained in two disciplines instead of one, integrating them into an effective psychotherapeutic modality of treatment. They are at the forefront of mental health professionals that have the training, background, and experience to integrate the power of spiritual resources competently and effectively with proven and accepted therapeutic methodologies. Consistent with the increasing interest on the part of other health disciplines, more than two-thirds of all U.S. medical schools now include course work, clinical case studies, and lectures on the topic of religion and spirituality.

OPM, which administers the FEHB health insurance program for Federal employees, in its decision to include Certified Pastoral Counselors in its program, stated, "We received several documents that compare the training of AAPC certified Counselors at the Fellow and Diplomate level with mental health professionals such as licensed clinical social workers. We have concluded that AAPC Counselors meet the requirements for comparable providers" (Frank O. Titus, Assistant Director for Insurance Programs, Federal Office of Personnel Management) (American Association of Pastoral Counselors, 2001).

Typical education and training for the Fellow level consists of a bachelor's degree from a college or university, a professional degree from a seminary or similar graduate educational institution, and a specialized master's or doctoral degree in the field, such as an M.A., D.Min., or Ph.D. degree. Candidates seeking AAPC certification are thoroughly evaluated to ensure that AAPC certifies only those who have reached appropriate levels of competence and who reflect the highest moral and professional standards. In addition to setting standards for the certification of individual pastoral counselors, AAPC sets standards and offers accreditation for Pastoral Counseling Centers, which includes the approval of training programs. All accredited centers and approved training programs are reviewed periodically to ensure maintenance of the standards.

Training is a top priority in pastoral counseling because the discipline continually seeks to provide the highest possible quality of care. Pastoral counselors impart their knowledge of mental health and addiction and skills to faith groups through community education events in congregations and to congregational leaders.

Consumer Attitudes

Past and recent public opinion polls have indicated that significant numbers of people desire to have the spiritual dimension and their personal value system incorporated into the treatment of mental and emotional illness for themselves and their families. In 1994, 96 percent of the U.S. population believed in God or a higher power, according to the Princeton Religious Research Center. Consumer attitudes have consistently reflected the desire to choose from a range of qualified providers, as demonstrated in research surveys, and pastoral counselors show up prominently in the preferences.

A 1991 Gallup poll (see American Association of Pastoral Counselors, 2001) showed that 66 percent of respondents preferred a professional counselor who represented spiritual values and beliefs, and 81 percent preferred to have their own values and beliefs integrated into the counseling process. A poll conducted in late 2000 by Greenburg Quinlan Research, Inc., of Washington, DC, not only underscored the findings of the Gallup poll but also revealed extensive consumer sentiment regarding pastoral counseling (American Association of Pastoral Counselors, 2001). The firm concluded, "There appears to be a favorable environment for the type of role Pastoral Counselors can play, especially for the growing elderly population. Voters say it is important to them that mental health counselors be able to integrate spiritual health and mental health in the course of counseling. These data also show a widely held belief that emotional well-being is closely linked with spiritual faith. Finally, the results show that a fear exists on some level that mainstream counseling and therapy may not always take seriously the spiritual and emotional beliefs of clients. These findings put the AAPC in a distinct position to make the argument that their members can fill a void that currently exists in treating mental and emotional problems" (American Association of Pastoral Counselors, 2001, Appendix C, p. 47).

Some survey findings from the Greenburg Quinlan Research, Inc., poll (American Association of Pastoral Counselors, 2001, Appendix C, pp. 47-48) are as follows:

1. Seventy-five percent of respondents say it would be important for an elderly parent or relative who was in need of treatment to get assistance from a mental health professional that knew and understood their spiritual -beliefs and values.



2. Among senior citizens, there were higher levels of support for seeking the assistance of pastoral counselors than for seeking the assistance of family physicians and psychiatrists.



3. Eighty-three percent of respondents feel their spiritual faith and religious beliefs are closely tied to their state of mental and emotional health.



4. Seventy-five percent of respondents say it is important to see a professional counselor who integrates their values and beliefs into the counseling process.



5. Sixty-nine percent of respondents believe it would be important to see a professional counselor who represents their spiritual values and beliefs if they had a serious problem that required counseling.



6. In all age groups, consumer preference for the services of pastoral counselors trained in psychotherapy and spirituality polled substantially ahead of the services of other trained and certified counselors and of family physicians, and merely two percentage points behind the services of psychiatrists.

Pastoral Counseling and Preventive Services

Pastoral counseling represents a paradigm for preventive mental health care. From the perspective of community prevention, early and easy access to Pastoral Counseling Centers through the family, place of worship, and other referral services provides intervention before the illness becomes chronic or more resistant to treatment. A place of worship is a natural community gateway through which millions of persons pass each week and in which a wide spectrum of mental health problems are presented. Many mental health and addictive issues are amenable to early detection, intervention, and treatment. Numerous programs around the country train clergy in the identification of mental and emotional illnesses and in forming relationships with treatment service networks offering a variety of specialized providers, effecting an early referral and avoiding long, costly treatments for chronic conditions.

The stigma of mental illness, a major obstacle to treatment, is in great part mitigated when the client is referred to a Pastoral Counseling Center for treatment. Persons have already acquired a level of comfort with their place of worship and, therefore, are less resistant to entering a Pastoral Counseling Center. This setting, consequently, often provides a more acceptable, hospitable, and therapeutic atmosphere that helps to nurture the healing process. The spiritual dimension in mental health care also helps strengthen inner personal resources for the maintenance of health following early intervention and treatment.

Many Pastoral Counseling Centers perform mental health screening to prevent or mitigate the effects of mental and emotional illnesses. The AAPC has been a principal party in a national campaign to fight depression through the education and training of community clergy and congregations, representing a wide variety of faith groups and congregations. This project has given trainees the knowledge and skills to identify people with depressive illnesses and link them with appropriate resources. These pastoral care and counseling tools will continue to be used long after this project is completed. Many congregation members have been screened for depression through this program, often being referred for further evaluation and treatment. Close working relationships with religious groups and their leaders enable pastoral counselors to be in the forefront of many valuable programs of disease prevention and health maintenance, especially for underserved the elderly and minority populations. Because Certified Pastoral Counselors bring a mature, holistic, and experienced presence to the public need for preventive services, their participation in these types of preventive activities helps to ease the enormous pressure and costs on the mental health delivery system.

Another example of preventive services, Addiction and the Family: Core Competencies for Pastoral Counselors, took place on November 19-21, 2004. Eighty-one pastoral counselors representing accredited AAPC and Samaritan Centers met in Rockville, Maryland, for the National Association for Children of Alcoholics (NACoA) Faith Based-Based Core Competencies Training Event. The goal of this training initiative "is the gradual integration of the Core Competencies for Clergy and Other Pastoral Ministers in Addressing Alcohol and Drug Dependence and the Impact on Family Members into the daily customs of clergy, pastoral ministers and religious leaders. The transformation of skill, knowledge, and behavior is a necessary antecedent to the desired change in daily practice" (Executive Summary, NACoA's Core Competencies Workshop: Final Evaluation, p. 3; available from NAPC).

In November 2001 the Johnson Institute and the National Association for Children of Alcoholics—the Clergy Training Project partnership convened a panel to recommend the development of "core competencies"—knowledge and skills—for congregational leaders to assist families, children, and individuals affected by alcohol and drug abuse. A second meeting was held February 26-27, 2003, representing a broad based panel. This meeting resulted in the Core Competencies monograph, published by the Substance Abuse Mental Health Services Administration (SAMHSA), which provided support for the meetings.

The need for such training and the integration of learned skills into the daily practice of congregational ministry is significant. According to SAMHSA, an estimated 7.7 million persons aged 12 or older need treatment for an illicit drug problem; 18.6 million need treatment for an alcohol problem. Of the 7.7 million individuals who need treatment for an illicit drug problem, only 1.4 million received treatment at a specialty substance abuse facility. Of those not getting needed treatment, an estimated 362,000 reported knowing they needed treatment—among them approximately 88,000 individuals had sought but were unable to obtain the necessary care (Core Competencies for Clergy and Other Pastoral Ministers, p. 1).

The capacity of pastoral counselors to enhance the health and well-being of communities is significant. As a result of this training initiative, pastoral counselors, working with local faith communities, behavioral health providers and organizations like the Johnson Institute and NACoA, will be able to provide the necessary knowledge and skills to religious leaders in the areas of assessment, referral, pastoral care, and community education to help those in need to access appropriate levels of care and treatment.

Additionally, AAPC is working with the American Academy of Child and Adolescent Psychiatry and Family Communications (producers of Mister Rogers' Neighborhood) to develop and implement a training model (train the trainer) for preschool child care providers to enhance their intervention skills to address a child's acting out and impulsive behavior. Training for the child's primary caregiver(s) would be provided as well. The training would take place in faith-based child care programs, which nationally provide the highest percentage of care with the least trained staff. It would have a threefold benefit: enhancing skills of staff care givers, assisting children to better manage their behavior, and providing the opportunity for early assessment , intervention, and treatment. It would assist in the fulfillment of The President's New Freedom Commission on Mental Health goal #4, "Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice."

The Future of Pastoral Counseling

The aforementioned examples of preventive care offer a window on the future of pastoral counseling. The profession has evolved from an intrapsychic model of care of the individual psyche, to the self in a system, to the context of the broader community. The focus is increasingly on the way cultural and political contexts shape people's lives. Gender, class, race, economics, privilege, age, sexual orientation, and religious worldview have become important factors influencing behavior and identity. New voices in pastoral counseling directs attention to the complexity of the person in culture. Particularity and difference—a respect for the knowledge and truth in a variety of voices—began to push against what had traditionally been held as more commonly applied universal diagnostic and treatment procedures in addressing human thought and action.

Intercultural influences have also had their impact. Ethnic racial communities and international communities and religious institutions have continued to grow and gain prominence. What was previously referred to as a "melting pot" where people from abroad and with cultural differences could be Americanized is now a cultural marketplace where a multitude of contexts and perspectives provide many places for a person to stand and view the world. "Globalization" was the norm in a clinical model that exported Western pastoral care and counseling to the non-Western world. In the communal contextual model, "internationalization" is now the order of the day where a mutual exchange of pastoral care knowledge takes place between Western and non-Western contexts. The emphasis is on authentic participation of all people so that each voice can be heard.

As Larry Kent Graham noted,

In short, the field of pastoral care and counseling is in the process of "widening its horizons..." .conceptually, methodologically, sociologically, culturally, and functionally. Conceptually, this ferment requires a more comprehensive view of the relationship between persons and the larger world shaping them. Methodologically, it incorporates political, cultural, and sociological disciplines into psychological-therapeutic perspectives, with theology, ethics, and pastoral practice reasserting their centrality as the grounding standpoints for theological construction and concrete practice...Sociologically and culturally, a new paradigm will have to take into account the care needs of a pluralistic world that is fundamentally structured by unjust power differentials and fragmented by contending value orientations between groups...Ethically, it calls for the development of criteria which guide practice with respect to just and liberated relationality at all levels of the social order. Further a new paradigm must attend to the limits and possibilities inherent in the social locations in which care is mediated and in the variety of lay, clergy, and secular providers of religiously based care. Persons practicing with a new paradigm in mind will need to create structures for accountability, economic viability, and accessible and diverse services, in the light of conceptual, methodological, sociological, and cultural factors (Graham, 1995, p. 221).

The effects of this paradigm shift in models and the financial, social, political, cultural, and professional changes on pastoral counseling centers have been persistent and progressive. Practitioners are beginning to see the need to develop skills and knowledge in a multiplicity of modalities and theoretical perspectives that will yield a variety of approaches for an array of contexts. There is a movement to look beyond the office and step into the community—to stand where those seeking care stand—to understand the places where people live and develop—to appreciate the specific needs and struggles they encounter there. Because care and counseling knowledge is multifaceted, pastoral counselors are finding it helpful to collaborate with partners who have complementary skills and knowledge. Pastoral counselors are talking more with diverse groups of people and thus expanding their understanding of themselves in the world. Boundaries are being examined not only in terms of making issues separate and distinct, but in terms of how issues interrelate and come together.

There is a need for a more viable business model to support the profession's new directions. Moving forward, there is an interest in funding and support for these more collaborative, inclusive, relational, communal, connectional styles of programming. Pastoral Care and Counseling Centers will most likely hang on to traditional programs and sources of funding as these continue to work and meet needs. Yet with fewer referrals from traditional sources and less money from those referrals, they will also need to look in new directions and areas for ways to create economic stability and address community needs. The profession is at the threshold of a new context, where the clinical pastoral counseling model touches the communal contextual model.

In his book Boundary Leaders (2004), Gary Gunderson discusses leadership in this "in between" place. Boundary leadership refers to "a way of seeing yourself... a way of seeing your time and place and your web of relationships. Within the unlimited, endless boundaries of 'boundary' leader, you will find that you know who you are, where you are, what you are to do there. You will find your own individual opportunities to build the capacity of others to choose life. You will find the zones, the places, where structures, ideals, organizations, visions, values—states of mind bump against one another, those permeable walls where all our hopes, dreams, and aspirations can emerge" (p. 8). Boundaries are the places where things come together and new relationships emerge, but they are not simple points of contact where one thing touches another. Boundaries come together in "boundary zones" where one paradigm washes over another. Gunderson uses the ecological image of the wetlands where salt water comes together with fresh water. There is no line of demarcation where salt water ends and fresh water begins, but there are vast estuaries full of beauty and incredibly rich and complex life forms where fresh and salt water clash, engage each other, and engender a new creative process. In this environment, life must adapt and adjust. Boundary zones are fields of relationship and power which are seldom, if ever, clear, stable, or certain. They are places of conflict where the powerful try to protect what they have from what they fear, but they are also places of courage, innovation, flexibility, adaptability—of newness and creative growth.

Leaders of pastoral care and counseling centers are roaming these boundary zones—struggling with those parts of themselves that would protect what has been while at the same time scanning the horizon for new opportunities to connect with those in need and others who care. Thus, new programming takes on an experimental nature. Projects are more likely to be research and development operations in which they are testing and shaping rather than implementing well planned and executed endeavors. As they engage in new clinical, communal models of care trials, they begin to see new structures take form. These structures will incorporate the best of what has been with the most relevant and meaningful aspects of what they have been embracing.

Pastoral counselors come face to face with individuals, families, and communities in the midst of change and transitions. The profession of pastoral counseling cannot expect anything less of itself than it does for the clients and community it serves—that is, to embrace the newness of what is possible and in the context of creative colleagues and leaders search for what can excite, energize, and mobilize the community for changing the world—or at least a corner of it.

Discussion

This chapter presents the current status of human resources in mental health. Each of the participating service-providing professions has presented, separately, demographic information about its clinically active mental health personnel and trainees. Previously, however, an overview of common patterns has not been available. This section, for the first time, offers a comparison of the current (for 2000 or later) distribution and demographic structure (age, gender, and race/ethnicity data) of clinically active mental health personnel in the different provider groups.

An examination of table 22.3, the distribution of rates of the distribution of clinically active providers per 100,000 persons in the civilian population by region and State, reveals that the highest rates of psychiatrists, psychologists, social workers, school psychologists, and advanced practice psychiatric nurses are found in the New England and Middle Atlantic States. These rates are at least 1.5 times the average for the United States. Thus, the recent average rates for psychiatrists, psychologists and social workers, school psychologists, and advanced practice psychiatric nurses for the United States are 13.5, 29.3, 30.7, 13.1, and 3.0 respectively. The corresponding rates in the New England and Middle Atlantic States are 27.2 and 21.8 for psychiatrists, 51.4 and 39.4 for psychologists, 83.4 and 64.3 for social workers, 22.7 and 19.9 for school psychologists, and 12.7 and 3.7 for advanced practice psychiatric nurses, respectively.

The regional distribution rates for counseling providers and marriage and family therapists are different than those of the other provider groups. Compared to the average rate for the United States (34.7 per 100,000 persons in the civilian population for counseling providers and 17.3 for marriage and family therapists), higher than average rates for counseling providers are found in the West South Central States (50.5 per 100,000), followed by New England (48.6) and the Mountain States (45.0), and higher than average rates for marriage and family therapists are found in the Pacific States (60.2).

In part, the availability of the different clinically active provider groups by region reflects availability within specific States. Illustratively, excluding the District of Colombia (the central city of a metropolitan area and not a State), the highest State rates for psychiatrists, social workers, and advanced practice psychiatric nurses are found in Massachusetts (32.3, 95.7, and 14.0 respectively), whereas for psychologists and counselors, the highest rates are in Vermont (72.7 and 83.0, respectively) and for school psychologists, the highest rate is in Connecticut (39.6). Unlike the other clinically active provider groups, the State with the highest rate for marriage and family therapists is not a New England State but California (76.0).

It should be noted that the State data in table 22.3 do not clearly identify that the rates for many types of clinically active provider groups are very likely to be highest in the central cities of the metropolitan areas within States. The current data provide only one example of this situation the rates for the District of Colombia, the central city for the Washington metropolitan area. Its rates for psychiatrists, psychologists, counselors, and social workers (57.6, 167.8, 227.5, and 207.8, respectively) are at least four times the U.S. averages. It is interesting to note that similar patterns do not occur for marriage and family therapists, school psychologists, or advanced practice psychiatric nurses.

The lowest rates for clinically active provider groups, at least 75 percent of the U.S. average, are found in East South Central States for psychiatrists (8.2 per 100,000 in the civilian population compared to the U.S. average of 13.5), psychologists (15.1 compared to 29.3), social workers (17.1 compared to 30.7), counselors (25.3 compared to 34.7), marriage and family therapists (7.4 compared to 17.3), and school psychologists (6.2 compared to 13.1) and the West South Central States for psychiatrists (8.3 compared to 13.1), psychologists (13.9 compared to 29.3), social workers (19.0 compared to 30.7), advanced practice psychiatric nurses (1.1 compared to 3.0), and school psychologists (9.2 compared to 13.1).

Within regions, specific States tend to have the very low rates. In the East South Central States, Mississippi has rates that are at least 50 percent of the U.S. rates for psychiatrists, psychologists, social workers, and school psychologists, and Alabama for social workers, marriage and family therapists, and school psychologists. Rates that are at least 50 percent of the U.S. average can be found in the West South Central State of Arkansas for psychiatrists and social workers; Oklahoma for psychologists, social workers, advanced practice psychiatric nurses, and school psychologists; and Louisiana for psychologists and advanced practice psychiatric nurses.

Occasionally the lowest rates can be found outside the South Central region. Thus California, a Pacific State, has the lowest rate for advanced practice psychiatric nurses (1.0); Illinois and Ohio, East North Central States, have the lowest rate for marriage and family therapists (3.3), and Minnesota, a West North Central State, has the lowest rate for counselors (2.8).

Table 22.2 provides information about the gender, race/ethnicity, and age distributions of the clinically active providers in the participating professional groups. An examination of this table reveals the following patterns:

• Gender. Clinically active psychiatrists and pastoral counselors are predominately male (72 and 68 percent, respectively), whereas the remaining clinically active providers, with the exception of psychologists, are predominately female. Approximately 70 percent of clinically active counselors and marriage and family therapists, 82 percent of social workers, and 95 percent of advanced practice psychiatric nurses are female. Slightly over one half (51 percent) of the clinically active psychologists are female.



• Race/ethnicity by gender. Across all reporting clinically active provider groups, both male and female, White non-Hispanics are the dominant race/ethnic category. With the exception of psychiatry, White non-Hispanics constitute 80 percent or more of each provider group. This holds for both males and females. Because a sizable percentage of psychiatrists are identified as Asian or Pacific Islanders (8.8 percent of the males and 13.2 percent of the females), the percentage of White non-Hispanic clinically active psychiatrists is about 5 or 6 percentage points below the other reporting provider groups (75.6 for males and 73.8 for females).



• Age by gender: Males. There are clear differences in the age structure of the provider groups by gender. Males in the clinically active provider groups that are predominately male (psychiatry and pastoral counseling) are older than males in the clinically active provider groups that are predominately female (nursing, counseling, marriage and family therapy, and school psychology). Thus, for the two predominately male provider groups, at least 28 percent of the males are 65 or older and less than 7.1 percent are under 40. A similar aging pattern is observed for psychologists (a provider group that is approximately evenly split between males and females). Thus, 22.2 percent of the male clinically active psychologists are 65 or older and 8.1 percent are under 40.
  
  Males in the predominately female provider groups are younger than male psychiatrists, pastoral counselors, or psychologists. Among the predominately female provider groups, clinically active male advanced practice nurses, social workers, and school psychologists tend to be slightly younger than clinically active counselors and marriage and family therapists. Thus, the percentage of males 65 or over among the predominately female provider groups ranges from highs of 13.5 percent for counselors and 10.3 percent for marriage and family therapists to lows of 3.3 percent for social workers, 2 percent for advanced practice psychiatric nurses, and 1.2 percent for school psychologists. The percentages under 40 range from 33 percent for school psychologists to between 12 and 15 percent for counselors, social workers, and marriage and family therapists to about 8 percent for advanced practice psychiatric nurses.



• Age by gender: Females. Overall, females in the clinically active provider groups, both predominately male and predominately female, tend to be younger than their male counterparts. Illustrating this, the percentage of clinically active females 65 or over in a reporting provider group never exceeds 13 percent of the females in the clinically active labor force. Specifically, the percentage of clinically active females 65 or over ranges from between 10.5 and 13 percent for psychiatrists, counselors, marriage and family therapists, and psychologists to 7.4 percent for pastoral counselors to under 5 percent for advanced practice psychiatric nurses, social workers, and school psychologists.
  
  For young clinically active females (under 40), only school psychology appears to be recruiting significant numbers. The percentage of women under 40 is approximately 40 percent for school psychology, whereas the percentages for women in the remaining clinically active provider groups range from about 22 percent for counseling, social work, and psychology to about 13 percent for marriage and family therapy to under 6.1 percent for advanced practice psychiatric nursing and pastoral counseling.

This examination of the distribution and demographic structure of the participating clinically active mental health service groups provides insights into the current and future availability of different types of mental health service providers. Some regions, specifically the New England and the Middle Atlantic States, clearly have higher rates of clinically active providers (psychiatrists, psychologists, social workers, school psychologists, and advanced practice psychiatric nurses) than others, such as the South Central region. To some extent this discrepancy represents the above-average availability of psychiatrists, psychologists, social workers, and advanced practice psychiatric nurses in the older, larger cities of the Northeast (i.e., the large metropolitan aggregations going from Boston metropolitan area in the north to the Baltimore-Washington metropolitan area or even the Richmond metropolitan area in the south) and the absence of these and other provider groups from the more rural and often poor areas of the East and West South Central States.

The below-average concentrations of counselors in the Middle Atlantic States (particularly New York) and marriage and family therapists in parts of New England (outside of Connecticut) and the above-average concentrations of counselors in the West South Central States, particularly Oklahoma, and marriage and family therapists in the Pacific States, particularly California, illustrates the operation of distributional forces, such as recruitment programs, other than the attraction of providers to the metropolitans of the East Coast. Since definitive information about the availability of clinically active providers in local communities and the forces contributing to their locations is not identifiable from State data, policy makers cannot ascertain from the present data the information they need to determine the amount and kinds of service they must provide to consumers in local areas.

Like the distribution of clinically the active provider groups, clear difference exist in the demographic structure of clinically active provider groups. While both males and female providers are predominately White non-Hispanic, two clinically active provider groups (psychiatrists and pastoral counselors) are predominately male and the remainder, except for psychologists, are predominately female. The clinically active psychologists are approximately evenly split between males and females.

An examination of the age structure the provider groups revels that with the exception of male and female school psychologists and perhaps female counselors and social workers, the provider groups are not attracting the numbers of younger persons, male or female, need for replacement or growth. Equally important, not only do the late life cycle stages tend to dominate most the provider groups (persons over 50 to 59 constituting the largest 10-year age category for female clinically active psychologists, advanced practice psychiatric nurses, counselors, marriage and family therapists, and pastoral counselors and male clinically active psychiatrists, psychologists, counselors, marriage and family therapists, school psychologists, and pastoral counselors), but both males and females in the predominately male provider groups (psychiatrists and pastoral counselors) are clearly aging (with concentrations of persons 65 and over). It should be noted that even though the current data are the best available, there are many questions about the demographic structure of provider groups that the data do not answer, such as the age characteristics by race/ethnicity and gender of the clinically active provider groups in different parts of the country.

The data presented here indicate that if clinically active provider groups that are racially and ethnically diverse by gender are to be readily available in all parts of the country, policy makers must review and evaluate the uneven distribution of providers among the regions and their component States, the underrepresentation African-American, Hispanic, and Native American providers in all clinically active provider groups, and the failure of most provider groups to recruit and retain sufficient young people to replace providers who are approaching or have reached retirement age.

In addition to the limited information about the distribution of clinically active providers and their demographic structure, the data currently available do not address many other critical human resources issues. The data do not permit effective examination of the increasing demand for cost-effective service or provide information on characteristics of the providers, clientele treated, actual services delivered, sources of referrals, and relationships with other health and social service professionals. This information deficit plagues all mental health professions. Given the severe consequences of psychiatric disability, it is essential that relevant policy makers work together to improve the quality of information available on human resources in mental health.

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Appendix

Sources and Qualifications of Data for Mental Health Practitioners and Trainees

Psychiatry

Scope of Data. Data are derived from the American Medical Association's (AMA) Masterfile, which contains current and historical data on all physicians practicing in the United States. Psychiatrists in the Masterfile include physicians who self-designated their practice specialty as psychiatry. This designation is determined by the largest number of professional hours reported by the physician on the AMA Physicians' Practice Arrangements (PPA) questionnaire, a rotating census that is sent to approximately one-third of all physicians each year. Data presented in the Physician Characteristics and Distribution in the U.S. are based on the self-designated practice specialty coding contained in the AMA Physician Masterfile. Data on medical residents and inactive psychiatrists have been excluded to reflect clinically trained and clinically active psychiatrists more accurately.

Limitations. Because the AMA Masterfile includes physicians who are self-designated or self-identified as psychiatrists, the data may include some physicians with no specialty psychiatric training.

Scope of Data. The 2002 American Psychiatric Association (APA) membership estimates were taken from the December 2002 APA membership database. At that time, the total APA membership was approximately 37,839, which included 26,258 clinically trained psychiatrists believed to be actively practicing in the United States. The remaining APA members were disqualified as they fell into one of the following membership categories: psychiatric residents, medical students, corresponding members and fellows; inactive members, associates, fellows; honorary and distinguished fellows; and members not practicing psychiatry in the United States.

Limitations. The APA membership data are limited in that not all of the Nation's psychiatrists are members of the APA. However, unlike the AMA Masterfile data, all psychiatrists in the APA membership are board-certified or board-eligible and have some specialty psychiatric training.

Scope of Survey. The 1988-89 APA PAS gathered data on both APA members and nonmembers who had identified themselves in the AMA Masterfile as primarily specializing in psychiatry. APA members and nonmembers were combined and cross-checked against the APA membership file to remove duplicate records, resulting in a residual list of 10,091 self-designated psychiatrists and 34,164 APA members.

Response Rate. Of the 34,164 APA members included in the study, 23,126 (67.7 percent) responded to the survey. The sample of 10,091 self-designated psychiatrists yielded a response rate of 28.9 percent, or 2,922 completed surveys. Of the 2,922 completed surveys, 341 respondents were found not to be psychiatrists and 125 psychiatrists were already members of the APA. The remaining total of 25,582 yielded 19,498 "active" psychiatrists (excludes psychiatrists who are residents or fellows, retired, or not primarily active in psychiatry), of whom 17,930 were APA members and 1,568 were nonmembers.

Data Limitations. In order to assess potential sources of survey nonresponse bias, an analysis was conducted in which demographic characteristics of respondents were compared with nonrespondents. Although this analysis revealed no major differences between the groups, other factors may have affected response. Other possible limitations may include self-reporting error of psychiatrists with respect to the recollection and estimation of weekly and monthly activities (Dorwart et al., 1992).

Scope of Survey. The APA National Survey of Psychiatric Practice (NSPP) is a biennial survey of 2,323 randomly selected self-identified psychiatrists from the AMA Masterfile of physicians. The primary purpose of the survey is to gather information at the physician level to assess the current status of psychiatric practice and to track trends in psychiatry.

Response Rate. Of the 2,323 members included in the study, 1,203 (52 percent) completed the 2002 NSPP and were considered active in psychiatry (excludes psychiatrists who are either retired or temporary not in psychiatric practice).

Data Limitations. Although this survey obtained a good response rate and included a very large number of respondents, the findings may be subject to some response bias. To reduce the impact of this bias, the data from respondents were weighted against the survey sampling frame (all psychiatrists believed to be active in psychiatry) using AMA Masterfile information (e.g., age, gender, race/ethnicity).

Psychology

Sources and Qualifications of the Data. The American Psychological Association Directory Survey is the source of the data. The preliminary question to be answered was, Who is to be counted as a mental health services provider in psychology? Not all psychologists are trained for health service provider roles, and not all of those with the necessary training are actively engaged in providing these services. In order to estimate the number of psychologists who are qualified to function as health service providers and the number who actually deliver relevant services, it was necessary to consider the type and amount of training and the acquisition of the appropriate credentials for delivering those services. This required the examination of several variables.

Licensure as a Psychologist. In all 50 States and the District of Columbia, licensure as a psychologist by a State board of psychological examiners is required for the independent practice of psychology. As is the case with most professions, these licensing statutes are designed in part to protect the public by ensuring that minimum training and competency requirements have been met by practitioners.

Doctoral Degree in Psychology. A significant amount of advanced and highly specialized training is required to independently provide the full spectrum of mental health services. In psychology, the doctoral degree meets this requirement, and this definition has been incorporated into State licensing laws and criteria used by third-party payers to recognize psychologists as eligible for reimbursement for their services.

Training in Mental Health Services. Only some of the basic subfields in psychology deal directly with the provision of health and mental health services: clinical, counseling, and school psychology. Although these three fields constitute those for which graduate training programs are accredited, a host of other postgraduate specializations exist in which psychologists can earn additional credentials (e.g., forensic psychology, clinical neuropsychology, behavior therapy, family psychology, and clinical hypnosis). Both field of degree and current major field were considered in this analysis.

Reported counts or estimates of mental health service providers in psychology do vary as a result of the differential application of these criteria by the individual counters. Examples include the counts of licensed psychologists by State boards, which often fail to account for the fact that some individuals may be licensed in more than one State—a situation characteristic of large metropolitan areas such as Boston and New York, or areas that are densely populated and near State borders, such as the Baltimore-DC-Richmond metropolitan statistical area. Dual licensure will be more common in such areas due to the proximity of State borders and the density of population. In addition, early versions of State licensing laws did not specify degree level as a major criterion, with the result that individuals with less than a doctoral degree may have been "grandfathered" in when new statutes were established.

Another problem with relying on counts of licensed psychologists provided by the States is that certain States encourage individuals in other non-health-service psychological subfields (e.g., industrial/organizational and experimental) who provide other kinds of services (organizational consulting, research and statistical services) to get their licenses. These people should not be counted among the clinically trained.

The majority of data on psychologists was derived from the 2003 APA Directory Survey. The survey is no longer conducted every 4 years, but is sent out to members on a rolling basis as pieces of information change in their files (e.g., mailing address), with interim updates in intervening years when some piece of data changes in a record (such as the mailing address), or as new members join. It is intended to be a census of all APA members. Its purpose is twofold: to provide updated individual listings for publication in the employment and professional activities directory and to describe and monitor changes in the characteristics of APA members.

The survey asks for updated information including current address, e-mail, phone, and fax information, date of birth, field and year of highest degree, major field and specialty areas, position title, employer, and licensure status. Most of this information appears in the Directory listing. Section II asks for more detailed information on (1) the nature of the individual's employment, such as primary and secondary employment settings, and a ranking of the three top work activities that the person performed for each setting; (2) the individual's involvement as a psychologist in specific activities during the past 3 years; and (3) additional demographic information such as race, ethnicity, and receipt of professional degrees in areas other than psychology.

Procedures for Identifying Health Service Providers in Psychology. As previously mentioned, individuals who are trained or employed in psychology work in a wide range of subfields and career roles. Thus, the criteria for inclusion as an active health service provider in psychology were as follows: (1) the individual was currently a U.S. resident; (2) the individual had earned a doctoral degree; (3) the individual reported being licensed by one or more States for the independent practice of psychology; (4) the individual reported being employed in psychology; and (5) the individual was involved in the provision of health and mental health services.

Those who are clinically trained constitute a slightly larger group, including all of the above, as well as those who (1) were licensed and trained in a health service provider subfield, but who reported no current involvement in direct services, or (2) were not licensed but stated that they had received their doctorate in a practice related subfield.

Given these criteria and the information available on members, attempts were made to derive estimates of the population of both clinically active and clinically trained personnel in psychology, rather than to simply report figures pertaining only to the APA membership. First, estimates were made of the numbers in the APA membership who were clinically trained, and what percentage of this group was clinically active. Practice Directorate files of State applications for Committee for the Advancement of Private Practice (CAPP) grants in 2004 included counts of the numbers of licensed psychologists residing in each State making application. These numbers ostensibly represent unduplicated counts of doctoral-level psychologists for those States. These numbers were available for 29 of the 51 States (including the District of Columbia). Twenty-nine of the CAPP grant State counts were used in the accompanying tables.

The raw numbers of licensed psychologists reported by each State licensing board could not be relied upon exclusively this year for the remaining 22 States because the figures had not been updated since 2002. However, a combination of the ASPPB data and the APA data was used to estimate the numbers of clinically trained psychologists in the United States. The count for each State was reduced by 13.8 percent, which is the representation of multiple licensures (licensed in more than one State) found among APA members. Thus, the estimate of clinically trained psychologists used in this chapter is based on a deliberate blend of several databases.

Using only APA counts of clinically trained psychologists would have yielded an unreasonably low count, one that was less than the number reported 2 years ago in an earlier version of this chapter. This did not make sense. Using only State licensing board raw counts of licensed psychologists would have resulted in what appeared to be an uncomfortably inflated count. This also did not make sense. There was little chance that psychology could have reached the State numbers based on the numbers currently graduating with doctoral degrees in appropriate fields in psychology.

These numbers represent estimates of the total numbers of clinically trained and clinically active psychologists overall, in each of the regions and in each of the States. The percentages reported in the tables are based on the responses to the APA membership survey.

The number of clinically active psychologists in 2004 was derived by using the percentage of clinically trained APA members who were clinically active in 2003. The clinically active in 2004 were estimated at just under 76 percent of the clinically trained, or 51,354.

Qualifications of the Data. As previously mentioned, the information reported in the tables in this chapter was based on analyses of the APA membership coupled with State-by-State data on the population of licensed psychologists, including those who did not belong to the APA. This strategy assumes that those who are licensed but do not belong to the APA are similar to licensed psychologists who do belong to the APA. Previous research on both APA members and nonmembers members indicated that the APA membership has been quite representative of doctoral-level providers in psychology with respect to demographic characteristics, education, and employment (Howard et al., 1986; Stapp, Tucker, & VandenBos, 1985). Comparisons of member data with data from the National Science Foundation also revealed similarities for doctoral-level psychologists. See the National Science Foundation's biennial series of reports on the doctoral science and engineering population, Characteristics of Doctoral Scientists and Engineers in the United States (http://www.nsf.gov/sbe/srs/nsf03310_). The growth in the number of APA members who report being active direct service providers parallels the national data on growth in degree production in the relevant fields as well as growth in employment settings focusing on service provision.

The number of clinically trained doctoral-level psychologists who are members of the APA was at least 63,265 in 2003. This was 75 percent of the estimated 84,833 clinically trained psychologists identified nationally for this chapter.

Because not all members responded to the APA membership survey, the extent to which the results are affected by nonresponse bias is unclear. Earlier comparisons of basic biographical information for nonrespondents with the data for respondents did not indicate marked differences with respect to highest degree, sex, and age. But conclusions could not be developed for information on employment. Thus, for example, we cannot be sure whether psychologists in certain types of employment settings were less likely to respond.

Psychological personnel at the master's, specialist, and baccalaureate levels also work in the general medical and mental health specialty areas. These individuals were not included in our analysis for two reasons: First, the data are based on APA membership, and this membership is not representative of those with less than a doctoral degree. Second, because the current licensing laws in most States require a doctorate in order to sit for licensure as a psychologist, this group is an increasingly small minority of psychologists qualified for the independent practice of psychology.

For additional information on the data presented in this chapter and on the characteristics of psychologists, please contact the Research Office, American Psychological Association, 750 First Street, NE, Washington, DC 20002, call (202) 336-5980, visit the Web site at http://research.apa.org, or e-mail research@apa.org.

Social Work

Data Collection for the National Association of Social Workers (NASW)—The data for this report were drawn from membership information and informed by the two NASW PRN surveys (2000b; 2005). Conducted in 2000 and 2004, the NASW PRN surveys captured demographic and practice data from two random samples of 2,000 regular members each. On the basis of the sampling techniques and the high rate of responses (81 percent and 70 percent, respectively), which minimized potential for selectivity and nonresponse bias, these results are highly representative of the membership. Table 22.1 is based on NSW membership data on the numbers of regular MSW and DSWs, excluding retirees, in 2004 (103,128). Table 22.2 reflects NASW membership on the number of regular MSW and DSWs, excluding retirees in the fall of 2004 (103,128), although the specific categories are based on percentages obtained from the 2000 PRN study. NASW membership data are collected from new applications and membership renewals. Tables 22.2 through 22.7 are based on the NASW membership count of regular MSW and DSW members (103,128), excluding retirees, in 2004 and informed by the NASW PRN survey, 2004. Table 22.8 reflects data from the Council on social Work Education on the numbers of BSW, MSW, and DSW enrollees as well as degrees awarded from CSWE-accredited social work degree programs for the academic year 1998-99. The response rate for these data was 87.1 percent (Lennon, 2001).

It is important to note that the numbers reported represent NASW members and that the universe of social workers is three to four times larger. Based on data from the Bureau of Labor Statistics, NASW membership comprises approximately 25 percent of the total number of trained social workers. Therefore, the numbers in the tables significantly understate the total numbers of trained social workers.

Psychiatric Nursing

The Registered Nurse Population: National Sample Survey of Registered Nurses — March 2000 (2001) uses a subset of the 2000 National Sample Survey of Registered Nurses (NSS) data set to describe the psychiatric registered nurse workforce. The NSS is a survey of registered nurses administered every 4 years by the United States Health Resources and Services Administration, Division of Nursing. The survey provides essential data about registered nurse (RN) demographic characteristics, educational background, area of specialization, and employment characteristics, including salary and job changes. A full description of the sampling and methodology can be found at the Health Resource and Human Services Web site, http://www.hrsa.gov/default.htm. Psychiatric registered nurses were included in a the subset if the respondent marked "psychiatric mental health" as the best description of the setting of their principal nursing position on March 22, 2000. Descriptive statistics were used to determine central tendency and dispersion as well as summarize characteristics of psychiatric registered nurses.

Data derived from the American Nurses Credentialing Center (ANCC, 2003) file are used in the tables of this chapter. The data contain information for all clinical nurse specialists and nurse practitioners certified in child, family, or adult psychiatric mental health nursing as of October 31, 2003. APRNs are required to have the ANCC certification to receive reimbursement from Medicare and some other public and private payors. APRNs do not require certification in many clinical and education settings. Thus, the number of APRNs far exceeds those who are certified by ANCC. While the ANCC-certified APRNs are a limited sample of the over 20,000 APRNs in practice, the data on ANCC-certified APRNs is the only data available on this workforce.

Counseling

Counselors may be defined in a number of ways. The purpose of this report is to estimate the number of available counselors who have the training necessary to provide independent or team treatment of populations in need of therapeutic mental health intervention and prevention and who are credentialed to provide such treatment. Sources used in calculations are National Board for Certified Counselors (NBCC) National Study of the Professional Counselor (2000); NBCC 1998 State Counseling Licensure Board Survey; United States Bureau of Census data (1999); American Counseling Association 2000 membership data; data base queries of NBCC; and Counselor Preparation, 1999-2001: Programs, Faculty, Trends (2000).

Most figures reflect a conservative estimate based on national certification, association membership, State licensure, and United States Bureau of Census data. These data inform the continued systematic collection of statistics about the counseling workforce. The collection of these data has reinforced the need for the counseling profession to collect systematic and equivalent data with other mental health professions.

Marriage and Family Therapy

Data Collection. The data for marriage and family therapy were collected from several sources: the American Association for Marriage and Family Therapy (AAMFT) Practice Research Network, Marriage and Family Therapist Practice Patterns Survey, the AAMFT Membership Database, the Annual Report for Accredited Programs submitted to the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE), the California Association of Marriage and Family Therapists (CAMFT) Member Practice and Demographic Survey, and data collected by AAMFT from State marriage and family therapy regulatory boards on the number of licensed or certified marriage and family therapists.

The count of MFTs for each State and the United States was derived from data collected by the AAMFT in 2004 and from State marriage and family therapy regulatory boards on the number of licensed or certified MFTs. For those States that did not regulate MFTs in 2004, the numbers were obtained from the count of clinical members from the AAMFT Membership Database.

The count for the U.S. total (50,158) from table 22.3 was used for tables 22.1, 22.2, and 22.4 through 22.6, with the data on the details of these tables coming from the AAMFT Practice Research Network Surveys conducted in 2000, 2002, and 2004 and reported by Northey and Harrington (2001; 2004) and Northey (2002; 2004a) and the CAMFT Member Practice and Demographic Survey reported by Riemersma (2004).

The data for table 22.7 were obtained from the 2004 national survey of clinical members of the AAMFT who reported on their primary and secondary job functions.

The data for table 22.8 come from a variety of sources, including the interns registered in the State of California; the Annual Report for Accredited Programs submitted to COAMFTE; a count of associate members (postdegree supervision students in other accredited programs) and student members (predegree students in other accredited programs) from the AAMFT Membership Database; and a survey of MFT graduate programs in the State of California.

The AAMFT Practice Research Network PRN Surveys. The AAMFT PRN surveys were conducted in 2000, 2002, and 2004. The surveys, funded by the Center for Substance Abuse Treatment, consisted questions and focused on clinical practices, work settings, education, and demographics. The surveys were conducted using a variety of methods, including paper-and-pencil surveys, telephone interviews, and online surveys. A total of 898 clinical members of the AAMFT participated in the survey, with an overall response rate of 60 percent.

The CAMFT Member Practice and Demographic Survey. The CAMFT Member Practice and Demographic Survey was conducted in the spring of 2004. The survey was designed to assess the current clinical practice of MFTs in California; it was sent to 3,524 CAMFT members and yielded a 26 percent response rate. In addition to questions about demographics, clinical practice, works settings, and education, questions about funding sources and income were included.

The AAMFT Member Survey. The AAMFT Member Survey was conducted in September 2004 and sent to 11,617 Clinical Members of the AAMFT, with a response rate of 19 percent. Respondents provided demographic data, basic information about their practice setting, and information about their satisfaction with AAMFT products and performance.

The AAMFT Membership Database. Data for the AAMFT Membership Database are collected from both applications for new membership and annual membership renewal forms. As the data are collected, they are entered into the membership database on a continuous basis.

Members of AAMFT are coded in the membership database according to their category of membership:

• Clinical Members—persons who have completed a qualifying graduate degree in marriage and family therapy (or in a related mental health field and a substantially equivalent course of study) from a regionally accredited educational institution and have 2 years of postdegree supervised clinical experience in marriage and family therapy.



• Associate Members—persons who have completed a qualifying graduate degree in marriage and family therapy (or in a related mental health field and a substantially equivalent course of study) from a regionally accredited educational institution but have not yet completed 2 years of postdegree supervised clinical experience in marriage and family therapy. Associate membership is limited to 5 years, since it is anticipated that associate members will advance to clinical membership.



• Student Members—persons currently enrolled in a qualifying graduate program in marriage and family therapy (or in a related mental health field and a substantially equivalent course of study) in a regionally accredited educational institution or a COMAFTE-accredited graduate program or postdegree institute. Student membership is limited to 5 years, since it is anticipated that student members will advance to associate, then clinical membership.



• Affiliate Members—members of allied professions and other persons interested in marriage and family therapy. Affiliate members come from related fields such as family medicine, family mediation, family policy, and research. Affiliate membership is a noncredentialing, nonevaluative, and nonvoting membership category.

COAMFTE Annual Report for Accredited Programs. Annually, the programs accredited by COAMFTE submit standard written reports concerning compliance with the accreditation standards, including, among other data, a list of all students currently enrolled in the marriage and family therapy program. Data reported include the student's name, year in program, gender, ethnicity, and academic background. Data on the number of students in each program were collated for table 22.8 from the most recent annual report of the accredited programs, which was either 2003 or 2004.

School Psychology

Sources of Data. The 2004 data on the profession of school psychology were obtained from four main sources: national surveys of State school psychology associations (Charvat, 2004; Thomas, 2000), past surveys of NASP members (Curtis, Chesno Grier, Walker Abshier, Sutton, & Hunley, 2002; Thomas, 2000), a comprehensive analysis of the demographic trends within the profession (Curtis, Chesno Grier, & Hunley, 2004), and the NASP membership database (NASP, 2004).

The number of school psychologists was determined by surveying the elected officers of the State school psychology associations in the fall of 2004 (Charvat, 2004) and comparing these results with the previous survey in 1999 (Thomas, 2000). The 2004 survey employed stratified random sampling to select a representative sample of 10 States. Five elected officers from each of these States' school psychology associations were asked to provide data for their State, including the number of clinically trained school psychologists and the number providing school psychology services. The data were obtained from the State departments of education and the State psychology licensing boards or, if official statistics were not available, extrapolated from other available data (e.g., State association membership data, school district data). All 10 States responded to the request, and these responses were analyzed to determine the overall rate of change in the number of school psychologists in the country between 1999 and 2004. Based upon the calculated rate of change, estimates of 2004 figures were made for each of the remaining States. Elected officers from associations in the remaining States and the District of Columbia were provided with the estimates for their States and asked to either confirm their accuracy or provide their official State data or their own estimates. State association officers from 33 States and the District of Columbia provided either official data or their own estimates; officers from the remaining 17 States accepted the study estimates for their States. These results appear in the text and in tables 22.1 and 22.3.

The demographic characteristics of school psychologists presented in tables 22.2, 22.4, and 22.8 were extrapolated from the results of NASP membership surveys (Curtis et al., 2002; 2004; Thomas, 2000) and from queries of the NASP membership database (NASP, 2004). Both the membership surveys (which NASP conducts every 5 years) and the database queries were focused on "regular" members. A regular member must be either currently credentialed and working as a school psychologist, credentialed and working as a supervisor or consultant in school psychology, or primarily engaged in the training of school psychologists at a college or university. Regular members comprise 15,133 of the total NASP membership of 22,021 in 2004. No new data were available for tables 22.5, 22.6, and 22.7.

Limitations. The text and tables of this chapter present the best available data on school psychologists. However, some limitations are worth noting. With regard to the number of school psychologists, some survey respondents reported that their State agencies were unable to provide certification and licensing data. In these cases, data were extrapolated from other valid information available to the survey respondents. It is unknown how closely these estimates match the official data, though it is likely that the elected officers of State school psychology associations are in the best position to make accurate estimates.

With regard to the demographic characteristics of school psychologists, it is important to note that they are based on NASP membership surveys. Since a significant percentage of school psychologists are not NASP members, it is possible that the demographic characteristics of school psychologists who are not members of NASP differ from those presented. However, there is no evidence to support this assumption. Currently, extrapolations based on data from NASP membership surveys and the membership database are the only available method of obtaining such information.

A special caution is needed for table 22.3, as the school psychology data in that table could easily be misinterpreted. Although school psychologists generally do not provide services to adults, this table presents rates for school psychologists per 100,000 civilian population, which includes adults as well as children and adolescents. It would be erroneous to consider the entire State population as the potential service population for school psychologists. School psychologists generally serve children and adolescents aged 5 through 18 and a subset of those aged 0 through 21 who have, or are at risk of having, special learning or mental health needs. According to the U.S. Census Bureau (2004), there are about 53.3 million children aged 5 to 17 in the United States, representing about 18.4 percent of the 289.6 million total population in 2003. Thus, table 22.3 should only be used with this caveat in mind.

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