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More Licensure Levels Needed for Services in Primary Behavioral Care
Many insist the access crisis in behavioral health is so dire that hiring more clinicians is simply inadequate. Yet better solutions are rarely offered. Entities like the Annapolis Coalition persist on the traditional path of recruitment and retention. Some favor technology solutions for their scalability. What if we are missing substantial, realistic sources for licensed counselors?
There are 3 viable solutions, and 1 will be the main focus of discussion here. Why focus on licensure? It is a way of ensuring the quality of human resources available. Licensed clinicians are preferable to today’s growing workforce of unlicensed behavioral specialists in primary care. Also, while technology is a fine source of solutions, we should prioritize personal, therapeutic conversations.
The first solution is to redeploy existing clinicians. This means shifting therapists to the primary care setting for brief therapeutic interventions. This is happening slowly today. It can potentially meet the needs of far more consumers than siloed, traditional care.
The second path is to focus on the estimated 57% of people with advanced behavioral degrees who never obtained licensure. Many would likely complete licensure with some assistance. Too many are a casualty of our underfunded field. People with masters and doctoral degrees work for little or no pay on the way to licensure. Many cannot persist. Given the size of this pool of candidates, it is worth pursuing.
The third alternative that will be explored in greater detail involves creating a new class of certification for nurses interested in behavioral health. This new credential for licensed nurses (RN and LPN) would involve training them to meet the behavioral needs of consumers in primary care. Each of these alternatives focuses on the primary care setting, fitting into a model called “primary behavioral care.”
The Nursing Solution
We need a lower tier of licensed staff in primary care to address behavioral issues. PCPs see the need, and this is the basis for the growing workforce of unlicensed staff. Is licensure really needed?
Some argue against it because the work is highly prescribed—the interventions are evidence-based and guideline-driven, and so people with basic training should be able to deliver validated protocols. Similarly, some argue that laypeople can achieve counseling outcomes comparable to licensed therapists. If so, we could simply measure clinical outcomes for all self-proclaimed counselors.
These points merit debate, but 2 counter-arguments stand out for preserving licensure:
- Therapeutic conversations are highly personal and idiosyncratic, always calling for some level of professional judgment, and so techniques are never so tightly prescribed that education and training are irrelevant to the quality of the work.
- Licensure is a screening mechanism for selecting motivated, qualified people—we should prioritize the career aspirations of those completing this arduous process over those with talents who neglect this path.
There is another good reason for nurses to gain additional credentials to provide behavioral counseling in primary care. This setting is calling out for professionals who understand both mind and body. Nurses are medically trained and will understand medical issues better than many licensed therapists—adding behavioral training to their repertoire makes them highly valuable clinicians.
The infrastructure for this nursing specialty is already in place. Over 200,000 new RNs are minted every year. We need more of them able to work in primary care promoting behavior change. Early indications are that a health coaching credential is being developed. Nurses excel at working on medical teams, and these new teams would have PCPs as medical leaders and licensed therapists as behavioral leaders.
The Urgency of Primary Behavioral Care
Ideally, primary behavioral care encompasses the work of clinicians with various credentials in behavioral counseling. Licensed therapists would supervise behaviorally credentialed nursing staff. While all might counsel patients during relatively brief visits, various support tasks can be assigned to behaviorally credentialed nurses in connection with digital therapeutics and measurement-based care (MBC).
Many patients will need help navigating digital platforms and using relevant clinical resources. MBC has many features to be managed, from questionnaire completion to clinical analysis and recommendations. All systems should strive to have clinicians practicing at the top of their licenses, and this is facilitated by having multiple levels of credentialed staff.
Issues of cost and quality need a frank debate now. In a few years, established practices may render such debates pointless. Unlicensed behavioral specialists may be more affordable and available, but multi-tiered credentialed resources are a realistic option.
Many people are driven to pursue a career in behavioral counseling, and PCPs are increasingly seeing the need. Leaders in our field need a sense of urgency. The window will be open briefly for them to transform primary care by building teams with multiple levels and types of expertise.
Ed Jones, PhD, is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health. Tamela Sadler, PhD, works as a health psychologist in various integrated care settings, and she serves as a management consultant with expertise in healthcare technology and employee wellness.
The views expressed in Perspectives are solely those of the authors and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
References
US Bureau of Labor Statistics. Occupational Outlook Handbook. US Bureau of Labor Statistics; 2022.
