What does your psychotherapy license allow you to do? Specifically, what can you do that an unlicensed person cannot?
States tend to define psychotherapy in roughly similar terms. California defines it as:
- the use of “psychological methods”
- in a professional relationship
- to help a person acquire greater human effectiveness or to modify feelings, conditions, attitudes and behavior which are emotionally, intellectually, or socially ineffectual or maladjustive.
Cal. Bus. & Prof. Code: § 2903(c); § 4980.02; § 4996.9; § 4999.20(b). See our Law & Ethics CE No. 3, Managing Your Practice under the Law, for further discussion.
So that’s pretty quick and easy to understand. Whatever you do must be within the scope of your own licensure. Specifically, if something is included within a different licensure, and is not included in yours, you cannot do it. As an MFT, you definitely cannot prescribe drugs, administer biofeedback, or perform dental surgery for that matter.
However, this does not mean you can do everything that is within the scope of your licensure. There is a separate rule, called “scope of competence,” which is just as important.
Everything you do, professionally, must be reasonable and competent. It is neither reasonable nor competent to use an assessment or treatment modality for which you lack adequate training and experience.
A clear example of this would be using a particular psychological test (such as the MMPI) without being trained in how to administer and interpret it. No matter what your licensure, this is below the standard of care.
The issue gets fuzzier when a therapist has some preparation, but not much, for dealing with a particular issue. Suppose, for example, that you are approached by someone seeking help for an eating disorder. If you have no knowledge or experience in eating disorders, accepting this client for treatment would be negligent. But what if you attended a 6-hour continuing education class and read a book on eating disorders? This is still not enough. Generally, you must have some clinical training and experience in an issue before treating someone for it.
But suppose you treat a client for several months, and have developed a strong, trusting, and supportive psychotherapeutic relationship. In many ways, the client is beginning to thrive under your care. Then you find out the client has an eating disorder, and you have little or no training in this area. What do you do?
This is a scope of competence issue. There are two ways to handle these. You can get additional training through consultation/supervision, or you can refer the client to another therapist. These are your only choices.
Consultation/supervision means that you find a colleague who has expertise in a particular area, for example, in eating disorders. The colleague gives you direct training and feedback as you work with the client.
Such arrangements vary considerably, depending on circumstances. A consultation could be a one-time telephone conversation. Supervision generally implies a longer-term arrangement, whereby the supervisor and supervisee meet periodically (in person or by telephone), and discuss the case, the issues presented, and the client’s progress. Supervisors usually charge for this service, and a one-time consultant may also charge.
A central issue to address, in any consultation/supervision, is your own capability. Are you, with the guidance you are receiving, able to provide competent treatment? Or are you still in over your head?
There is no shame in deciding the latter. No one can be an expert in everything. The only shame—or legal liability—lies in pretending to have expertise that you do not have.
Consultation/supervision is an expense that you bear to expand your own scope of competence. Clients do not pay for your education or training, they pay for your time with them. Therefore, consider at the outset whether it is worthwhile for you to take on a client, or continue treatment, given your need for supervision. If not, refer the client elsewhere.
If you require supervision to treat a client, this is something that the client needs, and deserves, to know. Your duty to obtain the client’s “informed consent” to treatment means that you have to explain the downsides, risks, and limitations of seeing you, as well as the potential benefits. See our Law & Ethics CE No. 1, Minimizing Legal-Ethical Risk in Psychotherapy, for an in-depth discussion. You would explain that, while you think you can provide effective treatment overall, you need additional training and guidance in a particular area, and that you will be discussing the client—without naming him or her, or providing other identifying information—with a colleague. This way, the client can decide, based on more complete information, whether to proceed with you. As CE No. 1 explains, this conversation must be documented in your notes.
While we are on this topic, you will also want to thoroughly document your consultation or supervision sessions themselves. Note the dates of any such sessions, the name of the consultant or supervisor, and describe the content. If there are any critical judgments that you are making during therapy—for example, what is this client’s diagnosis? does he/she present a suicide risk? which treatments would be most effective?—note the consultant’s or supervisor’s opinion. If it differs from your own, carefully explain how you reached your own judgment.
By the way, we are big believers in learning through books. It is perfectly acceptable for a supervisor to assign or suggest books—or CE courses, for that matter. Reading can radically expand your knowledge and understanding. But books or classes are not sufficient; you cannot acquire needed training through them alone. There must be a live, in-person or telephonic component—in other words, consultation or supervision.
At any time, if you find that you are simply in over your head, refer the client out. Anything else is below the standard of care.
And remember the all-important issue of proof. Specifically, you want to be able to prove, to any board, litigant, attorney, etc., that you have training in particular areas. Therefore, for every treatment modality you practice, or test you administer, keep complete records of how, when, and where you received competency. These records will help you show, if anyone ever inquires, that you are operating within your scope of practice and scope of competence.
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