THE HIGH COST OF LICENSING MENTAL HEALTH OCCUPATIONS

Michael Thom¹ and Conor Norris²

1: University of Southern California

2: Knee Center for the Study of Occupational Regulation at West Virginia University

 

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It is easy to understand why nearly nine in ten adults believe there is a mental health crisis in the United States.[1] In 2022, almost 13 percent of American adults reported ongoing worry or anxiety, and approximately five percent reported consistent depression.[2] Over 46 million people meet the criteria for having an alcohol or drug use disorder.[3] And emergency departments treat millions for mental health and substance abuse issues every year—a number on the rise.[4] Mental health professionals play an essential role by providing treatment and counseling for those suffering from poor mental health.

 

While mental health professionals are vital to mitigating the crisis, obtaining a license to practice is no easy task. Psychiatrists must earn a medical degree, complete several years of additional training, and pass one or more examinations. Psychologists must earn a doctoral degree and, like psychiatrists, complete additional training and pass one or more tests. Other mental health professions face only slightly less demanding requirements. Licensed marriage and family therapists (LMFTs) and licensed clinical social workers (LCSWs) typically require a master’s degree, supervised practice, and a passing score on one or more examinations. These requirements—which must be met before legally practicing—are designed to ensure patients receive high-quality care. However, they also limit entry into the profession. With mental health issues causing a steady increase in demand, limiting entry will lead to persistent shortages.

 

Obtaining a license is also costly. Beyond tuition and other education-related expenses, a prospective mental health professional must pay for exam(s), initial application fees, license renewal fees, and continuing education costs that span their career. However, the burden varies by state and profession. These costs are unlikely to improve quality, yet they represent a substantial cost and prevent some from entering the profession entirely.

 

This brief discusses the supervised practice mandates, fees, and continuing education requirements that state agencies impose on LMFTs and LCSWs to obtain and maintain a license. Although their specialties differ—LMFTs focus on family and other interpersonal conflicts while LCSWs concentrate on individual behavioral health challenges—both treat the most common mental health issues (e.g., anxiety, depression, and substance abuse) at a lower cost than psychiatrists and psychologists. This brief also suggests reforms that would reduce the licensing burden on LMFTs and LCSWs, easing the pathway to practice for two occupations whose services will likely remain in high demand for the foreseeable future. States should reevaluate supervised practice requirements, reducing licensing fees to the minimum necessary, and reducing continuing education requirements, all of which have little effect on quality in practice.

 

Supervised Practice Hour Mandates

 

Every state requires prospective LMFTs and LCSWs to complete a master’s degree in a related field (e.g., marriage and family therapy, social work, counseling, or psychology) at an accredited college. They also mandate the completion of varying lengths of supervised practice before issuing an initial license. Supervised practice is a form of “hands-on” training where an active, licensed professional oversees the practice of the student. The maps below illustrate the number of supervised practice hours a prospective LMFT and LCSW must complete, based on data collected from each state’s licensing board, administrative rules, or statutory language. Appendix Tables 1 and 2 list each state’s mandate for LMFTs and LCSWs, respectively.

 

 

 

Supervised Practice Mandate for Prospective Licenced Marriage and Family Therapists

Supervised Practice Mandate for Prospective Licensed Clinical Social Workers

Notes: Current as of June 2023 for new licensees not covered by a reciprocity program; South Dakota’s requirement is two years, but the state does not stipulate an hour equivalent. Source: Individual state licensing agencies, administrative rules, or statutory language.

 

Considerable differences exist across the states. Some, including Kansas, Minnesota, and Utah, mandate 4,000 hours for prospective LMFTs, while others, including Alabama, Hawaii, Indiana, and Michigan, mandate only 1,000 hours to apply for the same license. Some states, including Minnesota, New Hampshire, and Oklahoma, require 4,000 hours from prospective LCSWs, but several mandate less than 2,000 hours, and Mississippi only requires 1,000. Such a wide variation in practice hour requirements between states suggests that the length is determined by something other than quality.

 

Nationwide, the average supervised practice mandate for prospective LCSWs (3,032 hours) is higher than for LMFTs (2,389 hours).[5] That’s partly because 23 states require more social work practice than marriage and family practice, often by a substantial amount. For example, Michigan and Oklahoma mandate 4,000 hours of supervised practice for prospective LCSWs but only 1,000 hours for prospective LMFTs. Twenty-two states impose an identical mandate on both licenses. Only four—Virginia, Kansas, Utah, and Arizona—mandate more supervised practice in marriage and family therapy than for social work.

 

Career License Costs

 

Beyond completing a master’s degree and supervised training, a prospective LMFT or LCSW incurs licensing costs that span their career. That cost begins with fees for at least one examination:

 

• Every state except California requires that prospective LMFTs pass an examination administered by the Association of Marital and Family Therapy Regulatory Boards, which in 2023 costs $365. California applicants must pass two exams that cost a combined $650: the state’s clinical exam and another on therapy-related law and ethics. Like California, five other states require a separate exam on state laws. While Maryland and Oregon provide their exams at no cost, Colorado charges $20, Texas charges $39, and Oklahoma charges $45.

 

• Every state requires that prospective LCSWs pass an examination administered by the Association of Social Work Boards, which in 2023 costs $260. California, Colorado, New Mexico, Oregon, Texas, and Wisconsin applicants must also pass an exam on the state’s social work-related laws and regulations. Oregon and New Mexico provide free exams, but the other states charge between $20 and $150.

 

Licensing costs also include initial application and licensing fees and renewal fees that continue for the LMFT’s or LCSW’s entire career:

 

• Initial application and licensing fees vary by state and field. To receive their initial license in 2023, a prospective LMFT pays as little as $50 in Indiana, Kansas, and Nebraska and as much as $1,600 in Alaska. A prospective LCSW pays as little as $5 in Arkansas and as much as $478 in Hawaii.

 

• Most states require LMFTs and LCSWs to renew their license every two years. Renewal fees for LMFTs in 2023 vary from $50 in Indiana and Nebraska to $1,250 in Alaska. For LCSWs, renewal fees range from $4 in Arkansas to $350 in Mississippi.

 

Over a hypothetical 36-year career, the total cost of maintaining a license to practice as an LMFT or LCSW quickly reaches thousands of dollars. The maps below illustrate the career license cost in each state based on data collected from each state’s licensing board, administrative rules, or statutory language. It includes examination fees, initial application and licensing fees, and renewal fees. The career license cost estimates are conservative: they assume fees charged in 2023 will not change. Appendix Tables 1 and 2 provide each state’s career license cost for LMFTs and LCSWs, respectively.

 

The average career license cost for LMFTs ($4,859) is higher than for LCSWs ($3,336), but the range is broad. The most expensive state for LMFTs is Alaska, where a therapist can expect to pay nearly $25,000 in fees to maintain their license to practice. Only one other state, Connecticut, exceeds a career cost of $10,000, but the cost in four others—Nevada, New Mexico, North Dakota, and Washington—is above $7,500. In contrast, the career license cost for LMFTs is less than $2,000 in Ohio, Wisconsin, Illinois, Nebraska, and Indiana.

 

LCSWs generally face lower career license costs than LMFTs. In six states—Texas, California, Ohio, Iowa, Minnesota, and Mississippi—the career cost of a clinical social work license is greater than the cost of a marriage and family license. But in 43 others, an LCSW’s career license cost is below an LMFT’s.

 

 

Career Licensing Costs for Licenced Marriage and Family Therapists

Career Licensing Costs for Licensed Clinical Social Workers

Notes: Current as of June 2023; estimates assume a 36-year career; Colorado did not provide an LMFT renewal fee. Source: Author’s calculations based on fee data reported on individual state licensing agency websites or within administrative rules.

 

 

Continuing Education Requirements

 

In addition to holding a master’s degree, passing one or more exams, and paying continual license fees, nearly every state stipulates that LMFTs and LCSWs complete a continuing education requirement as a condition of renewal. A professional could meet the requirement through college-based coursework or programs offered by a state agency or professional organization. Some options have no cost; others carry a fee. The maps below illustrate each state’s continuing education requirement throughout a 36-year career as an LMFT and LCSW, based on data collected from each state’s licensing board or administrative rules. Appendix Tables 1 and 2 list each state’s requirement for LMFTs and LCSWs, respectively.

 

Career Continuing Education Requirement for Licenced Marriage and Family Therapists

Career Continuing Education Requirement for Licensed Clinical Social Workers

Note: All requirements applicable as of June 2023 and assume a 36-year career. Source: Author’s calculations based on data reported on individual state licensing agency websites or within administrative rules.

 

Compared to supervised practice mandates and career licensing costs, continuing education requirements are more consistent across the states. Overall, the requirement is less on average for LCSWs (608 hours) than LMFTs (643 hours). Four states require that LMFTs complete more than 800 hours of continuing education over their careers—Alaska, Wyoming, Maine, and West Virginia—while Tennessee and Vermont require less than 400, and Michigan requires none. Just two states—Alaska and Wyoming—require more than 800 hours for LCSWs.

 

Implications

 

The demand for services provided by mental health professionals will remain high as Americans face persistent and increasing levels of anxiety and depression. To earn a license as a LMFT or LCSW, however, a person must complete a master’s degree and thousands of hours of supervised practice before paying thousands of dollars in licensing fees over their careers, not to mention hundreds of hours of continuing education. These burdens fall disproportionately on lesser-paid mental health professionals, which includes LMFTs and LCSWs, who treat the most common mental health conditions at a lower cost than psychiatrists and psychologists. The data reported in this brief suggests three general reform avenues to lower licensing burdens and ease the path to mental health practice.

 

First, states should reevaluate supervised practice mandates. In theory, supervised practice offers prospective LMFTs and LCSWs an opportunity to apply concepts to clients in real-world settings under a mentor’s direction. That supervision often continues after a professional receives a license. But there is little rigorous evidence on supervision’s effects.[7] One review called the available evidence on the impact and cost-effectiveness of supervision in child welfare settings “surprisingly weak.”[8] Another found that evidence for any type of impact was “weak at best.”[9] That’s often because of poor research designs that do not assess whether supervision causes better outcomes—say, by comparing patients treated by a highly-supervised professional to patients treated by a professional with less or no supervision. States should thus consider lowering supervised practice mandates.

 

Second, states should lower the cost of maintaining licensure through their career. Possible strategies include cutting or eliminating initial application and licensing fees, reducing license renewal fees, or increasing the length of the renewal period (e.g., from two years to six years). Whereas supervised practice and continuing education may, in theory, provide value-added benefits to professionals and clients, license renewal fees do not benefit either party. Instead, they increase costs on professionals who almost certainly pass at least some of the burden to clients through higher fees. Elimination of testing requirements is another cost-reduction strategy worth considering. Given that prospective LMFTs and LCSWs already possess a bachelor’s degree and a master’s degree—the latter, by law, from an accredited university within a state-prescribed curriculum—one or more post-graduate licensing exams are arguably redundant. Alternatively, states could reduce licensing burdens by allowing individuals with a bachelor’s degree in a mental health field to “test out” of the master’s degree requirement if they can pass a national or state examination.

 

Third, states should reevaluate the necessity of continuing education requirements. Like supervised practice, continuing education should, in theory, benefit professionals by keeping them appraised of current practices and standards. But continuing education opportunities are not necessarily high-quality. One review criticized social work content for having “relatively lax” quality control; it also found “a considerable number of … programs convey content that can be labeled as pseudoscientific.”[10] And while nearly every state imposes such a requirement, many do not appear to take it seriously. Indeed, several states require LMFTs and LCSWs to disclose continuing education efforts on license renewal forms, but they do not verify the information from every applicant. Rather, they select a small percentage of renewal applications for audit; for instance, Kansas audits 10 percent of LCSW renewal applications and Montana audits “no more than 50 percent.”[11] Given the lack of evidence for beneficial impacts and low oversight, states should consider reducing or eliminating continuing education requirements.

 

The added cost and time to meet licensing requirements reduces the supply of professionals. For mental health professions, a shortage of professionals puts patients at risk. Removing or reducing unnecessary requirements that increase the cost of licensure without improving the quality of treatment received by patients is a simple way to increase access to mental healthcare.

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[1] McPhillips, Deidre. 2022. “90% of US Adults Say the United States is Experiencing a Mental Health Crisis, CNN/KFF Poll Finds.” CNN. Retrieved from https://www.cnn.com/2022/10/05/health/cnn-kff-mental-health-poll-wellness/index.html

[2] Schiller, Jeannine S., and Tina Norris. 2023. “Early Release of Selected Estimates Based on Data From the 2022 National Health Interview Survey.” Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease202304.pdf

[3] United States Department of Health and Human Services. 2023. “SAMHSA Announced National Survey on Drug Use and Health (NSDUH) Results Detailing Mental Illness and Substance Use Levels in 2021.” Press Release. Retrieved from https://www.hhs.gov/about/news/2023/01/04/samhsa-announces-national-survey-drug-use-health-results-detailing-mental-illness-substance-use-levels-2021.html

[4] Theriault, Kayla M., Robert A. Rosenheck, and Taeho Greg Rhee. 2020. “Increasing Emergency Department Visits for Mental Health Conditions in the United States.” Journal of Clinical Psychiatry 81(5): 20m13241.

[5] The average supervised practice mandate for LCSWs excludes South Dakota, which reports its requirement as “two years,” not a specified number of hours.

[6] These numbers exclude Colorado, which did not disclose a renewal fee for LMFTs.

[7] Bogo, Marion, and Kathryn McKnight. 2005. “Clinical Supervision in Social Work: A Review of the Research Literature.” In Supervision in Counseling: Interdisciplinary Issues and Research, ed Lawrence Shulman and Andrew Safyer. New York: Routledge.

[8] Carpenter, John, Caroline M. Webb, and Lisa Bostock. 2013. “The Surprisingly Weak Evidence Base for Supervision: Findings from a Systematic Review of Research in Child Welfare Practice (2000-2012).” Children and Youth Services Review 35(11): 1843-1853.

[9] Watkins, C. Edward, Jr. 2020. “What Do Clinical Supervision Research Reviews Tell Us? Surveying the Last 25 Years.” Counseling & Psychotherapy Research 20(2): 190-208.

[10] Thyer, Bruce A., and Monica Pignotti. 2016. “The Problem of Pseudoscience in Social Work Continuing Education.” Journal of Social Work Education 52(2): 136-146.

[11] See https://ksbsrb.ks.gov/docs/default-source/regulations/social-workers/102-2-11a.pdf?sfvrsn=4 and https://rules.mt.gov/gateway/RuleNo.asp?RN=24%2E219%2E435, respectively.