This Web site is a component of the SAMHSA Health Information Network
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Section 4: Key Elements of the National Statistical PictureChapter 20. Mental Health Practitioners and TraineesJoyce West, Ph.D.; and the Office of Research Jessica Kohout, Ph.D. Georgine M. Pion, Ph.D. Marlene M. Wicherski Rita E. Vandivort-Warren, A. C.S.W.; Margaret L. Palmiter, Ph.D., A.C.S.W. National Association of Social Workers Elizabeth I. Merwin, Ph.D., R.N, F.A.A.N.; Debra Lyon, Ph.D., R.N., C.S., F.N.P.; and Jeanne C. Fox, Ph D., R.N., F.A.A.N. Thomas W. Clawson, Ed.D.; and S. Christian Smith, M.S. Rex Stockton, Ed.D.; and Amy Gibson Nitza, M.S. John P. Ambrose, J.D. Laura Blankertz, Ph.D. Alex Thomas, Ph.D. Larry D. Sullivan, Ph.D.; and Kevin P. Dwyer, M.A., N.C.S.P. Michael S. Fleischer, Ph.D. Harold F. Goldsmith, Ph.D.; Marilyn J. Henderson, M.P.A.; Joanne E. Atay, M.A.; and Ronald W. Manderscheid, Ph.D. Late in 1987, research staff from the American Psychiatric Association, the American Psychological Association, and the National Association of Social Workers and representatives of professional psychiatric nursing formed a work group on human resources data with staff from the National Institute of Mental Health (Dr. Manderscheid). This work group had several major purposes:
The work group has addressed each of these purposes: a common, core data set was developed and published in Mental Health, United States, 1998 (Center for Mental Health Services, 1998); chapters were developed on human resources for Mental Health, United States, 1990, 1992, 1996, and 1998 (National Institute of Mental Health, 1990, and Center for Mental Health Services, 1992, 1996, and 1998, respectively); 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 core disciplines (psychiatrists, psychologists, social workers, and psychiatric nurses), early in the 1990's, 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 and sociology have also been added. The present chapter is designed to update information contained in the 1990, 1992, 1996, and 1998 chapters. It presents information on the size and characteristics for eight of nine disciplines (data are not available for sociology). Results are restricted to those data elements that are comparable across the disciplines. Exceptions to this general approach are noted in the footnotes and in appendix D. 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, with the preponderance of financial resources spent in this area, 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. In this context, the present chapter is another step along a path that is of potential benefit to the entire field. At the outset, it is important to specify the scope and limitations of the data. The reader needs to be sensitive to data coverage both within and across disciplines, as well as over time. The chapter addresses two types of human resources:
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. Other groups are not considered in this report. The reader should note that 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. Timeframes for the statistical information vary somewhat from discipline to discipline. The reader should note the variability within and across disciplines. Psychiatry This section describes the current workforce in psychiatry. Demographic and training characteristics, as well as professional activities and settings, are emphasized. Data sources for this chapter include the American Medical Association (AMA) Physician Characteristics and Distribution in the United States (2000); the 1999 membership records of the American Psychiatric Association (APA) (see Appendix D for description); the 1990–91 through 1998–99 APA Annual Census of Residents; the 1988–89 APA Professional Activities Survey (PAS); and the 1998 APA National Survey of Psychiatric Practice (NSPP) (see appendix D for description). The AMA data contain information on all physicians practicing in the United States who are self-designated or self-identified as psychiatrists. As a result, the AMA data 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 board-eligible or board-certified psychiatrists. It should be noted that the APA data do not represent the universe of psychiatrists in the United States. The membership of the APA does, however, include a significant majority of the Nation's trained and practicing psychiatrists (approximately 85 percent) (West, Zarin, and Pincus, 1997). Demographic and Training Characteristics The AMA (2000–2001) reported that in 1998, there were 40,731 clinically active psychiatrists (including child psychiatrists) in the United States, reflecting a 40. 4 percent increase in the number of psychiatrists since 1982 and a 3.9 percent increase since 1996 (Table 1). Table 2 provides data on the basic demographic characteristics of the clinically trained APA members residing in the United States. In 1999, approximately 73 percent of APA members were male and 27 percent were female, a slight increase from 1996 (Center for Mental Health Services, 1996). In 1999, the median age of APA members was 53 years. The median age of female APA members was 47 years compared with a median age of 56 years for male APA members. Female members who are 39 years old or younger comprise 20.2 percent, compared with only 9.3 percent for male members. Female APA members who are under the age of 50 comprise 59.8 percent, compared with 33.2 percent for male APA members. Psychiatrists who are white comprise 75 percent of APA members, compared with 83 percent of all persons in the general population (U.S. Bureau of the Census, 1995). Individuals of Asian origin represent 9.5 percent of the APA membership and 3.2 percent of the general population. On the other hand, Hispanics, African Americans, and American Indians are underrepresented in the APA membership when compared with their proportions in the U.S. population. Persons of Hispanic descent account for 4. 4 percent of the APA membership and 10.0 percent of the general population, African Americans comprise 2. 4 percent of the APA membership compared with 12.5 percent of the general population, and American Indians constitute 0.1 percent of the APA membership and 0.8 percent of the general population. Table 3 reports the number and rate per 100,000 in the population of clinically active nonfederal psychiatrists practicing in the United States in 1998, based on data reported by the AMA. There are approximately 14.2 clinically active psychiatrists per 100,000 individuals in the U.S. population. The distribution of clinically active psychiatrists, however, varies across geographic regions, ranging from 6.2 per 100,000 in Idaho, and 6.0 per 100,000 in Mississippi, to 30.3 per 100,000 in New York, 32.5 per 100,000 in Massachusetts, and 64.6 in the District of Columbia. During the 1980's the number of medical students entering psychiatric residencies increased by almost 25 percent (Dial et al., 1990). However, data from the APA annual Census of Residents indicate that since 1990, the number of residents has remained relatively constant (Table 8). Nonetheless, there continues to be a steady increase in the proportion of female residents. 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. Since 1990, there has been a 63 percent increase in the proportion of international medical graduates (IMG's) entering psychiatric residencies (APA Census of Residents 1990–1998). The greatest increase occurred during the early to mid-1990's, with the proportion increasing 91. 6 percent between 1990 and 1996. In recent years, it appears that this trend has slowed and begun to reverse itself, as demonstrated by the 15 percent decrease in proportion of IMG's between 1996 and 1998. Furthermore, in the past 4 years the proportion of Hispanic residents decreased slightly and the proportion of Asian residents increased slightly, while the proportions of whites, African Americans, and American Indians remained relatively constant. It is important to note, however, that where the previous census data had 100 percent responding to this question, only 84.3 percent chose to categorize themselves by race/ethnicity in the 1998–99 census. Professional Activities Data from the 1998 APA NSPP (see appendix D for a description of the survey) indicate that the majority of psychiatrists (55 percent) continue to work in more than one setting during the course of a week, although it appears that fewer are doing so than in 1988 (76 percent) (1988 APA PAS). Among psychiatrists working full time in the United States in 1998, 60.0 percent worked in two or more settings (Table 5), while the proportion of psychiatrists working part time in two or more settings was 35 percent. By contrast, in 1988, 79 percent of psychiatrists working full time and 59 percent working part time did so in two or more settings. However, the mean number of settings a psychiatrist works in per week remained basically unchanged between 1988 and 1998 (2.3 and 1.9, respectively). Overall, the average number of hours psychiatrists work per week remained unchanged at 48, while the proportion of psychiatrists working full time has increased from 74 percent to 78 percent in the past 10 years. Individual or group private practice historically has been the primary work setting for the greatest number of psychiatrists, but substantial changes in the health care delivery system may have resulted in a decline in the proportion of psychiatrists primarily working in these settings. Between 1982 and 1988 the proportion of psychiatrists reporting private practice as their primary work activity decreased from 57.7 percent to 45.1 percent (Dorwart et al., 1992). By 1998, this figure was up to 37 percent (Table 6). However, in 1998, psychiatrists reported spending less than half of their patient care time in either an individual or group practice (1998 APA NSPP). The shift away from individual/group private practice may be due, in part, to the diverse employment opportunities for psychiatrists created by the evolution of private psychiatric hospitals, general hospital psychiatric units, and organizations providing outpatient mental health care (Olfson, Pincus, and Dial, 1994). While 21 percent of active psychiatrists responding to the 1998 APA NSPP reported working in a hospital as their primary work setting (10 percent general, 5.9 percent public psychiatric, and 4.1 percent private psychiatric), this proportion is down from 1988 (28 percent). On the other hand, for 21 percent of psychiatrists in 1998, outpatient clinics are their primary work setting (Table 6), compared with 10 percent in 1988. Furthermore, in 1998 psychiatrists reported that nearly one-quarter (22 percent) of psychiatric patient care time was spent in either a general or psychiatric hospital, and 21 percent of psychiatric patient care time was spend in outpatient facilities (including private, public, and HMO clinics). In addition to working in more than one setting, psychiatrists are usually involved in more than one work activity (Table 7). In 1998, 96 percent of psychiatrists were involved in patient care, 90 percent in administration, and 20 percent in research. Psychiatrists spent a mean number of 28 hours per week in direct patient care in 1998, 4.9 fewer hours per week (a 15 percent reduction) than in 1988. In addition, in 1998, psychiatrists appear to be spending more time in administrative activities (11 hours/week) than in 1988 (5.8 hours week). However, since the 1988 PAS did not distinguish between administrative activities related to patient care and those that were not, as was done with the 1998 NSPP, and since in 1998 most of the administrative activities hours were directly related to patient care (e.g., maintaining medical records), it is possible that the differences observed are an artifact of differences in survey instrumentation. It is also possible that the decrease in direct patient care hours and increase in administrative hours during this period are 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; however, the rate of growth in the number of clinically trained psychiatrists has decreased. There has been an increase in the number of female psychiatrists entering the field, and the median age of psychiatrists has increased slightly. The number of psychiatric residents has remained relatively constant since 1990. There has, however, been significant growth in the number of international medical graduates entering psychiatric residencies, although this trend might be reversing. The average psychiatrist works in more than one setting. In the past 20 years, individual/group private practice and hospitals have declined as psychiatrists' primary work settings. Nonetheless, there has been an increase in the number of psychiatrists working in organized care settings. Psychiatrists continue to be involved in many types of work activities, including direct patient care, research, administration, and teaching (Zarin, Pincus, Peterson, et al., 1998). Research has demonstrated that psychiatrists treat a more severe and complex patient population than other mental health providers (Olfson and Pincus, 1996; Pincus, Zarin, Tanielian, 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, 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. Data on specific psychiatric patient populations also highlight key differences between the patients treated by psychiatrists and those treated by other mental health providers (Zarin, Suarez, Pincus, Kupersanin, and Zito, 1998). As the U.S. health delivery system continues to evolve, it will be increasingly important to track and understand the characteristics of psychiatrists as well as the populations they serve. Psychology In the first half of the 20th century, psychologists were primarily employed in traditional academic settings, while only a small proportion of individuals worked outside the university, actively engaged in mental health services. This picture began to change in the mid-1970's, with statutory recognition of the profession by State regulatory agencies (DeLeon, Vanden Bos, and Kraut, 1984). In 1975, there were an estimated 20,000 licensed psychologists in the United States. This number doubled to 46,000 by 1986, and by 1999 there were at least 77,000 licensed psychologists (see Table 1). Coupled with the dramatic growth in the number of practitioners was a significant increase in psychologists' roles as direct mental health service providers. Today psychologists are involved in every type of mental health setting, from veterans' hospitals to community clinics, whether research or treatment oriented, or general primary health care or specialty focused (e.g., sports and other injuries, elderly, seriously mentally ill). As the environments have expanded, the roles of psychologists also have had to change. Roles have diversified and become more complex, and they include more than the assessment and treatment of individual clients. They now include 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 for doctoral-level psychologists trained in specialties that focused on the provision of mental health services. Stapp, Tucker, and Vanden Bos (1985) estimated the number of doctoral-level psychologists at 44,600. Fourteen years later, that number had climbed to at least 77,000. This growth was fueled early on by a surge in degree production. The number of new doctorates awarded in the practice spe-cialties in psychology rose from 1,571 in 1979 to just under 2,400 in 1989 and about 3,200 in 1999 (Henderson, 1996; Sanderson and Dugoni, 1999; Sanderson, Dugoni, Hoffer, and Selfa, 1999). The training system has also 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 American Psychological Association. There were 134 such doctoral programs in 1979, 234 in 1989, and 329 in 2,000. These counts do not include the programs that do not seek accreditation by the APA but that do award doctoral-level degrees in psychology, which further expand the ranks of the clinically trained. The total number of graduate students enrolled in these doctoral programs (accredited) has risen from 14,586 in 1984–85 to at least 18,773 in 1996 (Williams, 1996). Although there appears to be a slight downturn in enrollments in doctoral programs in psychology, this is not the case for clinical psychology (Sanderson et al., 1999). 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 appear 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. Tables 1 to 8 present 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 comprised 48 percent of all clinically trained psychologists in 1999 (Table 2)— 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 1998, almost 67 percent of all Ph.D.s in psychology were awarded to women, compared with 49 percent in 1985 and 32 percent as recently as 1975 (Sanderson et al., 1999). In 1997, women accounted for 69 percent of all full-time graduate students in doctorate granting institutions (National Science Foundation, 1999). Although psychology attracts a greater percentage of racial and ethnic minorities than many other disciplines, their representation in the health service provider workforce is relatively small at 7 percent. This figure is lower than their representation in the U.S. adult population (over 28 percent in 1999) (U.S. Bureau of the Census, 1999). As reported by the National Science Foundation, the proportion of psychology Ph. D. s in science and engineering fields earned by racial and ethnic minorities was just under 16 percent in 1998 (National Science Foundation, 1999). The percentages of ethnic minorities in the clinically trained health service provider workforce are based on percentages derived from the APA membership. It appears likely that these percentages are somewhat less than what would be predicted given the Census and NSF figures, and as such should be interpreted carefully. As Table 2 indicates, the population of clinically trained women was slightly more racially and ethnically diverse than that of men. The pool of clinically trained psychologists continues to age. The median age in 1999 was 50.0 years, compared with 44.2 in 1989. Similarly, the median years since the doctorate increased from 12 years in 1989 to 16 years in 1999. Results reveal that women were somewhat younger than men and had earned their doctorates more recently. The median age for women was 48 years, compared with 52 for men; the median number of years since the doctorate was 12 years for women and 20 for men. These findings are to be expected, given the trends in degree production noted earlier. Professional Activities Table 5 indicates that for those who specified, most of the psychologists who are actively providing services were working full time (78 percent), and according to Table 6, 47 percent (27,616 out of 59,263) were doing so by a combination of two or more positions. For those who were working part time, it was more common to be occupying one position. The primary and secondary employment settings of active health service providers in psychology are presented in Table 6. The numbers and percentages may not precisely equal totals or 100 percent due to rounding. Just under half 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 (10 percent). The next most frequent setting, a far second, was university or college setting (17 percent). Other settings included clinics (8 percent), nonpsychiatric hospitals (7 percent), mental health hospitals (4 percent), and elementary and secondary schools (4 percent). About 11 percent were employed in other settings such as government or business. Based on Table 6, just under 47 percent, or about 27,616 of all clinically active psychologists, worked in more than one setting in 1999. Again, the most frequent was solo independent practice at 34 percent, followed by academic (20 percent), and other settings (19 percent). Much smaller percentages responded with other settings. Table 7 reveals that just under 88 percent of those who are trained to provide direct services did in fact report this as an activity in which they were involved. About one-fourth reported conducting research, and 40 percent were teaching (usually in higher education). Over one-third reported involvement in administration, and just over one-fifth reported employment activities not captured by these categories (such as publishing or writing). Additional activities not presented in this chapter but captured in other survey efforts reveal involvement in educational services in elementary and secondary school settings, and in other applied psychology activities (APA, 1999). Discussion The information in this chapter is important in examining the current status of human resources and care delivery in mental health, particularly within the context of managed care. Unfortunately, many critical issues are not addressed by these data. Given the increasing demand for cost-effective service, it is critical that evaluations focus on determining the cost-effectiveness of specific treatment and intervention outcomes. This necessary shift of attention away from the process of delivery to out-come will demand analyses of economic and clinical substitutability of mental health professionals. Presently available data do not permit examination of these questions in an effective manner. Other questions cannot be answered about how mental health professionals provide services. Additional information is needed 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 currently available on human resources in mental health. In conclusion, it should again be noted that the minimal core data elements required to identify the important characteristics of mental health and substance abuse providers have been developed (MH, US, 1998). Such information is expected to contribute significantly to improving information about service providers in the health care system. Social Work The social work profession started in the mid-19th century in response to grievous injustices to poverty, homelessness, children laboring in sweatshops, the plight of widows and orphans, mistreatment of prisoners, and neglect of people with mental illness. In 1998, the social work profession celebrated 100 years since the offering of the first classes in social work at Columbia University in New York City. The turn of the 20th century saw the emergence of social work as a profession. Massachusetts General Hospital in Boston pioneered the development of hospital and psychiatric social work, starting a social services department in 1905 and hiring social workers to work with patients with mental illness in 1907. School social work programs were started in New York and other cities in 1907. Social work's advocacy for children was reflected in creation of the U.S. Children's Bureau in 1912. The U.S. Veterans Bureau (now Department of Veterans Affairs) began hiring social workers to work in its hospitals in 1926. Social workers helped President Franklin D. Roosevelt implement the New Deal to fight the poverty of the Great Depression. Social work jobs doubled in the 1930's, from 40,000 to 80,000, as public-sector income maintenance, health, and welfare programs were created in response to the Depression. Social worker Harry Hopkins headed two major relief programs, the Federal Emergency Relief Administration and the Works Progress Administration. Social worker Frances Perkins was appointed Secretary of Labor by President Roosevelt in 1933. The first woman to head a Cabinet agency, Perkins advocated for improvements in working conditions, including a minimum wage, maximum hours, child labor legislation, and unemployment compensation. Social worker Jane Addams, widely known for her settlement house work and antiwar activism, was a co-winner of the Nobel Peace Prize in 1931. The National Association of Social Workers (NASW) was formed in 1955 through the merger of seven social work organizations and is the largest association of social work professionals in the world. NASW is a membership organization that promotes, develops, and protects the practice of social work and social workers. NASW also seeks to enhance the effective functioning and well-being of individuals, families, and communities through its work and through its advocacy. During the Great Society programs in the mid-1960's, Federal funding was used to train thousands of social workers in response to a social work staff shortage. Social worker Wilbur Cohen helped draft the original Social Security Act of 1935 and successfully worked to broaden coverage and benefits. Three decades later, Cohen was instrumental in the creation of Medicare and Medicaid. He served under President Lyndon Johnson as Secretary of Health, Education, and Welfare, which administered most Great Society programs. Social workers are everywhere— in private practice, family counseling centers, nursing homes, child welfare agencies, neighborhood centers, schools, prisons, corporations, public office, hospitals, and public and private agencies. By 1990, all 50 States and jurisdictions had enacted legal regulation of social work. More than 200 social workers hold elective office, including one U.S. Senator and four Representatives. Social workers deal with society's most intractable problems, working with troubled children and families, organizing communities for change, doing cutting-edge research, and administering social programs. Demographic and Training Characteristics Because this analysis includes only NASW members, it significantly understates the true number of clinically trained social workers. Conservatively assuming that 50 percent of social workers belong to NASW, the numbers in the accompanying tables can be at least doubled to estimate the total more accurately. Data for this report are drawn from 96,407 NASW members with master's or doctoral degrees, excluding students and retired social workers. The total number of clinically trained social workers in the United States is estimated to be at least double that number, or 192,814 (Table 1). The source for Tables 1 through 8 is membership applications and renewals that routinely solicit demographic and practice data. This report was also informed by a recent random survey of 8,992 NASW members, with an overall response rate of 52.5 percent. The survey items were the same as those collected by membership applications and renewals. The results generally supported the validity of using the renewal/application data as representative of the membership at large. The profession of social work is overwhelmingly female (80 percent) and white (92 percent). The proportion of female social workers has been growing steadily since 1990, when female social workers represented 72 percent of the total. This trend is consistent with 1995–96 enrollment data from the schools of social work (Lennon, 1997) indicating that 83 percent of master's students were female. There has been a decline of nonwhite social workers from 11 percent in 1996 to 8 percent in 1998. Data from the schools of social work reported that 23.7 percent of full-time master's students were non-white. This may suggest that persons of color are less likely to join NASW and are hence underrepresented in this analysis. African Americans represent more than half of all clinically trained social workers of color and 4.3 percent of the total clinically trained social workers, according to NASW data. Asian/Pacific Islanders represent 1. 8 percent; Hispanics, 1.3 percent; and American Indian/Alaskan Native, 0.6 percent. Although the school social work statistical analysis of M.S.W. students indicates greater participation by persons of color (Lennon, 1997), the data again indicate that African Americans represent the majority of persons of color at 12.5 percent. Hispanics represent 4.8 percent, Asian Americans 2.9 percent, and American Indians, 1 percent. The percentage of clinically trained social workers at different experience intervals is listed in Table 4. Generally, the number of years since completion of education shows a mature profession with good replacement levels. Of note is the percentage of newest graduates with less than 2 years of experience rising from 8.7 percent in 1996 to 13.9 percent in 1998. This probably reflects the popularity of social work, with ever-increasing enrollments, as seen in Table 8. Comparing the school years 1994–95 with 1995–96, the number of B S.W.s awarded rose 17.6 percent and M.S.W.s rose 11.2 percent. Total enrollment growth was 10 percent for B.S.W. students and 6.4 percent for M.S.W. students. Distribution of clinically trained social workers by State and region can be found in Table 3. New York and California continue to have the highest numbers, followed by Massachusetts, Illinois, and Michigan. The Mid-Atlantic, East North Central, and South Atlantic are the regions with the highest numbers of clinically trained social workers. Professional Activities Changes in practice setting continue to reflect the proliferation of managed care in both the public and private systems. Reflecting the general trend of shrinking inpatient hospital utilization, the numbers of social workers in hospitals fell from 19.2 percent to 11.3 percent. This decline in social work employment in hospitals represents a long-term decline since 1989, when 20.8 percent of social workers were in hospitals. Clinic settings saw an overall growth from 20.2 percent in 1996 to 22.3 percent in 1998. More specifically, while the number of social workers employed in health clinics declined, the number employed in mental health settings grew. Outpatient mental health settings showed surprising gains as a primary employment setting for 6.4 percent of the clinically trained social workers and 13.5 percent in secondary settings. On the other hand, both individual and group practices showed declines. Individual practices as the primary setting declined from 20.7 percent in 1996 to 18.1 percent in 1998. Still, this is a gain since 1989, when only 13.7 percent were in individual practice. Individual practices represent a larger percentage of the total as a secondary setting but showed a decline from 43.8 in 1996 to 34.9 percent in 1998. Group practices declined from 7.2 percent in 1996 to 5.1 percent in 1998 in primary settings and from 15 percent to 7.7 percent in secondary settings. It is possible that managed care's high hassle factor and difficulty in gaining reimbursement status have encouraged some social workers to leave private practice to become employees of clinics. Academic settings have seen a growth in participation by social workers, rising to 20.1 percent in 1998 from 8.6 percent in 1996. University/colleges as primary settings have grown from less than 1 percent in 1996 to 8.8 percent in 1998. University/college setting grew even more in secondary settings, from 1.8 percent in 1996 to 11.8 percent in 1998. Gains probably reflect the large increases in student enrollments noted previously. Social work practice in elementary schools has had modest increases from 7.7 in 1996 to 8.3 in 1998 as primary employment settings, but remained almost constant in secondary settings. Social services agencies rose from 16. 2 percent in 1996 to 20. 1 percent in 1998 as primary settings. On the other hand, as a secondary setting, social services declined from 8.8 in 1996 to 4.7 in 1998. And both are declines from 1989 data, when 27.4 percent of social workers were in social service agencies. Nursing homes as primary settings also declined from 5.0 in 1996 to 2.6 in 1998. The data in Table 7 describing type of work activity are not comparable to other professional groups in that the NASW survey requires respondents to select only one activity. Although patient care/direct service is still the largest category, it decreased from 91.7 percent in 1996 to 69.1 percent in 1998. Administration and supervision showed less dramatic declines, from 34.9 percent in 1996 to 30.9 percent in 1998. Teaching represented 11.1 percent in 1996 and 9.2 percent in 1998. Research continues to be a small part of what social workers do; about l.7 percent identified it as their least frequent activity. Psychiatric Nursing Educational preparation for the practice of psychiatric nursing begins at the prebaccalaureate level. While there are registered nurses practicing in psychiatric settings who received their professional education through associate degree and hospital diploma programs, the nursing profession endorses the baccalaureate degree in nursing as the basic education required for beginning general practice in psychiatric nursing. Nurses prepared at the baccalaureate level are considered generalists and may be employed in psychiatric specialty settings or may work with clients with mental illness in other general health care settings. The American Nurses Association (ANA) provides a certification process and examination for generalist psychiatric nurses as well as a certification for advanced practice psychiatric nurses. Advanced practice psychiatric nurses are educated in graduate programs and are required to complete at least a master's degree in psychiatric nursing. In the past several years, another psychiatric nursing educational and practice model has emerged— the psychiatric nurse practitioner. Psychiatric nurse practitioners complete a master's degree in psychiatric nursing, including graduate educational requirements for practicing as family or adult nurse practitioners, and they are certified as psychiatric-mental health nurse practitioners (PMH-NPs). In 1988, an estimated 13,045 nurses had graduate education in psychiatric mental health nursing. The ANA national certification program credentials psychiatric nurses as certified clinical specialists in adult and/or child and adolescent psychiatric mental health nursing. In 1995, 6,800 nurses were certified as specialists in psychiatric-mental health nursing. In addition, some States have procedures for credentialing advanced practice psychiatric nurses. The requirements for ANA certification as a psychiatric nurse clinical specialist include successful completion of a graduate degree in psychiatric mental health nursing, supervised clinical practice for a required number of hours in the degree program, and successful completion of a written examination. Until recently, certification could be granted to nurses who had obtained graduate degrees in related fields (e.g., social work or psychology). However, certification now requires graduate education specifically in psychiatric mental health nursing. The data presented in the tables of this chapter reflect information only on nurses with graduate degrees in psychiatric mental health nursing. Ninety-four percent of the nurses were prepared as clinical nurse specialists (CNSs), and 13 percent were prepared as nurse practitioners (NPs). Eighty-six percent are best classified as CNSs, 6 percent as NPs, and 8 percent as dually CNS and NPs. Thirty-two percent are recognized by State licensure/regulations as advanced practice nurses. The ANA also certifies a subset of these nurses (47 percent) as clinical specialists in psychiatric nursing. Demographic and Training Characteristics In 1988, an estimated 13,045 nurses had graduate degrees in psychiatric nursing. According to data from the National League for Nursing (NLN) (Merwin, 1998), there were 5,001 graduations from psychiatric mental health programs between 1988 and 1996. This study estimates the number of such nurses as 17,318 (Merwin, 1998). While the total number of graduate trained psychiatric nurses has increased somewhat, work patterns have changed dramatically. In 1988, 19 percent of clinically trained nurses were not working, compared with 11.5 percent in 1996. The percentage of parttime employed nurses declined from 27 percent to 26 percent during this 8-year period. As Table 1 shows, there are an estimated 15,330 employed nurses, 74 percent of whom are employed full-time; 99 percent are employed in nursing. Table 2 shows that 93 percent of psychiatric nurses are female, and 95 percent are white. The percentage of men increased from 4.2 percent in 1988 to 6.9 percent in 1996. Less than 5 percent of female graduate-prepared nurses are under age 35; in 1988, 18 percent of such nurses were under age 35. This trend continues with the decline in percentages of nurses in the 35 to 44 age group categories. The average age of female graduate-prepared psychiatric nurses was 48 years. The percentage of white nurses declined slightly, from 96 percent in 1988 to 95 percent in 1996, still reflecting the underrepresentation of minorities as psychiatric nurses. Table 3 shows the number of nurses in each region of the United States. The greatest percentage of advanced practice nurses reside in the South Atlantic, East North Central, and Middle Atlantic areas of the country. Table 4 shows that over 50 percent of the nurses received their highest degree in nursing over 10 years ago. The percentage receiving their highest degrees in recent years may be influenced by master's-prepared psychiatric nurses returning for doctoral education. Table 5 shows that 65 percent of the clinically trained, advanced practice full-time employed nurses hold one position in nursing. Sixty-three percent of part-time nurses do so. Table 6 reflects the primary work setting of advanced practice psychiatric nurses. Hospitals continue to be the most frequent employment site. There is a slight increase (from 8.5 percent to 9.7 percent) in the nurses working in solo or group practice settings. Of concern is the decline in the number of nurses working in outpatient mental health clinic settings. In 1988, 15.4 percent worked in these settings, compared with 7.8 percent in 1996. However, an additional 3.2 percent are working in other health care clinics. Nearly 19 percent are employed in university settings, while just over 5 percent are working in elementary and secondary schools. Table 7 shows that 84 percent of employed clinically trained psychiatric nurses are involved in patient care and direct service. Thirty-seven percent of these nurses report their dominant function as direct patient care, followed by teaching (13 percent), administration (10 percent), supervision (5 percent), consultation (3 percent), and research (2 percent). The number of nurses enrolled in graduate education in psychiatric nursing continues to decline. The number of graduates decreased from 781 in 1979–80 (which was an undercount) to 426 in 1998 (Table 8). Psychiatric nursing leaders have documented this decline since the early eighties (Chamberlain, 1983, 1987). As of 1998, there were 1,274 enrollees in psychiatric mental health graduate programs, with only 36 percent (458) enrolled full-time and 64 percent (816) enrolled part-time. There has been a steady decrease in enrollees. Additionally, in recent years, a decrease in the percentage of students enrolled full-time has contributed to the decline in graduates in any one year; however, from 1996 to 1998 there was a 10 percent increase in the percentage of full-time students. Professional Activities Several trends are occurring in the education and practice of specialty psychiatric mental health nursing. The recent proliferation of nurse practitioner educational programs in all clinical specialty areas, including psychiatric nursing, is producing a different nursing workforce than previously existed. In 1991, few nurse practitioner students (only 89, or 2 percent) specialized in psychiatric nursing (NLN, 1994, pp. 107–108). In 1994, there were 364 enrollees of such programs with 70 graduates (NLN, 1996). In 1996, there were 483 enrollees of NP programs and 100 graduates. Enrollees of graduate programs in psychiatric mental health nursing are enrolled in either nurse practitioner, advanced clinical practice, or teaching programs. In 1991–92, 8 percent of graduates were from nurse practitioner programs, 84 percent from advanced clinical practice programs, and 8 percent from teaching programs (NLN, 1994, p. 111). In 1998, 35 percent of graduates were from nurse practitioner programs, 60 percent from advanced clinical practice programs, and 5 percent from teaching programs. By 1994, enrollees' choice of program also shifted. Twenty-two percent of enrollees in graduate psychiatric mental health nursing were in nurse practitioner programs, 74 percent in advanced clinical practice programs, and 4 percent in teaching programs (NLN, 1996). In 1998, 35 percent were in NP programs, 60 percent in advanced clinical practice programs, and 5 percent in teaching programs, paralleling graduation rates (NLN, 2000–2001). In 1998, there were 444 enrollees of NP programs and 148 graduates (NLN, 2000). In response to changes in the Nation's health care delivery system and the proliferation and acceptance of nurse practitioners in primary and specialty health care settings, many graduate pro-grams in psychiatric nursing now offer specialty preparation that allows for several different options for the advanced practice psychiatric nurse (Pasacreta et al., 1999). There are currently three major advanced practice specialty preparations: (1) clinical nurse specialist; (1) combined clinical specialist/nurse practitioner; and (3) psychiatric nurse practitioner. Clinical nurse specialists are prepared to have a high degree of proficiency in therapeutic and interpersonal skills in order to work with individuals and families. In some States, clinical nurse specialists who are certified in psychiatric nursing have prescriptive authority. Nurse practitioners have prescriptive authority in 49 States and the District of Columbia. Advanced practice nurses who are dually certified as psychiatric clinical nurse specialists and nurse practitioners are prepared to offer both primary mental and physical health care to children, adults, or families (depending on the specialty focuses). These nurses must complete the requirements for both the nurse practitioner and clinical nurse specialist certification, necessitating a lengthy master's-level program. However, many nursing leaders believe that advanced practice psychiatric nursing is moving toward a single role that combines the therapeutic skills of the psychiatric clinical nurse specialist with the physical assessment skills of the nurse practitioner (McCabe and Grover, 1999). The psychiatric nurse practitioner has developed from the interest in and need for a combined advanced practice role for psychiatric nurses. Psychiatric nurse practitioners are registered nurses with a graduate degree in nursing who are prepared to deliver primary mental health and psychiatric care to clients and families (ANCC, 2000). The American Nurses Credentialing Center is developing a certification examination for psychiatric nurse practitioners that will be administered for the first time in late 2000. The credential requires completion of a master's or post-master's degree program with course work including advanced health assessment, pathophysiology, pharmacology and/or psychopharmacology, and diagnosis and medication management of psychiatric illnesses, together with supervised clinical training. Counseling The American Counseling Association defines 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. Counselors work, in the broad view, in a variety of settings, including community and government agencies, schools and colleges, business, and private practice. In addition to the traditional roles of individual counseling and supervision, counselors perform a variety of other functions related to the prevention of problems and the promotion of healthy development, including consultation, outreach, education, and other forms of indirect service. Since the beginning of the 20th century when Frank Parsons began what we think of as professional counseling, one of counseling's most salient characteristics has been how much it has been and continues to be dependent on the socioeconomic and political context of the era. Professional counseling has its origins in the social reform movements of the late 19th century and the early 20th century. As O'Brien (1999) has noted, "social justice or social change work can be defined as actions that contrib-ute to the advancement of society and advocate for equal access to resources for marginalized or less fortunate individuals in our society" (p. 2). One manifestation of the changes occurring early in the 20th century was the shift from an agrarian society to an industrial society. This shift was accompanied by both bureaucratization of organizations and the specialization of the workforce. The vocational guidance movement developed with the goal of helping people adjust to these major lifestyle changes. Commonly referred to as the father of guidance and counseling, Frank Parsons established the Vocational Bureau of Boston in 1908 (Gibson and 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. This book outlined his model of career guidance, which provided a basis for the career counseling of the time. Although career guidance took place initially in community agencies, it soon became popular in school settings as well. Paralleling Parsons' work in vocational guidance was a companion movement to establish specialized clinics to assist children. Also, during the same time period (1908), Alfred Binet developed the first individual intelligence test (Kimble and Wertheimer, 1998). Binet believed that guidance toward a career should be based on the measurement of abilities. The clinics were primarily focused on the emotional and behavioral problems of disturbed children and thus tended to focus on the assessment and treatment of individual pathology. Thus counseling, which at first focused on vocational guidance (armed with assessment instruments) but later expanded to include work with those with emotional distress, grew out of a response to social needs. National legislation helped the development of the counseling profession. During the era 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 also 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. Another significant 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 counselors across the country. Community mental health centers have traditionally employed a significant number of professional counselors. Many who worked in this environment went on to establish independent private practices. The passage of the National Defense Education Act (NDEA) in the late 1950's made it possible for graduate schools of education to establish funded programs to train guidance counselors. This decision became a landmark, linking personal needs and education with our Nation's well-being. The NDEA provided grants to States for stimulating the establishment and maintenance of local guidance programs, and grants to institutions of higher education for the training of guidance counselors to staff local programs (Gibson and 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. More specifically, Congress wanted talented math and science students to be screened and encouraged to further their education. Thus, 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-1960's, 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 needs of many college teachers. By the end of the 1960's, more than 300 academic units housed counselor education postgraduate training programs. 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. Rogers' book emphasized a nondirective, client-centered approach to counseling. As Smith and Robinson (1995) noted, Rogers' client-centered theory also emphasizes the client as a partner in the healing process, rather than as a patient to be healed by the therapist. This 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 other theories, techniques, and assessment instruments to help clients achieve coconstructed goals. While there is considerable overlap among the helping professions, counseling can be distinguished by its developmental and preventative orientation as well as its focus on the individual within an environmental context. Counseling thus takes a broad view of mental health care, emphasizing the developmental, preventative, and educational aspects in addition to the traditional focus on the remedial treatment of illnesses. "Simply stated, mental health counseling believes that a person does not have to be sick to get better" (Smith and Robinson, 1999, p. 158). Formal recognition of counseling as a unique profession has been fostered by the establishment of a professional counseling organization, accreditation standards for counselor training programs, and certification and licensure 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. Since that time, several other specialty areas have been developed under the auspices of the umbrella organization, based on interest and societal need. For example, those interested in gerontological counseling, and marriage and family counseling, as well as several others, have formed divisions within ACA. While not all professional counselors are ACA members, its membership represents the various specialty and interest areas in the field. The increasing number of States that are passing licensure and certification laws for master's-level practitioners indicates the increased acceptance of counseling as a unique and legitimate profession in the panoply of mental health service providers. Currently, 45 States plus the District of Columbia and Guam have regulations for the counseling profession, with 4 other States developing such regulations. The 108,000 credentialed professional counselors work in a large number of settings, assisting clients with a wide variety of problems. Demographic and Training Characteristics For the purpose of collecting data for this chapter, emphasis was placed on the number of clinically trained counselors. Clinical training was reflected by creating an unduplicated total of National Certified Counselors (NCCs) and licensed counselors by State. Where licensure numbers were unavailable, in States without counseling licensure, totals were determined by using the number of NCCs with an estimated number of licensable counselors using data from similar States. The total number of counselors reflected in Table 1 is the sum of these State totals. The ratios and percentages reflected in the remaining tables are based on National Board for Certified Counselors database queries 2000, American Counseling Association membership statistics, a 1999 National Job Analysis of the Professional Counselor, and Hollis (2000) Counselor Preparation 1999–2001. In addition to licensure, counseling has an accrediting body for its training programs. The Council on Accreditation of Counseling and Related Education Programs (CACREP) has established educational standards for master's-and doctoral-level counselor training programs. Currently there are 129 accredited institutions, and this number is growing rapidly. The influence of the CACREP standards goes far beyond their role with accredited institutions, however. The standards often serve as guidelines for the development of State licensure or certification requirements. Nonaccredited counselor training institutions also typically organize their programs around these same standards. Thus, the CACREP standards have helped to ensure uniformity in training across the field. The National Board for Certified Counselors (NBCC), established in 1982, certifies professional counselors. Along with CACREP, NBCC has had a significant impact on the field. It provides a registry of those who have met NBCC's national certification standards. These professionals are entitled to use the designation NCC. In addition to serving as a national registry, an NBCC examination instrument, the National Counselor Examination (NCE), is required by most States for licensure or certification. NBCC has five specialty certifications, including the clinical mental health counselor specialty certification that is used for CHAMPUS payments and other clinical work. This certification requires a 60-credit-hour master's degree as well as clinical supervision, taped counseling samples, and the National Clinical Mental Health Counseling Examination. Much valuable information regarding counselor preparation is provided in the book Counselor Preparation 1999–2001 (Hollis, 2000), which is the tenth edition in a longitudinal study of counselor training. According to Hollis, there are 542 entry-level counselor training programs in the country, of which ap-proximately 30 percent are accredited by CACREP. As shown in Table 8, there were 19,576 master's students in 1999. At the doctoral level, there are currently 54 programs, 39 of which are CACREP accredited. In 1999, there were 1,061 students in these doctoral programs, for a total of 20,637 counselor trainees across the country. Professional Activities Today's counselors (along with other mental health professionals) are faced with a world of rapid change. Among others, these changes include the changing face of the health care delivery system and responses to the extreme socioeconomic changes that are a part of the national scene. In a world of instant communication, it is clear that counselors will be using technology to provide services in new and different ways. Counselors will continue to respond to changing societal needs in ways that we cannot yet envision. Marriage and Family Therapy Marriage and family therapists (MFTs) are mental health professionals trained in psychotherapy and family systems and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples, and 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 1930's and 1940's, MFTs have developed into uniquely qualified health care professionals who are federally recognized as a core mental health discipline, along with psychiatry, psychology, social work, and psychiatric nursing (clinical training and instruction and clinical traineeships; stipends and allowances; research projects, 42 U.S. Code 242a). Federal law defines an MFT as "An individual (normally with a master's or doctoral degree in marital and family therapy, and at least two 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, is eligible for clinical membership in the American Association for Marriage and Family Therapy" (Designation of health professional(s) shortage areas, 42 CFR Part 5). MFTs apply both psychotherapeutic and family systems theories and clinical interventions to the delivery of health care services to individuals, couples, and families. They diagnose and treat mental and emotional disorders, whether cognitive, affective, or behavioral in origin. Research has found the services provided by MFTs to be effective for many severe disorders (often more effective than standard treatments) and to result in improved outcomes in both the health and functioning of clients (Doherty and Simmons, 1996; Pinsof and Wynne, 1995). The profession of marriage and family therapy has burgeoned since the 1970's, with the number of therapists increasing from an estimated 1,800 in 1966 to 7,000 in 1979, to over 40,000 in the 1990's. Demographic and Training Characteristics An estimated 44,000 marriage and family therapists were clinically active in the United States in 1998 (Table 1). Female practitioners (55 percent) slightly outnumber male practitioners (Table 2), and the mean age of MFTs is 52 years (Doherty and Simmons, 1996). Consistently, African Americans and those of Hispanic descent are underrepresented among MFTs, compared with their proportions in the U.S. population. The ratios of MFTs of Asian origin and Native Americans are more in line with their representation in the total population. As with the other mental health disciplines, whites are significantly overrepresented, making up 95. 5 percent of MFTs, compared with 75.6 percent of the U.S. population. Differences exist, however, between males and females. There are slightly more minorities among male than female MFTs (5.2 percent versus 3.9 percent). Increased representation of minorities among MFTs appears promising. Over 12 percent of the student members of the American Association for Marriage and Family Therapy (AAMFT) are from minority population groups, according to a 1995 AAMFT Membership Survey. An examination of Table 3 reveals that the dis-tribution 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 and/or the presence of accredited university/college training programs. In 1998, an estimated 9,200 individuals were in training to be MFTs (Table 8). This includes an estimated 7,696 students in 171 master's degree programs, 741 students in 19 doctoral degree programs, and 840 in 28 postdegree programs. Nearly 3,000 students were estimated to have graduated from these programs during 1998. 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 the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) of AAMFT. COAMFTE accreditation is required to enable accredited programs to establish eligibility to participate in Federal programs. COAMFTE is also 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 1998, there were 48 master's degree programs, 14 doctoral degree programs, and 16 postgraduate clinical training programs in 35 States accredited, or in candidacy status, by COAMFTE. Most marriage and family therapists in clinical practice hold a master's degree (54.3 percent), including 12.7 percent who hold the M.S.W. degree. About 40 percent of MFTs hold a doctoral degree, including the degrees of Ph.D. (24. 6 percent), Psy. D. (1.7 percent), Ed.D. (7.2 percent), M.D. (1 percent), and D.Min. (4.9 percent) (Doherty and Simmons, 1995). The majority (55.3 percent) of the estimated 4,400 clinically active MFTs in 1998 are estimated to have completed their training between 6 and 15 years ago, making them highly experienced therapists as a group. Only 2.3 percent completed their training within the past 2 years (Table 4). In-service education requirements vary greatly among the State marriage and family therapy regulatory boards. Many States have no formal continuing education requirements, presumably because of the cumbersome and expensive bureaucratic mechanisms necessary to monitor and enforce the regulations and to evaluate and sanction the providers. For those States with continuing education requirements, the typical requirement is between 30 and 40 hours per 2-year renewal cycle (Sturkie and Johnson, 1994). Professional Activities In 1998, most MFTs (67.5 percent) work full-time (Table 1), usually in one setting (60. 4 percent) (Table 5), that is, a private solo or group clinical practice (65.2 percent) (Table 6). While most MFTs are in private practice, the distribution between solo and group practices appears to be changing. According to a 1995 AAMFT Membership Survey, over a third of those in private practice reported being in group practices, including both group medical and behavioral health care group practices. Also, growing numbers of MFTs are employed in organized care settings. Nearly one in five (19.4 percent) now work in community mental health centers and other community clinics and agencies, hospital inpatient and outpatient units, and other settings such as employee assistance programs and health maintenance organizations (Table 6). The 1995 AAMFT Membership Survey suggests that those in the Another/not specified employment setting include about 6 percent in academic settings and 2 percent employed as consultants to businesses. Increasingly, as shown in Table 7, MFTs are involved in roles other than direct treatment, such as administration of human service and agency settings (56.0 percent), teaching (46.7 percent), research (16.5 percent), and other activities such as prevention program development, public welfare (especially child welfare through family preservation services), public policy development, client advocacy, consultation to businesses, and more recently, managed care case managers. MFTs treat the full spectrum of American society. Over half of the clients seen are female (58 percent). Nearly 12 percent of the clients are racial and ethnic minorities, and 64 percent of MFTs say they feel competent from their training to treat racial and ethnic minorities (Doherty and Simmons, 1996). About half of the adult clients of MFTs have a college or postgraduate degree, while the other half have a high school degree and some college. Clients range in age from 1 to 74, with a median of about 38 years old (Doherty and Simmons, 1996). Marriage and family therapists treat a wide range of individual, couple, and family problems. Depression is most often the presenting issue (43.9 percent), followed by individual psychological problems (35.1 percent), marital problems (30.1 percent), and anxiety (21.1 percent). The DSM-IV diagnoses most frequently used are adjustment disorder (25.3 percent) and depressive disorder (including dysthymia) (22.9 percent). The other diagnoses used in more than 5 percent of the cases are anxiety disorders, including posttraumatic stress disorder (14 percent) and personality disorder (6.5 percent). V-codes are used in only 10.6 percent of all cases (Doherty and Simmons, 1996). 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 of clients are taking psychotropic medication; 2 percent had been hospitalized in the past year; and 6.1 percent were hospitalized while under treatment by an MFT (Doherty and Simmons, 1996). Despite their focus on family systems, MFTs do not treat only couples and family units. Indeed, half of the cases seen by MFTs are individuals (49.4 percent); 23.1 percent are couples, and 12 percent are families (Doherty and Simmons, 1996). Clients report being highly satisfied with the services of MFTs. In a recent national survey of clients, nearly all (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 return to the same therapist in the future, and 96.9 percent said they would recommend their therapist to a friend (Doherty and Simmons, 1996). Overwhelmingly positive changes in functioning also were reported by clients: 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, improvement in their overall physical health; and 54. 8 percent, improvement in their functioning at work (Doherty and Simmons, 1996). 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 aver-age cost per case $780 (Doherty and Simmons, 1996). As of 1998, 41 States regulate the practice of marriage and family therapy, with most other States considering licensure bills. California was the first State to regulate the profession in 1963 (under the title Marriage, Family and Child Counselor), followed by Michigan in 1966 and New Jersey in 1968. The most impressive growth in State regulation began in the 1980's, with the vast majority (86 percent) of State regulatory laws being adopted since 1980. All these laws regulate MFTs at the independent level of practice. The most common title of the license is Licensed Marriage and Family Therapist (31 States), while 7 States use the title Licensed Marital and Family Therapist; 3 States use the title Certified Marriage and Family Therapist. During 1998, several State legislatures continued the trend in the regulation of marriage and family therapy of changing their laws from title protection laws to practice protection laws. Also, California's law was amended, effective July 1, 1999, to change the licensed title of Marriage, Family and Child Counselor (MFCC) to Licensed Marriage and Family Ther-apist (1998 Cal. Legis. Serv. Ch. 108 (A.B. 1449)), making California's title consistent with that of most other States. 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 follows:
While the overwhelming majority (80.8 percent) of the 44, 000 MFTs nationwide hold a State marriage and family therapy license or certification, half (50.4 percent) hold additional professional licenses. This reflects the multidisciplinary nature of marriage and family therapy. The licenses held in addition to the marriage and family therapy license include psychologist (7.2 percent), social worker (10.0 percent), professional counselor (12.5 percent), and nurse (1.1 percent) (Doherty and Simmons, 1996). Just under one-third (30.4 percent) of MFTs hold only a marriage and family therapist license, and 12.4 percent hold three or more licenses. Regardless of their training, the preponderance of MFTs (60.6 percent) describe their primary professional identity as marriage and family therapist (Doherty and Simmons, 1996). Psychosocial Rehabilitation Psychosocial rehabilitation (PSR) is a rapidly growing approach to working with individuals with severe mental illness in the community. Specifically, psychosocial rehabilitation programs usually provide residential services, training in community living skills, socialization services, crisis services, residential treatment services, recreation services, vocational rehabilitation services, case management services, and/or 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 the skills to cope with serious mental illness. The focus of PSR activities is in teaching individuals with severe mental illness the skills necessary to attain goals of their choice in the community and in 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 utilized 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 deafness and other physical disabilities. Specialized programs have also been developed for individuals over 65 years of age. 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 (Table 1). Demographic and Training Characteristics Like other mental health workers, PSR workers are predominantly female (65 percent) (Table 2) and white (70 percent); 21 percent are African American, 6 percent are Hispanic, 2 percent are Asian, and .04 percent are Native American. Their average age is 38, and they have been in the field for an average of about 15 years (Table 4). Those with advanced degrees have been in the field for an average of 8 years. PSR workers can be found in all 50 States, the District of Columbia, and the Virgin Islands. Thirty-eight percent of all PSR workers have a bachelor's degree, 22 percent have only a high school degree, 13 percent have some college or an associate degree, 24 percent have a master's degree, and 2 percent have a doctoral 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, throughout the Nation, there are 13 Ph.D. programs; 3 combined M.D. and Ph.D. programs; 10 master's-level programs; 1 bachelor's program, and 1 associate program. 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, in-service 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. It is typical for a practitioner to emphasize one of these fields over another. 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 5). PSR has taken a number of steps toward establishing itself as a distinct professional field. It has developed 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 had 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. These competencies include knowledge and skills in the areas of 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 this process. These guidelines were created by experts in the field based on research in the field and were validated by a field review by practitioners. These 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 effectiveness and efficacy of psychosocial rehabilitation has been rapidly growing 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 that can 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 The application of psychological principles of mental health delivery and assessing/planning services for children with learning problems in educational settings is the primary responsibility of school psychologists. Professional school psychology has grown significantly over the past 30 years. In 2000, it is estimated that over 31,000 school psychologists (Thomas, 2000) certified by State boards of education and/or licensed by State boards of psychological services are practicing in the Nation's schools. Additionally, perhaps thousands more are primarily associated with the discipline as university instructors, full-or part-time private practitioners, or in alternative settings (Fagan and Sachs-Wise, 1994). Most school psychologists are found serving in 15,000 local educational agencies and 85,000 schools, in all States and territories, as well as Department of Defense schools nationally and internationally (Lund and Reschly, 1998; NASP, 1998). School psychologists are involved in delivering a broad array of services related to mental health services in the schools. 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. School psychological services are one of the related services available to students with disabilities who need special education and related services as part of the Individuals with Disabilities Education Act (IDEA). School psychological services, as part of the pupil services, are also desig-nated services under Title I and other titles of the 1994 Improving America's Schools Act. Demographic and Training Characteristics The professional association representing school psychologists is the National Association of School Psychologists (NASP), which has 22, 345 members (NASP, 2000). Demographic data on school psychologists reflected in Tables 1 through 8 are based on data compiled yearly by the U.S. Department of Education (USDOE), Office of Special Education Programs, Data Analysis System (DANS) for its Annual Report to Congress on the Implementation of The Individuals with Disabilities Education Act (US-DOE, 1997, 1998, 1999), membership surveys by the National Association of School Psychologists (NASP, 1997, 1998, 1999, 2000), and a focused NASP-initiated inquiry regarding the numbers of clinically active school psychologists providing services in the United States (Thomas, 2000). This base number of clinically active school psychologists reflected in the Tables (31,278) provides the most accurate data available on school psychologists who are clinically trained. Data on sex, ethnicity, years of experience, and other demographic information are also reflected in the tables. These data provide an accurate portrayal of the numbers and demographics of school psychologists providing mental health services to children and families. 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/suburban areas, primarily in California, New York, Pennsylvania, and Ohio (Fagan and Sachs-Wise, 1994). The recognition of the civil right to education of children with disabilities increased that number to its present level, with a distribution across all communities— urban, suburban, and rural— across all States. As the profession has grown, it has become increasingly more female. Data from a survey conducted in 1986 showed that approximately 59 percent of school psychologists were female. Table 2 shows that by 2000, approximately 70 percent of clinically trained school psychologists are now female. Accompanying this increase in female representation has been a decrease in years of experience. Illustrating this trend, in a survey of the 218 university training programs, 80.5 percent of the 8,324 full-and part-time enrolled students were female (Thomas, 1998). Ethnic information reported in survey data in-dicates few minorities in the profession, with a total of approximately 5 percent identified (NASP, 1998). The ethnic distribution has remained relatively the same over the years, and current NASP membership data may underestimate the percentage of minorities in school psychology. A survey of all graduate education programs (Thomas, 1998) indicated that 17 percent of students in training were identified as minority. The data reported in Table 3 show that school psychologists are not evenly distributed across the Nation (also see Fagan, 1994). Lund and Reschly (1998) reported significant State and regional variations, and most States do not meet the NASP standard of one school psychologist for every 1,000 students. Recent survey data (Curtis, Hunley, Walker, and Baker, 1999) find that 25. 5 percent of full-time practicing school psychologists work in settings that are at or below the 1,000:1 ratio, and almost one-half (48.7 percent) work in settings with ratios of 1,500:1 or less. However, 32.5 percent of school psychologists work in settings with ratios of greater than 2,000:1. There is considerable State-by-State variation in student to school psychologist ratios (Thomas, 2000). All professional school psychologists are required to be certified and/or licensed by the State in which services are provided. Most States use certification and authorize the State's education agency to certify school psychologists. Although requirements vary from State to State, NASP offers a national certification (Nationally Certified School Psychologist, or NCSP) to all those eligible. The national certification is recognized by several States for certification eligibility. 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 passing score (660) on the National School Psychology exam; and course content to ensure substantial preparation in school psychology. NCSP renewal occurs on a 3-year cycle; NCSPs must submit 75 hours of continuing professional development for renewal. The students represented in Table 8 are predominantly studying for a 60-credit master's or specialist degree. Seventy-four percent of school psychologists have documented the requirements to be nationally certified (NCSP); 24 percent also hold a doctorate in school psychology, education, or related fields. Although the percentage of school psychologists with a doctorate remains constant, the percentage meeting the requirements for national certification continues to increase. School psychologists who are members of NASP or hold the NCSP are required to abide by the Standards for the Provision of School Psychological Services and Principles of Pro-fessional Ethics adopted by NASP (1992). Nationally, more than 151 school psychology training programs are accredited by NASP/NCATE (Thomas, 1998). At the end of the 1996–97 academic year, 1,897 school psychology students from 218 training institutions became initially certified/licensed to practice in the Nation's schools (Thomas, 1998). The U.S. Department of Education reports yearly that there have been, on average, over 600 unfilled, funded vacancies or additional certified personnel needed for the public schools. Currently, school psychologist shortages exist in most regions of the United States (Lund and Reschly, 1998). A shortage of school psychologists is predicted in the immediate future in light of the increase in retirement rates and the proliferating need for mental health services in the schools. Based on the NASP standard ratio of 1,000 students to 1 school psychologist, it is estimated that another 25,000 school psychologists are needed (Dwyer, 1995). Professional Activities Table 6 shows that school psychologists are typically employed in the following settings: public or private schools, universities, clinics, institutions, private practice, and community agencies. However, the majority (approximately 82. 6 percent) practices in primary and secondary schools. Recent survey data (Curtis et al., 1999) report that the percentage of school psychologists working in schools varies by setting: urban schools, 30.3 percent; suburban schools, 44.8 percent; rural schools, 24.9 percent. Some school psychologists are employed by mental health agencies that provide psychological services to the schools. Survey data indicate that of those listed as employed in a school setting in Table 6, only 2 percent practice in private schools. There are no officially recognized subspecialties within the profession of school psychology. The 1998 membership directory of NASP did provide survey data on the percentage of time members spent in various professional activities. Less than half of the school psychologists' time was spent in the assessment of children. Consultation and behavioral and other therapeutic interventions accounted for 30 percent of professional time. The remainder was spent in service training provided and received, administration, and research. Reschly and Wilson (1992) reported 55 percent of time for assessment, 42 percent for consultation and interventions, and 2 percent for applied research and evaluation. Included in the process of assessment is presenting results to parents and school/other staff as well as utilizing assessment information primarily to plan interventions for students experiencing academic or behavioral difficulties in school. Sociology The revival of the sociological practice movement can be traced back to the late 1970's (Friedman, 1987), a turbulent era in higher education, during which many academic institutions— particularly small private liberal arts colleges, 2-year private colleges, middle-level private urban universities, and a spate of remote State colleges and universities (Bingham, 1987; Smith and Cavusgil, 1984)— experienced (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, in turn, 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, characterizing the discipline's post-World War I efforts to legitimize itself, and toward a return to its original mission of social reform, based on application and intervention (Clark, 1990; Franklin, 1979; Huber, 1984, 1986; Kuklick, 1980; Parsons, 1959). The creation of new hands-on academic incentives— particularly workshops, supervised field work, and internships— was designed to attract the changing student demographic and to respond to the economic constraints mentioned above. Schools also integrated sociology departments into their respective communities and with their publics, thereby balancing students' substantive disciplinary interests balanced with more voca-tionally oriented courses (Olzak, 1981; Ruggiero and Weston, 1986; cf. Fleming and Roy, 1980). In an era of managed care, sociologists' entry into the heavily regulated behavioral health care industry has led many of them to realize the value of acquiring supplemental association and State professional credentials. Sociologists understand that without practice credentials, which serve as recognizable indications of their competence in service to the public welfare, health, safety, and the quality of social life, their opportunities as unregulated applied researchers, clinical interventionists, behavioral health care caseworkers, and administrators will continue to decline in this interdisciplinary field. As a result, sociologists have started to organize their own accreditation and credentialing programs. The Commission on Applied and Clinical Sociology, established in February 1995 as a joint initiative of the Society for Applied Sociology and the Sociological Practice Association (both founded in 1978, with the latter chartered as the Clinical Sociology Association), recently completed sociology program accreditation standards and peer-review guidelines for departments interested in augmenting their traditional educational emphases with clinical and applied curriculums and training. These in-house measures, sensitive to evolving behavioral health care training and administration standards, permit practicing sociologists to apply their unique perspectives and skills, assessments, and interventions to the complex set of interactions characterizing social relations between and among sundry behavioral health care populations, providers, networks, payers, employers, and their institutional environments. These concerns and practices have all too often been overlooked or underutilized in the allied health care marketplace. Sociologists' treatments will significantly add to the mix of existing approaches. The commission implemented its Pilot Sociological Practice Accreditation Program in fall 1997 to evaluate the content and quality of applied and clinical departmental augmentations to traditional liberal arts emphases in the discipline. It reviewed its first Application for Accreditation and Self-Study Report in February 1998, and conducted its first pilot site visit of said department's Applied Sociology Concentration in March 1998. This was followed by its first Accreditation Review Board evaluation in April 1998. A full commission review was slated for June 1998. In fall 1998, the Commission was scheduled to implement its inclusive Accreditation Program to replace its pilot program. Accredited sociological practice programs and their departments will be included in a National Directory of Applied and Clinical Sociological Practice Programs. Their graduates— beginning with baccalaureates and later masters and doctorates— will be listed in a National Registry of Sociological Practitioners. Once sociological practice legislation is approved, the registry may be used in conjunction with sociological practice credentials awarded by the Sociological Practice Association (SPA) to register, certify, and/or license practicing sociologists with the States in a variety of interdisciplinary practices fields, including social service administration and behavioral health care. Provisions will be made to "grandfather" non-program-accredited, qualified sociologists into the registry as well. Dif-ferent classes of association and State professional credentials will be awarded on the basis of recipients' specific educational and training accomplishments. Comparable core data will be incorporated into upcoming editions of Mental Health, United States. SPA certification (currently under revision) of-fers eligible master's and doctoral candidates a Certificate in Clinical Sociology (CCS). According to SPA officials, the association will be certifying ap-proximately 20 practicing sociologists in 1998, adding to its current base of 48 CCS recipients. Since its inception in 1983, the SPA credentialing program has served as a demonstration project for modeling and deploying a comprehensive national program, possibly in conjunction with the American Sociological Association. Future plans, according to SPA officials, will include forming partnerships with other scientific and professional associations and possibly changing the title of the SPA credential to Certificate in Consulting Sociology, based on clinical and applied sociology models. Current data on practicing sociologists, particularly for those employed in behavioral health care fields, are limited to the disparate studies of independent researchers. To date, there have been no discipline-wide or association-sponsored sociology performers to generate exhaustive findings for the entire population of postsecondary educated and trained and active practitioners, though such efforts are being considered by the Commission on Applied and Clinical Sociology. The Open System Practitioner Survey, recently conducted by Mental Health Update coauthor Michael S. Fleischer (1990), canvassed a nonrepresentative sample of 217 sociologists, graduates at all degree levels of 10 of 37 post-secondary institutions in the tri-State Chicago metropolitan area between 1977 and 1992; 69.5 percent of these individuals reported current or previous employment in the academic and nonacademic workplace and professional marketplace, with less than one-third practicing in academic settings and over two-thirds practicing in nonacademic settings; 21.8 percent of these self-reported practitioners work in mental health care and allied medical health care fields, domains that comprise the second largest industry for applied and clinical sociologists behind the aggregate of law, social policy, and community service, in which 23.1 percent work. Noteworthy is the fact that 9.2 and 2.6 percent of these practicing sociologists reported single or multiple professional association credentials, respectively (all nonsociological), and 25.8 and 3.3 percent, respectively, reported single or 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 these practicing sociologists, a plurality, obtained nonsociological professional association credentials in social service and mental health care fields, while 41 percent acquired State professional credentials as certified and licensed social workers or similarly credentialed clinical and school social workers. In a separate study, using data from the universe of 12,211 Ph.D. sociologists polled in the 1995 Survey of Doctorate Recipients sponsored by the National Science Foundation's Division of Science Resource Studies, independent researchers Koppel and Dotzler (1998) found that Ph.D. sociologists favor academic over nonacademic jobs by a margin greater than 3:1. 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, while 2.4 percent coded it as psychological and clinically 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. Discussion The information in this chapter is important for examining the current status of human resources and care delivery in mental health, particularly within the context of managed care. Unfortunately, many critical issues are not addressed by these data. Given the increasing demand for cost-effective service, it is critical that evaluations focus on determining the cost-effectiveness of specific treatment and intervention outcomes. This necessary shift of attention away from the process of delivery to outcome will demand analyses of economic and clinical substitutability of mental health professionals. Presently available data do not permit effective examination of these questions. Other questions cannot be answered about how mental health professionals provide services. Additional information is needed on characteristics of the providers, clientele treated, actual services delivered, sources of referrals, and relationships with other health and social service professionals. 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