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Chapter 22

Mental Health Practitioners and Trainees

Psychiatry

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

Psychology

Social Work

Psychiatric Nursing

Counseling

Marriage and Family Therapy

Psychosocial Rehabilitation

School Psychologists

Applied and Clinical Sociology

Pastoral Counseling

Center for Mental Health Services

Introduction

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

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



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



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



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

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

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

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

The chapter addresses two types of human resources:

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



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

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

Psychiatry

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

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

Demographic and Training Characteristics

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

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

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

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

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

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

Professional Activities

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

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

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

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

Conclusion

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

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

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

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

Psychology

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

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

Demographic and Training Characteristics

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

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

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

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

Professional Activities

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

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

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

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

Social Work

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

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

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

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

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

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

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

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

Demographic and Training Characteristics

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

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

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

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

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

Professional Activities

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

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

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

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

Psychiatric Registered Nurses and Advanced Practice Psychiatric Nurses

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

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

Psychiatric Registered Nurses (PRNs)

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

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

Advanced Practice Psychiatric Mental Health Nurses (PMH-APRNs)

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

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

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

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

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

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

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

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

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

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

Conclusion

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

Counseling

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Demographic Characteristics

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

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

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

Looking Ahead

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

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

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

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

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

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

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

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

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

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

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

Marriage and Family Therapy

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

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

Federal law defines an MFT as an individual with a master's or doctoral degree in marital and family therapy, and at least 2 years of supervised clinical experience, who is practicing as a marital and family therapist and is licensed or certified to do so by the State of practice; or, if licensure or certification is not required by the State of practice, who is eligible for clinical membership in the American Association for Marriage and Family Therapy (42 CFR Part 5, Appendix C). The Department of Labor defines MFT services as: "diagnose and treat mental and emotional disorders, whether cognitive, affective, or behavioral, within the context of marriage and family systems. Apply psychotherapeutic and family systems theories and techniques in the delivery of professional services to individuals, couples, and families for the purpose of treating such diagnosed nervous and mental disorders" (21-1013 Marriage and Family Therapists). Research has found the services provided by MFTs to be effective (often more than standard treatments) for many severe disorders and to result in improved outcomes in both the health and functioning of clients (Doherty & Simmons, 1996; Pinsof & Wynne, 1995).

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

Demographic and Training Characteristics

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

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

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

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

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

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

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

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

Professional Activities

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Psychosocial Rehabilitation

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

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

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

Demographic and Training Characteristics

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

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

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

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

Professional Activities

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

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

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

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

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

School Psychology

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

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

Demographic and Training Characteristics

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

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

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

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

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

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

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

Professional Activities

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

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

Sociology

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

Sociology's theoretical and substantive contributions to mental and behavioral health care derive from its