Anxiety manifests in different ways, many of them physical. For me, it’s a pit in my throat and a rapid heartbeat. When I was younger, I locked myself in restaurant bathrooms, never realizing the obvious (in retrospect) connection to the summer camp I would be attending the next day. I wasn’t sick—I was anxious. In elementary and middle schools, I spent days with the nurse, begging to go home; I skipped college classes to stay in bed. I grew familiar with the shaking, stomach-turning clench of nausea. And I as I grew older and anxiety’s grip tightened, I assumed the worst. I underwent MRIs and endoscopies; doctors told me they just didn’t know what was going on.
There was nothing for them to know. I was just anxious, and getting therapy earlier would have saved the thousands of dollars of doctor’s bills paid by me, my parents, my insurance, and the government.
America is in the middle of a mental-health crisis, an age of anxiety, a depression epidemic: However you define it, we’ve never been more open about our mental health and less stigmatized for seeking help. The Affordable Care Act makes it easier, requiring insurers to treat mental health as an “essential benefit,” along with services like emergency and maternity care. Good for us, and good for mental-health providers.
This is especially great news for mental-health counselors—that is, it would be if their qualifications were as universally recognized as their skills are needed.
I was just anxious, and getting therapy earlier would have saved the thousands of dollars of doctor’s bills paid by me, my parents, my insurance, and the government.
On the psychotherapy spectrum, mental-health counselors fall somewhere between clinical social workers, who are trained in both social work and clinical, outpatient therapy, and psychologists, who have undertaken doctoral work and are licensed to perform a wider range of services, like IQ and psychometric testing. Counselors can be found everywhere from state-run agencies to private practices to psychiatric hospitals, as their educational background lends them considerable flexibility within the scope of behavioral care.
Mental-health counseling gained popularity when states began licensing counselors in response to a swell in untrained individuals masquerading as professionals. Before, “anyone could complete any sort of training and hold themselves out as a psychotherapist,” says David Hamilton, executive secretary for the State Board for Mental Health Practitioners in New York. Just like in other medical professions, an untrained counselor can easily do more harm than good.
The mental-health counseling profession made itself ready and willing to rise up and fill the void with professional, licensed practitioners specifically trained to address common issues like depression and anxiety, in addition to more serious problems like personality disorders, psychopathy, and schizophrenia. Their education makes them ideal candidates for the one-on-one personalized counseling that could make a noticeable impact on mental illness in America.
Mental-health counselors are graduating in abundance, and have a clear role to play in the new paradigm of treatment in post-Obamacare America, but are, by and large, struggling to convince employers that their degree is legitimate—an endeavor not helped by the difficulties inherent in the government’s first attempts to regulate a new industry.
AS A CULTURE, WE finally get anxiety, or at least we’re starting to understand that it’s something treatable that happens to a person, not an inherent flaw. The Atlantic’s Scott Stossel wrote a celebrated 416-page book, My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind, about his struggles with—and the history of—the disease; basketball power forward Royce White had a public spat with the Houston Rockets when they failed to accommodate his anxiety disorder and OCD. All over, big names are coming out and saying, “Hey, me too.”
“Forty-five million people in the United States have a mental illness,” says Richard Yep, the executive director of the American Counseling Association. “I look at that and think, Gee, there’s a lot of people that need some help.” According to the Anxiety and Depression Association of America, anxiety disorders affect 40 million Americans and cost taxpayers more than $42 billion each year. Almost half of that goes to medical care—sufferers using the emergency room or their GPs to treat the physical manifestations of the disease.
But anxiety’s not the only mental illness with physical manifestations or repercussions. Untreated depression can lead to self-harm or suicide. A study in The Journal of Clinical Psychiatry indicates depressed patients tend to minimize the psychosocial symptoms of depression—increased isolation and social withdrawal, apathy, a loss of interest in previously enjoyable activities—and emphasize the physical pains instead. Traditional doctors aren’t trained counselors, and they can’t always recognize the spectrum of complaints that might add up to clinical depression.
“The burden of depression on society is sizable,” the study concludes. “Innate to this burden are underdiagnosis and under-treatment of unipolar and bipolar major depressive disorder in all parts of the health care system.” Some of that $21 billion funneled into physical care could be saved if we treated mental and physical health the same in one respect and went in for a check-up when we’re feeling a little blue. Just like cancer, depression is easier to treat the sooner it’s diagnosed.
Mental-health counselors exist for exactly this purpose. Their training is focused almost exclusively on counseling, not social work—in assessment and treatment and learning the various approaches to therapy. And despite a rigorous and sometimes brutal licensing process, and despite the Bureau of Labor Statistics’ “bright outlook” that suggests a 29 percent growth rate in the field between 2012 and 2022, MHCs often struggle to find employment and recognition.
MY BOYFRIEND GRADUATED WITH his master’s degree in mental-health counseling three years ago, and his initial job search read like a new graduate’s horror story: employer after employer asking, “Now what, exactly, is a mental health counselor?” The interviewers were people in the field, doing the kind of work he aspired to, and yet his degree—his livelihood, the certification he’d staked his career and future earnings on—was in question. They wanted clinical social workers. They understood a clinical social worker.
“If everyone in a managerial position is a clinical social worker, who are they gonna hire?” Yep says. “They’re gonna go with their own.” The job market’s tough for everyone, but when potential employers don’t understand your qualifications, that makes things even more difficult.
Granted, recognition has been growing. A mental-health counseling degree is now accepted in all 50 states, with the last hold out, California, finally instituting licensing requirements in 2002, 26 years after the founding of the American Mental Health Counselors Association. In April 2012, Veterans Affairs—one of the biggest mental health providers in the country—announced that it would accept the mental-health counseling licensure. But therapy is a loose network of individual practitioners, insular group clinics, and government-funded family services. And for many, many years, those institutions have been helmed by social workers.
"Forty-five million people in the United States have a mental illness," says Richard Yep, the executive director of the American Counseling Association. "I look at that and think, Gee, there’s a lot of people that need some help."
Clinical social workers are, by no means, poorly trained or bad therapists. I’ve been counseled by some who are wonderful, smart people with an airtight foundation in the fundamentals of therapy. But when there’s a small army of counselors specifically trained in the type of counseling we need now, as a nation, it’s downright silly not to take advantage of it.
“I know in my training and everywhere in the field there is a real commitment to lifelong learning,” says Sarah Noel, who since 2012 has served as the head of the New York City metro chapter of the New York Mental Health Counselors Association. “Mental-health counseling master’s programs are designed with the sole purpose of teaching students how to become clinicians and psychotherapists. There’s a real emphasis on it being a continuous process.”
Mental-health counselors have a “more holistic view” of their client, and of their approach to therapy, according to David Hamilton of the State Board for Mental Health Practitioners in New York. “That reflects how they view and work with the client,” he says. “There are lots of life stresses and life events where people can benefit from counseling—and that’s where the mental-health counselor has a different plan and training.”
Hamilton serves as the intermediary between the counselors and the state board that meets three times each year to review issues or potential new legislation. When the licensing requirements are too strict, he’s the one that hears about it from counselors in the field, and he’s the one that helps the state board make adjustments to ensure candidates aren’t being unfairly discriminated against, or that the process isn’t unnecessarily difficult.
“It’s a struggle to make sure agencies know what mental-health counselors can do,” he says.
Noel graduated from Fordham University the same year New York began licensing counselors. “The day I graduated, if I wanted to start my app for licensure, I couldn’t—because it didn’t exist yet,” she says. “It took a little while to navigate the licensing process.”
But just because mental-health counselors can get licensed doesn’t make the process easy: Hamilton says that the legislature mandated 3,000 hours of on-the-job training completed within two years, compared to 1,500 hours for other, similar professions, like marriage and family therapy.
“Word from the field was that people couldn’t get full-time jobs. They could only get part-time jobs, so they had trouble meeting the requirements,” he says. The law has since been amended, with more leeway in terms of extensions, but from personal experience watching my boyfriend crunch the numbers as the two-year clock ticks down, it’s still a stressful and frustrating process.
It’s not that it should be mindlessly simple for mental-health counselors to obtain a license and start practicing. Careful supervision is absolutely vital, and integral to producing professional, well-rounded counselors that are capable of kind and respectful treatment. But if, as a society, we’re increasingly accustomed to the idea that mental illnesses are out there and treatable, why shun the very workers being trained to solve our problems?
Widespread recognition of mental-health counselors is “a natural process that will take time and will eventually take care of itself, but doesn’t mean we should sit around and wait,” Noel says.
We’re telling stories all week on the theme of booms and busts. What’s on the edge—of becoming a big thing, or of falling off the radar? Read the entire series here.