North Carolina General Assembly: Consider a thoughtful approach to changing the North Carolina Psychology Practice Act to create a pathway to independent licensure and parity with other master’s level clinicians for Licensed Psychological Associates (LPAs).

Background 
The practice of psychology in North Carolina includes two levels of licensed mental health providers: Licensed Psychologists (LPs) and Licensed Psychological Associates (LPAs).  Current licensure reflects the distinction that LPs are trained at the doctoral level, whereas LPAs are trained at the master’s level. Under the current statute and rules, career-long supervision is mandated for LPAs.

LPAs have served the citizens of North Carolina since 1967.  The North Carolina Psychological Association (NCPA), which represents all psychologists in North Carolina, has been involved in negotiations on LPA licensure standards and practice requirements since the mid-1990’s when then-President Dave Filipowski advocated for LPAs before the General Assembly. In 1997, as a result of advocacy by NCPA, rules were adopted by the North Carolina Psychology Board (NCPB) that created a pathway to reduce supervision to once a month. Additionally, due to NCPA advocacy, LPAs were included as providers in the North Carolina State Employees Health Plan and Medicaid panels.  

During the period from 2012-2014, a joint work group formed by members of NCPA and the North Carolina Association of Professional Psychologists (NCAPP), an organization primarily dedicated to advocating for and providing information to master’s level psychologists, developed a joint proposal^[1] and issued a position statement that was released in January 2013. The collaborators intended that this proposal would be presented to the legislature.  Although both groups initially agreed that the joint proposal would be presented to the legislature and had developed a draft of necessary changes to the Practice Act, in November of 2014, before the proposal could be considered by the legislature, NCAPP withdrew from the negotiations and were apparently no longer interested in the collaborative agreement. 

After several years without formal engagement with NCAPP, NCPA learned in August 2018, that NCAPP had made a unilateral petition to the NC Psychology Board (NCPB) proposing rule changes that would eliminate career-long supervision.

While NCPA opposed the petition during the public comment period because the proposed rules changes would have reversed the long-time understanding that the North Carolina Psychology Practice Act requires supervision of LPAs based on their lower level of training, the NCPB voted to move these proposed rule changes to a technical review by the Office of Administrative Hearings. The Rules Review Commission did not approve the rules changes since it determined that the NCPB did not have statutory authority to eliminate all supervision of LPA’s. 

During the 2021 long session, NCAPP introduced H.B. 881 Licensed Psychological Associate Supervision Changes.  NCPA opposed H.B. 881 based on several important considerations including what was then the lack of national standards for master’s level training in psychology, the lack of consensus on the appropriate scope of practice for masters trained psychologists, and the critical importance of ensuring a well-qualified workforce in North Carolina.

Recent Work on Master’s Level Licensure Issues

State-Level: NCPA
NCPA organized a task force in 2020-21 that included both LPs and LPAs. This task force conducted a survey of NCPA membership to determine support for creating a pathway to independent practice for LPAs in North Carolina. The survey indicated that 67% of NCPA membership supports creating a pathway to independent practice for LPAs. There was an even stronger consensus (88%) that the pathway should follow APA’s guidelines on education and training standards and accreditation as these were developed. Concurrent with the work of this task force, the American Psychological Association (APA) released its first set of standards for a master’s degree in psychology in February of 2021 and is currently finalizing plans for an accreditation process. The NCPA task force determined that next steps should include a detailed review of how the current rules for LPA licensure may differ from the national standard, which is described in the section below.

Following detailed review of the newly developed national standards, it was concluded that current North Carolina rules are insufficient in that they do not require specific educational content in the academic foundation of psychology, nor do they specifically require applied training elements that are designed to protect the public (e.g., professional ethics, assessment, and intervention). Although some North Carolina master’s programs may fulfill these elements, it is not required in current rules so there is currently no guarantee that master’s program education and training content meets the national standard for quality. 

National Level: American Psychological Association (APA) and Association of State and Provincial Psychology Boards (ASPPB)
As mentioned above, in February 2021, the APA approved education and training standards for master’s level programs. Having finalized education and training standards for master’s level training in psychology, APA is creating an accreditation process for masters’ programs. Accreditation provides public protection via access to competent professionals in that it ensures programs are effectively meeting established training goals.  

Two national workgroups have been established to look at title, scope, and master’s level licensing.The APA Board of Professional Affairs workgroup is addressing scope of practice and title at the master’s level, with recommendations forthcoming in June of 2023. The ASPPB workgroup is examining the regulation and licensure of master’s level psychologists. Dr. Susan Hurt, a North Carolina Psychology Board member, serves on both workgroups.

How Do Other States Compare
Since only a small percentage of states (N=6, 12%) allow any independent practice by masters trained psychologists, it is important to recognize that this is not a current or common practice nor is it currently a national standard.  There are currently seventeen (17) states with masters-level licensure for psychologists that include various levels of supervision.  

 Recommendations

1. NCPA recommends that we move forward with care in creating a pathway to independence and parity with other master’s level clinicians inNorth Carolina e.g. social workers, clinical mental health counselors, and licensed marriage and family therapists.
2. NCPA deems that licensure of future LPAs who might be eligible for independent practice should be consistent with the now agreed upon national standards for education and training and accreditation, as is currently the case for doctoral level licensure. 
3. NCPA supports “grandparent” status for current licensed LPAs, disavowing them of whatever future education, training, and standards may be, provided they meet stipulations that would include successful supervised practice with no complaints for a specified number of years.
4. Prior to creating a pathway to independent practice for future LPAs, NCPA supports implementing a process in North Carolina that incorporates a thorough review and adoption of the accepted national standards for current educational criteria for licensure, required supervision, and scope of practice. 
5. To ensure competent practice in accord with national standards, changes to LPA licensure requirements will necessitate amendments to both the Psychology Practice Act and the Rules of the NCPB (Rules) that would need to include (a) amending the statutes to allow the NCPB to authorize independent practice for LPAs and (b) immediate and substantive modifications of the Rules to ensure quality training of LPAs and to protect the public.
6. NCPA recommends the adoption of the 500-level pass point on the Examination for the Professional Practice of Psychology (EPPP) for all LPAs who would be eligible for independent practice. ASPPB has determined that this is essential to demonstrate minimal competence for entry level practice as a psychologist.

 Bottom line
The North Carolina Psychology Practice Act clearly states that LPAs must be supervised by LPs in perpetuity and the rules regarding education and training standards were written with that expectation. Therefore, creating a pathway to independent licensure and parity with other master’s level clinicians for LPAs, requires a thoughtful approach which includes consistency with national standards for education, training, and accreditation.