Diversity Corner

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Licensing of Mental Health Professionals: Stigma Still Exists

Laurie Lindamer, PhD, and Caryn Kseniya Rubanovich, MS


Introduction

In the last several years, there has been a growing interest in addressing physician and allied healthcare provider “burnout syndrome”, and a desire to improve provider quality of life, job satisfaction, and performance. These issues have gained momentum and expanded discussions to fully understand the range of mental health conditions experienced by healthcare providers. For example, depression is not uncommon in physicians (Center, et al 2003), and physicians have disproportionately high rates of suicide relative to the general public (Shanafelt, et al, 2011). Effective treatments for many mental health conditions exist; however, some healthcare providers forgo diagnosis and treatment of mental health conditions due to stigma, or fear that disclosure may affect their reputations among peers and their ability to practice. Current licensing procedures for mental health providers perpetuate this stigma and as a result, healthcare providers may be less willing to identify and treat their own mental health issues.

Licensing Boards: The Basics

Disclosure of mental health conditions has been a necessary part of applying for and maintaining a medical or psychological license. The main purpose of professional licensing boards is protecting public safety by overseeing the qualifications of their members, surveilling competent and ethical practice, and, if necessary, administering disciplinary actions. However, the licensing process for mental health providers can be biased against professionals seeking and receiving care for their own mental health. In fact, the process that protects the public by overseeing the credentialing of mental health providers may harm the providers themselves, not only in hindering their desire to seek care for treatable disorders, but also by threatening their privacy and future ability to maintain a license.

Licensing Regulations and Recommendations on Querying Mental Health

Medical and psychology licensing boards’ application processes and questions are regulated at the state level, and thus, vary widely. For example, there is variation in whether licensing boards ask about current or past mental health diagnosis. The American with Disabilities Act (ADA) and subsequent rulings have determined that use of a diagnostic label alone, such as a mental health diagnosis, is discriminatory (Polfliet, 2008; Walker, 2004). A label, they reason, only defines membership in a category and does not necessarily provide information about an individual’s level of functioning. Unfortunately, many state medical licensing boards are in violation of ADA (Schroder, et al, 2009).

A history of a diagnosis or treatment may not be indicative of any impairment in current performance, and many professional organizations support this stance. The Federation of State Mental Health Boards advised medical licensure boards not to ask physicians about history of mental illness (Federation of State Mental Health Boards, 2006), and the American Psychiatric Association (APA, 2015) specifically stated that impairment and potential risk of harm to patients cannot be inferred from a diagnosis or treatment alone. A recommendation was made for medical licensure applications to include questions about current functional impairment of professional performance (APA, 2015; Council of Psychiatry and the Law; Council on Medical Education), and likewise, the American Psychological Association stated that decisions regarding licensure should be based solely on current performance and not on diagnostic history (APA Workgroup on Disclosure). According to Boyd and colleagues (2016), there needs to be a “distinction between competently functioning professionals who have lived with a mental health diagnosis or who are being treated for a mental health condition versus providers whose professional functioning is currently impaired for mental health reasons.” The American Psychiatric Association recommends the following phrasing: “Are you currently suffering from any condition that impairs your judgement or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner?”

In California, the Board of Psychology has adopted language consistent with the recommendation of the American Psychological Association in the “Fitness for Practice” section. The questions apply only to current mental or physical conditions or behaviors that would affect public safety or an individual’s ability to function as a psychologist (See Table 1). In contrast, the application to the California State Medical Board uses language that is not consistent with ADA or the American Psychiatric Association recommendations. The initial application continues to inquire about past mental health issues as well as diagnosis (See Table 2).

Impact of Licensing Questions on Treatment-Seeking

Aside from the risk of appearing “weak” in a culture that emphasizes strength of its practitioners, does admission of a past or current mental health condition or treatment on license applications really affect the well-being of mental health professionals? Recent studies in both physicians and psychologists suggest that these questions about “ever” having a diagnosis of a mental health condition decrease the likelihood of these mental health providers seeking treatment for themselves (Dyrbye, et al, 2017; Boyd, et al, 2016). Providers applying for an initial or renewal license in 50 states and the District of Columbia were asked about their willingness to seek help for a mental health condition. Data from these studies suggest a decreased likelihood to seek treatment in states where the questions on the license applications were inconsistent with the ADA recommendations (i.e., queried about “ever had”) versus being asked about current impairment.

Resources to Support Providers

Professional organizations have created programs to support members who have mental health symptoms and conditions. The American Psychological Association’s Advisory Committee on Colleague Assistance (ACCA) provides resources for state-level programs, called Colleague Assistant Programs.

UCSD Resources and Preliminary Research Findings from the HEAR Program

There are two programs at UCSD meant to support physicians, psychologists, and other health providers who may be facing mental health issues.

  1. The Healer Education Assessment and Referral (HEAR) Program is designed to provide confidential, online assessment of stress, depression, and other related issues and can make personalized referrals to local mental health clinicians. For more information, visit their website: HEAR.ucsd.edu.
  2. Moreover, the UCSD Physicians’ Well-Being Committee is dedicated to recognizing and offering assistance to staff physicians who may have problems with substance abuse or physical or mental illness, which impair their ability to practice safely and effectively. For more information, contact Robin Seaberg, MD, Chairman: (858) 534-8093 (confidential 24/7 voice mail) or email: Rseaberg@ucsd.edu.
Data collected through the HEAR referral screening process further highlight the need to provide resources and support for providers. From January to October 2018, 571 UCSD-affiliated providers, faculty, trainees, students, and staff accessed and completed the confidential, online screener to get connected with mental health resources. Over 42% reported at least moderate depression, almost 14% indicated having had suicidal thoughts in the past two weeks, and almost 6% reported functional impairment from alcohol use. More than 1 in 5 reported worry about stigma in seeking mental health care, and almost 1 in 4 chose not to respond to at least one demographic item, perhaps, as a means of maintaining anonymity in the screening process. There were significant associations between demographic item non-response (i.e., maintaining anonymity) and individuals indicating greater levels of suicidality as well as reporting stigma. These local data underscore the impact of stigma on treatment-seeking, reflect levels of mental health conditions amongst treatment-seekers, and raise awareness of the demand for and utilization of mental health resources and treatment-seeking here at UCSD.

Conclusion

The more open and frequent discussions of provider well-being and burnout in the medical and mental health professions have been helpful in initiating conversations about practitioners’ experiences with mental health symptoms, conditions, and treatment. Many advocate for providers with lived experience in mental health and other disabilities to speak out and engage in dialogue around these issues (Boyd, Zeiss, Reddy, and Skinner, 2016; Meeks and Jain, 2018). This kind of shift can be better realized if disincentives for seeking diagnosis and treatment are removed from the licensing process. While professional organizations continue to lobby state licensing boards to comply with ADA with regard to mental health in their credentialing process, numerous groups in medical education and healthcare systems continue to work to address barriers at the local level. Individuals can contribute to this systemic movement by contacting guild organizations and advocating for continued lobbying. At the interpersonal level, continued conversations on these topics amongst colleagues as well as peer acknowledgement and recognition when colleagues might be having a “tough day” can help build a culture of support.




Table 1. California License Application for Psychology
SECTION VII. FITNESS FOR PRACTICE
  • ​Are you currently affected by any physical or mental condition that in any way impairs or limits your ability to practice psychology with safety to the public?
  • ​Do you use any chemical substance(s) that in any way impairs your ability to practice psychology with safety to the public?
  • Are you currently engaged in the illegal use of controlled dangerous substances, or were you so engaged recently enough so that the use of drugs may have an ongoing impact on your ability to function as a psychologist?
.
​Table 2. California Medical License Application
​Practice Impairment or Limitations
  • Have you ever been enrolled in, required to enter into, or participated in any drug, alcohol, or substance abuse recovery program or impaired practitioner program?
  • ​Have you ever been treated for or had a recurrence of a diagnosed addictive disorder?
  • ​Have you ever been diagnosed with an emotional, mental, or behavioral disorder that may impair your ability to practice medicine safely?
  • ​Do you have any other condition that may in any way impair or limit your ability to practice medicine safely?
  • Do you suffer from a progressive disorder or a health condition that will likely result in a general decline in health or function that may impair or limit your ability to practice medicine safely?




References

Shanafelt, T.D., Balch, C.M., Dyrbye, L. et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011; 146: 54–62

Center, C., Davis, M., Detre, T. et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003; 289: 3161–3166

Polfliet, S. J., A National analysis of medical licensure applications. J Am Acad Psychiatry Law. 2008; 36: 369-374

Walker, Y. N. Protecting the public: the impact of the American with Disabilities Act on licensure considerations involving mentally impaired medical and legal professionals. J Legal Medicine. 2004; 25: 441-268

Federation of State Mental Health Boards American with Disabilities Act 1990: Licensure Application Questions; A Handbook for Medical Boards; Dallas, TX: Federation of State Mental Health Boards of the United States, Inc 2006

American Psychiatric Association Position Statement on inquiries about diagnosis and treatment of mental disorders in connection with professional credentialing and licensing https://www.psychiatry.org/home/policiy-finder?K=understanding. 2015

American Psychiatric Association Work Group on Disclosure. Recommended guidelines concerning disclosure and confidentiality Washington, DD American Psychiatric Association 1997

Council of Psychiatry and the Law Discrimination against persons with previous psychiatric treatment: Position statement. Washington, DD Document Ref No 97002

Schroeder, R Brazeau CB, Zakin, F et al. Do state medical board application violate the American with Disabilities Act: Acad Med; 2009; 84 (6):776-781

Dyrbye, LN, West, CP Sinsky, CA; Goeders, LE; Satele, DV, and Shanafelt, TD Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clinic Proc. 2016; 92 (10) 1486-1493.

Boyd, JE, Graunke, B, Frese, FJ, Jones, JTR, Adkins, JW, Bassman. State psychology licensure questions about mental illness and compliance with the American with Disabilities Act. American Journal of Orthopsychiatry, 2016; 86 (6) 620-631.

Boyd, JE, Zeiss, A, Reddy, S, Skinner, S. Accomplishments of 77 VA mental health professionals with lived experience of mental illness. American Journal of Orthopsychiatry 2016; 86 (6) 610-619.

Meeks LM, Jain NR. Accessibility, Inclusion, and Action in Medical Education: Lived Experiences of Learners and Physicians With Disabilities. Washington, DC: Association of American Medical Colleges; 2018.