by Rowena Dodson, LMFT

Becoming licensed as an MFT in California, and especially in the Bay Area, was already burdensome under pre-COVID circumstances. There are not many options for paid internships in the Bay Area, which means years of working either multiple jobs (i.e. one’s unpaid internship as well as a paid job), or being lucky to have someone else earning the living. Some associates go into debt to complete the process. Other frustrations have been the sheer number of 3000 hours; the byzantine rules for the correct number and type of hours required to meet the 3000 hour hurdle; and especially brutal has been the waiting time after submission of hours to the BBS (most recently it has been about 5.5 months, and as long as 9 months several years ago). This adds 6-8 months onto an already years long process before MFTs start to make a living wage. We must also recognize how many people this process keeps out of our field, reducing much needed diversity in our therapist pool. 

Now with COVID and shelter-in-place (SIP) restrictions in the state, an already strained system for licensing MFTs in California is buckling. This is impacting associates and their ability to do this vital work with often the most vulnerable and challenged clients. For this article, I talked to seven associates and one newly-licensed MFT in the Bay Area about their experiences (see gallery of therapists who participated): how are they coping, what are their challenges, where are they finding support? I spoke with these clinicians during the first two weeks of April.  Some things they reported then may have changed by the time you are reading this article. Three of the participants ultimately chose not to be named for the article as they were concerned about having their stories out in the public sphere.

In order to understand fully their challenges now, it is important to keep in mind the backdrop to this current moment: 1) the unpaid or reduced fee work for years, 2) the most fragile and needy clients, 3) the painfully slow process of navigating the BBS process to licensure, and 4) the lack of official acknowledgement for the vital role associates play in providing mental health care to Californians.

There were many overlapping themes from the therapists’ accounts of what was happening before and during SIP. These themes included financial impacts, issues with doing remote therapy, and frustrations with the BBS. They also discussed how these frightening times are affecting them even while they support their clients, and where they are finding support.  

FINANCIAL IMPACTS:
As discussed above, becoming a licensed MFT entails significant financial sacrifices.  Several therapists mentioned the financial strain on their families throughout their education and internships. Compounding this now are SIP restrictions, causing postponed exams and difficulty getting the administrative work done to submit hours for approval. Delay in licensure finalization means delay in starting to earn a viable living. Additional financial impacts are rental for an office that cannot be used immediately and the inability to start a private practice because of SIP.

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Because her licensing exam was postponed, Jyoti continues to be paid at associate-level wages, which are barely half of what she will earn when licensed (for doing the same work that she is already doing now). She has a May 1 exam date scheduled that she hopes will still go forward. Similarly, Connie has been earning associate-level pay for her private clients and earns no fee for her agency clients currently. She was looking forward to converting her agency clients into fully paying clients in her new private practice, now postponed. 

Connie and Susan had already rented an office for their practice, having anticipated that Connie would be licensed imminently. They are now bearing that expense without the income they anticipated. Sharon, newly licensed, was ready to find space for her private practice and to take on new clients, but has been prevented from proceeding because of the shut down. Moreover, “starting new clients with telehealth is not what I had imagined.” So for now, she is still not earning money. Although considering pro bono work supporting health care workers, that is more work for which she will not be paid. Looking to the future, Natalie agreed that “building rapport is more challenging when one starts off with telehealth.” She is also concerned that financial difficulties may prevent clients from seeking help as this crisis goes on, which will make it harder to build a practice once licensed. “Everyone is sort of in survival mode.”

For Dariah and Monica, the current crisis with its financial implications for non-profit agencies is very concerning. They each mentioned their worries about the stability of their own jobs in this financial collapse, even while acknowledging that their agencies are doing everything they can to keep their therapists. Monica has also been delayed by SIP in getting her final signatures on her hours from supervisors who are now not at the office, as well as getting an official letter that she needs from her agency showing their change of agency name.

TELEHEALTH—CHALLENGES/POSITIVES:
Therapists I interviewed explored the practical issues and challenges of not being able to meet in person with clients. Of course, licensed therapists are also experiencing these issues. The transition from office to home in normal circumstances gives therapists some space to switch roles, process and then let go of the work from the day. Not only is that commute transition gone for now, but telehealth necessitates switching roles quickly within the household. Additionally, with remote therapy, we lose information that we normally perceive in person from body language, facial expressions and a certain energy that we feel in a room together; we may feel less connected to each other, and building rapport is harder. There is also the difficulty for clients and therapists to carve out privacy at home for a therapy session. Therapists may encounter technical difficulties with the online platforms and the loss of clients who are not willing to do remote therapy. Also of note is the increased therapist disclosure of having the client see into one’s private home when on a teletherapy session.

Natalie has found that some of her middleschoolers prefer the phone over video. She thinks video may make them feel too exposed. Similarly, Susan reports that some depressed teens with whom she is working struggle with motivation and connection in video therapy. And some of her older clients prefer phone over video. Monica, on the other hand, finds video telehealth surprisingly positive in her work with teens who are depressed and anxious. She thinks for teenagers, video telehealth might be an even better way to do therapy. “They are comfortable in their screens.” 

Connie, Jyoti and Natalie, who each mentioned having kids at home, are finding it challenging to have privacy and quiet to do their sessions. Connie finds that the only remedy is to hold her sessions from her car. Jyoti has two typical teenagers at home and really misses the structure and quiet of going to work at her office. Natalie said initially her two young kids were knocking at her door during sessions, “but they have adjusted and now ask me when mommy will be done today.”  

Connie also finds it difficult working from home with “the constant switching of roles without any transition between them, mother/launderer/teacher/therapist, so few boundaries or transition points between these roles.” In the same vein, several therapists mentioned the difficulty of being there for their clients from home—while they are also experiencing their own stresses from this whole Coronavirus reality. “It is difficult to be totally present for the client and then just go back to my regular life,” says Connie. 

Dariah is really missing being able to see clients’ body language and believes that clients feel less connection with the clinician over the phone or on video.  Her clients’ lives are chaotic and they are more likely to miss their virtual appointments than they would be for a scheduled in-session appointment. Despite these misgivings, she does take comfort that even just checking in with them by phone briefly is a source of support for them.

Natalie mentioned having technical issues at times with the two online platforms she is using for teletherapy. Regarding her at-home therapy space, she has tried to make her work space “very neutral, I’ve taken down personal pictures in the space,” in order to maintain some boundaries with clients. 

FRUSTRATION WITH THE BBS (and some kudos):
There is appreciation for the BBS having made a few rules changes that have positively impacted associates (i.e. loosening some telehealth rules). Other desired changes have not been made—for example, associates cannot work pro bono with first responders and health care workers because of supervision requirements that have not been waived. Rules about the necessity of in-person supervision for associates have now been changed to allow video-conferenced supervision for most practice settings (but initially excluded associates in private practice). On May 6 this was also extended to associates in private practice. Additionally, closed testing centers during SIP has been a hardship on associates who had already had exam dates scheduled or were about to schedule their exam.  As of May 1, some testing centers have reopened. 

 Jyoti and Connie are both disappointed that they are not able to do pro bono work—Jyoti with first responders and Connie more generally with people struggling with grief and loss in this time. “It feels like there is such a huge need,” says Connie. No changes have yet made way for those associates who are almost licensed to start working with those in need before they are fully licensed.

Lissa has been fairly pleased with the information updates the BBS is providing on its website and on its Facebook page. She said the BBS has requested that it not be contacted during this period, but it has been good about regularly publishing where they are in processing hours that associates have submitted. The Department of Consumer Affairs (DCA) has been a good source of information about BBS updates.

In terms of frustration with the BBS, Connie’s BBS story is particularly harrowing.  Having submitted her hours in June 2019, they were approved in late November.  Because of a health condition, she had applied for and been granted accommodations for the the Law and Ethics exam.  That approval was supposed to continue through for the licensure exam.  However, the exam vendor changed and BBS required applicants to reapply for accommodations, which were finally approved in February.  She was able to schedule her exam for March 18 and “was super prepared.”  On March 17, the exam was cancelled and testing centers closed.  Without the earlier delays, she would have already taken the exam prior to shut down.

Susan is surprised that that the BBS has not made online exams available, noting that California is ahead of the technology curve in other ways to streamline the licensing process. For her own hours, submitted in early April, she is hopeful that the BBS is continuing to process hours submissions during this time of shutdown.

EMOTIONAL IMPACT:
Emotional impacts range from frustration and worry at cancelled exams, how slowly the BBS moves, and concerns about when exam centers will reopen; to feelings of sadness at not being able to support first responders and health care workers. There is also resentment at a system which exploits associates. Of course all of these therapists have been impacted by the pandemic, just as we all have, and have fears for their own families and jobs. And they are supporting their clients who are going through this same experience. Trying to study for upcoming exams during this time is also difficult because of anxiety. 

Susan is “frustrated that we are free labor until we get licensed.” She said the public mental health system in California is built on associates working for free or minimal wages. The BBS essentially has little incentive to quickly process applications for licensure, given that associates are staffing mental health agencies and keeping the system afloat while they wait. She is also very concerned how this financial piece affects diversity in our field.  

Several therapists mentioned feeling that the BBS does not acknowledge or recognize the sacrifices that associates are making and the challenges of working with the most vulnerable clients for little or no pay. Connie noted she “would like it if the BBS could acknowledge what all associates are doing for free in very challenging circumstances. This would really help.” On the other hand, Dariah said with awe in her voice that “only in this moment has she seen therapists and social workers being recognized as ‘essential health care workers.’ That feels really powerful.”

Monica said that her concentration has been impaired because of anxiety. She had been studying for her exam, “but now this whole situation has disrupted my concentration and ability to absorb information.” She may need to delay the exam because of that. 

Dariah is grateful that she has a job, that she is an “essential employee”  and can work. But she is worried about how this is impacting her family members and that her mom might lose her job. 

Natalie discussed how this is a mutual experience, that we as therapists are going through the very same stressors that many of our clients are bringing into sessions. “In most cases it is easier to have boundaries.  And this experience makes it much harder….  We are being called upon to support them with all this uncertainty. It is very strange.”  

FINDING SUPPORT:
All the associates who are still under supervision mentioned their supervisor as a major source of support in this time. Others are participating in group supervision still, or have their own loose group of fellow practitioners with whom they consult. They are finding fellow work colleagues and other therapists incredibly validating and helpful in weathering this. People also cited personal therapy as a source of support in getting through, as well as exercise and friends.  

Connie emphasized that “supervision has been super helpful and . . . a really good place to process some of what’s happening.” Monica is using the pre-licensed group from SCV-CAMFT as a good source of support, in addition to work colleagues and her supervisors.

Natalie said “CHAC has been really awesome about this.” In individual and group supervision: “A lot of the discussion has shifted from clients to supporting the clinicians in this process. They did that transition pretty early so that has been very validating, to hear others’ experience in groups.” Natalie observed that the mental health field seems to be handling issues around work/life balance and stress during SIP better than, for example, the technology sector where her husband is employed.  She appreciates this.

Lissa still attends CHAC trainings online, and finds her colleagues and supervisor at CHAC very helpful. 

CONCLUSION:
The current pandemic has exposed in dramatic relief the many cracks in our system of licensing MFTs in California as well as providing mental health care to people in need. It has exacerbated inherent problems in this system, as in many other systems (i.e. health care generally, education). Nevertheless, our interviews demonstrate the incredible resourcefulness, resilience and generosity of people in this field, seeking to provide mental health treatment to Californians. Associates deserve much more support and expeditious processing to licensure, that is clear. They also deserve acknowledgment of their tremendous contributions to the mental wellbeing of California citizens. Perhaps this pandemic will be an alarm signal that the system to license MFTs needs an overhaul. Associates should be paid fairly for the crucial mental health care they provide to our state. This would enable a much broader diversity of people into this field and ultimately provide better care for us all.  

Many thanks to the individuals who took time and shared openly with me. Just a brief update on some of our participants at the time of finalizing this article in mid-May. Jyoti successfully passed her exam on May 1 and wants to express that the Pearson testing center handled everything beautifully and safely (she was one of the first candidates on the first date that testing centers reopened). Natalie has since completed her hours and has submitted them to the BBS and finished her work at CHAC. She continues in private practice. Sharon has moved forward with starting her private practice from home using telehealth. Connie now has a rescheduled exam date of July 1. She notes that the BBS has become more responsive and interactive with associates on its Facebook page in the last few weeks, including conducting a live session. Lissa has not yet heard from the BBS concerning approval of her hours.  

PARTICIPANTS

Lissa Dutton, AMFT, most recently worked at Community Health Awareness Council (CHAC) doing school-based work and working with in-house clients. She submitted her 3000 hours to the BBS in December and hopes to hear soon that she can take the exam.  

Sharon Greenstein, LMFT, had submitted her hours in July 2019 and was approved to take the exam in early December. She took the exam in February and was licensed in late March. She had taken time off from her last position at CHAC to study and take care of her family. She would like to open her own private practice now.

Jyoti Nadhani, AMFT (and a SCV-CAMFT board member) is scheduled to take her exam May 1. She is concerned the date may be delayed given shelter-in-place restrictions. Jyoti works in private practice. 

Monica (not her real name), AMFT, works for an area agency in an Intensive Outpatient Program for youth. She completed her 3000 hours in March (she is still collecting hours for her LPCC). She has not yet submitted her MFT hours to the BBS and has found it more difficult to get final signatures and other administrative details done during this time when her supervisors are sheltering at home.  

Connie (not her real name), AMFT, has been working at an agency and also in private practice since she submitted her hours in June 2019. It took 5.5 months to get them approved by the BBS. She needed accommodations to take the exam given a health issue, so her approval process took longer than normal. She was finally scheduled to take the exam March 18 and then the day before the testing center closed. She is now in limbo not knowing when she can expect to take the exam.

Susan (not her real name), AMFT, finished her hours at the end of February but found it difficult during March to get her hours signed off from her supervisors, again because the supervisors were then sheltering in place  She did submit her hours to the BBS on April 1. She most recently worked at CHAC.

Dariah Brown, AMFT, is still earning hours at her job at Gardner Family Health Network. She has about 800 hours to go before reaching her 3000 hours.  

Natalie Shahar, AMFT, works for CHAC doing school-based counseling at a middle school. She also works in private practice. She has about 30 hours to go to have her 3000 hours.

Resources:

https://www.facebook.com/BehavioralSciencesBoardCA/ - there was a live session which was recorded recently on BBS facebook. There is a lot of information in this session.

https://www.bbs.ca.gov/pdf/updated_coronavirus_statement.pdf 

https://www.camft.org/Resources/Legal-Articles/Legal-Department-Staff-Articles/Telehealth-FAQS-for-Therapists-During-COVID-19 - 

https://www.bbs.ca.gov/pdf/bbs_wavier_faqs.pdf - associates whose registrations expire between March 31, 2020 and June 30, 2020 do not need to attempt the California Law and Ethics Examination in order to renew their registration.