TPA and Your License to Practice

A Brief History and a Call to Arms

Many of us fear for the future of psychology, and well we should. There are many threats to the profession (reimbursement woes, expanded liability, the intrusion of venture capital, ChatBot therapists, etc.), but the hazard lurking for all of us is the upcoming review of our licensing act.

The legislation authorizing the Texas State Board of Examiners of Psychologists (TSBEP) is up for sunset review in 2032. During the review, all aspects of the existing law will be scrutinized. Oh, well shucks, 2032's a long way off. Except, no, it's not. All legislation is drafted by staffers in the year prior to sunset. They, in turn, will rely on the recommendations of the Sunset Commission. In the past, the Commission began to gather information from stakeholders at least two years before making any recommendations. Stakeholders need to be ready by 2028.

Who are the stakeholders? Well, psychologists, for sure, but also patient groups, small business groups, religious leaders, insurance companies, and our many colleague/adversaries in the mental health marketplace (including physicians, LPCs, RNs, occupational therapists, etc.). Not to mention partisan groups who might use our profession to score political points for their own agendas. All these groups have opinions about our scope of practice — they will want legislators to tell us what our profession is. What we can and cannot do.

Sometime next year, TPA will start preparing the groundwork for our lobbying and public education efforts. We'll need planning, expertise, and money.

To that end, here's a history of how your license to practice came to exist and how TPA worked for the survival of the profession. You should understand the process and all the ways it may go astray.

The Texas Psychological Association was founded in 1947 and was an academic association through the 1950s. By 1960, a cohort had emerged who identified as practitioners. With TPA, leaders pressed for recognition of the profession and for the creation of a licensure mechanism for Texas psychologists. Opposition by the Texas Medical Association was vehement, and several efforts to create licensure for psychologists were scuttled by TMA's lobbyists.

Eventually, an exasperated legislator demanded that the physicians and psychologists work out their differences, pronto. Thus, TSBEP was established in 1969 through the Psychologists' Certification and Licensing Act. The board did not issue any licenses until 1979—after a decade of wrangling to build out the licensing infrastructure in the face of obfuscation from physicians.

TSBEP has weathered several cycles of recurring Sunset Review. In 1981, the Legislature added three public members to the board, creating a nine-member: four psychologist members from independent practice, teaching, or research domains, two psychological associate members, and three public members, all appointed by the governor with senate confirmation, with at least one member required to practice as a licensed specialist in school psychology. (Heretofore the LSSP license had been under the purview of the Department of Education.)

In the 1993 sunset review, TPA tackled two issues. First, after a decade of growth of inpatient psychiatric care, psychologists wanted to be allowed to admit patients directly to inpatient care. Physician's groups marshalled vitriolic opposition, but it seemed that a deal had been struck between the key legislators and TPA representatives. Then in the words of the TPA president, "we watched the committee chair walk in with the TMA lobbyists, stand on the floor of the chamber and pencil in changes to our compromise bill."  It passed on a voice vote that afternoon, without further input from TPA.

The other issue was brought by the psychological associates. Their arguments for independent practice were foiled by TPA lobbying efforts, but the legislature created an auxiliary body (the Psychological Associates Advisory Committee) to advise the TSBEP. This group attempted to create an independent license, which the legislature had not authorized. TPA toiled over the next decade to hold the TSBEP accountable to its legal mandate.

TPA's dominant concern in 2003-4 was the oral licensing examination. In 1987, the Board had required an oral examination for all applicants, adding a clinical-judgment component beyond the written national exam. Working from (in my view) an erroneous interpretation of data from other states, the Sunset Commission's asserted that the exam was "not valid" and recommended eliminating the oral exam. TPA mobilized its political allies and the oral survived.

In 2012, TPA succeeded in passing legislation enabling psychologists to bill for "extenders", i.e. work delegated to non-psychologists. This was a major triumph for practitioners.

In 2016, Mary Louise Serafine, PhD, JD sued TSBEP, arguing that the definitions in the licensing act were too broad and represented a violation of free speech. The courts agreed. As a result, TPA worked with the legislature to amend the language in the law, thus preserving the state's authority to oversee the profession.

In 2017, threats of legal intervention pushed the TSBEP to grant independent stature for LPAs in 2017. TPA strongly objected to the suggestion that there was "no difference" between master's vs doctoral training. TPA brought a valiant effort, but this battle paralleled fights happening nationally over the role of master's level clinicians brought by school psychologists, by behavior analysts, and by other counseling groups. The doctoral profession was increasingly under siege.

In 2019, major changes came to the regulation of psychologists. The sunset review identified fragmentation across the behavioral health boards as a barrier to efficient resource use and recommended a consolidation to capture economies of scale in administration. This had long been a project for the Sunset Commission. TPA argued strenuously that psychology, as the only doctoral-level profession, should be excluded from this board.

The consolidation was justified as a way to address the criticisms that regulatory boards in general are too often beholden to professional association interests (like TPA). This argument had been hinted at by the Serafine case as well as a landmark antitrust suit in North Carolina. The promise was that the subsidiary boards (psychology, marriage and family, etc.) would still develop the rules of their own practice and that BHEC would only exercise oversight to prevent possible antitrust problems.

Despite extensive meetings between TPA's legislative team (doctoral members and TPA's lobbyists) and key policymakers, we lost because of the desire to move the other mental health boards to a more efficient agency and the belief that consolidation would minimize antitrust issues. The legislature consolidated the TSBEP with the boards governing marriage and family therapists, professional counselors, and social workers under the BHEC in 2019. The structure established a nine-member council with one professional member and one public member appointed from each of the four professional boards, plus a public chair appointed by the governor.  Until recently, the chair of TSBEP had been elected by the board members, with the result that the board had been chaired by a member with psychological expertise. Now the chair is a patronage position, and has been held by a realtor and now by an insurance risk manager for an energy company. (The realtor is now the chair of BHEC.)

The board's authority to administer an oral examination was eliminated, despite extensive testimony from psychologists supporting its importance.  During the discussions of this issue, TPA was repeatedly assured that the new EPPP-2 would do the job of assessing clinical judgment and skills-based knowledge, rendering the "subjective" oral exam obsolete. As of this writing, this has not happened. The requirement of post-doctoral experience was maintained, but modified to represent a total number of hours combined with a minimum required internship hours rather than a one-year period.

This has not been an exhaustive account of all that has evolved with the licensure act, but it includes most of the significant high points. What might we conclude from all this?

First, that TPA has been involved at every major policy turning point for our profession since the 1960s. While we have not always been effective at protecting our professional identity or scope of practice, our profession continues to be threatened and attacked constantly, and any success we have requires the support and participation of its stakeholders.

Some wins:

• We achieved the licensure act
  • With a structure that promoted psychological expertise in rule-making
  • We fought hard to protect and preserve the doctoral standard for psychologists; we continue to argue for continuation of training standards for licensure (including post-doctoral supervision and formal internship requirements)
  • We carried on a long battle to preserve the oral examination
    • We educated policymakers on the ways to establish the validity of a "subjective" examination procedure
    • We achieved the ability for psychologists to bill for work done by extenders
    • We obtained the right for psychology interns to bill Medicaid
    • We had significant input into the rules adopted for telehealth service delivery
    • Not covered here, but in every legislative session since 1969, TPA has been both active and effective in stopping or amending bills which would have harmed the public or which would have damaged our scope of practice. The list would be extensive and require a separate article.

But we—TPA and all Texas psychologists—have also had some losses:

• We lost the fight to define the scope of practice for LPAs
• We never achieved hospital privileges
• We did not protect the oral exam, although it was a priority for us at the time
• Most substantially, we lost the effort to resist inclusion in the consolidated board (BHEC).

Win or lose, TPA was there, on the ground, devoting as much of our resources and volunteer time as we could muster.  As we look at the next five years, it is difficult to know what the hot buttons will be, but it is certain that there will be further threats to our professional integrity and our scope of practice. History has made two things clear:

• Only TPA will speak for psychologists.
• Preparation for the next battle must start now.

JOIN or RENEW YOUR TPA MEMBERSHIP

SUPPORT THE PAC!