Accreditation of Master’s Programs in Health Service Psychology: An Opportunity for Board Certification in Professional Psychology

Over a century ago, Leta Hollingworth argued that the title of expert psychologist be restricted to those holding a doctorate (Hollingworth, 1918). It took the Second World War for Hollingworth’s proposal to be actualized. With the expert and savvy leadership of James Grier Miller as Chief of the Clinical Psychology section of the Veterans Administration (VA), the first doctoral training program was established for what we now refer to as health service psychology (HSP; i.e., clinical, counseling, and school psychology; Moore, 1992). Shortly after, the American Psychological Association (APA) established the first accreditation system in clinical psychology and the scientist-practitioner model of training was born at the influential Boulder Conference (Baker & Pickren, 2007; Raimy, 1950). These events solidified the doctorate as the entry level degree for practice in HSP. 

The role of master’s level practitioners was considered at the Boulder Conference and subsequently by the APA Committee on Subdoctoral Education, which made strong arguments in favor of master’s level HSP practitioners (Committee on Subdoctoral Education of the Education and Training Board, 1955). APA, however, maintained Hollingworth’s goal of the expert psychologist being at the doctorate for 100 years. In a turn away from that history, the APA Council of Representatives voted overwhelmingly in 2018 to pursue the development of an HSP accreditation system at the master’s level (APA, 2018). After this vote, the Committee on Accreditation at APA developed HSP Standards of Accreditation as well as Implementing Regulations at the master’s level, with the first five applications currently being reviewed.

Although a complex amalgamation of guild and public health factors have driven APA to finally tackle the “master’s issue” (Callahan, 2019), master’s level practitioners have been a reality in the mental health system for decades. Indeed, available evidence suggests that as little as 16% of mental health practitioners are doctoral level psychologists. Master’s level practitioners – who are licensed or certified to practice in all 50 states plus the District of Columbia and Puerto Rico (Robinson Kurpius et al., 2015) provide the overwhelming amount of mental health care in the United States and across the world (Washburn, 2022).  

One reaction to the development of a multi-tiered HSP system is to protect the doctorate by restricting the practice of master’s level HSP practitioners, either by limiting their roles to very specific activities (e.g., not treating complex trauma or working in hospitals) or by having them practice under the supervision of a licensed doctoral psychologist. This reaction, however, ignores the reality of independent practice among master’s level mental health practitioners in other disciplines, such as counselors, social workers, and marital and family therapists. Limiting master’s level practice within HSP, while other disciplines are independently licensed, only serves to impair the ability of HSP as a field to influence the education, training, and practice of the vast majority of mental health practitioners. As such, protectionist policies have the unfortunate impact of also limiting the population from receiving the full benefits of HSP.  

An alternative reaction to the development of master’s HSP accreditation and practitioners is to frame it as a unique opportunity for board certification. A multi-tiered HSP system, particularly within a population health model (APA, 2022), provides an opportunity to “double down” on specialty preparation and recognition of specialty expertise through board certification. The available evidence suggests that master’s level – or even less credentialed – practitioners can be effective in the provision of psychological interventions when they have obtained high quality training and supervision (e.g., Driscoll et al., 2003; Erekson et al., 2017; Forand et al., 2011; Rizvi et al., 2017, Singla et al., 2017). As noted nearly seventy years ago, “[t]here will always be a large number of psychological positions which, although socially useful, are not sufficiently complex or challenging as to be appropriate career goals for doctorally trained psychologists” (Committee on Subdoctoral Education of the Education and Training Board, 1955, p. 541).

Master’s level HSP practitioners should be the frontline mental health provider for individuals seeking services for common mental disorders (e.g., anxiety and depression; WHO, 2017). Given that three master’s level HSP practitioners can be educated and trained in the time it takes to graduate one doctoral psychologist, unmet mental health needs will be more efficiently addressed by increasing the number of HSP practitioners at the master’s level. In contrast, doctoral psychologists, given their extended education and training as well as their greater per unit cost within a health system, should be reserved for individuals who require specialty and subspecialty services. From a stepped care perspective, generalist training in HSP is becoming increasingly insufficient at the doctoral level as future practice is likely to become increasingly specialized. Although all doctoral psychologists should have the generalist education and training necessary to develop minimum clinical competencies, preparation for specialty and subspecialty HSP should be integrated into all HSP doctoral education and training programs to fully prepare psychologists to practice at the top of their license. For example, while a master’s level HSP practitioner may effectively treat most patients with depression, they may refer to a doctoral psychologist with board certification in Behavioral and Cognitive Psychology for patients with more severe depression, particularly those who have not responded to psychotherapy delivered by a master’s level practitioner. At a systems level, healthcare centers may staff their general outpatient clinic with primarily master’s level HSP practitioners, while reserving board certified doctoral psychologists for leading specialty clinics (e.g., addictions, forensics, neurodevelopmental disorders, obsessive-compulsive disorder, serious mental illness) or for interprofessional care throughout the system (e.g., health psychology, neuropsychology, rehabilitation).

HSP has the tools necessary to pivot towards specialty preparation at doctoral, internship, and postdoctoral levels. Indeed, the Taxonomy for Education and Training in Professional Psychology Health Service Specialties and Subspecialties (APA, 2020) and the specialty-specific taxonomies available at the Council of Specialties in Professional Psychology (www.cospp.org) provide clear guidance as to the curricular, research, and clinical requirements necessary for specialty preparation at all levels of doctoral education and training. Board certification, with the established processes and quality control provided by ABPP, is the natural culmination of specialty-focused doctoral, internship, and postdoctoral education and training. Although master’s level practitioners may develop specific areas of expertise over the course of their careers, specialty education and training that is evaluated and recognized by an established body like ABPP is reserved specifically for doctoral psychologists.

The development of an HSP accreditation system at the master’s level provides an unprecedented opportunity for ABPP to be one of the primary distinguishing characteristics between master’s and doctoral psychologists. Embracing the master’s level HSP practitioner as the frontline mental health professional necessitates that the doctoral HSP practitioner do something other than providing general psychological services to individuals with common mental disorders. The provision of specialty and subspecialty HSP services is the “something other” that doctoral level HSP practitioners bring to the mental health system. Indeed, specialty and subspecialty HSP competencies, which can only be obtained from extended education and training at the doctoral level, provides a clear scope of practice and professional identity that differentiates doctoral psychologists from practitioners at the master’s level.

A quarter century ago, Bent, Packard, and Goldberg (1999) argued that “[i]t is not the exceptional specialist who should be board certified, but the specialist who is not board certified [that] should be the exception” (p. 72). Despite this, board certification in HSP remains the exception rather than the rule. A multi-tier HSP system may be the impetus to correct that problem, motivating doctoral psychologists to seek board certification as a primary way to differentiate themselves from master’s level HSP practitioners. It is my hope that ABPP works with APA and others to integrate specialty and subspecialty training into all aspects of doctoral level HSP education and training, and that board certification finally becomes an expectation rather than an exception.