To Improve Mental Health Access, Remove Unnecessary Licensing Barriers for Internationally Trained Newcomers
Today, more than 160 million Americans live in areas with mental health professional shortages, with more than 8,000 new practitioners needed to fill the gap.
Refugees and other forcibly displaced people experience mental health needs at the same or greater rates than the general population, with many individuals managing varied traumas before, during, and after their displacement journeys. Yet, they face additional barriers to accessing support, navigating an already scarce practitioner space that often fails to accommodate their linguistic or cultural needs. In 2021, the American Psychological Association (APA) estimated that only 10 percent of health service psychologists provided services in a language other than English. Psychologists in that same survey reported their cultural responsiveness abilities specific to immigrant populations as fairly low.
This reality is especially concerning considering that a recent survey of refugees and other forcibly displaced people found that access to mental healthcare, especially to practitioners that spoke participants’ native languages, ranked in the top five issues highlighted as a priority and major determinant of integration. In this context, the need for more mental health practitioners in general, and for more diverse mental health practitioners in particular, is increasingly clear.
In response, the International Refugee Assistance Project, the Refugee Advocacy Lab and the Center of Victims of Torture created a resource highlighting opportunities to advance policies at the local, state, and federal levels to improve access to behavioral healthcare. Among these policies, reducing unnecessary licensing barriers for internationally trained behavioral health professionals stands as one of the most impactful, both creating more culturally and linguistically responsive services and empowering communities to reach their full potential.
“Creating accessible pathways to licensure for those trained in countries outside of the United States would address not only the lack of needed cultural and linguistic diversity in the mental health profession, but also create opportunities for refugees and immigrants to practice their professions while reducing labor shortages in the field.”
Reducing Barriers to Licensing: How and Why?
Creating accessible pathways to licensure for those trained in countries outside of the United States would address not only the lack of needed cultural and linguistic diversity in the mental health profession, but also create opportunities for refugees and immigrants to practice their professions while reducing labor shortages in the field.
In a state-by-state analysis conducted by the American Immigration Council (AIC), many immigrants with healthcare-related professional and doctorate degrees were underemployed, working in a healthcare occupation that did not require their degree. Some states have begun to recognize this underutilization or “brain waste” and have taken steps to ensure that mental healthcare professionals trained abroad have pathways to re-licensure that can help address shortages across the country.
To gain a better understanding of the challenges and barriers that currently exist to practicing, some states are commissioning reviews or reports as a first step. In 2022, Vermont passed H. 661 requiring the Office of Professional Regulation (OPR) to conduct a study examining barriers to entry to the mental health profession faced by refugees and other disadvantaged groups. Similarly, Georgia’s H.B. 520, introduced in 2023, would require the Department of Behavioral Health to conduct a study to identify pathways for practitioners with non U.S. credentials to gain licensure through an endorsement or temporary licensure process pending final licensure (allowing people to work while navigating the licensure process). This bill would also require data collection on the cultural and linguistic competencies of the existing workforce and whether they adequately serve the state’s refugee and immigrant populations.
Similarly, recognizing the limitations of short-term studies that, for example, do not account for changing mental health trends or related demographics, in 2021 Illinois passed the Behavioral Health Workforce Education Center of Illinois Act to serve as a central hub for recruitment, research and policy reform. Among the Center’s duties are tracking demographic and linguistic data, as well “as assessing the credentialing and reimbursement processes and recommending reforms.”
One of the most impactful reforms is creating alternative pathways to licensure for those who obtained their training outside of the United States. Unfortunately, only a handful of states have passed bills or rules to this effect. Vermont, for example, implemented rules in 2021 to allow certain professionals trained outside of the United States to undergo an evaluation process through OPR. While these rules only apply to a few categories of mental health practitioners, it marks an important first step towards recognizing immigrant and refugee credentials.
Utah enacted comprehensive licensing legislation S.B. 43 (2022) and S.B. 35 (2023) which allow for the issuance of occupational licenses to individuals trained internationally or from another state if (1) they have at least one year of experience practicing the licensed occupation and their educational experience and skills demonstrate competency, or (2) if their previous jurisdictions licensing requirements were substantively similar to those in Utah when their previous license was issued. If a person was not licensed previously, this legislation also creates a pathway to licensure if it is determined that their education and experience are substantively similar to what is required for that profession in Utah. Utah also passed H.B. 250 (2023) which removed a redundant exam for social workers and provided accommodations for people with limited English proficiency in the licensing process, such as time extensions for exams.
Other states have aimed to make the process simpler by creating clear, targeted guidance on existing licensing processes for those with international credentials. For example, to make the process less daunting, Michigan provides an extensive range of professional licensing guides for immigrants. Currently, the state provides these guides for 41 occupations. Similarly, utilizing funding from the Workforce Innovation and Opportunity Act (WIOA), which provides funding and technical assistance to states for the purpose of integrating those with professional credentials from other countries into the US workforce, in 2018, Maryland established the Maryland Skilled Immigrants Task Force. The Task Force produced, among other things, a career pathways guide to help engineers trained and licensed outside of the country return to their work in Maryland. While this was specific to engineers, a similar approach could be utilized for mental health professionals.
More broadly, several states, as well as the federal government, have created programs to improve diversity in the mental health field through grants and other mechanisms. While these initiatives unfortunately do not create new or alternative pathways for re-licensure, they are geared towards assisting diverse populations with gaining licensure. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) has prioritized culturally responsive services as a strategic priority for the next four years. To further diversify the mental health workforce, the agency plans to engage in training, provide technical assistance, utilize telehealth capabilities, and increase support personnel such as paraprofessionals and peer counselors.
Minnesota, Oregon and Colorado have created grant programs to help diversify the field. In 2021, Oregon passed H.B. 2949 (2021), addressing mental health workforce diversity by (among other things): establishing programs that provide scholarships, stipends, loan forgiveness of up to $15,000 in mental health shortage areas, and retention activities; providing funding to BIPOC and immigrant communities to ensure access to mental health care; creating a Task Force on Expanding the Mental Health Workforce; and reducing the hours of supervised clinic experience required for professional counselor or marriage and family therapist licensure.
Reducing barriers for interstate practice is another important way states can expand the geographical reach of culturally and linguistically responsive services. The Covid-19 pandemic accelerated the need for interstate practitioners, setting an important precedent for new mechanisms to recognize credentials across state lines. Forthcoming in 2024, the Counseling Compact would allow professional counselors to practice across state lines within 29 participating states. Likewise, the PsyPact allows psychologists to practice across 39 states. Similar efforts are actively being made for social workers. While such compacts don’t resolve the shortage of culturally and linguistically responsive practitioners, they could improve access to the few that are available.
While these initiatives to reduce barriers to licensure are important steps in the right direction, more needs to be done. Refugees and other forcibly displaced populations not only need more qualified and culturally responsive service providers, they potentially hold the key to their own mental health wellness if accessible pathways to re-licensure were readily available. Reducing licensing barriers is a move to better employment opportunities for some and a better healthcare system for all.