Despite Rise in Teletherapy, BIPOC Still Face Barriers Due to Counseling State Laws
*To protect the confidentiality of clients (or potential clients), any examples I provide have been altered, to the extent that even the clients themselves would not be able to recognize I am referencing them
Several months ago, I received an e-mail from someone specifically seeking a South Asian Muslim male therapist for counseling. Everything seemed like a good match for this person, but there was one major problem: The client lived in a different state. Since I’m not licensed in his state of residence, I was unable to provide counseling. The client informed me that he could not find any Muslim male counselors in his state. After asking colleagues for potential referrals and searching through online directories, I found that there simply weren’t any Muslim male counselors in his state. I decided to contact his state’s counseling licensing board and explained the situation to a board representative to see if there was a possibility that I could be given a temporary waiver to provide care to the client. Their response was discouraging. “We can’t give you a waiver,” they said. “I’m sorry, I wish I could give you a different answer.”
Unfortunately, there was nothing new about this experience. Since the start of the COVID–19 pandemic, I’ve lost count of how many Muslims, South Asians, and other people of color I had to turn away due to restrictive counseling state laws. At the beginning of the pandemic, many states in the U.S. issued emergency temporary licenses for out-of-state providers. Whenever a potential client contacts me from a different state, the first thing I do is check their state’s counseling board website to see if such temporary licenses or waivers are offered for teletherapy services. States like New Jersey, Massachusetts, and Florida were among those that permitted out-of-state providers to serve people living in their states, for example. However, in the case mentioned above, the laws in his state had stricter licensing requirements, such as extra coursework, an exam, and additional documentation for out-of-state clinicians, not to mention the fees were quite expensive. No matter how quickly I acted, getting approval to see this client would not be an overnight process. In fact, due to many counseling boards being short-staffed, it could take months.
Another issue is that I’ve had to refer existing clients to a different therapist because they moved to a different state. Most of the time, this has not been a smooth process, especially for Muslim clients who prefer to continue therapy with me or cannot find a Muslim therapist in their new state. Counseling state laws conflict with a major ethical principle that we should not abandon our clients, as detailed in the American Counseling Associaion’s (ACA) Code of Ethics. You would think that counseling state boards would prioritize continuity of care for the client’s benefit, but I’ve had several experiences where certain state boards would make dismissive comments, including Islamophobic microaggressions, and downplay the importance of this ethical principle.
This is cause for concern because since the start of the pandemic, there has been a spike in mental health challenges and an increasing demand for counseling services. Due to existing health disparities upheld by institutional and structural systems of oppression, the impact of COVID-19 on communities of color and other marginalized groups like LGBTQIA2S+ people has been devastating.
As much as teletherapy has helped make mental health services more accessible, there are still barriers in place. The lack of counselor license portability limits people to choosing counselors who are only licensed in their state. This can be especially challenging for BIPOC, Muslims, LGBTQIA2S+ people, and other marginalized groups who may be seeking counselors from similar racial/ethnic, gender, religious, and sexual orientation backgrounds, but can’t find those counselors licensed in their state.
According to the American Counseling Association, 71.1% of Licensed Professional Counselors (LPCs) are white, while 13.1% are Black or African American, 10.5% are Hispanic or Latino, 3.0% are Asian or Pacific Islander, and 0.2% are Native American or Alaska Native. The U.S. Census Bureau reported in 2015 that “86% of psychologists were white, 5% were Asian, 5% were Hispanic, 4% were Black/African-American, and 1% were multiracial or from other racial/ethnic groups.” Similarly, a 2013 report from the Substance Abuse and Mental Health Services Administration (SAMSA) noted that only 10.3% of counselors are people of color.
In her article, How to Find the Right Therapist for You, Once and for All, Carolyn Kylstra highlights on some experiences of Black women seeking counseling. She mentions Ecaroh, who sought a Black therapist to discuss “the nuances of her life as a Black woman.” Ecaroh expressed, “That’s something that’s hard to talk about with people who don’t understand that experience directly.” However, as Kylstra notes, Ecaroh could not find a Black therapist in her small Texas town. Pre-pandemic, the issue here would be that Ecaroh would need to travel further to find a Black therapist. Now, during the pandemic, telehealth would allow her to expand her options and see counselors within the entire state of Texas. As helpful as this may sound, not everyone will be able to find a counselor who is the right fit for them within their state.
A point that I cannot emphasize enough is that the underrepresentation of people of color in mental health professions is not simply a problem about the lack of diversity and inclusion, but rather about social injustice and systemic oppression. One of the major problems with a “diversity and inclusion” framework is that the focus is exclusively on visual diversity. In other words, the solution to racism and other forms of oppression seems simple to many employers: Let’s hire more people of color, women, LGBTQIA2S+ people, Muslims, etc. However, this is a flawed and harmful approach for many reasons. For one, it ignores the reality that anyone can perpetuate and reinforce white supremacy and other oppressive ideologies. There are Muslims, for example, who support Islamophobic laws and policies. Similarly, there are BIPOC who advocate for more oppressive laws or reinforce racist narratives about other communities of color, not just their own. There are also BIPOC and LGBTQIA2S+ people who fuel oppressive attitudes and actions in more subtle and covert ways, such as claiming that marginalized groups are partly to blame for “not speaking out” enough to “educate” others.
Failing to recognize the reality that all of us can reproduce oppressive attitudes, practices, and hierarchies will lead to harm, including in therapy spaces. Let’s consider, for example, that a supervisor decides to match an Indian Muslim client with an Indian Hindu counselor under assumptions that a shared cultural identity may help the client. However, what if the Indian Hindu counselor is Islamophobic? Comparably, if a Muslim counselor is assigned to see a gay Muslim client — again, with assumptions that a shared religious background would be beneficial for the client — how effective would this therapeutic relationship be if the counselor is homophobic?
These examples probably make sense to most people, but let’s complicate things more. Consider a scenario where both the counselor and client are from the same racial/ethnic, gender, and religious background, but they have profoundly different social and political views. What if the client is looking for someone who understands the impact of white supremacy, heteropatriarchy, capitalism, imperialism, and settler-colonialism? This highlights a critical factor in a therapist-client relationship: Finding the right therapeutic fit. Of course, it is unrealistic to expect counselors to know about everything, but my point is, diversity and inclusion is simply not enough.
There has been some progress towards making counseling licenses more portable across the U.S. The ACA created the Counseling Compact in 2020, which is “an agreement among states to legislatively recognize other states’ counseling licenses.” In other words, a licensed counselor can practice in another state, as long as both the counselor and the client reside in Compact States. Thus far, the Counseling Compact been passed by the legislatures in 22 states: Georgia, Maryland, Alabama, Mississippi, West Virginia, Utah, Maine, Florida, Kentucky, Nebraska, Tennessee, Colorado, Louisiana, Ohio, New Hampshire, North Carolina, Delaware, Wyoming, Arkansas, Virginia, Kansas, and Washington.
However, there is still much work to be done. According to the ACA’s website, the Counseling Compact only applies to Licensed Professional Counselors (LPCs), leaving out Licensed Marriage and Family Therapists (LMFTs), Licensed Clinical Social Workers (LCSWs), and psychologists. The latter are considered distinct professions and a specific Compact would need to be created for those providers.
Furthermore, as implied earlier, the healthcare system overall in the U.S. needs to be anti-racist, anti-sexist, anti-homophobic, anti-transphobic, anti-oppression. It’s a mistake to assume that matching clients of color with therapists of color is going to lead to healing therapy. It’s part of the solution, but it’s not everything. I haven’t even spoken about the barriers and obstacles BIPOC often face in higher education that prevent them from becoming licensed counselors, psychologists, or other mental health professionals. I also haven’t touched upon how insurance companies make accessibility to counseling services challenging for BIPOC and other marginalized communities, telehealth or otherwise. These are topics for a different post, but what’s clear is that the multiple layers of these problems stem far deeper than a matter of “diversity and inclusion.”
