How to Become a Therapist
What’s the difference between:
a Marriage and Family Therapist
a Professional Counselor
a Clinical Social Worker
How do I know what to pick?
When thinking about how to become a therapist can be confusing with all the different options. In this Episode we’ll discuss the things you consider in choosing the pathway and school that is right for you.
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You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance podcast. This is episode 43. Be sure to listen to the previous episode of the student edition too!
On the Student Edition of the podcast today, we’re going to be talking about how to be come a therapist and choosing a pathway and a grad school. The conversation is pretty complex because you can’t just pick a school when there’s so much riding on the outcome.
So you’re at the place where you’re deciding about where to go to school. The conversation today is meant to tell you the things that a lot of us wish we knew before we went into school. For those of you who are listening who are already in graduate school, some of the information you might wish you had known before you got into a program. But I don’t want to cause undue panic if you feel like maybe you did something wrong. There are ways around potential problems and if you’re in grad school, then you still have time to take those classes that you might need or to switch gears a little.
What billing has to do with choosing a grad program.
In order to become a therapist, you have to get a master’s degree. So where do you go to school? Well, it’s not that simple. We have to back up a minute because where you go to school in terms of the name and location of the school, isn’t nearly as important as some of the other information that you need to know. I’m pretty passionate about this particular topic. I have talked to countless interns, students, and classrooms about these very issues.
The pathway to becoming a therapist should be streamlined and should be something that isn’t as difficult as it is, but it’s complicated. Now I’m going to be speaking to people in the United States. I know that in other places, it’s really different. For instance, in the UK, the difference between a counselor and a therapist is really wide. You have to go through different levels of counseling education, and it’s not necessarily regulated by the country. There are organizations in the UK who do the regulation of counseling, but it’s not like there’s active licenses the same way we have them in the United States.
There is a truth that you need to accept as you begin this process. If you can’t bill, you can’t work. There may be a few exceptions, but those are rare in the United States. And what I mean by bill is that you need to be able to bill insurances. If you can’t bill on your own without supervision, at some point in your career, your options for how you’re going to work are extremely limited.
With that in mind, I need to tell you a little story. Long ago, psychiatrists were the people who did therapy and medication. Psychiatrists have to go through medical school and have to take psychiatry as their specialty.
There was a time when psychiatrists didn’t feel like psychologists, those are PhD people, should be able to do therapy without a medical license. Well, the psychologists felt like they had enough education and should be recognized. So they got together and formed the APA, the American Psychological Association. They fought and they won for recognition to be able to provide therapy services
Well, the psychologists, the PhD people, didn’t feel like master’s level people should be on the same level as them. After all the PhD folks went through and got a master’s degree and a PhD. But those of us who only had master’s degrees, we didn’t do all of that extra work. And the psychologists didn’t feel like we should be able to do therapy in the same way they do. Well, this is where it gets complicated.
Types of therapists
Master’s level people in my opinion (and of course I’m biased because I am one) can provide therapy, do provide therapy and do a great job at it. In fact, statistically we tend to show up in more underserved areas than PhDs and there is a great need in those communities. Some of the master’s level therapists got together and were able to lobby and be granted recognition. Those are the MSWs or people who have a Master’s in Social Work.
But the other two types of masters level therapists, they didn’t have a banner with which to get behind. And so therapists with a marriage and family license or with a counseling license, don’t have the same recognition as clinical social workers.
Here’s what I mean. If you go and get a master’s in social work, it’s the same degree across the country. It’s an MSW, regardless of where you go and what school you’re in. It’s the same degree; you graduated with a Master’s in Social Work. That means that you can work in any state in the United States and that your licensure is nationally recognized. Remember I said, you couldn’t work if you couldn’t bill. Being able to bill in any state, that’s a big deal.
Now Marriage and Family Therapists have a lot of recognition. They have more consistent recognition across the country, but it’s not necessarily national and it’s not guaranteed.
That leaves the third category and that’s where I fall. My particular license is called an LPC, a Licensed Professional Counselor, but I’ve worked in other states and they’re called different things in different places. For instance, in Michigan, I was a Limited Licensed Psychologist, even though I had a master’s degree. That was the designation. There’s a lot of complexity to why the different licenses are called what they’re called, but just making a point here about the difference between state to state.
Those of us who got other degrees, other than MSWs, are all called different things. I have a degree in Clinical Psychology. Someone else might have a degree in Counseling Psychology. Someone else might have a degree in Clinical Mental Health Counseling, School Counseling, Student Affairs and Counseling Education or Community Counseling, just to name a few.
There are a ton of different names of these degrees. And so what banner do we get behind to demand recognition across the nation? We don’t have one. For the purposes of our conversation. I’m going to refer to them as LPCs. In different states they could be LPCC, LCPC, or any other designation, but that’s the general category. I’m going to refer to Marriage and Family Therapists as MFTs. And of course, for social workers, MSWs.
Marriage and Family Counselors
Marriage and family therapists are just that. They go through a program that focuses a lot on relationships and family systems. It doesn’t mean that these therapists are going to practice mostly in family therapy or in couples counseling. In fact, some of the MFTs I have known don’t do that work really at all and do more individual work. But in this case, the MFT is about their theoretical orientation. They tend to look at things from a systems perspective.
When it comes to LPCs, these Community Counseling or Clinical Psychology or Counseling Psychology degrees tend to be more focused on more classically thought of psychological concepts like modifying behavior, underlying pathology, development and therapy skills.
Social work therapists
When it comes to social workers their education is a little broader. In some programs, there’s going to be a clinical concentration where they’re covering things that would typically be in a counseling degree. Not necessarily to the same depth though, as there’s a lot of other things that need to be covered.
Social work looks at a broader community aspect of people’s life. They look at things like societal issues, race, social justice, criminal justice and poverty. The outcome for a person with a social work degree can be a lot of different things.
They use the terms, macro mezzo and micro in terms of social work. Macro of course, being on a broad level, mezzo being a mix of micro and macro, where micro is focused on the individual. Not all social work programs and in fact, many of them don’t have clinical concentration.
I have a colleague who’s working on her own training to help social workers transition into clinical work. She worked in child protection as a master’s level social worker for many years, and then moved into doing therapy. And a lot of social workers don’t know how to make that transition because they didn’t have the clinical concentration when they were in school. They didn’t necessarily get taught about different diagnoses and how to make them or doing specific therapy on an ongoing basis. That’s not to say that social workers didn’t have good education.
Some of you may be thinking, well, I want to be a therapist. I’m going to go the counseling route. Or I know I want to work with families and couples. So I’m definitely going to be an MFT. Well, there is an issue here and you may be surprised at what my advice is going to be.
What you need to know about insurance
In order to get to that place. We need to cover one more thing. We need to talk about insurance. I’ve been a therapist since 2003. I remember a time, I’m not sure if it was during grad school or my early career, where I remember having some naïve thoughts that I didn’t need to worry about how I made money.
I don’t mean that I didn’t need a salary. I meant that how the agency got paid for my work felt like it didn’t matter. That I was, I don’t know, maybe above such things. That my work was important and that somebody else had to figure out how to get it paid for. That’s not the case, even if that’s your philosophical stance, that is not how the United States runs in terms of providing healthcare services.
Everything is a matter of who is going to pay for it. We do not have Medicare for all. We don’t have a national health system or universal health care. And so it does matter who is going to pay for it because somebody has to.
When you’re providing therapy, there are four ways that an agency or a person in private practice are going to get paid. It is important that you know these and know the difference. So first we’re going to talk about the difference between Medicaid and Medicare. They are not the same thing and they have very different implications for your work.
The difference between the two has to do with eligibility. Medicare is for people who are 65 and older, and for younger people who have certain disabilities. The third category of eligibility is for people with end stage renal disease; Where they have permanent kidney failure requiring dialysis or transplant. I’m not certain why that specifically gets called out, but it is one of the three main eligibility criteria when you look at information about Medicare,
Medicare can sometimes be somebody’s primary insurance or it’s supplemental insurance. It depends on whether or not you have a way of getting insurance after age 65 without Medicare. But once someone hits that age, they are eligible for Medicare.
Medicaid has income eligibility guidelines. Medicaid is a program that is funded partially through state and partially through federal money. There’s a match that happens between the Fed and the states. When the Affordable Care Act went through, there was the option for a state to do what’s called a Medicaid expansion. Some states decided to do it and some didn’t.
For instance, Minnesota decided to take the Medicaid expansion, which means that more people are going to be covered and that the income limits are higher so there’s a higher chance for people to be covered. Just across the border in Wisconsin. The state did not take the Medicaid expansion. Typically this falls along political party lines. Most red states didn’t take the Medicaid expansion. Whereas most blue states did.
Medicaid covers low low-income people for adults, children, pregnant women, elderly adults, and people with disabilities. You can have both Medicare and Medicaid. So there are clients who have Medicare because they’re on disability and also Medicaid because they’re low income. But there are people who are on disability, who prior to going on disability had a pretty lucrative career and so their disability payments are too high to make income guidelines.
That’s not really difficult to do. In Wisconsin, if you make over about $1,035 a month. That’s gross. Meaning before taxes, you don’t qualify as low income. Not totally sure how a single person is living and paying rent on a thousand dollars, but that’s the income limit. In Minnesota the income limits a lot higher, and so people can make more money and still have healthcare coverage.
When Bernie Sanders talks about Medicare for all, the reason he uses Medicare, instead of Medicaid, is that Medicare is not dependent on income. And that’s why he chooses that word instead of Medicaid, because he wants there to be universal healthcare that doesn’t depend on income or disability or age.
The third type of payment is commercial insurance. This is any insurance that is not Medicaid or Medicare. So Blue Cross blue shield, Health Partners, Humana Tricare or any of the other companies where the insurance is not through one of those two programs, Medicaid or Medicare.
The last form of payment is self-pay. This is going to be the smallest amount. There are some therapists who do completely private pay or self pay, private practice . I’m not sure how they make a living at it, except that there are a number of them who do. However, it’s not a lot of people that I have found that are able to pay $150 an hour every week for therapy.
Getting the job as a therapist
When you go to get a job post-graduate school, the main thing that the agency needs to know is that they’re going to be able to get reimbursed for your services. In some cases, if you work for a hospital system, you might be billing through someone who has a higher degree than you, like a PhD. But that limits your usefulness because they’re not able to move you to a different department and they have to provide you with a certain level of supervision pretty much across the board.
So the question is can you bill all three insurance types? There’s only one of those licenses that can at this time, and those are MSWs. Remember when I talked about the master’s level, people getting together to lobby it, to be recognized. Well, the MSWs were able to do that.
They had a banner and a very large lobby, and they were able to get recognition on a federal level. That means that they were able to bill Medicare. LPCs and MFTs are not able to bill Medicare because they don’t have national recognition.
That can be a problem depending on the population that you work with. Now someday, that may change. Of course, there are groups working on getting national recognition for the MFTs and the LPCs, but we don’t know if that’s going to happen. It takes a while for those kinds of things to get changed and it’s only important to a few of us. MSWs are numerous, and it’s kind of a small subset of us who need those regulations changed.
I believe that they should be changed for a number of reasons. I think it would provide more therapists for people who are on Medicare. There are plenty of times over my career where I have had to turn someone away because they have Medicare. That’s the situation currently. In my private practice, I don’t take Medicare clients. Now it works for me because my populations don’t typically have Medicare, but there have been instances where I have had to transfer clients who were granted Medicare because of a disability and once they got that, they could no longer see me anymore.
There are hospital systems who will only hire MSWs because they don’t want to have to worry about whether or not a person can be covered. If the person has an MSW, then they’re covered for all standard level therapy. Now for psychological testing, that’s a purely PhD function. And so a master’s level therapist and licensure isn’t going to cover that anyway.
If you want to do psych testing, meaning you want to be the one that conducts the test, you could become a psychometrist, which you would need your master’s and you would need a place that hires psychometrists and you could perform the testing, but you still have to have a PhD to interpret the tests and to disseminate that information to the client.
Why social work might be the way to go
Here’s the part that you really need to hear. If your degree and subsequent license is not an MSW, there are states that you may not be able to work in. Period. Some states do not recognize certain degrees or licenses. Other states do recognize those degrees and licenses, but they don’t recognize them to the point that they will reimburse for them through Medicaid. Medicaid is incredibly important.
About 65% of the people I see in private practice are on Medicaid or what we call state insurance. That is a choice that I make because of the population of people that I work with. I generally work with people who are struggling with trauma and addiction, which a lot of times means that there are financial struggles as well.
I choose to take Medicaid. Not all private practice people do and certainly not even all agencies do. If you work in a non private practice setting, the chances are that they will take Medicaid and that Medicaid will be a large percentage of their population. And so if the state won’t recognize you and won’t reimburse for your services through Medicaid, you aren’t going to be able to work.
I’m going to tell you about my own licensure story so that you can understand sort of how this works. So I graduated from a grad school in Chicago, Illinois. I received a master’s in Clinical Psychology. I could have worked in Illinois and gotten what’s called an LCPC. Which is a Licensed Clinical Professional Counselor.
Life took me in a different route though and I ended up first being licensed in Michigan, then in South Dakota, then in Wisconsin and Minnesota. So in Michigan, someone with my decree first had to get their pre-license, which was called a T L L P, which is a Temporary Limited Licensed Psychologist. Since the time I’ve lived in Michigan though, they now have an LPC, a Licensed Professional Counselor. At the time I was there in 2003 and 2004, it was a Limited Licensed Psychologist.
So when I was moving to South Dakota to be with my then boyfriend now husband, I called the state board. And I asked them about their master’s level psychologist license, and they said “we don’t have one”. So I am facing a move to go be with the love of my life and relocate. And I was just told by the board that I can’t work in their state because they don’t have a master’s level psychologist license.
Now some of you already know the problem here and others are like, oh no, what did you do? Well, turns out I asked the wrong question. The word psychologist is a protected title for the most part. You can’t say that you’re a psychologist, unless you have a PhD. Now in Michigan at the time, I literally had a license saying that I was a Limited Licensed Psychologist.
With the limited license meant at that time was that I would always have to have the supervision of a psychologist for my entire career. My guess is that’s behind the change to the LPC there, although I haven’t looked into it.
When I got to South Dakota, I found out that there were master’s level therapists kind of all over, but it was called a different thing. In South Dakota it’s an LPC, Licensed Professional Counselor. And then there’s an advanced license called an LPC-MH, standing for mental health. It is a complex process and it depends on what state you’re in. So I moved to South Dakota, I got my LPC, I got my LPC. MH. I got another thing called a QMHP, which is a Qualified Mental Health Professional.
And That’s a totally different designation that does not have to do with billing, but it is something you need for crisis services. That, in my experience , was necessary only in South Dakota.
And then my family and I were going to be moving to Northern Minnesota. Well, Minnesota had an LPC and an LPCC license. The LPC of course, still Licensed Professional Counselor and the LPCC added “clinical” to that. I certainly had the requirements, although Minnesota would not grant reciprocity because there were some classes that I didn’t have that they required. But once I got those, I was able to practice. That did not mean I could bill.
I talked to the board at the time, and this is approximately 2008 and I clarified what I was reading and what I’d been told. That in order to bill in the state of Minnesota, I would have to bill through a master’s level social worker, or a psychologist. That Medicaid did not recognize me as a mental health professional. I have a master’s in Clinical Psychology. I had an advanced license in the state of South Dakota and Minnesota did not see me as a mental health professional. That was a problem.
The good news for me is that the town we were moving to is on the border. Right across the river in Wisconsin, I could be an LPC and Medicaid would cover me. And so that’s how I wound up working in Wisconsin. Because I literally could not work in Minnesota. Now in my area it means that on my side of the bridge in Wisconsin, we have an abundance of LMFTs and LPCs because in Minnesota, MSW reigns supreme.
Fast forward a few years, and eventually Minnesota did come to recognize the LPCCs. And so now I could work in Minnesota and I do take some clients who are from Minnesota and do tele-health from there.
But if not for being close to Wisconsin and being able to work there. I would have been out of luck and would have had to rely on finding a job where they didn’t need to use my license for billing. For an organization, that is a big stretch and they have to be really committed to you.
Complexity and controversy in licensing
I’m hopeful by this point that you understand the complexity of the licensing issue and that you’re starting to see where we might be headed in terms of a recommendation for where you go to grad school.
I do want to say that LPCs and MFTs have strong opinions about the fact that MSWs are able to bill all the insurances and that we are not. If you recall, MSW programs are really broad and they’re not necessarily focused on just therapy. They have a lot of other things that they work on.
Whereas MFTs are specifically geared towards family systems. And LPCs like me are specifically geared towards therapy. It is a bone of contention. If you’ve ever watched a conversation online, it gets super heated. It is not the MSWs fault that Medicare doesn’t recognize the rest of us. They did what they needed to protect their people and they were a hundred percent right to do it.
It is not the social work community’s responsibility to make sure that the rest of us get heard. I would like their support. And I’ve had that from all of my MSW colleagues, but it isn’t their job. I have seen these conversations go super sideways though, because it is hotly contested. I don’t know that anyone is actually saying that the MSWs are better prepared to do therapy. Only that they are covered and the rest of us aren’t.
Difference between licenses is about content
So the three main tracks that you need to pay attention to are MSW, MFTs, the marriage and family therapists. And then what we’re going to call counseling degrees or LPCs. In whatever state you’re in the license and the letters are going to be a little different. And eventually that matters. I am going to do a podcast on licensing so that we can talk about that and what you need to know, but for today’s discussion, those are the categories.
So what that means is that there’s content differences between each degree. You have to decide whether you’re going to go MSW regardless of content, so that you have national recognition and potentially less hurdles when getting a job. Or if the content matters more to you and you’re going to go that route regardless.
Here’s where I want to tell people who are already in grad school, not to panic. Those of you who chose MFT routes or counseling routes. I want you to breathe because it’s okay. You just need to know this information. You need to find out what your state rules are and you need to plan accordingly. It also means when you move to a new state, or if you’re on a border state, that you need to understand what that policy is going to be.
The problem comes when you get out of grad school and you don’t know these things. So you didn’t screw up. I have worked since 2003 as a therapist and have been able to support myself and build a great career as an LPC. So don’t panic. You didn’t make a mistake. It’s just going to be a different process
In order to better describe what an MSW, MFT and LPC means. I’m going to read you some of the names of the courses from the different degrees. I just took these from random universities that have these degrees so that you could hear what the content difference is.
In one program where you would get a Clinical Mental Health Counseling Master’s degree. Some of the courses are group counseling, research design and program evaluation, counseling skills and techniques, counseling theories and practice, psychopathology, lifestyle and career development, crises and community counseling, family therapy and assessment and counseling.
For a Marriage and Family Therapy Masters some of the courses might be: therapy with couples and intimate partners, introduction to trauma and crisis intervention, foundations of family therapy one and two, working with teenagers and families, school-based mental health, parenting interventions, systemic assessment and treatment of sexual concerns. psychopathology and treatment planning and developmental systems.
Now let’s look at a couple of the courses for a social work program. Social work with diverse populations, organization and community practice, individual family and group practice, human behavior in the social environment, social welfare policy, advanced practice in child welfare, advanced practice in administrative and community development. And of course the requisite course in research, which all three degrees have, even if I didn’t name them,
Those are the names of specific courses you would take at those specific grad programs. We’re talking about content here. This is what you’re actually going to be learning about. If you’re going to go an MSW route, there are some things you need to pay attention to. There is a change happening in the MSW world.
Social work and clinical concentration
For instance, in Minnesota, approximately I think five years ago, the MSW board decided that they needed to add clinical content to their requirements. They gave the pre-licensed people a time period where they’d be grandfathered in. But after a certain point, if you didn’t have those clinical classes, you would not be able to be licensed as an MSW in Minnesota.
What happened is that certain programs who didn’t have clinical concentration weren’t going to be able to prepare their people for licensure. So they had to adjust. In our area, a whole new master’s level program was started that had a clinical concentration, and the courses were a little different from your standard MSW. This is sort of the trend. Part of that comes from people in the social work realm feeling like they didn’t get prepared enough to do therapy when they got out of school. They have a really broad education, but sort of the nuts and bolts of it they didn’t feel like were getting covered adequately.
The MSW board in Minnesota put this on themselves. They decided that they needed their MSW graduates to have more clinical skills and so they made it part of the state requirement. The existence of clinical concentration is going to be important if you decide to go the MSW route.
You’ll notice that in this episode, we didn’t even get to talking about specifics in programs, in terms of accreditation internships, whether you need a thesis, whether you have to take a big test in order to get into graduate school, sort of like the act, but for grad school instead, or how many credit hours you need for a specific license. That stuff we’re going to cover in the next episode, because it is important. And the information will vary of course, from state to state. But I have a list of things that I’ve come up with to help guide you as you pick your program
During this discussion, the thing you need to be thinking about is, are you more concerned about making sure that you can work in any state currently, or are you more concerned about wanting the content to be the thing that drives your education?
The classes I took did not have much to do with social justice, poverty, community issues, systemic issues. My specific classes were things on theoretical orientation. I had a class on psychodynamic theory. I had a class on cognitive behavioral theory. I had a class on humanistic theories. I had a course on psychological testing. I had a course on psychopharmacology. I had a course on working with adolescents and on working with children and I had a group therapy class. My classes were about really specific day today techniques and processes that I needed to be a therapist.
The thing that really drives and motivates, you should probably be the way you go. Yes. Getting an MSW is what I recommend for people if they want to know what’s the simplest and most direct route.
A former colleague of mine went to the program up here that had a more clinical concentration. And while he had a lot of clinical classes, one of the things he said is that he felt like he didn’t get enough training on appropriate and differential diagnosis. He knew a lot from sitting in staffing with us before he got his degree and hearing the different conversations that we had about what makes this diagnosis fit better than the other.
Diagnosis is important, that is a totally different podcast though. There are people who will say, oh, well, diagnosis doesn’t matter. Yes it does. Because you have to bill for something, there has to be a code. There has to be a diagnosis. And if you’re going to make one, you need to make sure that it is as accurate as humanly possible. But like I said, we will cover that in a future episode.
I want to offer some encouragement. This can sound really daunting. I am certain for most of you who are considering this, this is new information and it’s a different way of thinking about your career. In the last episode, we talked about philosophical issues and the actual day-to-day work of being a therapist and what it’s like. Today we’re talking about stuff that you need to know in order to make that career happen.
I still want you to choose the job based on what you would love to do. And if being a therapist is what you would love to do. I don’t want you to be discouraged by all of the acronyms and the different billing, because it does make sense. It’s just in the beginning, it’s a little overwhelming, but it is worth it. And you will be okay. You will work through this and get to the other side. What I’m trying to give you is the information that I wish I had an understanding of before I went to school, rather than figuring it out on my own. It would have saved me a lot of stress, a lot of time and actually money.
So hang in there, we’re going to get to talking about the grad program in the next student edition episode in August. The student edition of the podcast comes out in the second week of each month. In that episode we’ll cover all sorts of things from accreditation, to online programs versus in-person programs and we’ll also talk about undergrad experience.
Next week we’re going to be covering ADHD medications. There are a lot of medications that get used in order to treat ADHD. Some are stimulants and some aren’t. The stimulants tend to be the medications that get diverted in order to be abused.
In addition to the complication of them being used recreationally, there’s an added issue here for those who are recovering from meth and experiencing ADHD symptoms. We’ll talk about math recovery and how that intersects with treating ADHD and the use of stimulant medications.
I hope you’ll join me for that podcast. And until then have a great week.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to firstname.lastname@example.org. I’ll see you on next week’s podcast. And until then have a great week.
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