8.3 Scope of Practice

As a fully licensed counselor, one experiences a dizzying amount of independence and flexibility regarding the style of practice and interventions they utilize. This fact, combined with a great deal of overlap in the scope of practice of professionals such as social workers, marriage and family therapists, psychologists, and counselors, can create ethically murky situations calling into question whether a counselor is qualified to practice a given modality of therapy, assessment, or intervention.

Before we explore this topic in greater detail, consider questions such as the following:

• Is it appropriate for a counselor with a master’s degree in clinical counseling to diagnose autism spectrum disorder? Does the answer change if the counselor has 20 years of experience in the field? Did they attend a week-long seminar on advanced diagnostics?
• What can a counselor do that a marriage and family therapist cannot, or vice versa?
• What can a counselor tell a client about psychiatric medications? Does this change depending on the training they receive?

Counselor scope of practice is defined as the sum of the domains of practice in which a fully-trained counselor can competently and ethically function. In determining whether a given type of practice is within a counselor’s scope, rather than asking: How do I gain competence in this domain? A counselor must ask: Can I gain competence in this domain? Returning to our discussion of counselor competence, this question is asking whether it is possible, in light of legal, ethical, and pedagogical constraints, to receive formal education, training, and professional and supervised experience within a given domain of practice.

Discussing a discrete counselor’s scope of practice is a controversial issue for which no easy or universally acceptable answer exists. This is partly driven by the fields of medicine, clinical psychology, and counseling, which remain historically very discrete entities regarding the practice of modalities falling under the umbrella of psychotherapy (CACREP, 2023; Grus & Skillings, 2018). Historical lack of collaboration between large governing bodies such as the American Psychological Association (APA) and CACREP has led to organizations publishing relatively homogenous boundaries of practice for their practitioners. A primary barrier to collaboration between governing bodies has been a fear that one group might lose credibility in the field by “giving up” part of their scope of practice or that the contribution of one group might be discounted if a hierarchy of practice were to be established (i.e., viewing doctoral clinical psychologists as superior to master’s level clinical counselors; Grus & Skillings, 2018). Finally, cost considerations and practitioner shortages have contributed to further blurring the practice lines between professions. The U.S. Consolidated Appropriations Act of 2023 (2022), for the first time, allowed master’s level counseling practitioners to receive reimbursement from federally funded health insurance programs (i.e., Medicare), opening the door for counselors to work in a variety of interdisciplinary and specialty settings such as pain clinics, sleep centers, and Veterans Affairs Medical Centers that had previously been reserved for medical doctors, psychologists, and master’s level social workers.

Despite these historical trends, the ethics codes, accreditation bodies,  and scholarly literature appear to converge on a general scope of practice for counselors. In the United States, most state licensing boards and counseling educational programs are based upon or heavily mirror the CACREP (2023) model. Using our previous definition of competence, an analysis of the core CACREP competencies reveals that the scope of practice of CACREP-trained counselors consists of therapeutic intervention and assessment of behavioral health pathology in addition to interdisciplinary and professional consultation relevant to counseling (Fischer, 2024). However, this is not to say that a recently graduated counselor is granted limitless practice within these domains. Instead, when gaining competence in a new intervention or beginning work with diverse populations, a counselor must follow the guidelines of the ethical codes, “pursuing formal education, training, and supervision” (Fischer, 2024, p. 7) with feedback from one’s supervisor regarding competence before adding competency to their scope of practice (ACA, 2014; NAADAC, 2021).

Qualifications for Employment

Given the historical lack of a defined scope of practice for counselors and the ever-evolving and broadening scope of practice ushered in by the Consolidated Appropriations Act of 2023 (2022), there is increased pressure for counselors to be mindful of their training, education, and experience when seeking employment. According to the ACA (2014) ethical code:

Though the latter portion of this section of the ACA code states that those hiring for positions must appropriately vet applicants to ensure practice by appropriately qualified practitioners, widespread staffing shortages may lead to individuals being hired with the expectation that they will ‘pick up the job as they go along’ or counselors in one position being expected to perform duties outside of their scope. For counselors who find themselves in situations such as those described, it is important to recognize the degree of diligence required by the field and one’s core ethical duties to their clients. Simply put, using clients to practice a new intervention with appropriate safeguards is only ethical. At best, one might deliver an intervention with modest success (Failing to promote beneficence). At the same time, at worst, a counselor may actively harm the client through incompetent practice (Failing to promote nonmaleficence). Furthermore, presenting oneself to clients and employers as competent to perform interventions and job duties for which one needs to be qualified directly violates the core counseling values of veracity and autonomy.

Thus, when considering a job application or offer of employment, ask yourself:

• Do I feel comfortable with completing the job duties required of me without any additional training?
• Of the essential job duties listed, do I meet the ACA Ethical Code’s prescription of having the requisite “education, training, supervised experience, state and national professional credentials, and appropriate professional experience”? (ACA, 2014, Section C.2.c)
• Will my employer appropriately train me in any domains I need to become competent? (i.e., nationally recognized training program, supervised practice, requiring disclosure of novice status to clients)

New and Emerging Specialty Areas

Counselors are often uniquely positioned to test new and emerging specialty modalities in direct practice with clients with treatment-resistant conditions. The relative freedom counselors are allowed regarding theoretical orientation provides much greater flexibility than professions operating under a medical model of treatment, and barriers to entry for specialty training programs are often relatively low. However, This flexibility of practice brings unique challenges and ethical considerations.

According to the ACA (2014) Code of Ethics:

Similarly, the NAADAC Code of Ethics (2021) states that:

When considering developing competency in a novel or emerging practice area, it is important to ensure that there are formal procedures for establishing competence before attempting training. This means following the steps outlined in the section on competence while ensuring that this novel intervention is within your scope of practice. In addition, it is essential to be a critical consumer of the available research on any area in which you are considering establishing competency. Ensuring that emerging methods and modalities are evidence-based is essential in protecting clients from harm. It is necessary when interfacing with managed care providers and insurance agencies for reimbursement.

Competency-Based Referrals

For most counselors, there will come a time when a client’s presentation and required treatment plan are done to align appropriately with the counselor’s competencies. Situations such as these must be navigated with caution to ensure clients receive the highest standard of appropriate and competent care possible in their presenting situation. On this topic, the ACA code states that:

If counselors need to gain the competence to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives. If clients decline the suggested referrals, counselors discontinue the relationship. (ACA, 2014, Section A.11.a)

Counselors in these situations must critically examine their ability to competently meet clients’ diverse needs. Consider questions such as:

• Am I competent in a best-practice intervention for treating this client?  If the client has an intervention in mind, am I competent in its use and application to their presentation?
• Are significant language barriers present that I would be unable to bridge with the help of an interpreter reasonably?
• Is the client’s presenting problem consistent with something that would benefit from counseling, or do they require the services of another professional?
• If I need to learn about my client’s cultural background, what does contemporary literature and supervision say about my ability to serve them? Can I educate myself regarding their culture to increase my competency?

If the answer to one or more of these questions is no, then a competency-based referral is likely in order. However, referral of prospective or current clients is not to be taken lightly. In the present landscape of the American healthcare system, referral often burdens the client substantially. It may mean repeating a lengthy process involving considerable paperwork, seeking re-approval from insurance and managed care organizations, and substantial wait times to receive care. Clinically speaking, this may manifest in increased levels of stress for the prospective client or a worsening prognosis as appropriate care is further delayed.

Keeping this in mind, an appropriate level of diligence is warranted when considering referral based on competency. Countertransference may influence one’s decision to refer, and counselors may inadvertently make values-based referrals, which are expressly prohibited by the ACA (2014) and NAADAC (2021) ethics codes, under the guise of a competency-based referral.