Analyzing CACREP-Accredited Programs’ Utilization of Criminal Background Checks

Maribeth F. Jorgensen, Kathleen Brown-Rice

The use of objective methods in gatekeeping processes has become increasingly more important due to legal and ethical implications and consequences. For example, the medical field has utilized criminal background checks (CBCs) as a gatekeeping assessment of a student’s ability to best serve future patients. This article focuses on the current use of CBCs by master’s-level counselor education programs (N = 83) accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP). A significant implication from this study is the need for counselor education to consider best practices and guidelines for the use of CBCs.

Keywords: criminal background, criminal background checks, gatekeeping, counselor education, counseling programs

Counselor educators and supervisors are ethically bound to not endorse any counselor-in-training (CIT) for certification, licensure, employment or completion of an academic program when they believe a CIT is not qualified for the endorsement (American Counseling Association [ACA], 2014). In particular, educators are required to screen all counseling program applicants prior to admission and to continually and thoroughly evaluate and appraise students during their progression through the program (Erwin & Toomey, 2005). It has been suggested that utilizing criminal background checks (CBCs) with students should be part of the gatekeeping process in behavioral health programs (Brodersen, Swick, & Richman, 2009; Cowburn & Nelson, 2008; Erwin & Toomey, 2005). In fact, government agencies and private and public employers are increasing their use of CBCs as a screening mechanism (Sheets & Kappel, 2007). CBCs may be conducted to determine if an individual is a potential threat to clients, vulnerable populations or fellow employees. According to Sheets and Kappel (2007), “Because most consumers are not in the position to run CBCs . . . they depend on professional licensing boards to conduct appropriate screening of applicants” (p. 64). This could be a concern, however, because CITs work with clients while they are in their training program. Counseling programs that do not have access to CBC data may be left without critical information to help best protect vulnerable populations. Therefore, the responsibility of having CBC results might more appropriately fall on counselor educators (ACA, 2014).

All 50 states, the District of Columbia, Guam, Puerto Rico and the Virgin Islands require a CBC for school counselors (American Counseling Association, Office of Public Policy and Legislation, 2011). According to ACA (2010), as of 2010 six states (i.e., Arizona, Maine, Mississippi, Missouri, Montana, Tennessee) required a CBC as part of the licensure application process. North Carolina requires applicants to sign a statement authorizing the licensing board to conduct a full criminal record search, including state and federal records (North Carolina Board of Licensed Professional Counselors 2013). The state of Washington requires applicants to submit fingerprints as a means to perform a professional criminal background check. Given that passing a CBC is a criterion for certification or licensure for professional counselors in some jurisdictions, it seems important to examine if counselor education programs are utilizing CBCs as part of the admission process, student evaluation for CITs, and ultimately as a tool for gatekeeping.

Gatekeeping in the Field

According to Kerl and Eichler (2005), “In the field of counselor education, gatekeepers are the professionals whose responsibility it is to open or close the gates on the path toward becoming a counselor” (p. 74). The Council for Accreditation of Counseling and Related Educational Programs (CACREP) requires counseling programs to start the gatekeeping process at the onset of screening applicants for admission. Unfortunately, there is ambiguity about specific ways to gatekeep during the admission process, which may prompt inconsistencies between those operating as gatekeepers. Several studies have examined barriers to effective gatekeeping (Brear & Dorrian, 2010; Brodersen et al., 2009; Brown-Rice & Furr, 2014). Some of the barriers include a need to meet desired enrollment, inconsistent screening procedures, likability effect, inadequate training on how to be a gatekeeper, social loafing, the leniency effect, and the empathy veil effect (Brear & Dorrian, 2010; Brown-Rice & Furr, 2014). The previous findings support the need to examine the current use of objective measures that may diminish some of these described obstacles.

Swank and Smith-Adcock (2014) examined the screening and gatekeeping methods used by 79 master’s- and doctoral-level CACREP-accredited counseling programs. Specifically, they asked programs about their use and perceived effectiveness of objective (e.g., grade point average [GPA]) and subjective (e.g., interviews) methods of gatekeeping during the admission process. The majority of surveyed programs placed higher weight on GPA and letters of recommendation during the admission process. Participants described their methods as inefficient and stressed the need to use consistent evaluation to reduce the impact of subjectivity. They also described a desire to use reliable assessments such as formal background checks to better assess psychological fit (Swank & Smith-Adcock, 2014).

Brear and Dorian (2010) conducted a study to examine how 63 counseling educators experienced their training and training as gatekeepers. Their respondents indicated a commitment to be effective gatekeepers, but they had difficulties minimizing their subjectivity because of vague guidelines and written policies. Many of their participants stated they observed other faculty being lenient and failing to capitalize on key moments when students were displaying behaviors of concern. Brear and Dorrian suggested that programs use objective procedures for gatekeeping and provide ongoing training to help faculty better understand their gatekeeper roles and related policies.

Brown-Rice and Furr (2014) discussed the role empathy can play in the gatekeeping process. Ultimately, the authors suggested that counselor educators benefit from finding a balance between being empathic and evaluative in their roles. Brown-Rice and Furr described that empathy may impact how counselor educators gatekeep and intervene with problematic behavior. They coined the term empathy veil effect and suggested that it is compounded by factors such as lack of consistent standards across faculty, lack of scholarly sources to refer, and fears of legal retaliation made by students. Although these factors have historically been barriers, the field of counselor education is at a critical point to establish well-documented, researched and supported screening procedures for potential CITs. This study aims to provide a greater description of how counseling programs currently use CBCs in the process of gatekeeping.

Criminal Background Checks

Literature searches revealed only one study that explored the use of CBCs by counseling programs (Erwin & Toomey, 2005). This is concerning given that some states require CBCs of school counselors and licensure candidates. Over 10 years ago, Erwin and Toomey (2005) conducted a study of 50 CACREP-accredited counseling programs to examine use of CBCs. Specifically, they sought to gather data about how counseling programs use criminal background checks and what resources are consulted when deciding how and when to use CBCs. At the time of their study and within their sample, five CACREP-accredited counseling programs were utilizing CBCs. Alarmingly, none of the programs that indicated use of CBCs answered the question about having established criteria to decide how criminal background check results are used.

Scholars within other human services fields have provided commentary or empirically explored the use of CBCs in their related training programs. Burns, Frank-Stromborg, Teytelman, and Herren (2004) wrote about the use of CBCs in the field of nursing. At the time of their commentary, most state nursing licensure boards made CBCs mandatory for nurses in order to practice. In contrast with nursing licensing boards, most nursing training programs had not made CBCs a requirement due to not having sufficient guidance in how to use the results of CBCs.

Farnsworth and Springer (2006) empirically investigated the use of CBCs by nursing programs. They surveyed 258 nursing schools from across the United States and found that fewer than 50% of the surveyed schools required background checks. Only 8% of the schools that conducted CBCs used them as a part of the admission process. For those that did obtain background checks, there was no standard way to process the results and no universal guidelines were available on how to interpret results. Farnsworth and Springer suggested that schools considering CBCs should seek legal counsel and communicate with other programs using CBCs. They also recommended programs require a criminal self-disclosure in addition to a background check to determine consistencies between self-disclosures and the results of CBCs (Farnsworth & Springer, 2006).

According to Kleshinski, Case, Davis, Heinrich, and Witzburg (2011), approximately 113 medical schools used background checks at the time of their commentary. Medical schools have benefitted from using CBCs by detecting patterns of behaviors that may impede a student’s ability to practice and best serve future patients. Kleshinski and colleagues found that common patterns across medical schools using CBCs included: (1) individually considering each situation by factoring in variables such as date and nature of offense; and (2) asking students about past criminal behaviors on admission applications. Importantly, there may be discrepancies between what students report on applications and what their CBCs show; therefore, solely relying on self-report could be problematic.

Within the field of sports science, Weuve, Martin, and White (2008) described many of the same concerns and uncertainties. They suggested that common reasons to conduct CBCs include “promotion of a safe school environment, protection of patients, clients, and student-athletes, because it is required of clinical facilities, and it enhanced student advisement and compliance with state or federal law” (Weuve et al., 2008, p. 28). These authors also speculated that programs may not conduct CBCs because of certain state and federal law, fear of further marginalizing minorities, and due to minimal resources to help the process be informed. Although these suggestions and concerns seem to be well-conceptualized across fields, few studies have taken the next step to empirically examine these issues.

Based on previous literature, there is consistent concern with a lack of universal policies across graduate training programs related to the use of CBCs. Additionally, only one study has empirically investigated how often and in what ways CBCs are being used with counseling graduate school applications (Erwin & Toomey, 2005). Unfortunately, this study is outdated and may leave the field of counseling without adequate evidence-based support to enhance their gatekeeping processes.

Currently, when programs are deciding to use CBCs, they will find minimal information about key aspects such as what company or vendor to use when conducting CBCs; who is financially liable for the CBC; when a CBC should be required; how information from CBCs are used; how students are informed about CBCs; and how to decide if an offense is related to the counseling profession (Weuve et al., 2008). Counseling programs could be held liable for not conducting CBCs, especially if the safety of others is compromised. At the same time, counseling programs also could face liability for using CBCs when guidelines are unclear, applicants are not informed, and policies are not in place about how CBC results may be used.

Given the limited research on this issue, the purpose of this study was to determine how CACREP-accredited master’s programs are utilizing CBCs regarding applicants and current students. Specifi-cally, the following research questions were addressed: (a) Do CACREP-accredited master’s programs require applicants to undergo a CBC? (b) What are the program’s procedures for performing the CBC of applicants? (c) Do programs have established protocols regarding how the results of CBCs affect applicants? ( d) Do CACREP-accredited master’s programs require current students to undergo a CBC? (e) What are the program’s procedures for performing the CBCs of current students? (f) Do programs have established protocols regarding how the results of CBCs affect current students? and (g) What do CACREP program representatives believe are their legal and ethical obligations related to performing CBCs with applicants or current students?


Participants and Procedures
Participants were the program contacts for the 270 CACREP-accredited master’s programs listed on the official CACREP Web site in summer of 2013. Due to the small size of this population, the entire population was sampled to provide the best approximation of the population’s true characteristics (Gay, Mills, & Airasian, 2009). Recruitment of participants was conducted via an e-mail to each program contact inviting them to participate in the study and including a link to an online survey. The sample size decreased due to invalid e-mail addresses, which resulted in the final sample of 261 CACREP-accredited program contacts. A total of 86 participants completed the survey; however, respondents with missing or invalid data (n = 3, less than 2%) were eliminated via listwise deletion, leaving a total number of 83 participants included in this study. Although there are multiple options for dealing with missing data, listwise deletion was used by eliminating participants with missing data on any of the variables in this study (Sterner, 2011). This resulted in a final response rate of 32%, which falls within the acceptable 30% response rate for online surveys (University of Texas at Austin, Division of Instructional Innovation and Assessment, 2011). Of the 86 program contacts who provided usable data, 29 indicated their programs were in the South, 28 defined their program being in the Northeast, 17 stated their program was in the Midwest, and 9 indicated that their program was in the West. The majority of the participants reported that their programs offered degrees in both the clinical mental health/community track (84%) and the school track (83%). Further, 17% offered the marriage, couple, and family track, 13% offered the student affairs/college track, 6% had the addiction track, and 4% reported offering the career track to students. Table 1 provides a breakdown of specialty track programs offered by participants.

The survey for the current study was designed based on the Criminal Background Check Survey developed by Erwin and Toomey (2005) related to admissions and CACREP-accredited programs performing CBCs. The 13 questions from the original Erwin and Toomey survey were used as a foundation for 30 questions that were created for the online survey utilized to gain information from CACREP-accredited program contacts. Participants were asked to identify if their programs required CBCs as part of admission to their program. Participants who responded in the affirmative then responded to six multiple choice items related to which specialty tracks required a CBC, type of CBC, who performs and pays for the CBC, how applicants are notified that the CBC is required, and whether the programs have established procedures for deciding non-admission based upon the results of the CBC. Further, two qualitative questions provided an opportunity to learn how CBC information is obtained and used.

Next, participants were asked to identify if their programs required CBCs of current students. Participants who responded in the affirmative then responded to seven multiple choice items related to which specialty tracks required the CBC, type of CBC, who performs and pays for the CBC, how applicants are notified that a CBC is required, at what time in the program CBCs are performed, and whether the programs have established procedures based upon the results of the CBC. Further, two qualitative questions requested information about how CBC information is used and protocols for removal of students. The final part of the survey consisted of 11 questions regarding ethical and legal issues (i.e., CBC required for certification, licensure, or employment as a professional counselor, privacy issues, client welfare, legal consequences of performing CBC, CACREP-standards, potential for screening out minority applicants and students). This section contained five multiple choice questions and six questions based on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree).

To establish content validity and reliability, a pilot study of the survey was completed. The pilot study included two former CACREP-accredited program contacts who were asked to look for clarity and conciseness of the survey questions and provide feedback and suggestions for improvement. Based upon the responses of the pilot participants, the survey was edited to provide a more conducive and efficient design.

Data Analysis
The Statistical Package for Social Sciences (SPSS) software (version 21) was utilized to screen and analyze the data. The participants’ responses to the survey questions were subjected to both descriptive and correlational analyses. First, a descriptive analysis of multiple choice responses was conducted to produce a set of summary statistics related to each of the seven research questions. Next, a Fisher’s Exact Test (a variant of a chi-square test for independence for small sample sizes) with an alpha level of .05 was used to determine if there was an association between the region of the country where participants’ programs were located and whether CBCs are required for applicants or current students.


Applicants and Criminal Background Checks
Regarding the first research question, of the 83 participants, 27.7% (n = 23) reported that their programs required applicants to undertake CBCs. Table 1 provides a breakdown of the specialty track that program contacts specified as requiring applicants to undergo CBCs. The Fisher’s Exact Test to determine an association between location of program and requiring applicants to have a CBC was found to be not significant (p = .426).

Table 1

Number and Percentages by Specialty Track and Criminal Background Required

Specialty Track Offered
by Program Criminal Background Required for Program Admission Criminal Background Required for Current Students in Program

Yes No Yes No Yes No
n % N % N % N % n % n %
Clinical Mental Health/
Community 70 84.3 13 15.7 16 22.9 54 77.1 26 37.1 44 62.9
School 69 83.1 14 16.9 15 21.7 54 78.3 33 47.8 36 52.2
Marriage, Couple, Family 14 16.9 69 83.1 2 14.3 12 85.7 9 64.3 5 35.7
Student Affairs/College 11 13.3 72 86.7 3 27.3 8 72.7 5 45.5 6 54.5
Addiction 5 6.0 78 94.0 1 4.5 4 95.5 1 4.5 4 95.5
Career 3 3.6 80 96.4 0 0.0 3 100 0 0.0 3 100

Procedures for applicants. Table 2 provides a breakdown of the type of CBCs performed, who performs the applicants’ CBCs, and who paid for the applicants’ CBCs. All programs that required
CBCs informed students of the CBC through at least one avenue: 45% (n = 10) reported notice was given only via the program’s Web site; 18% (n = 4) said they gave notice via program Web site, verbal discussion (i.e., interview), and written correspondence (i.e., e-mail, letter, handbook); 14% (n = 3) stated they gave notice by written correspondence only; 9% (n = 2) gave notice by verbal discussion only; 9% (n = 2) gave notice by both program Web site and written correspondence; and 5% (n = 1) gave notice via both verbal and written notification. An open-ended format was used to learn about how programs use information from the applicants’ CBCs. Thirty-five percent (n = 8) of the participants shared that they used results in different ways depending on if there was a criminal offense, the level of offense, and the date of offense. One participant reported their program uses the results to determine fit for their program and the counseling profession:

The nature of the crime and the time that has passed since then, and the applicant’s explanation (is it sincere, logical, etc.) will help faculty determine if the person will be considered or not. Also, we think about whether or not this person is likely to get certified as a school counselor or licensed as an LPC, or will be able to obtain liability insurance is all considered.

Established protocols for applicants. Regarding research question three, 59% (n = 13) of the 23 CACREP-accredited programs who reported requiring applicants to undergo CBCs had established procedures for deciding about the non-admission of an applicant in their program based on the CBC results. Twenty-three percent (n = 5) provided that their program had not established procedures and 18% (n = 4) reported that they did not know if their program had a recognized policy. Thirty-nine percent (n = 9) of the participants shared that they used professional standards for deciding about the non-admission of an applicant. One participant described, “We would not accept an applicant who had a background inconsistent with our discipline, and we would not accept an applicant who would not be able to obtain a license.”

Table 2

Number and Percentages by CBC Procedures and Applicants and Current Students

Applicants Current Students
n % n %
Type of CBC Performed
Local (i.e., city, county), state, and federal 10 45 14 37
State 3 14 5 14
Federal 3 14 6 16
State and federal 1 4 3 8
Cities of residency over last 7 years and sex offender data base 2 9 0 0
Did not know 3 14 6 16

Who Performed CBC
Outside private independent agency 8 36 7 19
Program’s university/college 7 32 6 16
Government agency 6 27 19 52
Multiple entities (i.e., state, federal,
private agency) 0 0 2 5
Did not know 1 4 3 8

Who Paid for CBC
Separate fee to applicant/student 17 77 33 89
Applicant paid as part of their
application fee 2 9 0 0
University/college paid 2 9 2 5
No charge, university police
department conducts 0 0 1 3
Did not know 1 4 1 3

Current Students and Criminal Background Checks
Regarding research question four, of the 83 participants, 45% (n = 37) reported that their programs
required current students to undertake CBCs. Table 1 provides a breakdown of the specialty track(s) that program contacts reported requiring students to undergo CBCs. The Fisher’s Exact Tests to determine an association between location of program and requiring applicants to have a CBC was found to be not significant (p = .500).

Procedures for current students. Table 2 provides a breakdown of the type of CBCs performed, who performs the current students’ CBCs, and who paid for the students’ CBCs. Further, two participants (5%) defined specific CBCs for certain specialty tracks: (a) state for all tracks plus federal for school students (3%, n = 1); and (b), state for college and marriage and family tracks, and state and federal for school students (3%, n = 1).

When asked when students’ CBCs are conducted, 35% (n = 13) reported it was before students are enrolled in internship, 27% (n = 10) reported during students’ first year, 19% (n = 7) reported before practicum, 8% (n = 3) reported before practicum and renewed for internship if the initial clearance was more than one year old, 5% (n = 2) reported during students’ second year, 3% (n = 1) reported at admission and then every two years after that, and 3% (n = 1) reported that CBCs are done every semester a student is enrolled in prepracticum, practicum, and internship. Participants reported various ways of letting students know that CBCs are a part of the program requirement. Twenty-seven percent (n = 10) reported that notice is given via the program’s handbook; 24% (n = 9) give it through orientation (i.e., new student, clinical), written correspondence (i.e., e-mail, letter), handbooks (i.e., program, clinical), and program Web site; 19% (n = 7) give it only through a verbal discussion (i.e., orientation, interview); 14% (n = 5) by give it by program’s Web site only; 11% (n = 4) through multiple methods of orientation (i.e., new student, clinical), written correspondence (i.e., e-mail, letter), handbooks (i.e., program, clinical), program Web sites and written correspondence; and 5% (n = 2) only via written correspondence (i.e., e-mail, letter, application).

Established protocols for current students. Sixty-eight percent (n = 25) of the 37 CACREP-accredited programs who reported requiring students to undergo CBCs had established protocols for deciding what action to take toward a student based on the CBC results. Twenty-seven percent
(n = 10) provided that their program had not established a procedure and 5% (n = 2) reported that they did not know if their program had a recognized policy. Although 25 participants reported that their programs had established procedures, a few responses suggested processes might be informal. For example, one participant stated, “Nothing formal. We hold informal conversations amongst faculty.”

Legal and Ethical Obligations
The following information was collected to answer the final research question. Of the 83 participants, the majority (64%, n = 53) reported that licensure or certification was dependent upon a successful CBC for students who graduate from their programs. Twenty percent (n = 17) of the respondents indicated that passing a CBC was not necessary for licensure or certification, leaving 16% (n = 13) who did not know if licensure or certification was contingent on having a successful CBC. The majority (89%, n = 74) believed that it was the program’s obligation to notify students that CBCs can be required as part of certification, licensure or employment as a professional counselor; however 5% (n = 4) believed it was not the program’s responsibility and 6% (n = 5) provided they did not know. Eighty-seven percent (n = 72) reported that their programs notified students that a CBC may be required to obtain certification, licensure or employment, leaving 13% (n = 11) of the programs saying they did not notify their students. When program contacts (n = 72) were asked how students are notified of this, 34% (n = 25) stated during orientation, 25% (n = 18) provided this information during the application process, 14% (n = 10) reported the information is continually given throughout the program (i.e., admission, orientations, before field placements), 10% (n = 7) stated the information was shared sometime during the first year of the program, 3% (n = 2) provided the information during field placement orientation for practicum and internship, 3% (n = 2) indicated information is given via student handbook, and 7% (n = 5) provided information was given via other means (i.e., during field placement discussions, when students apply for licensure due to licensure requirements varying by state).

When program contacts were asked if they believed it is ethical for their programs to perform CBCs on applicants or students, 41% (n = 34) believed it was ethical to perform CBCs on applicants and students, 29% (n = 24) felt it was not ethical for applicants or students, 19% (n = 16) responded it was ethical only for current students, and 4% (n = 2) said it was ethical only for applicants. Eight percent (n = 7) responded to this question by providing an alternate response.

All participants’ (n = 83) responses for strongly agree and agree were combined to report the subsequent findings. Sixty-six percent (n = 55) believed that counseling programs’ use of CBCs on applicants and students is important to ensure future clients’ welfare and safety. When asked if counseling programs completing CBCs on applicants and students violate the privacy rights of applicants and students, 17% (n = 14) either agreed or strongly agreed that it did not. Thirty-six percent (n = 30) believed that counseling programs can face legal consequences if CBCs are not conducted on applicants or students. Further, 24% (n = 20) responded that they believed that counseling programs can face legal consequences by performing CBCs on applicants or students. Thirty-three percent (n = 27) believed that there should be a CACREP standard regarding CBCs of applicants and students to ensure consistency and provide an established protocol. When asked if performing CBCs on applicants and students will result in a disproportionate screening-out of minority applicants and students, only 14% (n = 12) believed it would.


There were two primary aims of this study: (1) to assess the current use of CBCs by CACREP-accredited master’s counseling programs and (2) to offer current information for programs to reference when considering the use of CBCs and creating relevant policies. Within the field of counseling, few studies have explored the use of CBCs and related policies (Erwin & Toomey, 2005; Swank & Smith-Adcock, 2014). As aforementioned, Erwin and Toomey conducted a study in 2005 with only 50 programs that responded. Additionally, only five of the programs that responded used CBCs, which limited the utility of their findings. Swank and Smith-Adcock (2014) surveyed counselor educators about the effectiveness of their current screening procedures for applicants. Their participants reported wanting to use more reliable and objective methods such as background checks, but were unsure how to do so with minimal guidance in the literature.

In the present study, 27.7% (n = 23) of respondents reported requiring applicants to undertake CBCs. Although this may seem like a small portion of the sample, it still offers the field knowledge that can augment findings by Erwin and Toomey (2005). This result is not surprising given that there are so few guidelines for programs to use when considering CBCs as a screening and gatekeeping tool. The use of CBCs also remains underdeveloped in other fields such as nursing, medicine and sports science (Farnsworth & Springer, 2006; Kleshinski et al., 2011; Weuve et al., 2008). In fact, Farnsworth and Springer (2006) reported that fewer than 50% of the medical programs they surveyed reported using CBCs. They found this extremely concerning as the field of nursing requires all graduates to pass a CBC in order to become licensed. This is a related issue for those wanting to become a licensed mental health counselor as 17 states report requiring an applicant to pass a CBC in order to become licensed. All the states that do not require CBCs ask for the applicant to describe any criminal offenses on their application and provide further documentation when necessary.

Although 41% of the participants surveyed in the present study reported the use of CBCs as ethical, this finding did not correspond with actual use of CBCs (26.5%). One factor may be related to fear of potential liability when using CBCs. In a study conducted by Swank and Smith-Adcock (2014), participants, who are educators, stated that they would like to use background checks, but they felt hesitant due to the litigation that can come with such methods. These fears may be exacerbated by the fact that the use of CBCs is not universal across university programs and there may be little knowledge about how to seek out university lawyers when developing these requirements. At this time, most university guidelines around CBCs focus on use with employees (Swank & Smith-Adcock, 2014). Weuve et al. (2008) described that lack of guidance and misuse of results continues to keep graduate programs from using CBCs. In the present study, only 13 of the 23 programs who reported using CBCs had an established procedure for how to use the results. Ultimately, since few resources are available to assist in these decision-making processes, it would be important for programs to seek university counsel. For example, it would be important to seek legal counsel when deciding how requirements and standards should read on program Web sites, how to use the results, and how to inform students about the use of the CBC results.

It also is important to consider other related liability issues such as faculty subjectivity. Previous research indicated faculty subjectivity may interfere with gatekeeping fidelity (Brear & Dorrian, 2010). In the current study, only 13 participants reported their program had an established procedure for deciding about the non-admission of applicants based on CBC results. When procedures are not in place, there may be a greater potential for phenomena such as the empathy veil effect, leniency effect or likability effect. Such phenomena may prompt some faculty to look the other way if not held accountable to exercise a specific policy.

This research also has implications for counseling students. Given that not all programs execute CBCs, students may not understand the consequences of their legal violations until seeking licensure. Currently, 17 state licensing boards require CBCs and all states ask applicants to attest to criminal violations (ACA, 2010). There is potential for a student to get through his or her training program and be ineligible for licensure due to their criminal background. A need exists to consider how CBCs may be used to help students gatekeep themselves and be more conscious of barriers that may ultimately interfere with their professional goals.

Limitations and Areas for Future Research

This study has five basic limitations. First, the sample was obtained from program contacts of CACREP-accredited master’s counselor education programs. This approach omitted programs that were not CACREP-accredited. Therefore, generalizability of the results is limited to CACREP-accredited programs. Further, this study did not delineate whether the programs were housed in private or public institutions. Future research focused on investigating all professional counseling programs would be beneficial. The third limitation is that volunteers may have answered the survey questions differently than those members of the population who did not agree to participate (70%). The fourth limitation is associated with the survey being a self-report measure; some participants may have provided responses considered to be socially desirable. Even though the participants were informed in advance that their responses would be kept anonymous, they may have responded in a manner that was not representative of their true feelings or knowledge. The final limitation is related to instrumentation. The findings could have been expanded upon by including questions on the survey about consequences programs have experienced when using or not using CBCs. For example, have any programs been sued for using or not using CBCs?

Given the minimal amount of research in this area, there are multiple directions for future research. One suggestion is to qualitatively explore programs that have used CBCs for several years to get a more thorough understanding of how their processes have evolved. This may help programs understand the elements to consider when using CBCs as part of the screening and gatekeeping processes. It also may support programs in understanding how to protect themselves from liability concerns related to using CBCs. Another future study may involve surveying doctoral-level counseling programs to examine differences across training levels. Further research could examine student perspectives of the use of CBCs. It might be possible that students would welcome the use of CBCs at the program level so they are aware of legal standards at the start of pursuing a professional counselor license.


Since screening and gatekeeping is such an important role of a training program, the use of CBCs is an important topic for counselor education. The use of CBCs may assist counselor educators in executing their ethics related to not endorsing CITs they believe to be unqualified (ACA, 2014). The consequences of graduating a student with a criminal history could be great and ultimately put future clients at risk for harm. Perhaps CACREP could assist programs in understanding if and how to use CBCs by adding ideas for best practices in their accreditation standards. Previous literature has indicated that the field of counseling may benefit from creating more formalized screening procedures that include objective and reliable measures (Swank & Smith-Adcock, 2014). The current study offers support that programs are using CBCs as a part of the admission process and to continually evaluate their students. Given this is a trend, it may be important to establish best practices and policies around CBCs so that programs are using them in consistent ways.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.


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Maribeth F. Jorgensen, NCC, is an Assistant Professor at the University of South Dakota. Kathleen Brown-Rice, NCC, is an Assistant Professor at the University of South Dakota. Correspondence can be addressed to Maribeth Jorgensen, 414 East Clark Street, Vermillion, SD 57069,

A Comparison of Telemental Health Terminology Used Across Mental Health State Licensure Boards

Jay Ostrowski, Traci P. Collins

Telemental health—also known as online counseling or online therapy—has become a solution for increasing the public’s access to mental health care. Mental health state licensure boards have lacked consistency in the adaptation of laws and the use of language within these laws. Policies are examined from the mental health state licensure boards in all 50 U.S. states for counselors, psychologists, marriage and family therapists and social workers. The determination of whether a policy existed was made. If so, the terminology was compared across professions. Results indicated that fewer than half of mental health licensure boards included telemental health-related terminology in their policies, indicating the absence of telemental health policies. Future research, implications for counselors and limitations are discussed.


Keywords: state licensure boards, policies, telemental health, online counseling, health terminology

Mental health care professional shortage areas fall across the United States (Rural Assistance Center, 2015). According to the Health Resources and Services Administration, there is an immediate need for approximately 4,000 mental health providers nationwide (Kaiser Family Foundation, 2014). According to the Bureau for Labor Statistics (2014), the mental health counselor workforce is not distributed in proportion to the need. The National Institute of Mental Health (2014) estimated 43.6 million adults aged 18 or older in the United States suffered from some form of mental illness in the past year. Many individuals’ mental health needs go untreated due to gaps in resources or delivery of services (Brown, 1998; Gibson, Morley, & Romeo-Wolff, 2002; Modai et al., 2006).


The U.S. government has demonstrated a strong commitment to the development, promotion and integration of technology-assisted care into the U.S. health care system through ongoing work in telemental health (Godleski, Nieves, Darkins, & Lehmann, 2008; National Center for Telehealth & Technology, 2011, 2015; Pruitt & Woodside, 2015). In addition, the government has issued numerous grants for telemental health and other health services for license reciprocity (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2015), established the Office for the Advancement of Telehealth, and published the 2015 Treatment Improvement Protocol (Substance Abuse and Mental Health Services Administration, 2015).


Pruitt, Luxton, and Shore (2014) stated that “home-based telemental health has several important benefits for both patients and clinical practitioners including improved access to services, convenience, flexibility, and potential cost savings” (p. 340). Policymakers and advocates view telehealth technology as particularly promising given the continuing shortage of mental health clinicians and long travel distances to obtain care (Lambert, Gale, Hansen, Croll, & Hartley, 2013).


With advancements in technology and the availability of the Internet, mental health care providers have sought new ways to integrate technology into practice (Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2005), including implementing technology in scheduling appointments, distributing assessments and providing treatment services. Using Internet-based videoconferencing, mental health care providers can easily connect with clients without requiring in-office meetings (Baker & Bufka, 2011). Some individuals will not or cannot seek mental health services when in-person services are needed; therefore, the in-person treatment process becomes a treatment barrier (Bensink, Hailey, & Wootton, 2006). According to Brown (1998), some individuals fail to seek mental health services due to geographical restrictions. Other individuals may struggle with physical health restrictions, preventing them from seeking traditional, in-office services. Mental health conditions such as panic disorder (Klein, Richards, & Austin, 2006), agoraphobia and eating disorders (Zabinski, Celio, Wilfley, & Taylor, 2003) may restrict individuals from receiving traditional services. Using Internet-based services, mental health practitioners can reach clients who are in rural locations, who are seriously ill or who do not seek traditional counseling.


While the use of technology increases access to care, the technology itself creates new, unique challenges and potential risks for mental health providers (Baker & Bufka, 2011). Fifteen years ago, Riemer-Reiss (2000) discussed utilizing distance technology in mental health practice, listing foreseeable concerns for practitioners. More recent publications (Barnett & Kolmes, 2016a, 2016b) present similar concerns and questions for mental health providers. Counselors must attain competency in working with special populations or in specific practice areas, including the use of telemental health services (Baker & Bufka, 2011; Barnett & Kolmes, 2016a, 2016b). Yet, counselors are faced with a lack of clear guidance on ethical, legal and regulatory requirements for telemental health services, including security, assessments and best practices (Ostrowski, 2014).


A Brief History of Telemental Health

In September 1997, the National Board for Certified Counselors (NBCC) became the first organization to adopt standards for telemental health (Shaw & Shaw, 2006). At that time, NBCC called telemental health WebCounseling, defined as “the practice of professional counseling and information delivery that occurs when client(s) and counselor are in separate or remote locations and utilize electronic means to communicate over the Internet” (NBCC, 1997, p. 3). In October 1999, the American Counseling Association (ACA) released the Ethics Standards for Internet Online Counseling in order to “establish appropriate standards for the use of electronic communications over the Internet to provide online counseling services, [which] should be used only in conjunction with the ACA Code of Ethics and Standards of Practice” (p. 1). For psychologists, the American Psychological Association (APA) released a statement in 1997 regarding the use of services by telephone, teleconferencing and the Internet, urging psychologists to use the existing APA Ethics Code and the appropriate licensure board rules for services provided (Shaw & Shaw, 2006). The Clinical Social Work Federation (CSWF) issued a position paper in 2001 on Internet text-based therapy, stressing that practitioners must follow their CSWF code of ethics and all state licensing laws (Lonner, 2001; Shaw & Shaw, 2006).


Nearly 20 years have passed since NBCC broke ground by providing initial guidance for Web-based counseling. The ethical guidance for mental health professionals has continued to evolve as the body of research is growing and telemental health services are becoming more prominent. Several studies have discussed the ethical codes for mental health practice for counselors, psychologists, social workers, and marriage and family therapists (Alleman, 2002; Barnett & Scheetz, 2003; International Society for Mental Health Online, 2000; Mallen, Vogel, & Rochlen, 2005; Manhal-Baugus, 2001; Midkiff & Wyatt, 2008; Recupero & Rainey, 2005). However, while most major mental health organizations have released ethical guidelines for telemental health practice, counselors also must seek guidance from state mental health licensing boards to comply with state licensure laws. Competency requires more than familiarity with state licensure laws; counselors must understand the guidelines and be able to correctly apply the guidelines to clinical practice. As Pabian, Welfel, and Beebe (2009) discovered, 76.4% of surveyed clinicians were misinformed about their state laws concerning duty to warn. If the majority of counselors did not fully understand their state guidelines for practice on this single issue, there are serious concerns about ethical telemental health practice regarding numerous licensure issues across state lines. These concerns highlight the need for clarity and understanding on licensure guidelines. For the purposes of this paper, the authors examine the current telemental health terminology used in state licensure laws located on their Web sites.


Telemental Health Terminology


As telemental health technology has become a promising option, new descriptive terminology has been developed. Several major organizations use the term telemental health. The U.S. Department of Veterans Affairs describes telemental health as “behavioral health services that are provided using communication technology” (U.S. Department of Veterans Affairs, 2015, para. 3.). The U.S. Department of Health and Human Services’ Health Resources and Services Administration Office for the Advancement of Telehealth funds 14 Telehealth Resource Centers located across the United States (Telehealth Resource Centers, 2015). Telehealth Resource Centers use the terms telemental health and telebehavioral health. The National Center for Telehealth and Technology uses the term telemental health in the Department of Defense Telemental Health Guidebook (National Center for Telehealth & Technology, 2015). The American Telemedicine Association, a primary force of the telemedicine industry, uses the term telemental health (American Telemedicine Association, 2015). Thus, the term telemental health is used henceforth to broadly describe using the Internet to provide mental health care.


In the professional and academic literature and on the Internet, numerous terms are used to describe technology- or Internet-based mental health care including: online counseling, online therapy, video therapy, telemental health, telebehavioral health, e-therapy, cybertherapy, telepsychology, telecounseling, Internet therapy, Internet counseling, video counseling, video chat, e-mail therapy, clinical video therapy and Web therapy (Backhaus et al., 2012; Barak, Klein, & Proudfoot, 2009; Castelnuovo, Gaggioli, Mantovani, & Riva, 2003; Center for Substance Abuse Treatment, 2009; Day & Schneider, 2002; Maheu et al., 2005; Suler, 2004; Yellowlees et al., 2010). Some terms describe the medium used (e.g., e-mail therapy, clinical video therapy), while other terms describe the broad use of mental health services over the Internet (e.g., telemental health, online therapy).


Inconsistent terminology among organizations or state licensure boards can lead to a number of problems for mental health providers, as well as researchers, educators and other mental health workers. Using varying terminology, mental health providers must identify and follow state laws regarding telemental health practice, in addition to ethical guidelines. The purpose of this research was to (a) determine whether individual mental health state licensure boards (counseling, psychology, social work, and marriage and family therapy) have a policy or service provision regarding telemental health services, (b) identify the terminology used in the state licensure board policies, and (c) compare the differences in terminology used in licensure board policies across mental health professions.





Various terms, such as online therapy, telemental health and online counseling, were searched on the Internet and in the professional literature. We identified related terms in the search results and in the citations of articles; these additional terms were searched until no more semantically-related terms could be found. The initial generated list and the accumulated terms were compiled and used to begin data collection.


We searched state mental health licensure board Web sites (N = 151) in all 50 states for the counseling, marriage and family therapy, psychology and social work professions. State licensure boards’ Web sites were accessed and we reviewed telemental health-related laws, statutes, rules, policies (which will all be referred to as policies henceforth) and newsletters. In addition, the first author called and sent e-mails to state licensure board personnel to verify whether telemental health policies existed when policies were not located on the Web site. All terms related to telemental health services were collected and added to the initial list, resulting in a final list of 42 terms. We broadly defined the presence or existence of telemental health policies as the use of one or more of the 42 terms. Research assistants searched each state licensure board Web site with the final list of terms to ensure a thorough search.


     We collected the terms used on each state board Web site to examine the consistency in term usage across all state licensure boards. Next, we categorized the terms used on all state licensure boards’ Web sites by mental health profession (counseling, marriage and family therapy, psychology and social work). The data was then analyzed for themes.




State Board Policies

     We analyzed the data collected from state mental health licensure board Web sites. We identified the state mental health licensure boards with telemental health policies. Sixty-five mental health licensure boards had specific telemental health policies. In the following 14 states, not one of the licensure boards had issued a policy about telemental health: Connecticut, Florida, Idaho, Illinois, Indiana, Kansas, Maine, Minnesota, Mississippi, Missouri, New Jersey, Rhode Island, Washington and Wyoming.


Next, we examined the data across mental health professions. The existence of state board policies varied widely for each profession within most states. The number of state licensure boards that had issued telemental health policies for each profession was nearly evenly represented among the first three disciplines as follows: counseling (n = 22), psychology (n = 22), social work (n = 21), and marriage and family therapy (n = 1). We found that only 14 states had telemental health policies for all mental health professions: California, Colorado, Kentucky, Louisiana, Nebraska, New Hampshire, New York, North Carolina, North Dakota, Ohio, Pennsylvania, South Carolina, Utah and West Virginia.




State Terminology Used for Telemental Health

We identified the terms found on state licensure board Web sites. The following 19 unique terms were used across the 65 state licensure boards that had issued policies: distance counseling, distance therapy, electronic-assisted counseling, electronic means, electronic practice, electronic telepractice, electronic transmission, Internet counseling, Internet practice, online counseling, online psychotherapy, remotely, technology-assisted, teleconferencing, telehealth, telemental health, telepractice, telepsychology and teletherapy.


E-mails were sent to 40 state board personnel because telemental health-related laws or policies were not located on the state licensing board Web site. In these cases, 16 state licensure board staff members provided guidance that conflicted with policies published on their Web site or in their newsletter. For instance, many state board personnel who were contacted indicated that telemental health services were permitted as long as state laws were followed. In all 16 cases, the licensure board staff added information not available publicly. This information was excluded from the data, as it was not representative of an official, public policy. Only one state, New Mexico, explicitly prohibited professional counselors from providing mental health services online.


Lastly, we compared the terms used in state licensure board policies across mental health professions. The term used most often by counseling (n = 7) and social work (n = 8) state licensure boards was electronic counseling or therapy (n = 7). The term most prevalent among psychology state licensure boards was telehealth (n = 6).




With only 43% of mental health state licensure boards issuing at least a minimal policy regarding the use of telemental health services, mental health professionals are left without clear guidelines for acquiring proper training, educating clients and following sound procedures for using telemental health services to work with clients. Support and education may be warranted for licensure boards whose members may not have the time or expertise to craft policies based on evidence-based practice or best practice guidelines.


Among the states that do have policies, the data demonstrate that state licensure boards’ policies differ in terminology. With 19 telemental health-related terms identified in state licensure boards’ policies, the mental health profession lacks consensus as telemental health services have grown over the last decade. Agreement or consistency is needed for effective conversations among researchers, educators and mental health providers to ultimately provide clear guidance to clinicians and clinicians-in-training.


Mental health providers seeking to identify state policies regarding telemental health may search for online therapy, when their state uses one of 19 broader terms such as electronic means. The average mental health provider is likely unaware that nearly 20 different terms are used among state licensure boards, let alone aware of which term may be used to identify the laws in their respective state. Researchers, educators and state licensure board staff members should consider selecting the terms they use to include the common language of mental health providers. By narrowing the use of terms, state licensure boards would ensure mental health providers greater access to policies.


Inconsistent terminology leads to a number of problems. Since telemental health has grown over time and been through several iterations of research and development, some terms may be associated with one or more periods of development. Employers posting jobs in telemental health may identify the position with one term (e.g., telebehavioral health therapist) while a job seeker may use another search term (e.g., online counselor). Researchers also may have difficulty finding related research on telemental health services when there are many terms used for the same concept (e.g., cyberpsychology, Internet therapy, online counseling, Web therapy, e-counseling). Inconsistent terminology could hinder the development and dissemination of the body of research supporting telemental health services.


In addition, state licensure boards may consider how restrictions meant for one mode of services (e.g., text-based counseling) will impact another mode (e.g., video-based counseling). State licensure boards may use language to be as inclusive as possible, yet the specific types of telemental services permitted may be unclear to mental health providers. When identifying policies in different states, mental health providers may be confused when state licensure boards use the same terminology to refer to different services. For example, practitioners may use telephone, e-mail, text, smartphone apps, or interactive videoconferencing to provide counseling services and be unaware that certain formats are permitted where others are not. Implementing changes in terminology will assist mental health providers in finding the policies pertaining to telemental health as well as reduce confusion and hesitancy to provide services via the Internet.


Future Research

Future research is recommended to identify competencies for telemental health services for adults, children and special populations. Guidelines and ethical standards have been developed using reviews of the literature and consensus among a limited number of professionals in their respective associations (American Association for Marriage and Family Therapy, 2015; ACA, 2014; American Mental Health Counselors Association, 2015; APA, 2013; National Association of Social Workers, Association of Social Work Boards, 2005; NBCC, 2016). No formal study has yet to be conducted on the competencies of a telemental health provider or on the effects of counselor competency training on providing telemental health services. Professional communities and independent continuing education providers around the United States provide training services for counselors, and some graduate counseling programs offer students an elective course in technology and counseling. While these efforts provide counselors with training, research and advocacy are needed to identify competency areas related to ethical telemental health practice. Counselors may be extremely skilled in in-person counseling, yet unable to successfully transfer these skills to an online environment (Mallen et al., 2005). Established professional competencies in telemental health would inform educators and policymakers in future endeavors.


It is important for telemental health training to draw from outcome studies, lending direction for best practices in telemental health regarding ethical and therapeutic guidelines. Ford, Avey, DeRuyter, Whipple, and Rivkin’s (2012) survey provided insights into the biggest successes and challenges of integrating telemental health services into practice. They noticed the success of being able to reach an underserved population. They echoed the need for outcome research to inform practices and ethics, as well as a need for outcome research to inform sound cultural and contextual practice for counselors. In addition to counselor educators and researchers, it is important that clinicians currently engaged in telemental health practices inform colleagues of benefits and challenges through professional publications (Sude, 2013). Once further research outcome data are acquired and proposed counselor training competencies are in place, state licensure boards will have comprehensive best practice guidelines for creating more detailed information for licensees, leading to improved counseling practices and better results for clients.


Implications for Counselors

Counselors should be aware that their licensure board policies and ethical codes may include different telemental health terms than those with which they are familiar. Identifying the telemental health terms is a counselor’s first step toward locating telemental health guidelines, understanding the specific policies and developing beginning competencies for an online, electronic practice.


Counselors are encouraged to consult ethical guidelines for practice before engaging in telemental health activities. Important ethical considerations include duty to warn, scope of practice, confidentiality, record keeping and marketing (Mallen et al., 2005), among others. Other considerations that are unique to telemental health practice include legal and ethical requirements for training, protocols for emergency services, location and identity verification, and an informed consent process that is specific to telemental health (NBCC, 2016). Some state licensure boards require documentation of informed consent in addition to other security requirements, such as identifying the client’s local emergency services and verifying the client’s identity and age. Barnett and Kolmes (2016a, 2016b) discussed the risks associated with telemental health practices based on two cases and provided suggestions for practice, including specific competencies in telemental health, technology, general telemental health, multicultural practice, clinical practice for telemental health (e.g., assessing client’s appropriateness for telemental health), process of informed consent (e.g., fees, confidentiality, verification of legal consent), licensing issues, ethical issues (e.g., duty to warn, reporting abuse), and adequate liability insurance coverage. The number of telemental health competencies and concerns, including the use of technology (e.g., encryption), indicates a need for counselors to seek telemental training and guidance before engaging in telemental health services. In a recent survey, Ford et al. (2012) discovered that clinicians reported the need for training on equipment use as one of the biggest challenges for effective service delivery.


With sound training and competencies in place, counselors can take advantage of the benefits of telemental health by providing care for people who are not able to seek face-to-face counseling services (e.g., rural and frontier clients). Mental health professions are increasing the capability to reach the underserved through technology and telemental health practices. As technology and policies change, professional counselors are encouraged to become and stay literate in the efficacy and best practices for telemental health services.


Professional counselors are challenged to be aware that telemental health in general is growing rapidly, and the dynamics of the profession (e.g., laws, ethics, technology and reimbursement) are increasing counselors’ capability to serve the underserved through technology. Counselors who do not incorporate telemental health services into their practice may limit their practice as clients may seek accessible online providers in the near future (Myers & Turvey, 2013). Also, counselors who adopt telemental health services will capture more market share as the medical community heeds the incentives to make electronic service referrals and integrate telehealth and telemental health into medical practice.




Telemental health is no longer something of the future (Mallen et al., 2005). Telemental health is occurring now and rapidly expanding. Professional counselors, counselor educators, leaders in the counseling profession and state licensure boards are encouraged to consider the terminology used when creating regulations and how these decisions may impact the application of counseling services. Also, licensure boards may feel compelled to use all-inclusive language to cover future possibilities of telemental health practice. Broad terms such as electronic may be all-inclusive but are not aligned with common vernacular among practitioners and do not reflect the research or terminology used by associated entities (e.g., insurance companies that reimburse for services).
However, common terminology such as telemental health and online counseling could be used to help counselors identify these policies within professional codes of ethics, state licensure laws, and other documents. In addition, researchers must consider the terminology used within publications to increase understanding among readers and minimize confusion in the profession.

Professional counselors, counselor educators and counseling leaders are challenged to forge ahead, advocating for clear guidelines from their state licensure boards, debating what is sufficient for training guidelines and advocating to use technology to reach underserved clients with professional counseling services. Without exposure to research and best practices, licensure boards may be led to create overly restrictive regulations that prevent the benefits of telemental health from being possible and unintentionally limit access to mental health care for people who cannot seek face-to-face counseling. There is a need for specific communications about telemental health practices between different functional components of the counseling profession (i.e., practitioners, educators, leaders, state board personnel). For example, state licensure boards and counselors who are grounded in telemental health research and best practices can work together to form clear, all-encompassing information for licensees.


As mental health professions forge ahead with telemental health practice, counselors should continue to develop this important treatment medium to capture the clientele and referrals from the participating medical community. Failure to do so may leave counselors at a disadvantage in the marketplace. As the U.S. government moves forward to meet the mental health treatment needs of millions of Americans, counselors are encouraged to take a leadership role in this movement to reach the underserved with professional counseling services.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.





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Jay Ostrowski, NCC, is Director of Product and Business Development at the National Board for Certified Counselors, Inc. and Affiliates, and the CEO of Behavioral Health Innovation. Traci P. Collins, NCC, is a professional counselor at Triad Counseling & Clinical Services, LLC in Greensboro, NC, and a doctoral candidate at North Carolina State University.