Nationally public policy in this area has traditionally been grounded in an ideological perspective that classes these disorders as distortions of character that are best addressed through a criminal justice response. Underlying this perspective is a historically consistent generalized judgment that individuals with these disorders are weak of character. Those who hold these perspectives often cite the lack of volitional control despite significant consequences as their evidence of moral failing. These judgments continue to drive our national response to addictive disorders as evidenced in how substance use disorder treatment funding is prioritized. Changing public opinion through education is one necessary policy objective. Changing public opinion, however, will not address the primary policy objective which is to ensure counselor competence. A competent workforce is unarguably critical to address addictive disorders as a major public health concern. Competence development demands that scientific evidence in the areas of clinical and educational best practices must be properly deployed.

Addictive disorders cut across all aspects of our society. They impact all classes and demographic segments of those who live in the United States making addictive disorders a significant concern for all Americans. Americans should also be concerned about the effectiveness of treatment provider systems and oversight bodies. It is worthwhile to consider how the above entities affect counselor competence because credentialing is primarily a state function.

In theory, public opinion is meant to influence legislative decision through voting and lobbying by constituent groups. Those with addictive disorders meet the criteria for being a disenfranchised group thus impeding their ability to act as a lobbying body. Treatment providers and Credentialed Counselors also lack a unified voice. In order to change the inequitable policy debate, counselors, those with addictive disorders, and their families need to be organized into collective advocacy groups.

If the addictions industry does not take action and evolve, then it stands the chance of being subsumed by other disciplines. While the rest of the world follows a public health model, the United States spends its drug monies on militaristic interventions and the treatment industry squabbles over the legitimacy of “Harm Minimization.” In this environment, educating addictions counselors takes a back seat to the big money initiatives that are more immediately supported by the court of public opinion. The reason is due, in part, to the fact that the “disease” of addiction remains stigmatized by society as well as our medical and criminal justice systems. Chemical dependency is not viewed as “important” as other mental health or medical issues, resulting in a lower standard for educational development and professionalism.

The addictions treatment industry has voiced a concern regarding the lack of qualified staff. The concern has been termed “a workforce crisis.” To address the crisis, the response generally has been focused on workforce recruitment and retention. Recruitment and retention are important, but they do not involve ensuring that counselors have the critical determinants for success. Sequentially-developed competence through education and experience is an unarguable determinant for success.

Developing schemes to entice people to enter the field cannot logically address the root issues that are a central part of the industries vocational instability. From my perspective, the instability is rooted in the lack of a professional identity for credentialed alcoholism and substance abuse counselors (CASACs). Developing a professional identity involves unifying standards around the scope of practice, canon of ethics, industry specific jargon, and competency development processes.

The age of the paraprofessional has reached its zenith, and the time to develop a professional identity is now. To transform the system, an identity that is grounded in industry-specific best practice research, nomenclature, and education and practice standards must become institutionalized through policy driven standards.

It is not clear whether current credentialing processes reach their stated policy objectives. Does the credential meet the needs of the individual counselor, the general public, and the treatment industry?

The credential exists as one element of a public policy response to substance use disorders. Credentialed counselors are those who are charged with providing treatment or enacting policy on a daily basis. The oversight of their activities is provided by state and local oversight and monitoring bodies. It is important to note that treatment practice is heavily regulated,` while counselor educational systems are not. Each state has its own regulations that prescribe addictions treatment services. State regulations also prescribe the credentialing processes required to gain the title and privilege that are an inherent part of being credentialed.

The central question involves what the credential is supposed to accomplish and whether it reaches its intended policy objective. The charge of credentialing bodies is to issue credentials, establish minimum qualification standards, and to revoke credentials as necessary. It is important to note that this generally accepted charge does not involve competence development processes. The credentialing process provides minimum qualification measures and bureaucratic hurdles rather than competence measures. Based on this logic, a credential is not a reflection of competence; it is more of an event as in when one passes each bureaucratic requirement.

The majority of states are connected with the International Certification and Reciprocity Consortium or ICRC. Those states that are members of the ICRC follow the ICRC credentialing guidelines. The guidelines outline the required amount of work experience hours and education. The ICRC also outlines the main elements of the credentialing examination. The credentialing application process is administered by the individual states.

Credentialing is not a competency development process. It is a minimum qualification benchmark. Based on this reality, the question then becomes, who or what group oversees the competency development standards? The reality is that there is no one group that outlines and oversees competency development standards. Thus, the educational development systems are laissez faire in that they are unregulated. When this is the case, then individuals are left to determine what competence development means alone. Most individuals who are not educators do not know what a competence development process is and, thus, they are left to exist in a proverbial educational “wild west.”

Today, counselor competence development is defined by the individual and not by the system. It may be argued that individual educational providers are the ones that outline the competence development process; this argument rests on the assumption that these individuals and groups know what competence development processes are and how to enact these processes. In comparison, most other areas of human services competency development processes are standardized through accreditation.

Counselor credentialing, as it stands, does not claim to ensure the competence of counselors. The language, “minimum qualification standards” refer to one’s ability to sit for a test and is not a test of one’s ability. An assurance of basic education is impossible without competence development standards. Standardized educational processes are a fundamental aspect that defines what it means to be a profession. How can evidence-based practice be expected without evidenced based competency development?

Is the system meeting the needs of the individual counselor that depends on how the needs are defined? From an educational perspective, a unified system does not exist and this brings the meeting of the educational needs into question.

Are the time, effort, and expense of earning the counseling credential worth the effort?

The credential provides a vocational identity but cannot provide title security. Title security is brought about by establishing what it means to be a bona fide substance use disorder treatment professional. The foundation of title security is a clear scope of practice, standardized education, and title specific privileges. Title security conveys the rights, privileges, and security that are acquired when someone successfully passes through a competency development process. Our system lacks title security because it does not meet the above criteria. Consider that CASACs who earn the credential are commonly treated as second class to other related disciplines that have no addictions specific education. In order to compete and be recognized as valid, counselors need professional education by professional educators who have a working knowledge of substance use disorder treatment best practices.

My belief is that bureaucratic oversight bodies are not well equipped to lead those who seek to gain the skills that will serve them well in the pursuit of helping others. A criminal justice policy perspective is dissonant to the growth of professional healers. Bureaucratic institutions, by definition, are not designed to develop those who are called to enter a vocation.

Without standards, the problem is that education has become a commodity to be purchased, rather than an apprenticeship process. When education becomes commoditized then profit takes precedence over learning. Counselor education within the substance use disorder treatment industry is an example of a commoditized structure. In this model, the consumer of educational services is at a disadvantage because they are mandated to acquire education to enter the industries workforce, but he/she is not guided on what the educational process should be. A dynamic is constructed wherein the consumer must determine what competency development is. When left in this position, the individual turns to educators for guidance on the process; educators who may or may not have an understanding of how competency is best developed.

An industry without standards fails to meet the definition of an industry.

There is a clear inequity in the access to education and a socio-economic educational divide is becoming apparent. The inequity exists between those who have the means to seek higher education and those who do not. Does it make sense to seek a counseling credential when you can run an agency as a social worker with no addictions education or experience? A significant percentage of addictions treatment programs are administrated by social workers who have little or no addictions treatment education. In literal practice, the industry is saying that addictions education is not necessary to provide treatment services.

Substance use disorder counselor education is, for the most part, unregulated wherein most anyone with minimal relevant education can open a training program. Unregulated systems by definition rely on the market to regulate it. The logic here is that poor providers of educational services will be driven out of business by the lack of consumers. The substance use disorder industry is the only human service discipline that follows this model with most other disciplines applying competency development standards that are enforced by accrediting bodies. The status quo is a lack of attention to basic educational standards. Education theory is not commonly integrated into instructional practice. Incorporating instructional best practices is essential to transform the addictions counselor landscape.

The unregulated system cannot be measured. Thus, consumers are exposed to a wide variance in terms of quality and instructional qualification. The general public is forced by the system to interface with providers the competence of which cannot be guaranteed. It is dysfunctional to have a credentialing process without a supporting educational system. Pass rates can be expected to be low when educational systems are not standardized and the solution is not exam preparation courses, but standardized competency development processes.

The industry is forced to accept into its ranks a workforce that is educated according to no set standard. An industry cannot expect consistency and professionalism from a workforce that is educated according to what is most profitable. The workforce crisis is not an issue of recruitment and retention; rather it is an issue of an industry that has not developed a fundamental aspect of its infrastructure. It is surprising that the general public and treatment provider organizations accept the irrationality of a laissez fair counselor development system. The industry has evolved from the only requirement to be a counselor is to be in recovery. The next step in the evolution has been recognition that addictions specific training is required to provide addictions treatment services. My belief is that in order to survive, the industry will need to adopt standardized educational requirements.

Competent addictions treatment requires specific knowledge, skills, and attitudes. How does the industry ensure that individuals are competent to practice? Those that are competent to practice demonstrate the requisite knowledge, skills, and attitudes.

The ICRC credentialing examination is comprised of a written test. From a factor analysis perspective, multiple-choice tests are ineffective at measuring a range of competencies. One cannot demonstrate ability through a written response; a written response can only be used to describe or to illustrate an understanding. Multiple-choice tests primarily assess memorized knowledge and not performance ability. The educational process should demonstrate the relationship between the educational process and job performance. The knowledge that is measured should be process oriented as operationally defined information that is necessary to perform a job specific task.

If the credentialing process involves a minimal qualification application process and a written examination only; then it cannot logically measure the requisite knowledge, skills, and attitudes. It may be argued that supervisors are directly responsible for competency development that is specific to the addictions counseling competencies. Again, this argument is based on an assumption that supervisors are acting as competent instructors. My understanding is that the majority of supervisors are acting without instructional training. It would be ideal if supervision processes were in synch with commonly accepted research-driven competency development standards.

The paraprofessional credential does not carry the immediately recognized and accepted validity of other disciplines like nursing. People generally seek education and subsequent credentialing to be able to earn a living wage and many have told me that the compensation is not worth the effort that it takes to gain the credential? My observation is that individuals from other fields such as social work earn higher wages without demonstrating any addiction specific education or training. Should these social workers and psychologists be forced to demonstrate competence prior to working within the addictions treatment industry? Some states require a graduate degree for advanced practice. Should that degree be addictions studies specific?

Addictive or behavioral disorders are extremely complex in their etiology, symptom manifestation, and treatment requirements. Co-occurring disorders further complicate the treatment of this class of disorders. These realities demonstrate the critical need for professional educational systems that guarantee addictions specific clinical education. Current credentialing requirements involve minimal addictions specific education and no set clinical protocols. Further, the credentialing requirements do not mandate work experiences that involve the full range of clinical competencies thus effectively nullifying the concept of work experience competency development.

The intent and the values behind the process should involve development of competence. Minimal qualifications currently involve 350 hours of education (knowledge) and 6000 hours of work experience with a sign off that the experience involved addictions competencies. I assert that these requirements have had an adverse impact on the labor market because the requirements are not in line with business necessity. In other words, a disconnect exists between the credentialing process and job performance requirements. The process does not provide a guarantee of competence and title validity that provides occupational desirability.

The paradigm shift that I am suggesting involves moving our attention and efforts into a standardized competency development processes. The scope of practice may be integrated into the competency development process through occupational benchmarks against which the candidate can be measured. Tests should include a valid sample of job specific competencies. This type of test requires candidates to demonstrate conceptual, analytical, critical thinking, and interpersonal relational skills.

Degraded qualification and educational processes parallel a decrease in occupational identity. The counselor development system is unquestionably not meeting the demand for bona fide substance use disorders treatment professionals. Recruitment and retention are peripheral to the structural flaw that is apparent as to how counselors are developed.

In order to become employed, people must demonstrate that they are employable. In the field of substance use disorder treatment this means proving that one is competent to provide counseling services. The majority of states in the United States offer a credentialing process that is used to provide state verification that individuals have demonstrated minimal qualifications; which will allow them to gain employment through the holding of the credential. Credentialing processes usually involve verification of relevant work experience and education. The work experience is commonly verified by a statement from an administrator who oversees treatment services. Education is commonly verified through the presentation of certificates or transcripts to a credentialing processing body. It is important to note that credentialing bodies are commonly associated with state run public policy oversight agencies; based on this, their primary charge is ensuring public safety and not education. Credentialing bodies commonly certify individuals and organizations to offer the relevant educational services. What I have found after nineteen years as a treatment practitioner and eleven years as a substance use disorder counselor / educator is agencies that provide work experience hours are focused on people working and not on ensuring that individuals are developing core competency. Treatment agencies are not educational institutions and supervisors are not commonly taught how to instruct. Based on this reality it is critical that those seeking to develop their competency as counselors develop a working knowledge of what supervision is and how to advocate for their educational needs. Further, my research has found that our industry does not have competency development standards. What this means is that there is no prescribed step by step process that one must follow to expand proficiency as treatment practitioners. As such, it is critical that those seeking proficiency develop an individual competency development plan.

Individuals who want to move in their growth as substance use disorder treatment practitioners are forced to seek education from minimally regulated educators. Currently the education system is laissez-faire; as it is unregulated. When any system is laissez faire, individuals who interface with the system must represent themselves, because there is no one representing their interests. It may be argued that the United States has The International Certification & Reciprocity Consortium (IC&RC) and individual states have counselor credentialing regulations. However, each of these examples involve credentialing, which represents a final benchmark that must be passed to gain a credential; but they do not illustrate a standardized educational process. It is the perspective of this writer that those looking for addiction counseling education must represent themselves.

By Philip Ward

Education is a service that is bought for the purpose of becoming educated/ competent in a specific area of study. Those who purchase these services are educational consumers and as such have associated rights and responsibilities. In summary, consumers of educational services have a right to an accurately represented, research driven, goal directed, measurable process that is presented by competent instructors. Consumers have a responsibility to know what it is that they are purchasing, why they are purchasing it, and what they need to do to meet their side of the contract. The goal is for each party to have the same expectations of the contracted activity.

This handbook is designed to provide information that will enable those who are entering or presently working in the substance use disorder treatment industry to be smart consumers of educational services.

In the substance use disorder treatment arena, education is defined as competence. Competence is defined as a demonstrated ability to effectively practice the core functions/competencies standards of addictions counselors. For additional information, review the following resources:

Bureau of Labor Statistics: Provides statistically- based information on the addictions counseling industry. Utilize the resource below as a means of understanding prevalent wages, educational requirements, and a basic overview of the industry http://www.bls.gov/oco/ocos067.htm#emply.

Ÿ Herdman, J. (2006). Global Criteria: The 12 Core Functions of a Substance Abuse Counselor. 4th Ed.

Ÿ Substance Abuse and Mental Health Services Administration. (2007). Technical Assistance Publication (TAP) Series 21. DHHS Publication No. (SMA) 07-4171.

Ÿ The National Addiction Technology Transfer Center: Provides an overview of state specific counselor credentialing requirements http://www.nattc.org/getCertified.asp)

The Technical Assistance Publication (TAP) Series 21 outlines the “Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice”. The Technical Assistance Publication (TAP) Series 21A outlines: “Competencies for Substance Abuse Treatment Clinical Supervisors”. To develop as a competent substance use disorder counselor, one would strive to master the competencies outlined within the TAP Series 21. To develop competency one should seek appropriate mentoring and supervision and the TAP Series 21 A provides insight into supervisory processes. To obtain the entire TAP series free of charge, utilize the following resource: ncadi.samhsa.gov.

To become educated, it is helpful to understand what education is. To do this, I recommend individuals review adult learning theory, competency based education, and “Blooms Taxonomy of the Cognitive Domain”. Education is not memorization and a passing score; it is demonstrated practice proficiency in daily interactions with patients and their families. Finally, it is important for a person to understand h/her individual learning style. For more on this topic, view the web resource: http://www.centeach.uiowa.edu/learningstylepreferencesmaterials.shtml.

All competent counselors have the following in common:

• Interpersonal relational skills
• Ability as critical thinkers
• Empathy and dedication

Beyond competence, in the 12 Core Functions and the TAP 21 competencies, education is further defined by the elements that define any profession. All professions are defined by:

• Ÿ A function specific jargon;
• Ÿ A scope of practice;
• Ÿ A canon of ethics that guides practice;
• Ÿ A body of empirical knowledge/ research that guides practice; and
• Ÿ A standardized/accredited educational process.
• The treatment profession should be defined by these same criteria.

The goal:

To develop the knowledge, skills, and attitudes that will allow you to practice as a competent addiction counselor.

What is a competent counselor?

A competent substance use disorder counselor is one who consistently demonstrates an ability to accurately apply what they have learned.

An educated person has a working knowledge of each of the above elements:

• Ÿ They can speak the language;
• Ÿ They know what their training allows them to do or not do;
• Ÿ They can problem solve using the canon;
• Ÿ They continually review relevant best practice research; and
• Ÿ They follow a prescribed educational path

Now that we have defined what education is and identified your role as a consumer, the next step is to develop a plan on how to get the best education you can for your money!

Develop Your Educational Plan

The first step is to develop an educational plan using the following outline:

1. Envision: Develop a statement of purpose.

“My objective is to become an addiction counselor.”

2. Clarify: List the competencies that you would like to develop.

“I want to master each of the core functions and competencies.”

3. Identify: List learning resources.

“This is my list of people, places, and things that can help me in my journey toward competence.”

4. Apply: Write an action statement.

This is concretely and specifically what you will need to do to work toward your goal: To become an addictions counselor “I will have to _______.”

5. Measure: Write examples of how you would know that you were moving toward your goal.

The objective is to become a competent practitioner, not to simply follow the steps to a credential. Realize that a credential is the result of a regulatory review process and not a standardized educational process. The United States and the majority of international countries do not have a standardized/accredited addictions educational system.

Once you have a plan it is time to research programs to find the one that best fits your plan.

Each state has their own process of certifying programs to offer counseling education.

What are the state requirements that are required for individuals or entities to provide addiction- specific education and training? Does the state provide regulations that outline a credentialing process? Most state agencies have web resources that you can look up and review. When reviewing, collect and review all of the information pertaining to:

• Training program certification processes;
• Education and training regulations; and
• Credentialing processes.

Is the program that you are interested in certified by the state or another legitimate accrediting body?

Note: the majority of states in the United States are members of the:

The International Certification & Reciprocity Consortium (IC&RC), which sets the international standards of practice in addiction counseling, prevention and clinical supervision through testing and credentialing of addiction professionals. www.icrcaoda.org

IC&RC boards are located in 44 states, the District of Columbia, 2 US territories, and 12 global jurisdictions. IC&RC certification boards also include those affiliated with the Indian Health Services, and the World Federation of Therapeutic Communities. Over 35,000 certified addiction professionals currently belong to IC&RC Member Boards. Based on this reality it is a good idea to see if your state is a member of the ICRC and, if so, review all of the relevant information that is presented on the ICRC web site.

Gather Information

Now that you have an idea of who oversees your program at a state level, it is a good idea to check out the program through the county governmental unit that oversees addictions services in your area..

Do your home work and be prepared before proceeding.

Gather information before making the major decision to enter into an educational contract.

Once you have identified a program check it against all of the following elements:

• Ÿ Is the program certified by the state?
• Ÿ Does it offer an entire competence development program or individual classes?
• Ÿ Are there any complaints against the program or any of its staff? (You can ask the state or county)
• Ÿ How well does the program fit with your educational plan?
• Ÿ Is the program research based?
• Ÿ Is the staff of the program certified/qualified educators?

Develop a list of questions and methodically process through and address each of the questions.

When you have addressed each of the questions to your satisfaction, it is time to interview the program.

Ask for review and discuss the following policies:

• Attendance
• Payment
• ŸAcademic discipline/probation
• Withdrawal and return
• Inclement weather / course cancellation
• Instructor continuing education/qualification
• Record retention
• Transfer of credit
• Field placement
• Confidentiality
• Transcript
• Cultural competence
• American Disability Act
• Student instructors
• Instructor ethics
• Student instructor communication/ interaction
• Safety/security
• Infection control
• Complaint process
• Oversight reporting requirements
• Accreditation or oversight requirements

Ask for:

• A sample education contract/learning contract;
• Program mission statement;
• Organization overview/educational philosophy;
• Purpose statement: why the program exists;
• List of available education resources: computers, research journals, books;
• List of instructors and their qualifications;
• How and how often instructors are evaluated?
• How students are evaluated/tested?
• How evaluations/progress reports are presented: grade written narrative, oral interview;
• Student manual, program guidelines, procedures;
• Course schedule;
• Program affiliations (e.g., connection to other learning organizations, professional organizations);
• Entrance and graduation procedures;
• Who oversees the program and what does the oversight consists of?

Use the program-specific information to gain insight into how the program operates. Go in with a list of questions or forward your questions prior to meeting with program officials.

Consider what the program asks or requires of you. Match all of the program elements against the state regulations. If the program offers distance learning, how do they manage the above elements? Does the program’s curriculum focus on developing the counseling competencies?

When you leave the program what does the program expect that you will take with you?

Now that you have all of the information, you can make an informed decision about your educational future and let the journey begin.

Preamble:

Consumers of addictions treatment services have the right to be treated by qualified practitioners. Qualified practitioners are those who have engaged in a development process that, upon completion, certifies them as competent to practice. Research based standards are the rules that define both competence development and professional practice.

All addictions treatment professionals have a right to field-specific standardized competencies that define competence and illustrate a process for professional development.

All addictions treatment professionals have a right to clearly defined professional development processes that provide opportunities for objective assessment of requisite knowledge, skills, and attitudes.

All addictions treatment professionals have a right to be mentored by qualified addictions treatment practitioners. The term qualified indicates that they have completed a process that certifies them as competent instructors.

All addictions treatment professionals have a right to be trained within regulated academic institutions. The term regulated indicates that the programs must meet prescribed educational practice, administrative and clinical training standards. Also, that monitoring of programs is an ongoing process.

All addictions treatment professionals have a right to a career ladder that is built upon a competence continuum. A competence continuum is one that illustrates competence beginning at the novice level and ending at the master level. Competence involves educational processes, relevant experience, and a demonstration of ability.

All addictions treatment professionals have a right to an individualized development plan that considers and incorporates their relevant strengths and experiences.

All addictions treatment professionals have a right and an obligation to contribute to the evolving body of knowledge that defines the field.

Author: Philip Ward

I received your email to CanadianNetwork@ccsa.ca because I’m the National Priority Advisor focused on workforce development.  Your paper does not identify your credentials – what makes you qualified to address the issues – nor have you listed the references you used in writing this paper.  With such items missing, the credibility of your paper may be reduced. Nevertheless, your paper raises good points.

It appears that you’re not familiar with the CCSA 2007 report entitled “Core Competencies for Canada’s Substance Abuse Field, version 1.”  It identifies the most essential technical competencies for the substance abuse workforce and details four levels of proficiency for each competency. Note that this is version 1 of what CCSA considers to be a dynamic, fluid document; it will change in version 2, which we expect to have available by 2010.

“Core Competencies for Canada’s Substance Abuse Field” is available at www.cnsaap.ca; however, I’ve attached it for your perusal.  CCSA also examined social work programs in Canada to identify how many of them already discuss the core technical competencies.  This report, “An Examination of Substance Abuse Core Competencies in Academic Curriculum: The Social Work Example” discusses the research findings.  It’s also available at the same website.

I’m delighted to tell you CCSA has also completed research on the core behavioural competencies. It will be version 1, for the same reason as for the technical competencies and available in the fall of 2009.  CCSA consulted with the workforce across Canada in 11 focus groups in March 2009 to clarify the core behavioural competencies and to create a profile of 7 occupational clusters.  For each cluster, we have created a list of necessary competencies and the appropriate level of proficiency in each competency.  .

Given the difficulty organizations can experience in using behavioural competencies effectively, CCSA also created an guide for competency-based interviewing and an interview tool for each of the 7 occupational clusters.  Further, CCSA has created a guide for performance management and a performance management tool for each of the 7 occupational clusters.  These documents will also be available in the fall of 2009.  Watch www.cnsaap.ca for the news.

If you do not already receive the CCSA newsletter “Network News,” I encourage you to subscribe.  You can do so at www.cnsaap.ca.  The research we have been conducting on competencies is discussed in this quarterly newsletter, along with other points of interest for the substance abuse workforce.  Also, you can access the published reports at cnsaap.ca. Other CCSA reports are available at www.ccsa.ca.

Elva Keip
National Priority Advisor / Conseillère, Priorités nationales
Canadian Centre on Substance Abuse /
Centre canadien de lutte contre l’alcoolisme et les toxicomanies
75 Albert Street, Suite 500 / 75, rue Albert, bureau 500
Ottawa, (Ontario)  K1P 5E7
Tel / Tél: 613-235-4048 x288
Fax / Téléc: 613-235-8101
Email / courriel: ekeip@ccsa.ca
www.ccsa.ca
www.cnsaap.ca

“Every person’s map of the world is as unique as their thumbprint. There are no two people alike. No two people who understand the same sentence the same way…. So in dealing with people, you try not to fit them to your concept of what they should be.” -Milton Erickson

INTERVIEWER: Why did you ask that?
ERICKSON: So that she knew I was really interested.
INTERVIEWER: So that you could join her in this?
ERICKSON: No, so that she knew I was really interested

Copyright 2005. National Organization for Competency Assurance. All Rights Reserved.

The NOCA Guide to Understanding Credentialing Concepts The NOCA Guide to Understanding Credentialing Concepts
NCCA Commissioners

Chair
Lawrence J. Fabrey, Ph.D.
Vice President, Measurement Research, Applied Measurement Professionals, Inc.

Co-Chair
Christine Reidy
Executive Director, Commission on Dietetic Registration of the American Dietetic Association

NOCA Board Appointee
Carolyn Lewis, Ph.D., RN, CNAA
Principal, The PRINE, LLC

NCCA Appointees

Reed A. Castle, Ph.D.
Director of Research and Development, Schroeder Measurement Technologies, Inc.

Paul D. Naylor, Ph.D.
Psychometric Consultant

Janice Scheuneman, Ph.D.
President, Quality Assessment Services

Elected Commissioners

Lynn Anderson
Executive Director, Joint Commission on Allied Health Personnel in Ophthalmology

Denise Fandel, MS, ATC
Executive Director, Board of Certification, Inc.

Cynthia Miller Murphy, RN, MSN, CAE
Executive Director, Oncology Nursing Certification Corporation

Jan Towers, Ph.D., NP-C, CRNP
Director, American Academy of Nurse Practitioners Certification Program

Public Member

Rebecca LeBuhn
Chair, Board of Directors, Citizen Advocacy Center

EDITORS

NOCA Board of Directors

President
William Kersten
Senior Vice President, Operations, National Institute for Automotive Service Excellence

President-Elect
Cynthia Durley, M.Ed., MBA
Executive Director, Dental Assisting National Board

Immediate-Past President
Susan Eubanks, NCC, NCSC, LPC
Associate Executive Director, National Board for Certified Counselors

Secretary/Treasurer
Francine Butler, Ph.D., CAE
Executive Director, Biofeedback Certification Institute of America

NCCA Chair
Lawrence J. Fabrey, Ph.D.
Vice President, Measurement Research, Applied Measurement Professionals, Inc.

Sustaining Member
Richard Goldberg, Esq.
Principal, Richard Goldberg & Associates

Elected Board Members
Melissa Murer Corrigan, RPh
Executive Director, Pharmacy Technician Certification Board

Christopher Damon, J.D.
Executive Director, American Medical Technologists

Carol Hartigan, RN, MA
Certification Director, American Association of Critical Care Nurses Certification Corporation

2

The NOCA Guide to Understanding Credentialing Concepts The NOCA Guide to Understanding Credentialing Concepts

EXECUTIVE SUMMARY

Nearly every profession uses credentialing to establish criteria for fairness, quality, competence, and/
or safety for professional services, products, or educational endeavors. In some cases, professions
voluntarily develop quality standards of practice; a profession may also be regulated by the State or
Federal government. Despite the widespread use of professional designations, credentialing terms
are often misused and general concepts often misunderstood. The National Organization for Competency
Assurance (NOCA), the national membership association for professional certification organizations,
developed The NOCA Guide to Understanding Credentialing Concepts to assist its stakeholders,
including legislators, educators, employers, credentialing agencies, professionals and the
public, in understanding and correctly using credentialing terms and concepts.

This paper addresses the following:

• Purposes served by credentialing
• Definitions and descriptions of credentialing terms
• Processes used in conducting or choosing a psychometrically sound and legally defensible credentialing examination program
• Differences between didactic (end-of-course) examinations and professional credentialing examinations General NOCA Information (www.noca.org)

Established in 1977, NOCA serves as a clearinghouse for information on the latest trends and issues
of concern to practitioners and organizations focused on certification, licensure, and human resources
development. NOCA’s accrediting body, the National Commission for Certifying Agencies (NCCA), is
the international leader in setting quality standards for credentialing organizations and grants accreditation
to those organizations that meet these Standards.

NOCA’s mission is to promote excellence in competency assessment for practitioners in all occupations
and professions by:

• Providing expertise and guidance
• Developing and implementing standards for accreditation of certification programs through NCCA (NOCA’s accrediting body)
• Providing educational and networking resources
• Serving as an advocate on certification issues

NOCA’s vision is to:

• Establish NOCA as the authority in certification and NCCA as the authority in accreditation of certification programs.
• Educate the general consumer so they understand the value of voluntary certification and recognize the NCCA seal as representative of quality certification programs.
• Enhance quality member benefits and resources so all certification organizations will join NOCA and aspire to NCCA accreditation of their certification programs.
• Lead the global transformation to excellence in competency assessment.

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The NOCA Guide to Understanding Credentialing Concepts
WHAT PURPOSE DOES CREDENTIALING SERVE?
Credentialing programs serve many purposes including, but not limited to:

• Protecting the public
• Establishing standards for professional knowledge, skills, and practice
• Assuring consumers that professionals have met standards of practice
• Meeting the requirements of governmental regulators
• Helping members of an association or organization work with governmental agencies to regulate the profession
• Developing a customized credential to meet unique needs in the marketplace, because: such a credential does not currently exist; a credential exists, but the organization wishes to differentiate itself from its competition; or because new technologies or procedures have developed into a new scope of practice or body of knowledge
• Meeting the needs of employers, practitioners, and the public to identify individuals with certain knowledge and skills
• Furthering a company’s overall business goals – that is, to ensure that consumers have access to skilled professionals knowledgeable about the company’s products and services
• Advancing the profession
• Reflecting an individual’s attainment of knowledge of a specifically defined course of study or of technical skills recognized by a manufacturer or service provider
• Providing the individual certificant with a sense of pride and professional accomplishment
• Demonstrating an individual’s commitment to a profession (and to life-long learning, if the credential is a professional certification, requiring recertification by continuing education, examination, self-assessment, etc.)

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DEFINITIONS AND DESCRIPTIONS OF TYPES OF CREDENTIALS
Credit for the sources of these definitions is shared among the resources listed in the bibliography.

Credentialing is the umbrella term that includes the concepts of accreditation, licensure, registration,
and professional certification.

Credentialing can establish criteria for fairness, quality, competence, and/or safety for professional
services provided by authorized individuals, for products, or for educational endeavors. Credentialing
is the process by which an entity, authorized and qualified to do so, grants formal recognition to,
or records the recognition status of individuals, organizations, institutions, programs, processes, services
or products that meet predetermined and standardized criteria.

The credentialing process is essentially a method for maintaining quality standards of knowledge
and performance, and in some cases, for stimulating continued self-improvement. Credentialing
confers occupational identity.

Accreditation is the voluntary process by which a nongovernmental agency grants a time-limited
recognition to an institution, organization, business, or other entity after verifying that it has met predetermined
and standardized criteria.

Professional certification is the voluntary process by which a non-governmental entity grants a
time-limited recognition and use of a credential to an individual after verifying that he or she has met
predetermined and standardized criteria. It is the vehicle that a profession or occupation uses to
differentiate among its members, using standards, sometimes developed through a consensus-
driven process, based on existing legal and psychometric requirements. The holder of a professional
certification is called a certificant.

Licensure is the mandatory process by which a governmental agency grants time-limited permission
to an individual to engage in a given occupation after verifying that he/she has met predetermined
and standardized criteria, and offers title protection for those who meet the criteria.

Registration has at least three meanings: one is the governmental process by which a governmental
agency grants a time-limited status on a registry, determined by specified knowledge-based requirements
(e.g., experience, education, examinations), thereby authorizing those individual’s to
practice, similar to licensure. Its purpose is to maintain a continuous record of past and current occupational
status of that individual, and to provide title protection.

A second meaning of registration is simply a listing of practitioners maintained by a governmental
entity, without educational, experiential, or competency-based requirements; for example, maintaining
a list of practitioners on a state ‘registry.’

A third use of the term registration is a professional designation defined by a governmental entity in
professional regulations or rules. However, the governmental regulatory body does not itself maintain
a listing or registry of those who purport to meet registration requirements. Verification and authentication
of such individuals are left to the employer of the individual claiming to be registered.

Therefore, when conducted according to legally defensible and psychometrically sound methods
and standards, credentialing, in the form of accreditation, licensure, the first form of registration, or a
professional certification, assures that a highly qualified, objective, recognized third party (the credentialing
body) has examined this person, program, product or service and found it to meet defined,
published, psychometrically sound, and legally defensible standards.

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While the following may be considered by some to be types of credentialing processes, these certificate
programs are not held to the objective standards required of the other types of credentialing programs.

A certificate program is a training program on a topic for which participants receive a certificate after
attendance and/or completion of the coursework. Some programs also require successful demonstration
of attainment of the course objectives. One who completes a professional certificate program is
known as a certificate holder. A credential is usually NOT granted at the completion of a certificate
program.

There are three types of certificate programs: knowledge-based certificate, curriculum-based certificate,
and certificate of attendance or participation.

A knowledge-based certificate recognizes a relatively narrow scope of specialized knowledge used
in performing duties or tasks required by a certain profession or occupation. This certificate is issued
after the individual passes an assessment instrument.

A curriculum-based certificate is issued after an individual completes a course or series of courses
and passes an assessment instrument. The content of the assessment is limited to the course content
and therefore may not be completely representative of professional practice (and therefore it is
not as defensible to use this or the knowledge-based type of certificate for regulatory purposes as
compared to a professional certification).

A certificate of attendance or participation is issued after an individual attends or participates in a
particular meeting or course. Usually, there is no knowledge assessed prior to issuing this type of certificate.
A certificate of attendance or participation is not a credential, because the recipients are not
required to demonstrate competence according to professional or trade standards.

(These aforementioned certificate programs should not be confused with high level, post-master’s degree
programs offered within some nursing specialties.)

PROCESSES USED IN CONDUCTING OR CHOOSING A PSYCHOMETRICALLY SOUND,
LEGALLY DEFENSIBLE CREDENTIALING PROGRAM
While professional regulation may occur on the Federal level, it is most often conducted by State professional
regulatory boards whose mission it is to protect the public by ensuring that professionals
meet Federal or State-specific credentialing requirements such as completing specific educational
and/or experiential requirements and passing an examination to demonstrate competence to practice
the profession. Only those who meet the regulatory requirements and remain in compliance with the
State professional practice act may legally practice the profession.

Some professional regulatory boards use national examinations prepared specifically for regulatory
purposes. Others recognize examinations prepared by voluntary credentialing programs. In this case,
the regulatory body must ensure that all required or recognized credentialing programs and their examinations
are developed and conducted according to legally defensible and generally accepted psychometric
principles and standards. These standards include the following:

• Standards for Educational and Psychological Testing (1999, American Psychological Association, American Educational Research Association, National Council on Measurement in Education)

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• Principles of Fairness: An Examining Guide for Credentialing Boards (Revised 2002, Council on Licensure, Enforcement, and Regulation, National Organization for Competency Assurance).
• Uniform Guidelines on Employee Selection Procedures (1978, Equal Employment Opportunity Commission, Civil Service Commission, US Department of Labor, US Department of Justice)
• NCCA Standards for the Accreditation of Certification Programs (2003, National Organization for Competency Assurance’s National Commission for Certifying Agencies)
• Engaging the services of a psychometrician is necessary to interpret and implement these standards as part of a psychometrically sound and legally defensible credentialing program.
• According to Larry Early in Starting a Certification Program, 2nd Edition, psychometrics is the science and technology of mental measurement, including psychology, behavioral science, education, statistics, and information technology.

A professional psychometrician is needed to:

• Design and analyze results of a job analysis or role delineation to define knowledge and/or skill associated with performance domains and tasks associated with the identified profession.
• Establish examination specifications based on a job analysis or role delineation.
• Select appropriate examination item format to meet measurement goals.
• Facilitate examination development based on examination specifications and item writing principles.
• Facilitate passing standard (‘cut score’) studies, such that the cut score is consistent with the
• purpose of the credential and the established standard of competence for the profession.
• Advise on examination administration policies and procedures that are appropriate, standardized, and secure.
• Analyze examination results using appropriate statistical methods.
• Establish scoring and reporting procedures, and ensure the security and confidentiality of such scores and reports.
• Ensure that the reported scores are sufficiently reliable for the intended purpose(s) of the examination.
• Ensure that different forms of an examination assess equivalent content and that candidates are not disadvantaged for taking a form of an examination that varies in difficulty from another form.
• Conduct ongoing research in the areas of reliability and validity.

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DIFFERENCES BETWEEN END OF COURSE TESTS AND PROFESSIONAL
CREDENTIALING EXAMINATIONS
According to the Education Policy and Leadership Center, high stakes testing is the use of test scores
to make decisions that have important consequences for individuals, such as tests some states require
before individuals can graduate from high school; college and graduate school admissions tests;
and credentialing (licensure, registration and certification) examinations.

Therefore, any examinations used to meet state licensure or registration requirements are considered
“high stakes” because passing such examinations allows individuals to perform professional duties as
proscribed by State or Federal regulatory bodies. End-of-course examinations should not be allowed
to substitute for professional credentialing examinations in these high stakes testing situations, because
these examinations are not designed for, and are therefore not valid for, these purposes. Educational
courses and examinations offered as part of a course or degree program are not designed to
stand alone; few if any such tests are developed and scored according to psychometrically sound principles
and standards, and therefore, are not likely to be legally defensible in making employment and
promotion decisions.

Unfortunately, sometimes confusion exists regarding the concepts of end-of-course (didactic) examinations
or educational knowledge-based certificate programs as compared to professional certification
or other professional credentialing examinations. In addition to the differentiating characteristics described
earlier in this paper, there are five major criteria that distinguish a professional credentialing
(certification, licensure or registration) examination from an end-of-course examination:

1. A professional role delineation or job analysis is conducted and periodically validated.
2. A demonstration of how the examination is linked to a defined body of knowledge, based on the professional role delineation or job analysis, is provided.
3. A demonstration of reliability and validity of the examination, based on psychometrically accepted statistical methods, is provided.
4. A minimum passing score is developed using psychometrically accepted statistical methods.
5. A demonstration that alternate forms of the examination are parallel in construction and content coverage, and equated for difficulty using psychometrically sound techniques, is provided.

In addition, when a professional credentialing examination is part of a professional certification, credential
maintenance or recertification is (or should be) required. The credential maintenance process
or recertification requirements involve the enhancement and/or the evaluation of continued competence,
with an emphasis on lifelong professional learning and development.

A knowledge-based or curriculum-based certificate program, on the other hand, often has a short ‘shelf life.’ To earn the certificate, individuals are exposed to and learn information and/or skills, and then take a test of some type. A professional disadvantage to a certificate program is that the knowledge gleaned to earn the certificate may be too generic to be useful in one’s career, or may be too narrow in its focus, or may quickly become outdated. These types of certificate programs may become insufficient in and of themselves for demonstrating continuing competence, or for moving people forward in their careers. In addition, certificates obtained at the conclusion of such courses may not be developed and are not bound by generally accepted psychometric principles, as noted above.

While curriculum-based end-of-course examinations are usually based on curriculum guidelines and
learning objectives, valid, accredited professional credentialing examinations, including licensure,

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The NOCA Guide to Understanding Credentialing Concepts The NOCA Guide to Understanding Credentialing Concepts registration, and certification examinations should be based on a professional role delineation or job
analysis. According to the National Commission for Certifying Agencies’ Standards for the Accreditation
of Certification Programs, a job analysis or role delineation study is defined as:

Any of several methods used singly or in combination to identify the performance domains and associated tasks, knowledge, and/or skills relating to the purpose of the credential and providing the basis for validation.

A role is likewise defined as:

A more specific or narrower set of knowledge and skills than may be encompassed by the term ‘profession’ or ‘occupation,’ and may also be the focus of certification for a particular product or service.

The results of the job analysis or role delineation are used to develop the blueprint or outline for the credentialing examination.

The reason that credentialing examinations are based on a job analysis and the application of knowledge in the work setting and not based solely or primarily on theoretical knowledge is grounded in concepts surrounding the legal defensibility of these examinations to regulate entry into a profession or promotion within a profession. A legally defensible credentialing examination tests the application of knowledge required to perform a specific task, not necessarily the underlying theory that serves as the foundation for this application of knowledge. This does not mean that the theory is not important, just that it is not often tested. There have been legal cases that have set precedent to support this decision to test the application of knowledge rather than theory. Individuals have argued that if they can perform the task, they should be able to become employed, whether or not they have the theoretical foundation.

Certainly one can argue that the theoretical foundation helps a professional or other certificant to understand the duties performed on the job. While this may very well be true, a credentialing examination cannot discriminate against those who do not know the theory, as long as the examination candidates can demonstrate that they have the knowledge required to perform the tasks reflected in the job analysis or role delineation.

Therefore, in summary, if state or federal regulatory bodies allow end-of-course examinations to substitute for professional credentialing examinations, they may be vulnerable to legal challenges. Questions of particular importance in the determination of whether or not a high stakes examination may be successfully defended against a legal challenge include but are not limited to these:

• How was it objectively determined that the examination measures content representative of the profession or the duties to be allowed to be performed by the professional?
• How was the passing point determined so that candidates are not penalized for taking a more difficult form of the examination?
• How can one determine if various forms of the examination are equivalent or equated in both content coverage and difficulty?

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CONCLUSION

Organizations sponsoring professional credentialing programs and State and Federal regulatory bodies share a common mission: Public protection. Optimally, if a professional regulatory body recognizes or requires examinations developed and administered by an independent credentialing organization, the organization’s professional certification programs would be accredited by the National Commission for Certifying Agencies (NCCA), the accrediting body of the National Organization for Competency Assurance (NOCA). All professional certification programs accredited by NCCA have demonstrated that they meet generally accepted psychometric principles and standards, leading to legal defensibility and public protection.

Please note that whether or not an educational institution sponsoring a course with an end-of-course examination is accredited is immaterial in this discussion, because accreditation of an educational institution does not address whether or not its end-of-course examinations are developed based on generally
accepted psychometric standards, and are therefore valid for use as ‘high stakes’ examinations. In addition, accreditation of an educational institution does not, in and of itself, assess whether or not the four standards mentioned previously in this paper as crucial to the development of psychometrically sound and legally defensible examination programs have been applied to the development of end-of-course examinations.

There is a nationwide trend whereby state regulatory agencies are getting out of the testing business, and instead recognizing professional certifications as meeting state regulatory requirements. Public protection is the core business and primary responsibility of both State and Federal regulatory agencies. As such, the examinations required of professionals regulated by these agencies must be legally defensible and meet generally accepted psychometric standards. The reader should note, however, that there are few if any legal restrictions governing certification bodies. Virtually any organization can claim to be one.

Therefore, when choosing or recommending a professional credentialing program, stakeholders should investigate key components, and determine whether or not the credentialing program is accredited, and if so, by which accrediting body. If the credentialing program is accredited by NCCA, this means that the credentialing organization has independently demonstrated that the examinations within its NCCA-accredited certification programs are developed, administered, scored and reported according to generally accepted psychometric standards and its governance and administration also meet NCCA Standards. Insisting on NCCA accreditation of a certification program is a safeguard for regulatory bodies looking to use professional certification programs or examinations when implementing professional regulatory requirements.

For more information about NOCA membership and NCCA accreditation, and the topics discussed in this paper, contact:

NOCA
2025 M Street, N.W., Suite 800
Washington, DC 20036
Phone 202.367.1165
Fax 202.367.2165
Email info@noca.org
www.noca.org

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BIBLIOGRAPHY
Certification: A NOCA Handbook, Browning, A., Bugbee, A., and Mullins, M., Editors. National Organization

1. for Competency Assurance, Washington, DC, 1996. (Note that some chapters, including the section referring to NCCA Standards, are outdated. NOCA is working to develop a second edition, likely to be published in 2006.)
2. NCCA Standards for the Accreditation of Certification Programs, National Organization for Competency Assurance’s National Commission for Certifying Agencies, 2003.
3. Principles of Fairness: An Examining Guide for Credentialing Boards, Council on Licensure, Enforcement, and Regulation, National Organization for Competency Assurance, Revised 2002.
4. Standards for Educational and Psychological Testing, American Psychological Association, American Educational Research Association, National Council on Measurement in Education, 1999.
5. Uniform Guidelines on Employee Selection Procedures, Equal Employment Opportunity Commission, Civil Service Commission, US Department of Labor, US Department of Justice, 1978.
6. Early, L.A. Starting a Certification Program, 2nd Edition, National Organization for Competency Assurance’s National Commission for Certifying Agencies, Washington, DC, 1998.
7. Impara, J.C. (Ed.) Licensure Testing: Purposes, Procedures, and Practices. Lincoln, NE: Buros Institute of Mental Measurements, University of Nebraska—Lincoln, 1995.
8. Jacobs, J.A. and Glassie, J.C. Certification and Accreditation Law Handbook, 2nd Edition, American Society of Association Executives, Washington, DC, 2004.
9. Knapp, L.G. and Knapp, J.E. The Business of Certification: A Comprehensive Guide to Developing a Successful Program, American Society of Association Executives, Washington, DC, 2002.
10. Styles, M.M. “Credentialing as a Global Profession in Progress,” in Quality Assurance Through Credentialing, Volume I, Global Perspective, American Nurses Credentialing Center Institute for Research, Education, and Consultation, Washington, DC, 1999.

This character is puzzling and enigmatic, and as his name suggests, he appears to be crazy. Certainly his behavior is peculiar, and the Cheshire Cat actually specifically warns Alice that the character is insane. However, in the books, he is never directly referred to as the Mad Hatter, although he is sometimes known as “Hatter.”

Alice first meets the Mad Hatter at a peculiar tea party. His vocation is readily identifiable from his large and ornate hat, which still bears a price tag. The Mad Hatter and the March Hare have in fact been having the same tea party for an extended period of time, ever since the Queen of Hearts declared that the Mad Hatter had murdered time by singing especially badly in a public performance. Originally sentenced to death, the Mad Hatter escaped, but decided that time had actually stopped, condemning him to an endless tea party.

At the tea party, guests switch seats constantly, and exchange scraps of conversations, peculiar verses, and strange riddles like “how is a raven like a writing desk?” When the Mad Hatter pops up again later in Alice, the Queen threatens him with decapitation after recognizing him, but he escapes to live again in Through the Looking Glass. However, he doesn’t evade his legal troubles, as he finds himself condemned for a crime he hasn’t committed yet.

Like some other Carroll characters, the Mad Hatter is probably based on a real life person. Some people believe that the character is a fictionalization of Theophilus Carter, an eccentric who would have been known to Lewis Carroll.

The Mad Hatter’s name is a reference to a common slang term, “as mad as a hatter.” The origins of this term appear to relate to the harmful chemicals which many hatters used in their trade to treat materials like felt and leather. These chemicals would have been inhaled constantly in hat manufacturing shops, causing brain damage which could have resulted in a variety of psychological symptoms.

A version that I have for some odd reason memorized

What is the difference between a stage coach?
An orange because a vest has no sleeves

I have no idea where I learned this phrase

These riddles may be part  of a basic clinical skills because they allow the clinician to assess the individuals response as part of a mental status exam –this portion of the exam looks at abstract thinking- note whether the patients’ responses are concrete, abstract, or irrelevant.  Another way to get at this is to look at similarities as in how are the two things similar a cat and a mouse- a church and a theater etc-

While our clinicians/ counselors are not trained to conduct mental status exams they should demonstrate an ability to observe and articulate what they have experienced using behavioral terms.

As an instructor or supervisor-

The purpose of supervision is competency development

Critical thinking—the goal is for the supervisee to demonstrate an ability to explain their decision making process, explain and rank the outcome of their decision making using a holistic model that illustrates an understanding of contextual and other relevant factors that impact the patient, demonstrate an ability to view the situation using different frames of reference such as the patients perspective (reframe), present an analysis of the case as it pertains to agency clinical philosophy, personal values & attitudes, demonstrate an ability to tie the case to clinical theory and best practice models,  explain the potential impact and consequence of action or inaction, explain the case using a socio-cultural perspective

Diagnostic impression- state potential diagnosis, provide examples that are tied to diagnostic criteria, verbally walk through the decision making process (Decision tree)

Explain presenting problem (what brought them in) explain relevant demographic factors, explain the case using  bio, psych, social, spiritual, legal, mental health perspectives.

State and rank issues

A wiki overview from the internet http://en.wikipedia.org/wiki/Mental_status_examination I know that the wiki is not entirely valid but this is a decent overview

MSE, is an important part of the clinical assessment process in psychiatric practice. It is a structured way of observing and describing a patient‘s current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgement.[1] There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.

The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient’s mental state, which when combined with the biographical and historical information of thepsychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning.

The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests.[2]

The MSE is not to be confused with the mini-mental state examination (MMSE) which is a brief neuro-psychological screening test for dementia.

Theoretical foundations

The MSE derives from an approach to psychiatry known as descriptive psychopathology[4] or descriptive phenomenology[5] which developed from the work of the philosopher and psychiatristKarl Jaspers.[6] From Jaspers’ perspective it was assumed that the only way to comprehend a patient’s experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives.

In practice, the MSE is a blend of empathic descriptive phenomenology and empirical clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective descriptions of a psychiatric patient (a synonym for signs and symptoms), is incompatible with the original meaning which was concerned with comprehending a patient’s subjective experience.[7][8]

Application

The mental status examination is a core skill of psychiatrists and nurses and is a key part of the initial psychiatric assessment in an out-patient or psychiatric hospital setting. It is a systematic collection of data based on observation of the patient’s behavior while the patient is in the clinician’s view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient’s insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting.[9]It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition.[10] The MSE can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings.[11]Information is usually recorded as free-form text using the standard headings,[12] but brief MSE checklists are available for use in emergency situations, for example by paramedics or emergency department staff.[13][14] The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan.

Domains

Appearance

Clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height, weight, and manner of dress and grooming. Colorful or bizarre clothing might suggestmania, while unkempt, dirty clothes might suggest schizophrenia or depression. If the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories of a particular subculture, body modifications, or clothing not typical of the patient’s gender, might give clues to personality. Observations of physical appearance might include the physical features of alcoholism or drug abuse, such as signs ofmalnutrition, nicotine stains, dental erosion, a rash around the mouth from inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor which might suggest poor personal hygiene due to extreme self-neglect, or intoxication with alcohol.[15]

Attitude

Attitude, also known as rapport,[16] refers to the patient’s approach to the interview process and the interaction with the examiner. The patient’s attitude may be described for example as cooperative, uncooperative, hostile, guarded, suspicious or regressed. The most subjective element of the mental status examination, attitude depends on the interview situation, the skill and behaviour of the clinician, and the pre-existing relationship between the clinician and the patient. However, attitude is important for the clinician’s evaluation of the quality of information obtained during the assessment.[17]

Behavior

Abnormalities of behavior, also called abnormalities of activity,[18] include observations of specific abnormal movements, as well as more general observations of the patient’s level of activity and arousal, and observations of the patient’s eye contact and gait. Abnormal movements, for example choreiform, athetoid or choreoathetoid movements may indicate a neurologicaldisorder. A tremor or dystonia may indicate a neurological condition or the side effects ofantipsychotic medication. The patient may have tics (involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette’s syndrome. There are a range of abnormalities of movement which are typical of catatonia, such as echopraxia, catalepsy, waxy flexibility and paratonia (or gegenhalten[19]). Stereotypies (repetitive purposeless movements such a rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism. More global behavioral abnormalities may be noted, such as an increase in arousal and movement (described as psychomotor agitation or hyperactivity) which might reflect mania or delirium. An inability to sit still might represent akathisia, a side effect of antipsychotic medication. Similarly a global decrease in arousal and movement (described as psychomotor retardation, akinesia orstupor) might indicate depression or a medical condition such as Parkinson’s disease, dementiaor delirium. The examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient’s emotional state). Lack of eye contact may suggest autism.[20][21][22]

Mood and affect

The distinction between mood and affect in the MSE is subject to some disagreement, for example Trzepacz and Baker (1993)[23] describe affect as “the external and dynamic manifestations of a person’s internal emotional state” and mood as “a person’s predominant internal state at any one time”, whereas Sims (1995)[24] refers to affect as “differentiated specific feelings” and mood as “a more prolonged state or disposition”. This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner’s inferences of the quality of the patient’s emotional state based on objective observation.[25]

Mood is described using the patient’s own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymicindividuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may be suffering from anhedonia.

Vincent van Gogh‘s 1889 Self Portrait suggests the artist’s mood and affect in the time leading up to his suicide.

Affect is described by labelling the apparent emotion conveyed by the person’s nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia. The intensity of the affect may be described as normal, blunted, exaggerated, flat, heightened or overly dramatic. A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders. Mobility refers to the extent to which affect changes during the interview: the affect may be described as mobile, constricted, fixed, immobile or labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one’s disability may be described as showing belle indifférence,[26] a feature of hysteria in older texts.[27][28][29]

Speech

The patient’s speech is assessed by observing the patient’s spontaneous speech, and also by using structured tests of specific language functions. This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought form and thought content (see below). When observing the patient’s spontaneous speech, the interviewer will note and comment on paralinguistic features such as the loudness, rhythm,prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity and latency of speech. A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under Cognition (see below).[30]

Language assessment will allow the recognition of medical conditions presenting with aphonia ordysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. People with autism orAsperger’s syndrome may have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia (repetition of another person’s words) and palilalia (repetition of the subject’s own words) can be heard with patients with autism, schizophrenia or Alzheimer’s disease. A person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them. Speech assessment also contributes to assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.[31][32][33]

Thought process

The paintings of the outsider artist Adolf Wölfli could be seen as a visual representation of formal thought disorder

Thought process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient’s speech. Regarding the tempo of thought, some people may experience flight of ideas, when their thoughts are so rapid that their speech seems incoherent, although a careful observer can discern a chain of poetic associations in the patient’s speech. Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem or progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and thought perseveration refers a pattern where a person keeps returning to the same limited set of ideas. A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight’s move thinking. Thought may be described as circumstantial when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Flight of ideas is typical of mania. Conversely, patients with depression may have retarded or inhibited thinking. Poverty of thought is one of the negative symptoms of schizophrenia, and might also be a feature of severe depression or dementia. A patient with dementia might also experience thought perseveration. Formal thought disorder is a common feature of schizophrenia. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders.[34][35][36]

Thought content

A description of thought content would describe a patient’s delusions, overvalued ideas, obsessions, phobias and preoccupations. Abnormalities of thought content are established by exploring individual’s thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one’s own and under one’s control, and the degree of belief or conviction associated with the thoughts.[37][38][39]

A delusion can be defined as “a false, unshakeable idea or belief which is out of keeping with the patient’s educational, cultural and social background … held with extraordinary conviction and subjective certainty”,[40] and is a core feature of psychotic disorders. The patient’s delusions may be described as persecutory or paranoid delusions, delusions of reference, grandiose delusions,erotomanic delusions, delusional jealousy or delusional misidentification. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychoses, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic passivity.Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses.

An overvalued idea is a false belief that is held with conviction but not with delusional intensity.Hypochondriasis is an overvalued idea that one is suffering from an illness, dysmorphophobia is an overvalued idea that a part of one’s body is abnormal, and people with anorexia nervosa may have an overvalued idea of being overweight.

An obsession is an “undesired, unpleasant, intrusive thought that cannot be suppressed through the patient’s volition”,[41] but unlike passivity experiences described above, they are not experienced as imposed from outside the patient’s mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. Inobsessive-compulsive disorder, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes).

A phobia is “a dread of an object or situation that does not in reality pose any threat”,[42] and is distinct from a delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview.

Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person’s mind. Clinically significant preoccupations would include thoughts of suicide, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortions of anxiety and depression. The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person’s suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life.[43]

Perceptions

A perception in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, pseudohallucinations and illusions. A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. A pseudohallucination is experienced in internal or subjective space (for example as “voices in my head”) and is regarded as akin to fantasy. Other sensory abnormalities include a distortion of the patient’s sense of time, for exampledéjà vu, or a distortion of the sense of self (depersonalization) or sense of reality (derealization).

Hallucinations can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations. Auditory hallucinations are typical of psychoses: third-person hallucinations (i.e voices taking about the patient) and hearing one’s thoughts spoken aloud (gedankenlautwerdenor écho de la pensée) are among the Schneiderian first rank symptoms indicative of schizophrenia, whereas second-person hallucinations (voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of psychotic depression or schizophrenia. Visual hallucinations are generally suggestive of organic conditions such asepilepsy, drug intoxication or drug withdrawal. Many of the visual effects of hallucinogenic drugsare more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of sensory experiences, and are not experienced as existing in objective reality. Auditory pseudohallucinations are suggestive of dissociative disorders. Deja vu, derealization and depersonalization are associated with temporal lobe epilepsy and dissociative disorders.[44][45]

Cognition

This section of the MSE covers the patient’s level of alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation. Alertness is a global observation of level of consciousness i.e. awareness of, and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporose. Orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). Attention and concentration are assessed by the serial sevens test (or alternatively by spelling a five-letter word backwards), and by testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual’s spontaneous speech and response to instructions. Executive functioning can be screened for by asking the “similarities” questions (“what do x and y have in common?”) and by means of a verbal fluency task (e.g. “list as many words as you can starting with the letter F, in one minute”). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE.

Mild impairment of attention and concentration may occur in any mental illness where people are anxious and distactible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain functioning such as delirium, dementia orintoxication. Specific language abnormalities may be associated with pathology in Wernicke’s area or Broca’s area of the brain. In Korsakoff’s syndrome there is dramatic memory impairment with relative preservation of other cognitive functions. Visuospatial or constructional abnormalities here may be associated with parietal lobe pathology, and abnormalities in executive functioning tests may indicate frontal lobe pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formalneuropsychological testing.[46]

The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. “paper-scissors-stone”). The posterior columns are assessed by the person’s ability to feel the vibrations of a tuning fork on the wrists and ankles. The parietal lobe can be assessed by the person’s ability to identify objects by touch alone and with eyes closed. A cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg’s sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again. Pathology in thebasal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements. A lesion in the posterior fossa can be detected by asking the patient to roll his or her eyes upwards (Perinaud’s sign). Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders.[47][48][49][50][51]

Insight

The person’s understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. In this context,insight can be said to have three components: recognition that one has a mental illness,compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological.[52] As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient’s explanatory account descriptively.[53]

Impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent to treatment.[54]

Judgment

Judgment refers to the patient’s capacity to make sound, reasoned and responsible decisions. Traditionally, the MSE included the use of standard hypothetical questions such as “what would you do if you found a stamped, addressed envelope lying in the street?”; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual’s executive systemcapacity in terms of impulsiveness, social cognition, self-awareness and planning ability.

Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe of the brain. If a person’s judgment is impaired due to mental illness, there might be implications for the person’s safety or the safety of others.[55]

Cultural considerations

There are potential problems when the MSE is applied in a cross-cultural context, when the clinician and patient are from different cultural backgrounds. For example, the patient’s culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations, and cognitive assessment would take the patient’s language and educational background into account. Another confounding element is the clinician’s own possible racist bias.[56][57]

Children

There are particular challenges in carrying out an MSE with young children, and others with limited language such as people with intellectual impairment. The examiner would explore and clarify the individual’s use of words to describe mood, thought content or perceptions, as words may be used idiosyncratically with a different meaning from that assumed by the examiner. In this group, tools such as play materials, puppets, art materials or diagrams (for instance with multiple choices of facial expressions depicting emotions) may be used to facilitate recall and explanation of experiences.[58]

As a general rule, the addictions treatment industry does not use instructional theory to guide instructional practice. Other similar fields; such as psychology and social work, guaranty practitioner competence through accreditation standards. Because practitioners of these industries are trained through educational institutions it is reasonable to assume that education theory underlies their instructional practice.

Second, the addictions treatment industry does not provide competency development pathways. Psychology and social work both provide pathways that illustrate a step by step educational process. For these fields, education is directly tied to licensure through evaluative processes. Educational processes are loosely tied to credentialing within the United States. State regulations may prescribe the general educational areas that are required for credentialing but they do not explicitly state what must be learned.

As addictions treatment is not the direct focus or even generally required by psychology and social work accreditation standards, these individuals may be viewed as not qualified to treat addictions. A meta issue exists in that it is not clear who leads the addictions treatment industry. The truth is that the addictions treatment industry is the one industry that does not lead itself. The majority of agencies are administrated by social workers; as credentialed counselors are generally considered to not be qualified. A disconnect exists in that that social workers do not have a direct charge or mandated initiative to lead the addictions industry.

Based on this, recruiting more social workers to the field does not address the underlying concern. The concern is operationalized as a lack of defining standards or infrastructure. The infrastructure is comprised of elements that define any area of professional practice. The elements exists as grounding principles that are defined, stated, and institutionalized as a foundation to be followed by all those who work in that profession.

Counselors cannot be connected to a laissez faire system. The field of addictions treatment currently exists as an abstract set of concepts that are individually defined and interpreted.In order to be recognized as a bona fide field we must address the above outlined requisite elements.

Education research

Clinical research

Something can only be held to be true after it has been validated through an empirical process –this is called science

Thus, evidence based is information practice that has been validated by more than one study

Click on the link below for an article on Standardized counselor Education that I had published in the September edition of Recovery Today:

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Consumers of addictions treatment services have the right to be treated by qualified practitioners. Qualified practitioners are those who have engaged in a development process that upon completion certifies them as competent to practice. Research based standards are the rules that define both competence development and professional practice.

All addictions treatment professionals have a right to field specific standardized competencies that define competence and illustrate a process for professional development.

All addictions treatment professionals have a right to clearly defined professional development processes that provide opportunities for objective assessment of requisite knowledge, skills, and attitudes.

All addictions treatment professionals have a right to be mentored by qualified addictions treatment practitioners. The term qualified indicates that they have completed a process that certifies them as competent instructors.

All addictions treatment professionals have a right to be trained within regulated academic institutions. The term regulated indicates that the programs must meet prescribed educational practice, administrative and clinical training standards. Also, that monitoring of programs is an ongoing process.

All addictions treatment professionals have a right to gain a credential that provides a guaranty of clinical and academic integrity.

All addictions treatment professionals have a right to a career ladder that is built upon a competence continuum. A competence continuum is one that illustrates competence beginning at the novice level and ending at the master level. Competence involves educational processes, relevant experience, and a demonstration of ability.

All addictions treatment professionals have a right to an individualized development plan that considers and incorporates their relevant strengths and experiences.

All addictions treatment professionals have a right and an obligation to contribute to the evolving body of knowledge that defines the field.