It took Judy Applefeld some 20 years to face her problem: She trusted no one. Ironically, the therapist she wound up seeing proved the person she could trust least of all.
After a productive 15 months of therapy, she watched her counselor's demeanor change dramatically. The therapist began hurling insults at Ms. Applefeld, grew sarcastic and even once ridiculed another client in a session.
Incredulous, Ms. Applefeld consulted other counselors who told her this behavior was clearly out of line.
In retrospect, it also seemed odd that the therapist didn't have a degree posted and that Ms. Applefeld's treatment was not covered by insurance.
She called the state Board of Professional Counselors to complain. It turned out she had no recourse: The therapist wasn't certified.
They call themselves counselors. In Maryland, anyone can adopt that title. And a slew of people, from psychics to clergy to job recruiters, has done just that. Unlike 24 other states, Maryland doesn't require licensing or certification for counselors.
A license, conferred by the state, controls a person's ability to practice. Psychiatrists, psychologists, social workers and nurses must be licensed in Maryland. Certification, which can be obtained through the state or professional organizations, merely gives someone the right to use a certain title, such as "certified professional counselor."
Currently, counselor certification -- which requires at least a master's degree in a professional counseling field, three years of experience and passing a national exam -- is voluntary here.
Unlike lawyers or doctors, who are required by law to pass exams of their governing bodies before they can practice, counselors are not compelled to prove any expertise before setting up shop.
"I wish someone would explain to me why people who work on your house have to be licensed when people who work on your head and spirit and soul don't?" asks Ms. Applefeld, 40, an interior house painter who lives in Waverly.
Although there are 1,300 "certified professional counselors" in the state, Aileen Taylor, administrator of the Maryland Board of Professional Counselors, believes it's impossible to determine how many people are in the counseling field.
"We have so many unqualified people," says Ms. Taylor. "They all are counseling and most of them have no education at all."
What complicates matters even more is the crowded mental health field. Time was, if you needed help, you visited a psychologist, psychiatrist or clergyman. But as therapy has lost its stigma and the pop psychology movement has flourished, more people are seeking guidance and more professionals -- from certified nurse psychotherapists to licensed social work associates -- are offering to listen.
The upshot for patients is that at a time when they're feeling most vulnerable, they must be sleuths to research a professional's credentials and watchdogs of their own emotional and financial fate.
There are some safeguards. Psychiatrists, psychologists, social workers and nurses are regulated by separate state boards. But while there are many competent and caring professionals in the field, an advanced degree and license are no guarantee of expert treatment.
Complaints are lodged against licensed therapists to various boards every year. While the numbers are small, they indicate consumers' growing reluctance to accept what they consider substandard care.
In the last two years, the state board for psychologists has received more than 75 complaints about the 3,000 licensed psychologists in Maryland.
And so far this year, six psychiatrists -- of the more than 1,000 in the state -- have received sanctions, ranging from a written reprimand to the revocation of a license. By comparison, only one psychiatrist was disciplined in 1988.
"In general, people trust professionals less than they used to," says Michael Plaut, an associate professor at the University of Maryland School of Medicine, who chairs a state task force to study sexual exploitation by therapists. "We're a more consumer-oriented society."
But J. Michael Compton, executive director of the state Board of Physician Quality Assurance, which regulates psychiatrists, says, "The problem with psychiatrists is that where you'd chew out your auto mechanic, you won't do that to your doctor. For years, physicians in general were looked upon as gods. . . . Now people understand they're human beings and have problems like anybody else. They're not superhuman."
In an effort to deal with increased complaints and consumer skepticism, many boards have streamlined their complaint forms and added members to deal quickly with abuses, which most often involve sexual misconduct, unprofessional behavior and fraud.
While complaints to the state psychology board used to take as long as three years to be settled, chairman Sherod Williams says they are now completed within 12 to 15 months.
And abused patients have a place to turn for other types of help. Support groups have formed for those who have been mistreated by therapists. And some psychologists now insist on giving new clients pamphlets similar to a bill of rights.
Career of catching
As the state health occupations investigator, Bill Heidel has made a career of catching licensed psychologists, social workers and certified professional counselors who are in the wrong.
Seventy-five percent of the time, he says, he gets some kind of satisfaction -- whether it's a reprimand, suspension or revocation of a license. But there are many he can't touch, he says, because they're not certified or licensed -- or simply because the allegations are "he said/she said" in nature.
Undeterred by the obstacles of his job, Mr. Heidel, a lanky man whose freckles and strawberry-blond hair remind one of Huck Finn, travels the state in his 6-year-old Ford Escort, carting his files in a blue plastic grocery bag and sticking yellow notes on his --board. They remind him to subpoena witnesses and interview sources.
"The system doesn't realize: You mess with people's minds, you mess with their lives," says Mr. Heidel, who was disappointed that a recent case -- an Anne Arundel County psychologist working with a revoked license -- wound up with the professional receiving only probation before judgment.
But therapy -- which can cost as much as $150 an hour -- is not unlike any other service: The buyer must beware. That was exactly the reaction many legislators had to a Senate bill to license counselors that was introduced during the last legislative session. An amended version passed with licensing removed from it. The only gain was voluntary certification for marriage and family therapists.
Burden of proof
"The burden is to prove that there's a problem," says Ronald Guns, a state delegate who represents the Upper Eastern Shore. "The halls of Annapolis are not filled with consumers complaining that they've been abused by professionals who are acting unprofessionally. One of the concerns is that there are thousands of different professionals you'd be licensing -- marriage and family counselors, guidance counselors, career counselors. Is the job being done sufficiently now? I think so."
But with Washington, West Virginia and Virginia requiring licensing for counselors, Maryland consumers face a greater risk, says Harriet Glosoff, assistant executive director of the American Counseling Association in Virginia.
"You have untrained people who have been told they don't cut it -- they failed a test or lacked the education in another state," she says. "They can come to Maryland and put up a shingle. It's almost like setting up a haven for those who have flunked out elsewhere."
Susan Gann, a certified professional counselor in Baltimore, says that the lack of licensing hurts respectable members of her field.
Without a license, certified professional counselors are seen as less qualified than psychologists or psychiatrists and frequently have trouble getting insurance coverage for their patients, she says.
"I am extremely proud of the training I've gotten," says Ms. Gann, who holds a master's degree in mental health from the Johns Hopkins School of Medicine and trained for three years in the hospital's psychiatry department. "Yet I'm treated like a second-class citizen by employers and insurers."
Many patients who see certified professional counselors find that insurance won't reimburse them for their visits, since the therapist is unlicensed. While licensing would virtually guarantee compensation, legislators fear it would increase health-care costs.
And some psychologists and psychiatrists worry about losing clients to licensed counselors whose fees are generally less than theirs -- sometimes by as much as 50 percent.
"There's money to be made here," says Mr. Compton. "Economics is the force behind it all. Everybody wants to keep the field as limited as possible. [Mental health professionals] want to ensure the quality of care and make sure they still have a job."
Ms. Gann states it more dramatically: "It's a turf war. They don't want to have to share their clients with us."
But Catherine Nugent, co-founder of Treatment Exploitation Recovery Network, a local group for survivors of sexual exploitation by therapists, says that licensing can sometimes lull patients into a false sense of security.
"People think that by seeing someone who's a licensed psychiatrist or psychologist that that ensures them appropriate, ethical and competent treatment. Unfortunately that isn't always the case," says Ms. Nugent, a survivor of sexual exploitation by a therapist.
License would have helped
Yet Ms. Applefeld believes that licensing might have weeded out counselors like the one she saw. Out of curiosity, she recently called Catholic University to verify that her counselor had, as she said, received her master's degree there. The school had never heard of her.
Now she is considering suing for misrepresentation, although the therapist has since closed her practice and disconnected her phone. (Efforts by The Sun to reach her were unsuccessful.)
Not only is Ms. Applefeld out $4,000 for therapy sessions, she is left with greater problems than when she started. Working with another therapist, a licensed and certified clinical social worker, she's spent many sessions unraveling how she could have been led astray by her previous counselor.
She's also had to face people who blame her for the experience, saying she should have asked more questions about the counselor's background.
"My position is that if somebody goes into the emergency room, all busted up and bleeding, do you ask for credentials before they can fix you?" she asks. "Emotionally, when you go to a therapist, you're in the same fragile state. You assume that there are rules and regulations protecting you."
What to ask before you start
Here are some questions to ask before working with a !B therapist:
* What are your qualifications and background?
* Are you licensed or certified by the state?
* Do you have a professional code of ethics? Which one?
* Have you ever been charged with unethical conduct?
* What forms of therapy will you be following?
* How much experience have you had treating this problem?
* How often would you meet?
* How much will therapy cost? How long are sessions? And do you accept insurance?
For many consumers, the mental health field has become an alphabet soup of initials and titles. Here are some of the most common professions, with the organizations that regulate them.
* Psychiatrist: A medical doctor who has completed a three-year residency in psychiatry. Psychiatrists prescribe drugs, are licensed by the Board of Physician Quality Assurance and may be certified by the American Board of Medical Specialties or the American Board of Psychiatry and Neurology.
* Psychologist: Licensed by the state Board of Examiners of Psychologists, these professionals must have a doctoral degree, two years of supervised training and pass a state and national exam.
* Social worker: There are four designations.
-- Licensed Social Work Associate (LSWA): A person who has a bachelor's in social work from an accredited school and has passed a national exam administered by the state Board of Social Work Examiners may perform social work with supervision from a higher-level professional.
-- Licensed Graduate Social Worker (LGSW): This person has a master's in social work in addition to the qualifications of the associate. (The undergraduate degree does not have to be in social work.)
-- Licensed Certified Social Worker (LCSW): Besides meeting the requirements of a graduate, this person has a minimum of two years (at least 3,000 work hours) of supervised social work experience with a licensed certified social worker or licensed certified social worker -- clinical.
-- Licensed Certified Social Worker -- Clinical (LCSW-C): A person who has a master's in social work with a clinical concentration, has met the qualifications of the graduate level and also has at least two years of supervised clinical work (at least 3,000 supervised clinical work hours) and 144 hours of direct clinical supervision.
* Certified Nurse Psychotherapist (CS-P, which stands for certified specialist -- psychotherapy): A registered nurse with a master's in nursing and a concentration in psychiatric nursing. In addition to taking a national exam to become certified by the American Nurses Association, this person is licensed as a registered nurse and certified as a nurse psychotherapist by the state Board of Nursing.
* Certified Professional Counselor (CPC): A certified professional counselor has a master's or doctorate in counseling or a related field, two to three years of supervised experience in professional counseling and has passed a national exam administered by the state Board of Examiners of Professional Counselors.
Boards examine, regulate and discipline their professions. Their
aim is to protect the public by setting qualifications, training and experience standards. To verify a professional's credentials or lodge a complaint, here are numbers.
* Board of Examiners of Professional Counselors: (410) 764-4732.
* Board of Examiners of Psychologists: (410) 764-4787.
* Board of Physician Quality Assurance (for physicians -- including psychiatrists): (410) 764-2480.
* Board of Nursing: (410) 764-5124.
A5 * Board of Social Work Examiners: (410) 764-4788.