The Senate Committee on Commerce and Labor was called to order by Chairman Randolph J. Townsend, at 9:30 a.m., on Monday, March 1, 1999, in Room 2135 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

COMMITTEE MEMBERS PRESENT:

Senator Randolph J. Townsend, Chairman

Senator Ann O’Connell, Vice Chairman

Senator Dean A. Rhoads

Senator Raymond C. Shaffer

Senator Michael A. (Mike) Schneider

Senator Maggie Carlton

COMMITTEE MEMBERS ABSENT:

Senator Mark Amodei (Excused)

STAFF MEMBERS PRESENT:

John L. Meder, Committee Policy Analyst

Ardyss Johns, Committee Secretary

OTHERS PRESENT:

Chairman Townsend opened the meeting with the introduction of Senate Bill (S.B.) 218.

Helen A. Foley, Lobbyist, Marriage and Family Therapists, told the committee Marriage and Family Therapists (MFT) was a profession over 20 years old in the State of Nevada and added there were more MFTs here than any other mental health profession. She presented a packet of information (Exhibit C) outlining what MFTs are, what they do, where they work, etc. She said they are recognized by the National Institute of Mental Health as one of five core mental health professionals and claimed they are the fastest growing discipline with over 60,000 MFTs in the United States.

Ms. Foley drew attention to the first page of Exhibit C which lists a number of services provided by MFTs and stated those services include crisis intervention after catastrophic incidences, such as a shooting at an elementary school. She said unlike psychologists who do the longer-term testing and analysis, the MFT diagnoses the problem and tries to find solutions. Ms. Foley pointed out they work very closely with managed care organizations and have major contracts with those organizations. They also work with the State of Nevada in victims of crime programs and with the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and are recognized by the federal government in many areas. She mentioned domestic violence intervention as another service provided by MFTs and explained the whole family setting has to be analyzed in order to resolve the issues involved. Ms. Foley said they are the largest group who deal with divorce mediation and told the committee the court system now mandates people going through a divorce to take a special course taught by MFTs. She stated because many problems are created due to drugs and alcohol, MFTs provide counseling in that area also.

Ms. Foley said MFTs work in several settings such as hospitals, community resource centers, family and child treatment centers and even the Red Cross, as well as those in private practice. She referred to Nevada Revised Statute (NRS) 433B.090 wherein licensed MFTs are recognized as individuals professionally qualified in the field of psychiatric mental health along with psychiatrists, psychologists and social workers with master’s degrees. She declared MFTs are well recognized as an organization that diagnoses and treats, as noted in NRS 49.296. Ms. Foley told the committee social workers had been codified in 1987, in NRS 641B.030, in their ability to diagnose mental and emotional conditions. She said the fact that this was not done by MFTs at that time, was strictly an oversight since the educational level of social workers does not in any way exceed that of MFTs. She explained the only change the Marriage and Family Therapists Association is seeking in S.B. 218 is to add the word "diagnosis" in section 2, subsection 1 in order to codify existing practice.

Ms. Foley said the other changes in the bill were a result of a request by the Board of Marriage and Family Therapists and were summarized in Exhibit D. She pointed out a couple of questions had been raised by John Meder, Committee Policy Analyst, Research Division, Legislative Counsel Bureau. The first one she said, was in regards to page 1, line 3, which states, "The board or any member thereof may issue subpoenas…." She noted "or any member thereof" could be removed. She said also questioned was the word "ex parte" on line 10 of page 1 and stated the board had no objection to removing it also.

Ms. Foley concluded the final change in the bill increases the fee for the exam to $250 since the current fee of $200 was not even enough to rent the room in which the exam was given.

Senator O’Connell clarified the Marriage and Family Therapist Association is separate from the Board of Marriage and Family Therapists.

Chairman Townsend asked what was occurring in the current state of practice that required the change to include diagnosis.

Stephen Sprinkel, President, Board of Examiners for Marriage and Family Therapists, stated all mental health care providers make their diagnosis by referring to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). He said it is the bible of diagnosis and for two and a half decades, MFTs in this state have been making diagnoses from it and being reimbursed by health care organizations and insurance companies. He reiterated Ms. Foley’s testimony stating the change would only codify what has been, in fact, the practice all along.

Mr. Sprinkel acknowledged there are many diagnoses in the book that MFTs are not qualified to make, but pointed out there are diagnoses as well that cannot be made by psychiatrists or psychologists. He said just because there are certain diagnoses a therapist cannot make, it does not mean they cannot make diagnoses. The issue then, he stressed, is not whether or not MFTs can diagnose, but what they are competent to diagnose. He stated further MFTs in Nevada are required, in their graduate training at both universities, to take course work in diagnosis, and claimed in 26 years there has never been a complaint to the MFT board of misdiagnosis or incompetence. In conclusion he reiterated the object of S.B. 218 is simply to bring the language up to par with what has been the practice of MFTs all along.

Richard Vande Voort, Vice President, Board of Examiners for Marriage and Family Therapists, told the committee he was an adjunct faculty member of the counseling department at the Greenspun College of Urban Affairs, University of Nevada, Las Vegas (UNLV). He said the educational requirements that allow MFTs the privilege of diagnosis are stringent with a course specifically for appraisal and diagnosis. Before they are awarded a master’s degree, he added, they work with Ph.D.s from the university in a supervisory role for 600 hours of internship, and after the degree is awarded come under the auspices of the board of examiners. He declared at that time, there are 1500 hours of internship with 1000 hours direct client contact in which they work with supervisors approved by the MFT board. These postgraduate requirements generally last about 2 years he stressed.

Mr. Vande Voort stated there exists camaraderie among psychologists, psychiatrists, social workers and the MFTs and added there is a hard-core trend of cooperation in all of these areas.

Senator O’Connell, addressing the issue of subpoena power asked if over the past year or two the number of cases has grown so as to require the need for subpoena power. Mr. Sprinkel responded stating the attorney general’s office and not the Board of Marriage and Family Therapists had requested that particular change.

Senator O’Connell asked about the change on line 30 of S.B. 218 from "doing" research to "conducting" research, and Mr. Sprinkel said it was just a language change by the Legislative Counsel Bureau.

Senator O’Connell called attention to the last line of the bill and asked if that too had been requested by the attorney general. Mr. Sprinkel said it had been requested by the Board of Marriage and Family Therapists as one way to recover some of the increased costs incurred by the board for investigations and disciplinary hearings, which are continuing to skyrocket.

Senator O’Connell inquired as to the average case cost and Mr. Sprinkel told her of two with which he was familiar; one costing approximately $12,000 and the other approximately $16,000. Those costs, he said, were for investigative work from private investigators, attorney fees, the cost of paying board members to attend meetings, and the cost of meeting rooms in which to hold those meetings.

Senator Townsend referred to page 3, line 14, regarding an administrative fine of not more that $5,000, and Mr. Vande Voort claimed it was the board’s intent to replace that line with lines 16 and 17.

Deborah R. Roberts, Legislative Chair, Nevada Association for Marriage and Family Therapy, told the committee her credentials were numerous including national and managed health care organizations and preferred provider lists. She said the Human Behavior Institute in Las Vegas, Health Management Center, Value Options, United Behavioral Health Care and United Health Care also credentialed her. She stated she had contracts with three employee assistance programs (EAPs) and worked with the Victims of Crime Program which is a State of Nevada program, and the Victim Witness Assistance Center in dealing with sexual assault victims and children who have been sexually abused.

Ms. Roberts, after naming several other programs with which she had worked, told the committee that in addition to MFTs being scrutinized by the Board of Examiners for Marriage and Family Therapists, they are watched very closely by the organizations with which they get involved as managed care. She said they have to fill out applications that are often one and a half to two inches thick for these organizations who want to know what education, continuing education, formal education in graduate programs and what kind of experience MFTs have. Those organizations send out quality assurance evaluation forms to clients she added, in order to get feedback on MFTs just as they do for a psychiatrist, psychologist and licensed clinical social workers. Therefore, she remarked, MFTs have an ethical and moral obligation to do what is right and an ethical standard they follow, set forth by the American Association for Marriage and Family Therapy.

Ms. Roberts gave the committee an example of the kind of diagnosis seen in the typical marriage and family practice. She told of two siblings, two-and-a-half and four years old who were suffering from the experience of a car accident 6 months earlier. She said they would become hysterical if their mother started the car before they were in their seat belts, as well as having night terrors, waking in the middle of the night screaming. The diagnosis for these children, she maintained, was post-traumatic stress disorder which she had determined with the DSM-IV used by all mental health professionals and is considered by them, as Mr. Sprinkel pointed out earlier, the bible of diagnosis. After giving other examples of cases in which she had made diagnosis according to the criterion in the DSM-IV, Ms. Roberts concluded by telling the committee MFTs have been doing these diagnoses for years and encouraged the committee to "vote yes on S.B. 218."

Robert G. Whittemore, Ph.D., Lobbyist, speaking for Nevada Board of Psychological Examiners, identified himself as Licensed Psychologist No. 9, in the State of Nevada and stated there was nothing in S.B. 218 except the word "diagnosis" to which he objected both as an individual psychologist and on behalf of the Board of Psychological Examiners. He read from prepared testimony (Exhibit E), which stated in summary because MFTs have only a master’s degree they are not qualified to make diagnosis, which can only be made by psychologists and psychiatrists, both of whom must possess an earned doctorate. He stated he had not been aware at the time he prepared his testimony, that UNLV offered a course in diagnosis per Mr. Vande Voort’s testimony. However, he added, he doubted if that course included training in biological bases of behavior or the use of diagnostic statistical classifications.

Dr. Whittemore read through a long list of courses required by psychologists to diagnose, and said it totaled 90 semester hours. He also said he was sure there were not many MFTs with that number of hours. He concluded diagnosis would be an unwarranted expansion of MFTs scope of practice and the board would have no control over them.

Senator O’Connell asked Dr. Whittemore if he knew if any other states allow the word "diagnosis" in their laws governing MFTs. Dr. Whittemore replied he did not.

Louis F. Mortillaro, Ph.D., Board of Psychological Examiners, stated in all his capacities as president of the board and as a licensed psychologist, he was opposed to the word "diagnosis" as written in S.B. 218. He said psychological text, articles and books on diagnosis all say that accurate diagnosis is most important in defining the problem, giving the prognosis and outlining treatment options. An incorrect diagnosis he added, will delay treatment, and at its worst lead to ineffective, dangerous treatment to the public. He stressed once made, diagnostic errors can be difficult to reverse as it passes along from one clinician to another via the individual’s records and charts.

Dr. Mortillaro pointed out accurate mental health diagnosis was facilitated by a number of rules and principles, most of which were logically and empirically derived. He said one could not ethically learn diagnostic skills from a one-time workshop or a class on how to use the DSM-IV in ones clinical practice, but are best learned in an academic program along with supervised experience. He told the committee if S.B. 218 were passed as written, it would allow MFTs to practice beyond their scope of practice which is limited to adjustment problems in the area of marriage, family or personal relationships. In conclusion, Dr. Mortillaro urged the committee to protect the public by not allowing MFTs to diagnose mental disorders because, he said, it was beyond their education, training and experience and recommended the word "diagnosis" be omitted from S.B. 218.

Christa Peterson, Ph.D., Licensed Psychologist, Deputy Administrator, Southern Regional Services, Division of Child and Family Services, Department of Human Resources, mentioned though she was a State of Nevada employee, she was testifying as a private citizen and licensed psychologist. She told the committee she had served on the board of psychology in Nevada for 10 years, 5 of those as president, and was currently on the Board of Directors of the Association of State and Provincial Psychology Boards. Their mission she explained, is to protect the public by bringing together mental health regulatory boards across the United States and Canada. She said based on her experience in the field of regulation, adding the word "diagnosis" to S.B. 218 presents a threat to the public by significantly expanding the scope of practice for MFTs without any increase or addition to the training requirements for that profession.

Dr. Peterson maintained with their current training, MFTs may treat individuals with adjustment problems; however, she added they are not able to diagnose those individuals without much broader and more extensive training. This is because, she stressed, identifying a diagnosis of adjustment problems requires skill and ability to rule out many other, more serious conditions that show similar symptoms. She said there are over 350 diagnostic categories listed in the DSM-IV and only 7 of these diagnoses are considered adjustment problems. Therefore she continued, subsequent course work and supervised experience with the 343 other disorders, is necessary to properly diagnose.

Dr. Peterson asked the committee to consider the consequences of having individuals with insufficient training perform the diagnostic process and stated misdiagnosis of a mental health problem is as serious as misdiagnosis of a medical problem. She said a patient who presents with a complaint of poor interpersonal relations, must be evaluated for a range of disorders from mental retardation to schizophrenia, depression or substance abuse. Specialized psychological testing, she pointed out, which can only be done by a licensed psychologist, is often necessary to rule out or confirm some of these diagnoses. Dr. Peterson concurred with both Dr. Whittemore and Dr. Mortillaro in recommending the deletion of diagnosis from S.B. 218.

Shelley Chase, M.A., Executive Director, Nevada State Psychological Association, presented to the committee a packet of information (Exhibit F) she said would substantiate the information provided in testimony to be given by Dr. Paul Saskin.

Paul Saskin, Ph.D., Licensed Psychologist, President, Nevada State Psychological Association, read his testimony from Exhibit F which also contained a copy of a letter dated December 11, 1997, from Stephen L. Sprinkel to MFT licensees and interns. Information about a Diagnosis Training Workshop and a registration form to be completed by those planning to attend the workshop was attached to Mr. Sprinkel’s letter.

Dr. Saskin’s testimony reiterated the testimony given by Dr. Whittemore, Dr. Mortillaro and Dr. Peterson. He asked the committee to note in the December 11, 1997, letter written by Mr. Sprinkel, the only training required by the State of Nevada Board of Examiners for Marriage and Family Therapist, in order to be able to diagnose, was one 8-hour training workshop in the use of DSM-IV.

Chairman Townsend asked Ms. Foley if she had spoken with the people from the Board of Psychological Examiners. She replied she had not personally spoken with the board but said she was quite shocked at their testimony since MFTs work with the psychologists on a weekly basis. Ms. Foley added, in answer to Senator O’Connell’s earlier question, there are 42 states whose laws associate the word "diagnosis" with MFTs. She said those MFTs are extremely limited because it applies only to their scope of practice.

Ms. Foley told the committee social workers have no more training than MFTs and yet they have been approved to diagnose. She pointed out drug and alcohol counselors who are certified are also approved to diagnose, and they have less training than MFTs. She stressed if the committee wanted only people with Ph.D.'s to diagnose, they should not have allowed others to diagnose.

Chairman Townsend closed the hearing after announcing that further testimony on S.B. 218 would be taken in a subcommittee meeting to be chaired by Senator Carlton.

There being no further business, the meeting was adjourned at 10:30 a.m.

RESPECTFULLY SUBMITTED:

Ardyss Johns,

Committee Secretary

APPROVED BY:

Senator Randolph J. Townsend, Chairman

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