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Study of a Proposal to Mandate the Inclusion of Marriage and Family Therapists Within Mental Health and Alcohol and Drug Abuse Treatment Insurance Benefits

Report No. 00-01


The Legislature, through Senate Concurrent Resolution No. 26, Senate Draft 1, of the 1999 session requested the State Auditor to study the social and financial impacts of mandating the inclusion of marriage and family therapy (service) within mental health and alcohol and drug abuse treatment insurance benefits. The resolution referred to Senate Bill No. 860, House Draft 1, as the measure proposing this coverage. However, the senate bill proposed to mandate the inclusion of marriage and family therapists (provider) within mental health and alcohol and drug abuse treatment benefits. Our study was conducted pursuant to Senate Bill No. 860, House Draft 1, and the criteria set forth under Sections 23-51 and 23-52, Hawaii Revised Statutes (HRS).

Marriage and family therapy is defined as the application of psychotherapeutic and family systems theories and techniques to diagnose and treat mental, emotional, and nervous disorders within the context of an individual's relationships. Therapists help people with childhood and adolescent problems, marriages in crisis, and families needing assistance with senior parents. They also provide assistance in the areas of domestic violence, physical and sexual abuse, and substance abuse. The National Institute of Mental Health has recognized the field of marriage and family therapy as a core mental health discipline.

Currently, Hawaii and 41 states regulate marriage and family therapists. Marriage and family therapists in Hawaii receive title protection under Chapter 451J, HRS. Members of other licensed professions, such as physicians, psychologists, social workers, or registered nurses may practice marriage and family therapy within the accepted standards of their professions. They may not, however, use the title of marriage and family therapist unless they have been so licensed. As of August 1999, there were 59 licensed marriage and family therapists in Hawaii. Of these, seven were also certified as substance abuse counselors.

Senate Bill No. 860, House Draft 1 would designate marriage and family therapists as one of the types of practitioners covered under Chapter 431M, HRS, to prescribe, perform, and/or supervise the provision of alcohol or drug dependence nonresidential (outpatient) treatment services, day treatment services, mental health nonresidential treatment services, and partial hospitalization services. The proposed legislation would also allow marriage and family therapists to make determinations of whether the services covered under Chapter 431M, HRS, are medically and psychologically necessary. Finally, marriage and family therapists would be given the authority to approve individualized treatment plans that outline the covered services needed to produce remission or improve a patient's condition.

Enacting Senate Bill 860, House Draft 1, would have limited social or financial impact in Hawaii. There is little known public demand to include marriage and family therapists under Chapter 431M, HRS. Only a small portion of the public use marriage and family therapy to treat mental illness or substance abuse and even fewer see marriage and family therapists for treatment. Physicians, psychologists, clinical social workers, and advanced practice registered nurses are currently available to provide any necessary marriage and family therapy services. Thus the lack of the proposed coverage would not result in individuals being unable to obtain necessary treatment.

Passage of the legislation might have a negative impact on the quality of health care. There are concerns about marriage and family therapists' qualifications to provide the mental health and substance abuse illness services described in Chapter 431M, HRS. Various groups reported that the scope of practice is beyond the training and experience of marriage and family therapists. Exposing consumers to the potential risk appears unnecessary because other licensed and qualified health providers are currently providing the necessary services.

Finally, it is unclear whether the bill would actually require health plans to include marriage and family therapists as network providers. Insurers noted that the bill gives the appearance of expanded services but does not require health plans to include all providers mentioned in Chapter 431M, HRS. Senate Bill No. 860, House Draft 1, will require clarification.

Recommendations and Response

We made no formal recommendations. The Department of Health's response to our draft report noted that a licensed marriage and family therapist would need to be certified as a substance abuse counselor in order to provide substance abuse treatment under Chapter 431M, HRS.

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