Letters from America: A tale of two systems

Dear Shana,

It is now just over a year since I arrived in Cincinnati, Ohio. I have got my license to practice and am fortunate to have found a job that builds on my UK experience – working in early childhood.

I did lots of internet research before I arrived, but the path to licensure was still somewhat confusing. I eventually realised that each state has a psychology association and a licensing board – a bit like the UK situation with the BPS and the HPC. My state psychology association were very helpful in linking me up with people and giving me advice. I also joined a listserve hosted by the American Psychological Association (APA) for early career psychologists. I have learnt a lot through the regular questions, answers and comments that come through on those e-mails.

I found out that Ohio would not accept my supervised experience because a US psychologist had not supervised me. Luckily, Kentucky (just a 10-minute drive south) did accept my UK supervised practice. I was able to apply for a ‘temporary license’ with the State Licensing Board before I left the UK. I was fortunate to be a dual-citizen so I do not need a visa to work here.

Once I had my temporary license, I was authorised to take the computerised multiple-choice national exam, the Examination in the Professional Practice of Psychology (EPPP) and a state exam. I needed to pass both of these to obtain my ‘independent license’. The EPPP is harder and more frustrating than you would think if you are used to being able to write essays to argue points rather than deciding on the ‘right’ answer. My state exam wasn’t too bad and consisted of an oral vignette and a test on some state laws. I was lucky to have been put in touch with some other ‘early career psychologists’ who gave me helpful revision guides.

I passed those and am now independently licensed. In Kentucky that means that while there is no requirement for ongoing supervision, I must get outside supervision or consultation if I am working with an issue/client-group outside of my regular scope of practice. I chose to pay for supervision, however, in order to increase my chances of mobility to other states in the future and to help me acclimatise.

Five months after I got here, I was really excited to be offered a position as ‘Early Childhood Mental Health Specialist’ in a ‘community mental health organisation’. These organisations predominately serve people who have some level of state or federal assistance with their health care (Medicaid, Medicare and local state programmes for kids) and are the closest you get to the NHS here. In Kentucky different community mental health organisations cover different geographical areas and so the whole state is covered. I’m not sure if that is the same in other states.

The main distinction between disciplines where I work is between ‘therapist’ and ‘psychiatrist’. Although there are other distinctions (clinical social worker, marriage and family therapist, psychologist), we all get referred to as therapists. Cases are allocated based on availability and experience with that client/problem, and it is rare for cases to be transferred (e.g. for family work), unless the client has asked for a different therapist. Another difference is that there are rarely times when more than one therapist is working with a family in the same room (although you may have lots of different therapists involved with many different family members).

I have at times missed being around as many clinical psychologists as I was in my post in London (although being involved in my state psychology association has helped with this – I am on the Early Career Psychologist Committee).

My job is a mixture of consultation to daycares, training daycare workers and other therapists, and direct clinical work. On my clinical days it is expected that I book back-to-back clients throughout the day. I have ‘billable hour expectations’ to meet, i.e. hours spent in actual sessions. There is no official time for admin/making phone calls, and the assumption is that you will do that when one of your clients does not come. Only face-to-face time is billable.

Once we have done an assessment, we have to write a ‘treatment plan’ (this can be done any time up to the fourth session). We have some treatment plan templates that are diagnosis-specific and intended to outline best practice. Thereafter, following each session, a note must be made on which goals you addressed. Formulation is not a term people are familiar with, and things move directly from ‘assessment’ to ‘treatment’. There is also the flexibility to write your own treatment plan. While treatment plans can feel constrictive and overly prescriptive, the idea of routinely having documented specific goals that must be reviewed at certain points (at least every six months in my agency) has been helpful.

I have come to realise that DSM seems to primarily exist for insurance companies (and Medicaid/Medicare which is state/federal insurance). When we see a client, the organisation bills individually for that client. Without a DSM code, the insurance company will not pay. Initial diagnoses are often based on one short face-to-face intake assessment. Therapists seem to vary in how broad or specific they make their initial diagnoses (e.g. using Disruptive Behaviour Disorder Not Otherwise Specified vs. an ADHD diagnosis). These are working diagnoses and can be changed with proper documentation as your work progresses.

In my organisation, therapists have their own offices where they have a desk and computer and also see clients. Child therapists offices are much more ‘child friendly’ than in the UK. There are more toys, beanbags and cushions, and therapists often put children’s artwork on the walls. Seeing artwork on the walls when I first arrived made me think back to the service-related research I did during my training on children’s experiences of coming to a CAMHS service. They suggested having artwork on the walls, but a team meeting decided confidentiality precluded this.

I have learnt that community mental health organisations are overseen by regulating bodies who have many requirements about how files should be kept, what assessment information should be gathered, how paperwork should look, etc. Files are regularly reviewed both internally and externally. This is something that I remember happening to some extent in the NHS prior to my leaving, but which seems to occur much more frequently here.

One big surprise is how few employment laws there are in the US. Some of the things we think of as ‘fair work conditions’, Americans consider as benefits. The rumoured ‘they only get two weeks annual leave’ is fairly accurate. I get nearly three weeks and an extra week once I have worked here for 18 months. Annual leave is accrued every two weeks and sick leave seems to be managed differently by different organisations. This is an issue America-wide, and I have met clients who have lost their jobs due to sickness and had to move across the country to live back with family. Other parents have had to leave their jobs for taking too much time off to take their kids to appointments. Flexible working doesn’t really seem to exist here, and it seems a lot harder for working parents with children.

So how are things going with you?



Dear Jemma,

How nice to hear from you! I’ve finally traversed the US immigration and visa ordeal and have spent the past eight months settling into life and work in Virginia (VA).

I’m still pursuing the license to practice psychology here. After several months of persistent communication between the state board and my previous academic institutions and past supervisors, I have finally been given the go-ahead to sit the EPPP! I have recently passed the VA state exam, which wasn’t really too bad and am now in the process of ploughing through the examination prep materials for the national exam. I completely connect with the frustration you described about the multiple-choice format, especially when we’re so used to being able to discuss and deconstruct a point!

However, this positivistic approach has equipped me to navigate working life within the state-/Medicaid-funded community mental health agency I’ve been employed within for the past six months as a ‘mental health therapist’. It seems that most of the opportunities to work as a ‘clinical psychologist’ are limited to the private or academic sectors. The agency I work for sounds very similar to the organisation and encounters you’ve described, although I’m working with a different client population (adults affected by severe mental health problems). The extent of social deprivation I’ve witnessed working with the agency, which primarily addresses the needs of those that have no health insurance, housing or recourse to other public assistance due to unemployment and long histories of mental health difficulties, has been eye-opening and has certainly furnished me with a new perspective of the NHS and UK public assistance system. The pervasiveness of DSM nomenclature, which so evidently influences all areas of clinical and non-clinical activities (including the incredible amount of paperwork necessary to document and bill for client-related contacts), has been a challenging pill to swallow – and Geez, the amount of pills available to swallow sure is amazing! I’ve been struck by the extent of clinical activity that’s dictated by (mis-)diagnosis, which I have come to learn so much more about: making regular use of all five axes! I can’t help but think about what our dear old clinical director would have to say…

My biggest challenge by far, especially with a young, expanding family, are the employment and healthcare benefit systems. It pains to me say that I am also coming to terms with the minimal leave (not only annual, but also sick and maternity leave). I have also been struck by the ‘employment-centric’ organisation of everyday life over here, to the extent that all other aspects of life (e.g. healthcare, family life, etc.) are governed by employment status. As for the healthcare system, well, that deserves a follow-up letter… Look forward to catching up with you soon!


If anyone is thinking of making the move to the USA, Jemma and Shana say they would be happy to try to help you out.

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