Justice Boyd delivered the opinion of the Court.
Over twenty years ago, the Texas State Board of Examiners of Marriage and Family Therapists (the Therapists Board) adopted a rule that permits licensed marriage and family therapists (MFTs) to provide "diagnostic assessment ... to help individuals identify their emotional, mental, and behavioral problems." Nearly ten years ago, the Texas Medical Association filed this suit asserting that the rule is invalid because the Texas Occupations Code does not authorize MFTs to provide diagnostic assessments. The Medical Association asserts that, subject to a few exceptions that do not include MFTs, only those who are licensed to practice medicine may provide a diagnostic assessment. We conclude that the Code authorizes MFTs to provide the type of diagnostic assessment the rule permits. We reverse the court of appeals' judgment and render judgment that the rule is valid.
The Texas Licensed Marriage and Family Therapists Act (the Therapists Act) regulates the practice of marriage and family therapy in Texas. TEX. OCC. CODE §§ 502.001-.455. "Marriage and family therapy" means "providing professional therapy services to individuals, families, or married couples, alone or in groups, that involve applying family systems theories and techniques." Id. § 502.002(6). The Therapists Act expressly provides that these professional therapy services include "the evaluation and remediation of cognitive, affective, behavioral, or relational dysfunction in the context of marriage or family systems." Id.
In 1994, the Therapists Board, relying on this statutory authority, adopted a rule listing specific therapeutic services that MFTs may provide. See 22 TEX. ADMIN. CODE § 801.42. In addition to various types of therapies, consultations, referrals, and other services, the rule permits MFTs to provide "[d]iagnostic assessment which utilizes the knowledge organized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) ... as part of their therapeutic role to help individuals identify their emotional, mental, and behavioral problems when necessary." Id. § 801.42(13).
The DSM, published by the American Psychiatric Association, is a comprehensive collection of information regarding a wide range of mental disorders. To promote consistency in the identification of mental disorders, the DSM provides diagnostic classifications, criteria, and descriptions of mental disorders based on the presence or absence of particular signs, symptoms, and features.
The Therapists Board and its amici contend that the ability to provide diagnostic assessments using the DSM is essential to an MFT's practice. When necessary to assist a client, MFTs perform DSM-based diagnostic assessments to identify a client's mental disorder, develop a proper treatment plan, determine the client's eligibility for various services, consult with physicians and other health professionals about the client, provide statistical information to government health agencies and private health institutions, and obtain insurance payments for their services. According to the Board and its amici, if MFTs cannot provide a diagnostic assessment using the DSM, they simply cannot provide adequate marriage and family therapy, and Texans would lack a substantial source of mental health care at a time when the shortage of such care has reached crisis levels.
In 2008, fourteen years after the Therapists Board adopted rule 801.42(13),
In response, the Therapists Board and its amici do not assert that their practice requires or that the rule permits them to provide diagnostic assessments of every kind of mental disorder. They concede that the rule does not permit them to provide a "medical" diagnosis or any diagnosis that requires them to act beyond their area of expertise and level of training. But they contend that both the Therapists Act and the rule authorize them to diagnose some "nonmedical" disorders like relational dysfunction, adjustment disorder, mood disorder, anxiety disorder, behavioral dysfunction, sexual dysfunction, anorexia, depression, conduct disorder, personality disorder, and addiction, which are DSM diagnoses that relate to conditions often caused not by medical issues but by psychological and social experiences like sexual abuse, physical abuse, trauma, domestic violence, physical illness, and loss.
In the trial court, the parties filed cross-motions for summary judgment on the Medical Association's declaratory-judgment claim. The court granted the Association's motion, denied the Board's motion, and entered judgment declaring the diagnostic-assessment rule invalid because it "exceeds the scope" of the Therapists Act. The court of appeals affirmed. 458 S.W.3d 552, 560 (Tex.App.-Austin 2014).
In defense of the diagnostic-assessment rule, the Therapists Board and its amici note that the DSM itself permits MFTs to
Accepting all of that as true, however, we must decide this case based on the relevant Texas statutes, not on whether MFTs are qualified to make DSM diagnoses or whether the DSM or other states' laws allow them to. As a state administrative agency, the Therapists Board has only those powers that the Texas Legislature has expressly conferred upon it and those implied powers that are reasonably necessary to carry out its statutory duties. Public Util. Comm'n of Tex. v. City Pub. Serv. Bd., 53 S.W.3d 310, 315 (Tex. 2001). As such, it can adopt "only such rules as are authorized by and consistent with its statutory authority." R.R. Com'n of Tex. v. Lone Star Gas Co., 844 S.W.2d 679, 685 (Tex. 1992) (quoting State Bd. of Ins. v. Deffebach, 631 S.W.2d 794, 798 (Tex. App.-Austin 1982, writ ref'd n.r.e.)). Courts generally presume that agency rules are valid, so parties who challenge a rule have the burden of proving its invalidity. See Harlingen Family Dentistry, P.C. v. Tex. Health & Human Servs. Comm'n, 452 S.W.3d 479, 481 (Tex. App.-Austin 2014, pet. dism'd).
To meet its burden, the challenging party must show that the rule's provisions are not "in harmony with the general objectives of the act involved." Edgewood Indep. Sch. Dist. v. Meno, 917 S.W.2d 717, 750 (Tex. 1995) (citing Gerst v. Oak Cliff Sav. & Loan Ass'n, 432 S.W.2d 702, 706 (Tex.1968)). We discern those "general objectives" from the plain text of the statutes that grant or limit the agency's authority. Pruett v. Harris Cty. Bail Bond Bd., 249 S.W.3d 447, 454 (Tex. 2008); Rodriguez v. Serv. Lloyds Ins. Co., 997 S.W.2d 248, 254 (Tex. 1999). Generally then, the objecting party must show that the rule: (1) contravenes specific statutory language; (2) runs counter to the general objectives of the statute; or (3) imposes additional burdens, conditions, or restrictions in excess of or inconsistent with the relevant statutory provisions. Moers v. Harris Cty. Appraisal Dist., 469 S.W.3d 655, 664 (Tex. App.-Houston
Applying the relevant Texas statutes here, we conclude that the rule is valid because (A) the Therapists Act authorizes MFTs to provide diagnostic assessments using the DSM as the rule describes, and (B) the Medical Practice Act does not negate that authorization.
We begin by determining whether the Therapists Act authorizes the diagnostic-assessment rule. As noted, the Therapists Act authorizes MFTs to engage in "the evaluation and remediation of cognitive, affective, behavioral, or relational dysfunction in the context of marriage or family systems." TEX. OCC. CODE § 502.002(6). The rule, in turn, authorizes MFTs to provide a "[d]iagnostic assessment which utilizes [the DSM] as part of their therapeutic role to help individuals identify their emotional, mental, and behavioral problems when necessary." 22 TEX. ADMIN. CODE § 801.42(13). We conclude that the Therapists Act authorizes the diagnostic-assessment rule.
The Medical Association does not dispute that, by authorizing MFTs to provide an "evaluation," the Therapists Act permits MFTs to make "assessments." See WEBSTER'S THIRD NEW INTERNATIONAL DICTIONARY 131 (2002) [hereinafter WEBSTER'S] (defining "assessment" as "an appraisal or evaluation"). In fact, the Association's counsel confirmed at oral argument that the Association "would be fine" if the Therapists Board would simply amend the rule to delete the word "diagnostic" and instead provide that MFTs can make "assessments using the DSM...." But by referring to a "diagnostic assessment," the Association contends, the rule authorizes more than the "evaluation and remediation" that the Therapists Act permits. In response, the Therapists Board asserts that deleting the word "diagnostic" would not resolve the parties' real dispute because the rule authorizes "assessments" using the DSM — the "D" standing for "diagnostic" — so DSM assessments are necessarily "diagnostic" assessments, at least as the DSM uses that term.
Because the statute and the rule do not define these key terms, we must apply their common, ordinary meaning unless a contrary meaning is apparent from the statute's language.
The common, ordinary meaning of the Therapists Act's term "evaluate" is "to examine and judge concerning the worth, quality, significance, amount, degree, or condition of" something. WEBSTER'S at 786. The term "remediation" refers to "the act or process of remedying," and a "remedy" is "something that relieves or cures a disease." Id. at 1920; see STEDMAN'S MEDICAL DICTIONARY 1219 (1982) [hereinafter STEDMAN'S] (defining "remedy" as an "agent that cures disease or alleviates its symptoms"). "Diagnostic" means "adapted to or used for the furthering of diagnosis" or "serving to distinguish, identify, or determine." WEBSTER'S at 622.
Relying on these definitions, the Therapists Board argues that the terms "evaluate," "assess," and "diagnose" essentially have the same meaning in this statutory
In response, the Medical Association contends that, unlike an evaluation or assessment, a diagnosis involves the specific act of "identifying" or naming a condition as a specific disease or disorder. Noting that no commonly accepted definition of evaluation includes the "identification" of diseases, the Association argues that an evaluation or assessment "may be part of the process of arriving at a diagnosis, but the terms are not synonymous and the term evaluation does not include diagnosis." In support, the Association notes that even the Therapists Board has acknowledged that the terms are not synonymous by adopting a rule that requires MFTs to "base all services on an assessment, evaluation, or diagnosis of the client." 22 TEX. ADMIN. CODE § 801.44(s) (emphasis added). By authorizing MFTs to evaluate — but not diagnose — conditions, the Association contends, the Therapists Act excludes diagnosing from the practice of marriage and family therapy.
We agree with the Medical Association that the term diagnose typically involves the identification or naming of a condition, but we disagree with its narrow construction of the term evaluate in this context. To evaluate includes not only to assess the value, amount, or quality of a thing, but also to "judge" the thing's significance, quality, or condition. WEBSTER'S at 786 (defining "evaluate" to mean "to examine and judge concerning the worth, quality, significance, amount, degree, or condition of" something); see also WEBSTER'S NEW WORLD COLLEGE DICTIONARY 502 (5th ed. 2016) (defining "evaluate" to mean "to judge or determine the worth or quality of; appraise"). To evaluate, in other words, means not merely to inspect, examine, or review, but also to make a determination regarding that which is inspected, examined, or reviewed. Within the context of marriage and family therapy, to judge or to find the nature of a dysfunction is to identify the dysfunction so that it can be properly treated. A therapist who merely examines, assesses, or reviews a client's condition without making a determination regarding the nature of that condition cannot adequately "remediate" the condition as the Therapists Act requires. And the determination regarding the nature of a dysfunction is commonly known as a diagnosis.
The Medical Association contends that within the context of the Occupations Code the term "diagnosis" refers to a service that is necessarily distinct from an "evaluation." In support, the Association notes that several of the Code's provisions refer to the two terms separately and often in the disjunctive. See, e.g., TEX. OCC. CODE §§ 159.002(b) (referring to a "record of the identity, diagnosis, evaluation, or treatment of a patient"); .004(7) (referring to "the diagnosis, evaluation, or treatment of the patient"); 162.102(b)(2) (referring to "patient evaluation, diagnosis, counseling, and preparation"); 201.402(b) (referring to "the identity, diagnosis, evaluation, or treatment of a patient").
Other Code provisions, however, refer to the terms in a manner that demonstrates
We thus conclude that the term evaluate, as used in the Therapists Act, encompasses an assessment that includes the determination or identification of the dysfunction to be treated. So with regard to the rule at issue, we conclude that the Medical Association makes too much of the rule's use of the word "diagnostic." See Nat'l Fed'n of Fed. Emps., Local 1309 v. Dep't of Interior, 526 U.S. 86, 93-94, 119 S.Ct. 1003, 143 L.Ed.2d 171 (1999) ("[T]hese linguistic arguments ... make too much of too little."). The rule uses the term "diagnostic" as an adjective within the phrase "diagnostic assessment." An adjective either describes a noun or limits it. See BRYAN A. GARNER, THE REDBOOK: A MANUAL ON LEGAL STYLE 202-03 (3rd ed., 2013); see also THE CHICAGO MANUAL OF STYLE 165 (15th ed., 2003) ("An adjective is a word that adds a new idea to a noun or pronoun either by describing it more fully (a descriptive adjective) or by narrowing a noun's or pronoun's meaning (a limiting adjective)."). The rule thus uses the term "diagnostic" to either limit or more fully describe the type of assessments that MFTs can make.
In either case, "diagnostic assessment" is not broader than "assessment," and thus is not broader than the "evaluation" the Therapists Act authorizes. See Jaster v. Comet II Const., Inc., 438 S.W.3d 556, 566 (Tex. 2014) (plurality op.) (stating
The Medical Association argues that, because the term diagnosis means the identification of a disease or disorder, the Therapists Act cannot be construed to authorize diagnosing under the DSM because it only authorizes the evaluation of a "dysfunction." According to the Association, a dysfunction is a symptom, not a disease or disorder that causes a dysfunction. Thus, even if the Therapists Act authorizes MFTs to identify or determine a "dysfunction in the context of marriage or family systems," TEX. OCC. CODE § 502.002(6), it does not authorize them to identify a mental disorder under the DSM.
We are not convinced. Based on their common, ordinary, and even medical meanings, diseases and disorders are merely types of dysfunctions. See MOSBY'S MEDICAL DICTIONARY (8th ed. 2009) (defining "disease" as "a condition of abnormal vital function involving any structure, part, or system of an organism"); THE AMERICAN HERITAGE MEDICAL DICTIONARY (2007) (defining "disorder" as a "disturbance or derangement that affect the function of mind or body"). "Disease" and "disorder" are often interchangeable, see WEBSTER'S at 648 (defining disease to include a "disorder or derangement (as of the mind)"); STEDMAN'S at 403 (defining "disease" to include a "disorder of bodily functions, systems, or organs"), and a disorder — a "derangement of function," WEBSTER'S at 652 — is a type of dysfunction, id. at 711 (defining dysfunction as "impaired or abnormal functioning (as of an organ of the body)" or "a nonadaptive trait or condition").
Noting that perceived symptoms of mental disorders may instead be symptoms of a physical disorder, the Association suggests that we cannot construe the Therapists Act to authorize MFTs to diagnose mental disorders because any mental disorder that has a "medical component" is beyond MFTs' expertise and outside of their authorized practice. But the Therapists Board does not contend — and we do not conclude — that the Therapists Act authorizes MFTs to diagnose all human dysfunctions. Under the Act, an MFT's services — including any evaluation — must "involve applying family systems theories and techniques" and be made "in the context of marriage or family systems." TEX. OCC. CODE § 502.002(6).
The Medical Association argues, however, that the rule at issue is invalid
The Medical Association asserts that we cannot construe the Therapists Act to permit any diagnostic assessments because doing so would create an impermissible conflict between the Therapists Act and the Medical Practice Act, which defines the practice of medicine as including the diagnosis of medical disorders and prohibits practicing medicine without a medical license. See TEX. OCC. CODE §§ 155.001, 151.002(a)(13). As "a matter of public policy," the Medical Practice Act protects the public interest by recognizing that "the practice of medicine is a privilege and not a natural right," and it is necessary to "regulate the granting of that privilege and its subsequent use and control." Id. § 151.003(1). The Medical Association argues that construing the Therapists Act to permit MFTs to diagnose mental disorders — and thus engage in the practice of medicine — undermines this important policy concern and threatens the public interest.
As the Medical Association acknowledges, the Occupations Code expressly permits some healthcare professionals who do not have a medical license to make particular types of diagnoses.
In principle, as a matter of statutory construction, this argument bears significant merit. But within the context of the Occupation Code's various provisions and diverse uses of the terms at issue, we are ultimately not persuaded. As the Therapists Board notes, several other Code provisions expressly prohibit certain professionals from "diagnosing."
In light of these inconsistencies throughout the Occupations Code, we return to the Therapists Act's plain language. Having concluded based on that language, as construed within its context, that the Therapists Act authorizes MFTs to provide a diagnostic assessment as the rule allows, we conclude that the Therapists Act provides a limited exception to the Medical Practice Act's prohibitions. In light of that exception, the Acts do not conflict as the Medical Association contends.
Finally, the Therapists Board argues that, to the extent the Therapists Act and the Medical Practice Act conflict, the Therapists Act controls because it was enacted later and is more specific than the Medical Practice Act. See TEX. GOV'T CODE §§ 311.025(a) ("[I]f statutes enacted at the same or different sessions of the legislature are irreconcilable, the statute latest in date of enactment prevails."); 311.026(b); Tex. Lottery Comm'n v. First State Bank of DeQueen, 325 S.W.3d 628, 639 (Tex.
In response, the Medical Association asserts that the Therapists Act cannot prevail over any conflict with the Medical Practice Act because amendment or repeal by implication are not favored doctrines. See, e.g., United States v. Fed. Deposit Ins. Corp., 560 S.W.2d 119, 121 (Tex. Civ. App.-Houston [1st Dist.] 1977, writ ref'd n.r.e.) Instead, the Association contends, we must harmonize the two Acts to give effect to both, and — as the court of appeals concluded — the only way to harmonize them is to conclude that the Therapists Act authorizes evaluations other than the diagnosis of a mental condition.
We need not and will not address these construction canons unless we conclude that the statutes' language is ambiguous. See TGS-NOPEC Geophysical Co. v. Combs, 340 S.W.3d 432, 438 (Tex. 2011) (explaining that the Court will not defer to agency interpretations if the statutory language is unambiguous). A statute is ambiguous if its words are susceptible to two or more reasonable interpretations, and we "cannot discern legislative intent in the language of the statute itself." DeQueen, 325 S.W.3d at 639 (refusing to rely on construction canons because statute's unambiguous language resolved any apparent conflict). We conclude that, in light of the common, ordinary meanings of the terms at issue and the statutory context in which they are used, the Medical Association's interpretation of the Therapists Act is not reasonable and the Act is not ambiguous. As a result, we need not address the Therapists Board's reliance on the construction canons.
In short, nothing in the rule's use of the term "diagnostic assessment" compels the conclusion that it refers to diagnosing of physical or mental diseases or disorders in a manner that constitutes the practice of medicine. This is especially true within the context of the Therapists Act and the restrictions the rule places on the practice of marriage and family therapy. Presuming, as we must, that the Therapists Board acted within its authority when it issued the diagnostic-assessment rule, we cannot say that the Medical Association established that the rule is invalid.
This case has required us to carefully evaluate the Therapists Board's diagnostic-assessment rule in light of the language of the Therapists Act and the Medical Practice Act. As is true with MFTs and the services they provide, our careful evaluation would be for naught if we merely reviewed and assessed the rule and statutes yet failed to identify our findings and conclusions. Completing our evaluation of the statutes' relevant language, we conclude that every act that a physician may do is not automatically the unlawful practice of medicine when done by a non-physician, and terminology in one field may overlap with that of another. That the diagnosis of physical and mental diseases and disorders lies within the province of physicians does not preclude MFTs from making diagnostic assessments of emotional, mental, and behavioral problems as part of their efforts to evaluate and remediate mental dysfunctions within the marriage and family setting. Although MFTs' authority to provide a diagnostic assessment
At oral argument, the Medical Association also argued that the term diagnosis has a "meaning unique to the code." But the Medical Association does not explain what the "unique" meaning of diagnosis is in the Occupations Code. We note that the Code uses the terms "medical diagnosis" and "working diagnosis," neither of which the Code defines, but they are presumably different from each other. Id. §§ 204.202; 301.002(2), (5).