Yes, Tweets can be considered advertisements

For California therapists promoting their practices on Twitter, there isn’t enough room to include legally-required disclosures on every tweet. Here’s what to do.                                                                                                                                                                                                                                                                                                            

Twitter is a web site that allows for “micro-blogging,” or posting of messages that are 140 characters or less. Because of Twitter’s open and social nature, it can be a good platform for sharing news about your practice. However, as you can imagine, 140 characters is often not enough room to include both your legally-required disclosures and whatever meaningful content you had hoped to include in a post on the site (otherwise known as a “tweet”).

If you are an LMFT, LPCC, or LCSW in California (other state laws vary), you can advertise your practice on Twitter, you just need to use caution in doing so. The California Board of Behavioral Sciences reported in a committee meeting that they had consulted with legal counsel on therapists’ use of Twitter [page 6 of linked PDF]. If the BBS were to receive a complaint about such advertising, they said they would consider advertising “as a whole.” In other words, if your tweet only links to your web site, they would consider the tweet and the site together. As long as a potential client must have seen your legally-mandated disclosures in at least one of those places, you should be safe.

Another way to think of it is, do NOT include any direct contact information – like your phone number, email address, or office location – in a tweet or on your Twitter profile. If you do that, a potential client could come to you just from the tweet, never having seen your required disclosures. Instead, make sure your Twitter profile and individual tweets ONLY include a link to a web site or other resource where you do meet all of California’s advertising standards.

Standard caveat applies here: I’m not a lawyer, so if you are in need of legal advice, this isn’t that. Talk with someone who has actually, like, gone to law school. I’m giving my best clinician’s understanding of both the law and what the BBS has said about it.

California’s child abuse reporting act is naive and discriminatory

California law defines normal, consensual, adolescent heterosexual behavior — and all same-sex sexual behavior — as child abuse. The law is discriminatory. It harms the therapeutic relationship. It needs to be changed.
                                                                                                                                                                                                                                                                                                           

California Capitol-fromSWUnder California’s existing standards for child sexual abuse, if minors are having consensual sexual intercourse, their ages determine whether a therapist needs to report it as abuse to the local child protective agency. The math goes something like this(1):

  • One partner 13 or younger: If the other partner is also 13 or younger and both children are of similar maturity, report only if there is evidence of intimidation, coercion, bribery, or other exploitation. If the other partner is 14 or older, report.
  • One partner age 14 or 15: If the other partner is under 14, report. If the other partner is 14 to 20 years old, do not report unless there is evidence of exploitation as described above. If the other partner is 21 or older, report.
  • One partner age 16 or 17: If the other partner is under 14, report. If the other partner is 14 or older, do not report unless there is evidence of exploitation as described above.

That’s all fine and good, right? It is complex, sure, but it reasonably takes into account the ages of the partners, and the nature of their relationship (truly consensual versus exploitive). So far, that seems okay.

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The problem is that the above guide only applies to heterosexual, vaginal intercourse.

Under the same law — officially the Child Abuse and Neglect Reporting Act, or CANRA — oral sex, anal sex, and object penetration (including fingers or any other part of the body) are always considered child abuse if either partner is under 18 years old, even when the activity was consensual and there is no evidence of coercion or exploitation of either partner. Similarity or difference in the ages of the partners does not matter.

This results in problems for three groups of adolescents in therapy: Normally-developing heterosexuals, normally-developing gays and lesbians, and religious adolescents seeking to preserve a specific notion of virginity. (Yes, those three groups cover just about everybody.) Let’s look at each.

  • For normally-developing heterosexual teens, it is common to engage in oral sex before progressing to intercourse. Most of those who have had sex before age 18 have also had oral sex(2), and a 2006 review of national data showed that at almost a quarter of teenagers who had not had vaginal intercourse had engaged in oral sex. This sets up a backward reporting standard, where sex itself may not be considered abuse depending on the ages of the adolescents, but behavior that occurs earlier in development or as foreplay to intercourse is considered abuse.

  • For normally-developing gays and lesbians, any sexual activity before reaching adulthood is classified as abuse in the eyes of the law. Remember, oral sex, anal sex, and object penetration are always considered abuse if either partner is under 18. If we have finally reached the point where consensual sex between gay or lesbian adults can no longer be criminalized, it seems a natural extension to treat consensual sexual activity among gay and lesbian teens on a par with consensual sexual activity among straight teens. If we say consensual, heterosexual sex between minors that meets specific criteria (not exploitive, and weighing the minors’ ages) is not abusive, shouldn’t that same treatment be given to similar consensual, homosexual behavior under the same conditions?

  • Religious teens get caught in this mess too, as was pointed out by Dr. Judy Johnson, a Licensed Educational Psychologist who serves on California’s Board of Behavioral Sciences. It is not unusual for religious, heterosexual teens to engage in oral or anal sex instead of vaginal intercourse. These teens often specifically cite their religious beliefs as a reason for delaying intercourse. At an April committee meeting for the BBS, Dr. Johnson noted that these teenagers often say they are seeking to preserve their virginity. So, even in a consensual relationship, a teenager preserving their virginity on their own terms means engaging in what the state would consider child abuse.

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Therapists are caught in a terribly awkward place by the law. When working with adolescents who are experiencing normal development, the therapist has several options, all of them problematic:

  1. Direct the client not to share important sexual experiences. This usually starts with educating the client on the law’s limits to confidentiality, and may involve frequent reminders to the client about what cannot be discussed in therapy. This keeps the therapist from having to report, and thus keeps them compliant with the law, but it also closes potential conversation about a key area of adolescent growth and social development. Teenagers often want to discuss their relationships in the safe context of therapy precisely because they trust the therapist to have such conversation in private and without judgment. Stopping this conversation means that teenagers cannot have honest conversations with their therapists about sexual feelings and behaviors, including the risks and consequences of their actions. For teenagers who already distrust adults, this only further fuels that distrust. Finally, as should be obvious, directing teens not to talk about sexual experiences means directing them not to talk about experiences of real abuse that should be reported.

  2. Educate the client about what must be reported, and then allow them to use coded language. I have known some therapists who felt better using this as a middle-ground option, to at least give their adolescent clients some leeway to discuss sex. However, it (by design) leaves the waters of what is being discussed muddy on both sides, and leads to awkward, stilted conversations about sexual behavior. It also doesn’t really protect the therapist; regardless of what specific words the client is using, if the therapist reasonably believes the client is communicating that a reportable act took place, the therapist is legally obligated to report it.

  3. Choose not to follow the reporting law, accepting the liability that comes with that decision. A therapist who knowingly fails to report what the state considers child abuse can face up to six months in jail. However, taking on this risk allows for the most open and honest discussion of a client’s sexual behavior, and comfortable communication about sexual activity actually delays risky sexual behavior.

In practice, none of these options strikes an effective balance between protecting minors from actual abuse and allowing for an open and safe therapeutic environment. Therapists who want to provide appropriate clinical care to teenagers, which should include openly addressing sexual behaviors and the client’s thoughts and feelings about them, simply cannot do so under the current law. Few therapists today would disagree with the notion that truly abusive behavior should be reported, but requiring therapists to label behavior that is developmentally normal as “abuse” does far more harm than good.

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In 2010, Gerry Grossman and a group of colleagues pushed for clarifications to the law. While they were unsuccessful, their efforts did yield a number of stories from practicing therapists about the damage CANRA does in its current form. One example (emphasis mine):

Because of this antiquated reporting law, I warn my adolescent clients not to talk to me about these things, as I am required by law to report it. As one of my grad students asked, “You mean, you have to tell a teen not to talk about something they most likely need to talk to someone about?” I sadly must explain, yes.

While I’m no lawyer, the fact that the law is discriminatory on its face would seem to make it unlikely to withstand a legal challenge. If I were the state of California, I certainly would not want to be defending the existing law in court. But why should the state wait to be sued by a 17-year-old reported as a child abuser for having consensual oral sex with his or her 17-year-old, same-sex partner? It would be far preferable to resolve the issue through legislation, but so far there has not been enough political will to make the needed changes. Because an amendment to make the law fair would necessarily reduce the mandated reporter’s obligations, it would look like a weakening of the child abuse reporting law — and in the wake of the Jerry Sandusky scandal at Penn State, lawmakers have reflexively moved in the opposite direction. An analysis from the California Assembly Appropriations Committee lists no less than seven bills in the state legislature this year that would expand mandated reporting and stiffen penalties for failure to report.

The Board of Behavioral Sciences has expressed interest into at least examining the issue. I brought this to them at their April [page 27] and July Policy and Advocacy Committee meetings, and they have agreed to place it on a future agenda for discussion. What’s really needed, though, is a lawmaker with the nerve to stand up and say, “The current law is wrong, it discriminates against gay and lesbian youth, and it makes it harder to provide a safe therapeutic environment for normal, healthy adolescents. Let’s make the law do what we intended for it to do in the first place: protect vulnerable people from harm. Let’s stop requiring therapists to label normal teenagers as child abusers.”

References

1. Atkins, C. L. (2007). Reporting consensual activity between minors: The confusion unraveled. The Therapist, 19(1), 32-35.
2. Halpern, C. T., & Haydon, A. A. (2012). Sexual timetables for oral-genital, vaginal, and anal intercourse: sociodemographic comparisons in a nationally representative sample of adolescents. American Journal Of Public Health, 102(6), 1541-0048.

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As I said, I’m not a lawyer. The above information should not be construed as legal advice when determining whether a child abuse report is required. Consult with a supervisor and/or an attorney about your specific situation.

What are your thoughts about the law and how to best fix it? Post a comment below, email me at ben[at]bencaldwell[dot]com, or post a message to my Twitter feed.

Money for MFTs

Stipend and loan reimbursement programs for family therapists, updated for 2012 with current links, updated amounts, and additional programs.
                                                                                                                                                                                                                                                                                                           

A number of state and federal programs offer tens of thousands of dollars in stipends and loan reimbursements for marriage and family therapists to advance their careers. Generally, these programs aim to help bring mental health services to underserved areas and to reward therapists who dedicate themselves to such communities. Here are just a few of the programs MFTs may find enriching.

The federal National Health Service Corps program offers a whopping $60,000 in loan reimbursement, on top of the salary one would already make in an eligible position, for two years of service. Continue working in an NHSC-eligible position over time, and you can get as much as $360,000 in loan reimbursement for 16 years of full-time service. NHSC-eligible jobs can be found at the NHSC Jobs web site.

Also on the federal level, the Indian Health Service (IHS; www.ihs.gov) offers a similar program, awarding $20,000 per year for two years of service at an IHS site. (A cautionary note: MFTs are legally recognized for employment within IHS, but appear to fall within “other professions as determined by need” in the loan repayment program.)

The American Association for Marriage and Family Therapy (AAMFT) / US Substance Abuse and Mental Health Services Administration (SAMHSA) Minority Fellowship Program awards stipends to cover education, plus funding to conduct research and travel to conferences and trainings, to doctoral students in MFT programs. These awards can be worth tens of thousands of dollars and are renewable for multiple years.

In California, there are additional state-based stipend and loan reimbursement programs. The awards offered by each of these programs are in addition to the salary one would already earn in an eligible position.

The California State MFT Stipend Program provides awards of $18,500 per year to MFT Interns who agree to work in public mental health positions in underserved areas for at least one year. In 2010 and again in 2011, 60 of these stipends were awarded through the statewide MFT Consortium, which covers most of the state; Loma Linda University and CSU-Chico each administered a handful of additional stipends through the same state fund. For 2012, Alliant International University (where I teach) also is administering its own stipend program, awarding 15 stipends per year of $18,500 each, distributed across our four CFT campuses.

There are separate stipend programs at the county level. The Los Angeles County MFT Stipend Program has awarded more than 300 stipends of up to $18,500 since 2005, with recipients committing to similar service requirements. San Diego County and Orange County have more recently launched similar programs.

Finally, the state offers MFTs and MFT Interns its Mental Health Services Provider Education Program, which awards up to $15,000 in loan reimbursement for two years of service in an underserved area, and its Mental Health Loan Assumption Program, which offers $10,000 in loan reimbursement for a one-year commitment. Though these programs are both run by the same state agency, their separate amounts and selection processes are because their funding comes through two distinct streams (license renewal fees, and the Mental Health Services Act). They have different application forms and run on different deadline cycles. The next MHLAP deadline is in August; the next MHSPEP deadline is in September.

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To put in a plug for my program: Alliant students are eligible for our own stipend program, the county programs in San Diego and Los Angeles, and the state and federal programs. Some campuses are still accepting applications for fall 2012; more information is available here: Alliant Couple and Family Therapy programs.

Are you aware of other federal or state-based programs that should be added to this list? Email me at ben[at]bencaldwell[dot]com and let me know, and I’ll be happy to expand this post.

Call for Change group offers non-rebuttal rebuttal

MFT Call for Change group responds to my previous post, where I highlighted several of their erroneous statements about California.                                                                                                                                                                                     

The group calling themselves “MFTs Call for Change” (CFC) has posted a lengthy rebuttal to my earlier post criticizing CFC misstatements about California, specifically in areas related to the LPCC license and its development here.

Notably, they rarely, if ever, challenge my statements of fact. They claim that my post included “misinformation,” but their arguments are more often of the moving-the-target (“yes, but”) variety than they are factual disagreement. And they add at least one to the list of factual errors of their own.

  • CFC criticizes my statement that “When CAMFT was negotiating changes to various versions of the LPCC bill, they sought to make MFTs and LPCCs as indistinguishable as possible.” They would prefer I label this as my own belief, or an opinion of AAMFT-CA. But there’s no need. I saw, firsthand, CAMFT’s opposition to language supporting distinctiveness of professions during the negotiation process. Remember, CAMFT wanted grandparenting to be automatic for licensed MFTs based just on coursework (this version of the bill allowed exactly that), and indeed, CAMFT has continued to argue there are no meaningful differences in practice between the MFT and LPCC professions (as CAMFT themselves said, they believe “LMFTs and LCSWs may do in practice everything LPCCs may do“) — which would make the licenses effectively indistinguishable. That’s not my belief, that’s an argument CAMFT itself is continuing to make and act upon.
  • Along similar lines, CFC calls my discussion of CAMFT’s lawsuit against the BBS “patently irresponsible” because… well, I can’t tell why, exactly. I’m not even sure which part they’re taking issue with. CAMFT sued the BBS to try to make the “gap exam” for MFT grandparenting go away, based on their belief that the practices of the professions are indistinguishable. They have very clearly said so. That the lawsuit attempted to use technical means (like the BBS’s failure to consult with a state agency on exams, the one point of three in the lawsuit on which CAMFT won) to reach their desired ends (no gap exam) does not change those desired ends or the publicly-stated rationale behind them.
  • AAMFT-CA and AAMFT have not been “against the LPCC bill since its inception,” as CFC newly and falsely claims. Primary sources here tell the tale. California counselor legislation was first introduced in February 2005. In November 2005, nine months later, I first spoke to a legislative committee about AAMFT-CA’s concerns with bill language. Even then, AAMFT-CA took no formal position, as we understood the bill would be further amended. AAMFT-CA only formally opposed LPCC legislation in 2007 (this legislative committee analysis is the first mention of AAMFT-CA opposition), after it became clear that the legislation was moving in a direction that would hurt the MFT profession. Furthermore, in 2009, once we worked out the compromise language that became the LPCC law, AAMFT-CA’s opposition was removed [page 2], helping the bill pass. The larger AAMFT never took any formal position at all on the bill.
  • In discussing Kim Madsen, the BBS Executive Director, the CFC rebuttal suggests that in my post, “The reader has been lead [sic] to believe Ms. Madsen would be less than forthcoming” when discussing licensure issues. Nonsense. Ms. Madsen has been, in my experience, extremely professional, highly ethical, and very forthcoming, even when we have disagreed on policy. In my earlier post, what I suggested was that CFC, not Ms. Madsen, was being less than forthcoming by leaving out important details. This should have been evident in my preface “I suspect what Ms. Madsen said was…” Given my experiences with each of them, I trust her to be complete and forthcoming much more than I presently trust CFC to do so.

As I said previously, the CFC group seems to be well-meaning. I just don’t understand their dogged pursuit of this line of criticism. It is not supported by facts, and makes CFC look more interested in finding fault with AAMFT than actually supporting or developing the profession.

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If I did make any errors of fact — there or here — I would like to correct them. Email me at ben[at]bencaldwell.com, post a comment, or call for a change to my Twitter feed.

In “Gap Exam” and supervision rulings, California licensing board says MFTs and LPCCs are different

In a unanimous vote, the California Board of Behavioral Sciences (BBS) today determined that a Gap Exam will be necessary for marriage and family therapists (MFTs) seeking licensure as professional clinical counselors (LPCCs). A separate ruling on supervision has similar themes.                                            

JudgesTools IconThe “Gap Exam” for currently-licensed MFTs seeking to grandparent into LPCC licensure will be shorter than regular licensing exams, and will focus on the differences in practice between MFT and LPCC.

In a separate vote, the BBS also agreed to move forward with a legislative proposal that would require LPCCs to complete additional coursework and experience in couple and family work in order to supervise MFT interns and trainees.

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Gap Exam

Today’s vote was the fourth the Board has taken on the Gap Exam issue, which has become controversial because of its broader implications about the distinctiveness of the professions. (For some of the history, see “CAMFT sues California licensing board” and “Ruling mixed in CAMFT-BBS gap exam lawsuit.” Full disclosure: I resigned CAMFT membership in response to their actions on this issue.) Earlier votes had been set aside for a variety of reasons; the most recent prior vote was set aside after CAMFT sued the BBS, and won on their argument that the BBS had not first consulted with the state’s Office of Professional Examination Services, as required in the law. The court ordered the BBS to set aside its prior vote and do the required consultation.

In that required consultation, OPES said they believed a Gap Exam was indeed necessary (last pages of PDF), and the BBS today voted to move forward with the Gap Exam. The exam development process will start immediately. Today’s hopefully-final vote supports the notion that while mental health professions have much in common, there are still meaningful differences between the practices of the specific professions.

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Supervision

Similar themes arose in discussion on supervision in mental health care. In current law, LPCCs must complete additional coursework and experience to be able to legally assess or treat couples and families. The question at hand was whether LPCCs who had not met those requirements should be able to supervise MFT trainees and interns who would be providing direct services to couples and families.

I argued the AAMFT-CA perspective, that one should not be legally able to supervise an activity that is outside of one’s own scope of practice. The BBS voted in agreement. Unlike the exam ruling, however, this vote was by no means a final determination. It merely moves forward proposed legislation that would allow LPCCs to supervise MFTs only if the supervisor has completed those additional requirements. The proposal still must go through the legislature and be signed by the Governor to become effective. CAMFT indicated they will oppose that provision during the legislative process. If CAMFT moves to simply kill the proposal, and is successful in doing so, LPCCs will be left with what is in current law — which prevents them from supervising MFT interns or trainees at all.