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.

Psychotherapists typically cannot do phone or internet therapy across state lines

Some therapists are willing to take the risk, though. And not just for the money. (See update below.)

2screensystemIf you are in California, and your client is in Texas, can you meet with that client by phone or internet?

I’m no lawyer, but the answer seems to be no. Licensure laws in all the mental health professions are state-specific. A California license in marriage and family therapy only enables you to work as an MFT within California.


In a mobile society, where many clients travel and videoconferencing technology is rapidly improving, it is common for therapists to do some sessions by phone or videoconference with clients who cannot come in to the office. (Indeed, such technology has the potential to dramatically improve access to quality mental health care.) But the technology raises an interesting question: If you and your client are in different places, where exactly is the therapy taking place? There are three possible answers to that question:

  1. Where the client is. Hopefully the change process that results from therapy is with the client’s thoughts, behavior, and relationships, and so that change is taking place wherever the client is located.
  2. Where the therapist is. The person performing specific interventions — the therapist — is the one doing the therapy, so it makes some sense to argue that the service takes place wherever the therapist is located. However, adopting this answer would mean that a therapist licensed in any state could legally serve clients in every state. While state licensure standards do not differ all that much, they do have some meaningful differences (particularly in California).
  3. Either, both, or someplace else (like where the server is). Adopting any of these as the answer to where the service takes place would lead to chaos. If you are in California, and your client is in Texas, but your Skype server is in Pennsylvania, would you need to be licensed in Pennsylvania to treat them via Skype? I would hope not.

It makes the most sense to me to say that therapy takes place where the client is located. State licensing boards certainly seem to see it that way. Colorado psychiatrist Christian Hageseth was sentenced in 2009 to nine months in prison for practicing medicine in California without a license after he precribed Prozac to a patient located in California through an internet pharmacy.


CAMFT added the following piece to their Code of Ethics a few years ago, that makes their view of the issue clear:

3.11 ELECTRONIC SERVICES: Marriage and family therapists provide services by Internet or other electronic media to patients located only in jurisdictions where the therapist may lawfully provide such services.

Note the key word “located.” Not “residing,” which would give MFTs some leeway if they wanted to provide therapy to a California resident who was temporarily out of the state. As I read it, “located” refers to the client’s physical location at the time the service is being provided. By this standard, marriage and family therapists absolutely cannot perform therapy across state lines by phone or internet (unless the MFT is also licensed in the state where the client is).

Except that life happens. Clients sometimes choose to leave the state abruptly, or are forced to by work transfer, military deployment, or other circumstances beyond their control. If your client is in the middle of an intensive therapy process, what happens? Does the therapist simply say they will no longer treat the client, and refer them to a local therapist who will need to do their own assessment and perhaps change the course of therapy?

Some therapists willingly arrange for a few sessions with clients moving out of state (temporarily or permanently) to ease the transition to a new location and a new therapist, or to allow for strong continuity of care. Those who provide such sessions by phone or video across state lines argue that they are supported by another portion of the ethics code (emphasis mine):

1.3.2 ABANDONMENT: Marriage and family therapists do not abandon or neglect patients in treatment. If a therapist is unable or unwilling to continue to provide professional services, the therapist will assist the patient in making clinically appropriate arrangements for continuation of treatment.

It would seem the safest thing for a therapist to do when a client is outside of state lines is to not treat them, but to arrange for services local to the client. Legal requirements trump ethical standards, and the law allows you only to practice where you are licensed. But when therapists argue that their ethical requirement of non-abandonment not only allows, but actually compels, them to ensure that a client leaving the state is receiving adequate care until they can be connected with local services, in my mind they make an awfully strong case.

Update 7-19-2012: Some states have started adopting laws and regulations that either specifically allow, or additionally restrict, the provision of mental health services via telephone or internet. California’s Board of Behavioral Sciences has gathered current regulations from a number of other states here: State regulations for phone and internet therapy [starting on page 38].

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Just to reiterate, I’m not a lawyer. Real lawyers do important lawyerly things, like going to law school. I’m just a family therapist with a really strong interest in policy issues. I’ll make a case — in a later post — that the time has come for a national licensure standard.

Julea Ward wins court ruling, while legislation bearing her name advances

Her religious discrimination suit is returned to a federal jury. Meanwhile, a proposed law in Michigan would allow students to refuse to treat any client they chose, out of any genuine religious or moral belief.

EMUstudentCenterYpsilantiMIJulea Ward has enjoyed two big victories so far this year.

For the first time, she won a court ruling in her case against Eastern Michigan University, which had disciplined her for refusing to provide counseling services to a gay client as part of her graduate practicum training. Just weeks later, legislation bearing her name moved forward in the Michigan legislature despite protests from universities and professional associations that the Julea Ward Freedom of Conscience Act would make it harder to effectively train mental health professionals.

In the court case, Ward’s victory was limited but it does keep her case alive. While not making a determination of the merits of the case, the 6th Circuit Court of Appeals ruled that Ward should have the opportunity to argue that her religious beliefs were used against her, according to the Associated Press. The case will be returned to a Detroit-based federal jury.

In the Michigan legislature, the House Education Committee advanced HB5040, the bill bearing Ward’s name. According to the Holland Sentinel, the bill would “prohibit religious discrimination against students who are studying counseling, social work, and psychology.” That description seems a bit narrower to me than the bill itself, which goes beyond just prohibiting discrimination: it actually prohibits universities from any disciplinary actions against students who refuse to treat clients based on “a sincerely held religious belief or moral conviction of the student, if the student refers the client to a counselor who will provide the counseling or services.”
You can keep up with the bill’s progress here: HB5040.

I wrote about Ward’s case for Family Therapy Magazine a couple of months ago (full article: Can a religious therapist refuse to treat gay and lesbian clients?). She described the events that led to her lawsuit in this video for the Christian-based legal organization that is defending her:

I’ll be writing more about HB5040 and other “conscience clause” legislation in the near future. In the meantime, the Pew Research Center offers a fascinating legal history of conscience issues in health care.

Update: About a week after this post was initially published, I posted another piece about conscience clause legislation.

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Share your thoughts on this case: Email me at ben[at]bencaldwell[dot]com, post a comment below, or find me on Twitter (@benjamincaldwel).

Proposed Ethics Code revision would remove MFTs’ social responsibility

The proposal would eliminate three sections of the AAMFT Code of Ethics that currently call for service and responsibility to larger systems. Members have until January 31 to weigh in.

Angry Talk (Comic Style)The AAMFT Board of Directors is proposing an incremental change to the marriage and family therapy profession’s Code of Ethics, the guiding document that defines professional standards in the field. At least one of the proposed changes would drastically redefine what it means to be an MFT.

Some quick background: The AAMFT Code of Ethics was last updated way back in 2001, and much has changed in the profession since then. In particular, the emergence of new technologies for both marketing and service delivery has raised concerns about how to best manage confidentiality and informed consent. The AAMFT Board has known the Code was in need of updating, but did not want to engage in a full-scale overhaul of the Code at this time; that would be about a two-year undertaking. So, they instead are looking at smaller-scale changes. (Full disclosure: I chaired a Task Force, at the Board’s request, looking at possible changes to the Code over the summer. The Task Force was just one of several sources of input for the Board as they developed the current proposal.)

One element of the proposed revised Code is shocking to me. It would change what it means to be a marriage and family therapist. The Board is proposing removing each of the following sections from the AAMFT Code of Ethics:

6.6 Marriage and family therapists participate in activities that contribute to a better community and society, including devoting a portion of their professional activity to services for which there is little or no financial return.

6.7 Marriage and family therapists are concerned with developing laws and regulations pertaining to marriage and family therapy that serve the public interest, and with altering such laws and regulations that are not in the public interest.

6.8 Marriage and family therapists encourage public participation in the design and delivery of professional services and in the regulation of practitioners.

Together, these are the sections that place MFTs in a position of larger social responsibility and make us accountable to the communities we serve. The removal of these sections would have far-reaching implications: If MFTs no longer need to have a place at the table when laws are being developed or altered that are not in the public interest, do we simply allow others to set for us the legal standards that govern our profession? Do we now need to stay out of the same-sex marriage debate? Is it OK for us to be ignorant of major legal issues in our field, from the fight for Medicare reimbursement to the Texas lawsuit over MFTs’ ability to diagnose?

Perhaps on an even more fundamental level, we can look at the proposed removal of 6.6. Is contributing to a better community and society no longer a value of this profession? If so, I would be a lot less enthusiastic about being a part of it.

And that’s the rub. A Code of Ethics is more than just a list of behaviors that can get you in trouble in a profession; it also serves as a vital statement of what it means to be an MFT. It reflects our values and desires as a professional group. One of those values, historically, has been responsibility to the communities we serve. If nothing else, devoting some of our professional activity to services with minimal return is a clear way of demonstrating through our behavior that we truly understand systems and our role, as professionals, in those larger communities.

The Board did not provide its rationale for this proposed change (or any others). But the reasons are likely not important. These subprinciples are key to my identity as a marriage and family therapist. They set AAMFT, as an association, and MFTs as professionals apart from other professional groups. Serving the community through pro bono work and involvement in policy discussions is part and parcel to being an MFT. Isn’t it?

Members can review the full proposal of changes to the AAMFT Code of Ethics through the AAMFT web site (you will need to log in). Members can submit comments through January 31 via email; the address to send feedback can be found here. Whether you agree with me on this issue or not, if you are a member, please do weigh in on the full proposal. The more feedback AAMFT gets from members on the proposed changes (most of which are really quite good!), the better.

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If you’re wondering, the CAMFT Code of Ethics encourages (but does not require) pro bono work. It also has language nearly identical to AAMFT’s 6.7 above, about influencing laws.

Like AAMFT, I, too, appreciate your feedback. And you don’t even have to log in to give me a piece of your mind. Post a comment below, drop me an email to ben[at]bencaldwell[dot]com, or post something to me on Twitter.

On ethics and CAMFT’s record of published statements about AAMFT

In their own words.
All bold text is my emphasis added.


“Marriage and family therapists, when acting as teachers, supervisors, and researchers, stay abreast of changes in the field, maintain relevant standards of scholarship, and present accurate information.”
CAMFT Code of Ethics, principle 3.5


On AAMFT and AAMFT-CA’s legislative interest

CAMFT statement: “The opposition [to the LPC bill] in California from AAMFT and AAMFT-CA never surfaced until 2007 and their legislative interest was limited to this single effort – this single piece of legislation.”
– CAMFT Feature Article, The Therapist magazine, March/April 2008

Fact check 1: “Assembly bill 894, introduced last year, would create a professional counselor (LPC) license in the State of California. While AAMFT-CA has no objection to the licensure of mental health professions, we had major concerns with the content of this bill, and therefore took a position of opposition. […] I spoke to the legislature’s Joint Committee on Boards, Commissions, and Consumer Protection in November [2005] to let them know our position and the reasoning behind it.”
– AAMFT-CA newsletter, Legislative and Advocacy column, Spring 2006

Fact check 2:Among our accomplishments in 2007, we have worked with the BBS to improve license portability into California. […] We also helped to defeat the bill that would have created an LPC (licensed professional counselor) license in California […] We are not opposed in principle to counselor licensure […] We also have been very vocal with the BBS in helping shape the new educational requirements for MFT graduate programs, which are likely to be put into legislation next year.”
AAMFT-CA newsletter, Legislative and Advocacy column, Fall 2007

Fact check 3:In 2007 the AAMFT experienced many successes on important advocacy initiatives. In particular, the AAMFT is pleased to announce that we were successful in obtaining participation for MFTs in the U.S. Substance Abuse and Mental Health Service Administration (SAMHSA) Minority Fellowship Program. […] Also, for the first time, the US House of Representatives passed a bill including MFTs in Medicare.”
– Membership renewal message from the AAMFT Executive Director, 2008


On working collaboratively

CAMFT statement: “CAMFT has approached the [AAMFT-CA] division about legislative issues that CAMFT is sponsoring to involve them in joining our efforts — efforts to work together to further the interests of the profession. There has been no willingness or interest in working with CAMFT on these legislative matters.
– CAMFT Feature Article, The Therapist magazine, March/April 2008

Fact check: “With the resources I have available [through] AAMFT, I think that a joint and collaborative effort would be valuable. If you let me know when and where the meeting is taking place, I would like to make arrangements to join you.”
– Email regarding counselor legislation from AAMFT-CA Executive Director Olivia Loewy to CAMFT Executive Director Mary Riemersma, March 27, 2007


On AAMFT’s interest in federal legislative matters

CAMFT statement: “Historically, AAMFT, at the federal level, had no interest in legislative matters. It was actually Richard Leslie at CAMFT who pushed AAMFT, thereby turning the tide on their involvement in federal legislative matters to attempt to advance the MFT profession.”
– CAMFT Feature Article, The Therapist magazine, March/April 2008

Fact check 1: “The association not only incorporated as a trade organization in Washington, but also began a long association when it hired Steven L. Engelberg as legal counsel for Washington (federal) affairs in 1974. […] Failing to make progress in two months of negotiations with the Department of Defense [after CHAMPUS reimbursement for MFTs had been eliminated], the AAMFT sued the DoD for reinstatement on April 26 [1975].”
– William C. Nichols, The AAMFT: Fifty Years of Marital and Family Therapy, pp. 41, 63.

Fact check 2:CAMFT contracted with Richard S. Leslie, Attorney, in 1976.”
– CAMFT Executive Director Mary Riemersma, “The building of a profession”


On correcting false information, Part I

My correction request: “At the article’s conclusion, Ms. Riemersma writes, “No one gains by steadfastness, an unwillingness to negotiate, and casting barbs at the perceived opposition.” With this, I would agree wholeheartedly. Unfortunately, much of the Feature Article appears to be an attempt to cast barbs at AAMFT – an organization that, like CAMFT, has the best interests of the profession at heart. Even when the organizations disagree, it serves us best to present information that is clear and accurate.”
– My May 7, 2008 Letter to the Editor requesting CAMFT correct the provable factual errors detailed above

CAMFT response: “Your letter will not be printed in an upcoming issue of The Therapist due to the fact that members are troubled by the debate and do not benefit from it.”
CAMFT response to my request


On CAMFT informing the legislature (and its members) about a one-license future

CAMFT magazine: “I attended the AAMFT Long Beach Conference where their president Mike Bowers made a pronouncement at a conference forum of about 500 people that Mary Riemersma of CAMFT informed the California legislature that all therapists will hold the same license in the near future! I became alarmed. […] I knew Mary. This could not have been accurate. I called Mary and she quickly informed me of this misinformation.”
– Letter to the Editor, CAMFT’s The Therapist magazine, Jan/Feb 2011, p. 5

Fact check: “CAMFT states, “At some time in the future, we project that there will only be one masters level profession in California, with individuals specializing within that license. Thus, those who wish to specialize in systems work will do so; those who wish to specialize in art therapy will do so, etc. The current system with a variety of acronyms is confusing for consumers who just want to be helped and do not perceive greater value from one professional compared to the next.””
California Senate Committee Analysis of AB1486, July 2007
– Same text appears in a CAMFT email to members, May 24, 2007


On correcting false information, Part II

My request for correction: “Michael Bowers [is] AAMFT’s Executive Director, not its president […] It is true that Riemersma’s letter refers to “some time in the future,” and not the “near future” as the letter writer wrote – but this minor difference is an error on the part of the letter writer, not Bowers. Bowers quoted, in his speech and in his presentation slides, the exact text the legislative report quoted.”
– My Letter to the Editor again requesting CAMFT correct provable errors of fact

CAMFT response: “Your request to print the proposed correction was denied.”
– CAMFT response email


Marriage and family therapists treat and communicate with and about colleagues in a respectful manner and with courtesy, fairness, and good faith, and cooperate with colleagues in order to promote the welfare and best interests of patients.”
CAMFT Code of Ethics, principle 5