internet

Psychotherapists typically cannot do phone or internet therapy across state lines

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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.

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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.

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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.

To ease stress, and maybe save your marriage, try doing nothing

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When it comes to making a healthier self and a happier family, doing nothing may be the next big thing.                                                                                                                                                                                     

TratakaOne of the hardest things for many of us (myself included) to fathom when we dedicate our careers to solving problems is that sometimes the best solution is no solution at all — just do nothing. Refraining from action can be just as vital a problem-solving strategy as taking action.

Michele Weiner-Davis, the author of Divorce Busting, offers a touching blog entry about how doing nothing helped her own marriage. And there’s the website that challenges you to do nothing for two minutes, which is harder than it sounds if you’re used to moving at a fast pace.

Best of all: Doing nothing can be surprisingly effective.

“Taking a moment to do nothing can be very centering and calming. It allows you to slow the entire experience down and get back to a place of rational thought,” says my good friend and Caldwell-Clark cofounder Aimee Zakrewski Clark, who also runs the No Stress Foundation (full disclosure: I’m on the Board of Directors at No Stress). Indeed, doing nothing can be a surprisingly useful treatment for depression, which fairly quickly improves on its own in as many as 1 in 5 untreated cases. (Naturally, if you’re experiencing depression, talk it over with a doctor or mental health professional — just keep “no treatment” on the table as an option.) And doing nothing can improve family life; the tendency for kids to be over-scheduled has been widely covered. The impact of that hyperscheduling may actually be good for kids, but at the same time, studies routinely show that families do better when they simply spend time together… even if they aren’t actually doing anything in that time.

How does one go from doing a lot to doing nothing, even if for just a few minutes a day?

“Commit to one 5-minute practice per day that invokes the nothingness. You can do a simple exercise I call Choosing Your Thoughts, which engages the breath and mind to help you do just that. As you inhale and exhale through your nose, say to yourself, ‘I am aware that I’m doing nothing,'” says Clark. “You can even add a smile, which will help you to enjoy the exercise.”

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Adding a smile will help us both enjoy your emails to me at ben[at]bencaldwell.com, your posted comments, or your messages to my Twitter feed.

CAMFT changing therapist-referral site to “Counseling”

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CAMFT is rebranding their therapist-referral site as CounselingCalifornia.com. The change, and how it was announced, continue CAMFT’s pattern of treating MFTs and LPCCs as indistinguishable.

In an announcement on November 1, the California Association of Marriage and Family Therapists (CAMFT) said it would be re-branding its therapist-referral web site as CounselingCalifornia.com. While their email described this as an effort largely to improve search engine optimization, it also fits their pattern of making marriage and family therapy (and the MFT license) indistinguishable from counseling (and the LPCC license). The change will take effect on January 4, exactly three days after the Board of Behavioral Sciences begins accepting applications for LPCC licensure through grandparenting.

Notably, not once in CAMFT’s email announcement did they refer to their own clinical members as what they are by licensure: “marriage and family therapists.” Instead, the clinicians who would gain referrals through the site (limited to CAMFT’s Clinical Members, which at this time means just MFTs) were referred to only as “therapists” or “licensed therapists.” The words “marriage” and “family” were nowhere to be found. The name change for the referral site, and the announcement of that change, certainly leave the door open for the site to be a referral site for both MFTs and LPCCs.

I can understand that, from an organizational-numbers point of view, it may benefit CAMFT to be as welcoming as possible to LPCCs as that license opens in California. However, CAMFT’s continuing efforts to make MFTs and LPCCs indistinguishable work against the best interests of both professions, who should collaborate effectively when it benefits us (lobbying for Medicare reimbursement, for example) and be able to advance our unique professions when it benefits us (publishing journals or holding conferences, for example). The constant push to make us indistinguishable, culminating in a lawsuit against the BBS, was enough for me to finally cancel my CAMFT membership. It will be interesting to see how other MFTs who value the MFT title will respond, especially if this pattern continues.

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Another reason CAMFT likely changed the name: The existing name has earned them the unlucky honor of being regularly counted among the unintentionally worst company URLs on many a list.

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CAMFT is separate and independent from both AAMFT and its California Division.