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.

Teen texting study an example of a researcher misleading the media

A new study connects the texting habits of teenagers with drug use and other risky behavior. Contrary to media reports, the study did not show texting to cause the teens’ risk-taking.

Teenagers who send more than 120 text messages a day are more likely than their peers to engage in a variety of risky behaviors, including sexual activity, smoking, drinking, and drug use. That much we can agree on. It was the key finding of a Case Western Reserve University School of Medicine study presented this week.

Media coverage was predictably breathless:

But there is a big problem with each of the stories linked above. As compelling as these stories are, texting did not cause poor health or risky behaviors in this study. More precisely, the study did not show a cause-effect relationship. It found correlations — associations between certain behaviors that tend to rise and fall together. It did not say what causes what.

If we know that one behavior (texting, in this case) is more common among people who also do another behavior (let’s use drinking), then we can say the two behaviors are correlated. But that leaves at least three very different possibilities when it comes to cause and effect:

  1. Texting causes drinking.
  2. Drinking causes texting.
  3. Some other thing (lack of parental supervision, maybe?) causes both drinking and texting.

A correlational study (like this one) does not tell us which of those three possibilities is most likely (the third strikes me as by far the most plausible). And reporters understand that conclusions about correlation are not especially enticing news stories. “This one thing is related to this other thing, but we do not really know what causes either one of them” makes for a lousy article.

So reporters sometimes go beyond what a study actually shows, and pull a cause-effect relationship out of thin air. In essence, they pick their favorite out of the three possibilities listed above, and run with it. They do this in spite of a complete lack of data supporting their conclusion over the other cause-effect possibilities.

That seems to be what happened here. What is unusual in this case is the degree to which the study’s lead author actively promoted the made-up conclusion.

Even though the press release about the teen-texting study largely uses the right terms in describing the results (labeling behaviors as being “associated with” each other), Scott Frank, the lead author of the study, was remarkably cavalier in determining a cause-effect relationship his study did not demonstrate. He is quoted in that same press release as saying

“When left unchecked, texting and other widely popular methods of staying connected can have dangerous health effects on teenagers.”

The medical school where the study was conducted is also encouraging this unsupported conclusion. The link to this study from the Case Western School of Medicine home page currently reads “Hyper-texting and Hyper-Networking Pose New Health Risks for Teens.”

Frank’s promotion of a conclusion his own data does not support prompted an unusually direct rebuke from John Grohol, the CEO of PsychCentral, whose own site had reported on the study earlier. Grohol wrote that Frank’s conclusions about texting having negative health effects are (emphasis Grohol’s)

all pure crap. You could just as easily write the following headlines:

Teens Who Smoke, Drink Also Text a Lot
Outgoing Teens Like to Do Things Outgoing Teens Like to Do
Teens Who Enjoy Sex Like to Text Too!

Scott Frank, MD, MS should be ashamed of himself.

I’m with Grohol on this. For Frank to say that texting can have negative health effects is, as Grohol put it, “sloppy at best, and unethical at worst.” Frank is promoting a conclusion his study simply does not support. And some media outlets appear to be all too happy to run a story confirming parents’ worst fears about teenagers and technology, even when the story and the data do not match.


In deference to my journalist friends, it must be noted that the examples of poor media coverage above are far outweighed, in both quantity and quality, by the many stories covering this study that ignored Frank’s quotes and reported his results accurately. Search “teenagers texting drinking” on Google’s news site and you will find far more headlines using phrases like “linked to” or “associated with” than you will find “causes.” Kudos to those writers (of both the stories and the headlines, since they are often not the same person) who understand the difference.