The core issue of delivering telemental health across state lines is each state can take disciplinary action if a complaint is filed. Telemental Health needs to stand on it's own as a therapy. It becomes hazardous to you and your patients when it "tries" to be face-to-face psychotherapy.
Delivering Telemental Health Across State Lines
Proliferation of Telemental Health
Bottom line: counselors nationwide are trying to figure out how to legally deliver telemental health across state lines. It is potentially lucrative. The revolution of electronic communication pervades our lives including how psychotherapy is delivered.
As such, online counseling proliferates. Many insurance companies now reimburse online therapy. Many online third party providers have entered the game. Their model is they provide the platform, referrals and pay the counselor. The counselor delivers the services.
"...he fielded questions and concerns with no condemnation." Jane Phillips, Battlefield Ministries (on Eric's personalized design of her interstate practice).
What is Telemental Health
The definition of Telemental Health varies from state to state. It is also referred to as online counseling, electronically assisted psychotherapy, teletherapy and others. Georgia's Composite board rules use the term Telemental Health. The gist of it is that it's counseling delivered to a client in a different physical location and does not mean in-person counseling.
*Disclaimer: This information is not to be construed as legal advice. For legal advice, seek counsel. This information is based upon experience enforcing Georgia practice law for Professional Counselors, Social Workers and Marriage and Family Therapists. It only suggests how Georgia's Composite Board has enforced rules in the past and real possibilities for how it will enforce it in the future.*
State Licensing and Jurisdiction
Jurisdiction means having the authority to make formal legal judgement. This legal right may be dictated by geography. Jurisdiction can also be determined by whether a licensing board has authority to make legal judgments on state law that is separate from practice law.
For example, client confidentiality is addressed in the "Evidence" section of Georgia law. Whereas the composite board addresses confidentiality in it's code of ethics, it does not have jurisdiction over the confidentiality law.
Telemental Health Across State Borders
1) Who has jurisdiction over the license-- the state in which the client resides or the state in which the therapist resides?
2) If a client travels for business or leisure outside of the licensees state, is it legal to provide services during the client's travels?
3) Which state board takes disciplinary action?
It's Not OUR State's Problem
Many states have telehealth laws that apply to medical providers such as physicians, nurses and physicians assistants. However, most states do not have telemental health laws.
1) Most state boards including Georgia's Composite Board of PC, SW and MFT are charged by law with protecting it's citizens and not necessarily the citizens of other states.
2) If the therapist was licensed out-of-state, the client would file the complaint with that state board.
3) If you are licensed in Georgia, you are under the jurisdiction of the Georgia Composite Board.
4) For example, if a Georgia LPC received a complaint of unlicensed practice by a patient residing in Arizona does the LPC respond to the Arizona Board or the Georgia Board?
Theoretically, they are accountable to both states. Arizona can issue a cease and desist order. Georgia can take disciplinary action since it holds the license. What if you are licensed in both states?
In 2014, the state of Pennsylvania sued a psychologist licensed in Israel for unlicensed practice. The Pennsylvania state court determined because the psychologist listed a Pennsylvania address and maintained citizenship, civil action could be taken against the psychologist.
Some counselors resolve this dilemma by obtaining licensure in multiple states. This creates another problem: the counselor is subject to the laws and rules of all of those states.
It IS Our State's Problem
In contrast, the state of California has determined marriage and family therapist licensees delivering telemental health services outside of the state must meet board requirements to practice in that state. Under that law, CA has the legal right to take action against a California licensee if they are delivering services to a client in Georgia if the MFT is not licensed in Georgia. California has also suggested this includes travel out of state. This raises questions about enforceability.
Required Training in Georgia
In order to deliver telemental health, Georgia Composite board rules require 6 (six) telemental health continuing education hours approved by an eligible professional association. Telemental health training hours are required once. You do not need to obtain the hours prior to each the biennial license renewal period.
Required Telemental Health Supervisor Training
In order to deliver telemental health supervision, Georgia Composite board rules require 6 (six) telemental health continuing education hours plus 3 (three) hours of supervising telemental health therapy approved by an eligible professional association such as LPCA or NBCC. Again, the hours are required one time. You do not need to obtain the hours prior to expiration of each biennial license renewal period.
There are important factors in selecting an LPC supervisor for telemental health supervision. The same applies to social workers, marriage and family therapists and psychologists.
What is critical is they --and you-- understand:
1) Ethical delivery of telemental health.
2) The risks of providing telemental health
3) Find a telemental health supervisor who is properly trained.
4) Understanding what NOT to do will help you understand what TO do.
You may want to send supervisors/supervisees to this page. I believe it is the most accurate and reliable information available that is specific to Georgia licensees.
Telemental Health Ethics and Protecting Your License
Research and The Effectiveness of Telemental Health
Quality research of online psychotherapy is sparse. Just as psychiatric medication research often does not control for psychotherapy, online psychotherapy research often does not control for face to face therapy. Therefore, it is difficult to evaluate the effectiveness of telepsychotherapy.
Obtain the NBCC DCC or other distance counseling credential and obtain frequent telemental health continuing education training because it will help you establish that a standard of care was met. Telemental health is emerging and many states' rules have not been tested. At minimum be prepared to defend your counseling with 'most well- trained telemental health counselors are also doing it like this'.
Appropriate Online Therapies
You can still provide effective online psychotherapy. For example, by connecting a client with a psychiatrist for a medication evaluation you are serving an important role in treating the client's depression--the client became less depressed because you connected them with a psychiatrist. It is a direct intervention with a measurable outcome.
Screening, referral and case management are great telemental health interventions. On the other hand, delivering psychodynamic or process therapies that prompt your client to explore sexual or other trauma in-depth can be hazardous partly because messages can be taken out of context, what do do when a patient becomes suicidal, and other concerns.
Can I Call it Coaching?
If you wish to bypass Georgia composite board rules by naming your services "coaching", you are still responsible for your license even if you don't advertise you are licensed. If you're licensed and violate board rules while coaching, action can still be taken against your license. If you surrender or don't renew your license, you can only coach since you are no longer licensed.You can only have it one way. You can't have it both ways.
Security Issues and HIPAA
How often have you heard, '"...but is it HIPAA compliant?" We can be trained to be HIPAA compliant, but it is not possible to completely protect electronic communications because too many others have access to the data.
Telemental health data resides on a server. In other words, someone else' computer. It may be on your web hosting company's server. The data may be on third party servers such as a web-based online counseling company you have contracted with or an insurance company. You may think their information is only on one server, but your cable company, Google and others have it on their servers.
Perform an Initial Face to Face Evaluation.
Know your client by confirming their identity. Obtain a copy of official identification with a Georgia address. Add to your intake paperwork an attestation that to the best of their knowledge all information they provided is truthful and accurate. Now you have double-covered yourself that you are not delivering telemental health across state lines. In addition, the informed consent should specifically address telemental health. If you choose to deliver the first session online, still obtain the same intake information.
Most Frequently Overlooked Risks of Telemental Health
Another risk that transcends HIPAA is that your work can be taken out of context through a single screenshot, email or video recording. For example, if you are working as a counselor in a STD clinic you are required to ask detailed questions about sexual behavior. However if providing online psychotherapy to a survivor of molestation, these questions can be misinterpreted and taken out of context. This risk can be reduced by carefully considering each communication and utterance. Review messages carefully before you click send.
Anonymity. Do you believe that effective counseling requires a psychotherapeutic relationship? If so, understand the limitations of an online relationship. We are aware of the limitations of online relationships since we regularly express this to our clients who are online dating. Some believe there are advantages to anonymity particularly with counseling teens. On the other hand, you've taken responsibility and liability for a patient you don't know and can't locate.
Let's chat. We all know we can get casual and 'chatty' when expressing ourselves online. It is inherent in the medium. As such, it can be difficult to manage boundaries.
Can telemental health equal face to face counseling? Probably not. Just as face-to-face psychotherapy cannot equal teletherapy. Teletherapy should stand on it's own as a therapy model. Telemental health continuing education often teaches a controversial model that attempts to replicate a face to face experience.
Take advantage of the aspects of telemental health that cannot be rivaled by face to face therapy-- convenient and efficient rapid screening, referral and coordination of care with other medical professionals.