Can I Practice TeleHealth Across State Lines?

lpc lcsw practice-across-state-lines

Delivering Telemental Health Across State Lines

**Update: 10/22/20, Novel Coronavirus COVID-19 Outbreak and Telehealth Changes** Some states’ emergency executive orders and policies have expired. How states will handle this expiration is largely unknown. The core issue of delivering telemental health across state lines is whether a state has legal control over out-of-state licensees.

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. Also, the novel coronavirus outbreak of 2019/2020 triggered sudden state of emergency licensing policies and telehealth. Some states made these COVID-19 rule changes permanent.

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.

COVID-19: Federal government and waiving out of state licensing requirements

I receive this question from mental health professionals nationwide. Has the federal government or U.S. president issued a mandate or recommendation that allows anyone with an unrestricted license to practice telemental health in any state? Yes. There have been mandates, but they are gestures. The legality of out-of-state practice by the federal government is a suggestion. The U.S. Department of Health and Human Services (HHS) has asked that states be more flexible with practice across state lines in the interest of addressing the COVID-19 novel coronavirus pandemic. The federal government has jurisdiction over their law. States have jurisdiction over state law. Sometimes legal cases are appealed at the federal courts level, but the laws are still states’ rights. As much as any other law if not more, states control healthcare professional licensing law. The federal government’s Center for Medicare and Medicaid Services (CMS) has implemented emergency policies that expand the delivery of telehealth across state lines, but again– federal program, federal law.

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.

I am a Georgia Licensed Professional Counselor. Client confidentiality is addressed in the title of Georgia law, “Evidence”. Whereas the composite board addresses confidentiality in it’s code of ethics, it does not have jurisdiction over the confidentiality law.

COVID-19: Telehealth Practice Across State Lines

The policies of states’ to allow interstate practice varies widely:

1) In response to COVID-19, some states have determined it’s not legal and they consider it Unlicensed Practice if you attempt to deliver telehealth to their residents. Period and end of the story.

2) Other states’ policy is that they intend to address this as soon as possible as they are aware of the public health threat of the virus.

3) Yet other states have rapidly implemented legalization of out-of-state licensees practicing in their state.

Georgia Boards and Telehealth Emergency Policies

Composite Board of Professional Counselors Social Workers and Marriage and Family Therapists

No emergency action has been taken to waive out of state licensees delivering telehealth to Georgia residents. Nothing stated or implied. The board has enforced this as unlicensed practice.

States Now Resuming Pre Covid-19 Licensing Waivers

North Carolina Board of Licensed Clinical Mental Health Counselors

North Carolina governor Roy Cooper signed an executive order temporarily waiving certain practice requirements for telehealth delivered by healthcare professionals. The order was set to expire 6/7/20. As of this writing a superceding executive order has not been issued by the governor. This means all licensing law and rules will return to normal requirements by default. North Carolina is one of the first states to terminate COVID-19 licensing waivers.

*I will keep you abreast of state’s changes in future newsletters.*

States With Aggressive Waivers of Their Licensing Laws

New York Office of Professions, Mental Health Practitioners

NY Governor Andrew Cuomo has taken swift action to expand access to healthcare for NY residents. The executive orders are sweeping and include mental health professionals. This message received from the board Executive Secretary:

“On April 9, 2020, the Governor issued an executive order that provides a temporary suspension and modification of Education Law and Regulations of the Commissioner of Education to the extent necessary to allow mental health counselors, marriage and family therapists, creative arts therapists and psychoanalysts licensed and in current good standing in any state in the United States to practice in New York State without civil or criminal penalty related to lack of licensure. No application is required; the State Board will not review an out-of-state licensee’s qualifications. However, it should be noted that EO 202.15 does not temporarily suspend or modify a licensee’s responsibility to practice his/her profession in accordance with New York law, including the restrictions on practice and definitions of unprofessional conduct.”

Missouri Committee for Professional Counselors

Missouri is also a great example of a fast and streamlined suspension of licensing law. Missouri governer Mike Parker signed a COVID-19 executive order on 3/13/20 waiving telehealth and telemental health laws which prohibit out -of-state licensees from practicing in MO. “Dear Eric…boards only have the authority given to them in statute and regulation and can only regulate Missouri licensees. In normal circumstances without the governor’s executive order, if licensees of other states are practicing here without a license, most boards can do two things – seek an injunction to stop the unlicensed practice or refer the person to their own state. During COVID-19, if a licensee of another state does telehealth services for a client who is in Missouri, the waivers would preclude taking any action.” – MO Attorney General’s Office.

In effect, Governor Parker used executive privilege to prevent their licensing boards from taking action against out of state licensees. This order waives for psychotherapists and psychologists, nurses, physicians and many other healthcare professionals. Read on for an explanation of these two options boards’ have for handling unlicensed practice.Telemental Health Across State Lines

Pre-COVID-19, the following conditions of practice across state lines prevailed and in many states still do:

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?

Unlicensed Practice Or Refer To Home State

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?

Special Circumstances of Unlicensed Practice

The California Board of behavioral Sciences 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 the practicality of enforcement of this law.

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 which is the best solution legally and ethically. However, you usually need to apply as a new licensee or seek licensure by endorsement.

Telemental Health 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. Minor provisions have been made for COVID-19 that allow you to practice for six weeks with minimum training.

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, BC-TMH 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, 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.

When you accept an app’s privacy policy, you may be granting access to your patients’ information. Further, when you are sent updated privacy policies, it often translates to ‘less privacy’. Determine whether you are comfortable with third party access to your patients’ PHI. Read below to learn ways to restrict communication you have with them.  

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.

Can LPC Diagnose in GA | SB 319: 2019 and Beyond

Ethics Demystified: Can LPC Diagnose in GA

Georgia Composite Board Diagnose Law -Updated 1/23/2020

“I have heard that prior to SB 319 it was illegal for LPC’s in GA to diagnose”. This is false. The Georgia composite board has always enforced it is legal for LPC’s to diagnose. The driving force behind the new law was the Licensed Professional Counselors Association of Georgia. It further establishes the professional identity of masters level therapists. Now the word, “diagnose” is in the LAW and allows LPC, SW and MFT to inform a judge they can legally diagnose. Amending the law to include “diagnose” was important especially for civil suits.In practical terms, SB 319 addressed reimbursement issues and compliance with other state laws. For example Medicaid chooses which credentials they will reimburse for mental health services. If you bill Medicaid without that credential they can seek remedy including reporting this to federal authorities as fraud, but legality of “diagnosing” is determined by the state licensing board.

What is GA SB 319?

First, SB 319, is the most sweeping change to our practice law since the law creating these licenses was passed in 1984. My ethics workshops provide opportunities for you to ask questions about my experience enforcing this law. Senate Bill 319 includes an amendment to GA Code § 43-10A-3. This section of our law states what PC, SW and MFT can perform, what we can not perform, and what is an infringement especially on other licensed healthcare professions. can lpc diagnose georgia

Do I need to understand this law?

The language of this amendment is complex and convoluted. The law contains many other elements and changes that impact everyone licensed by the Composite Board- GA Social Workers, Marriage and Family Therapists and Professional Counselors. The other issues in the new law are related to education requirements and the various instruments used for psychological testing. However, now that GA law contains the word “diagnose” for LPC SW and MFT, they now also must prove they’re qualified to do it. You should read that law, but it is not possible to interpret because the board enforces it in a manner that suits the current climate of the profession. What is important is that you read and understand Board rule Chapter 135-12.

Corresponding Rule Chapter 135-12, Testing and Assessment

Board Acceptable Educational Requirements

What has changed is there are now educational requirements that must be met in order to be in compliance with the new rules. If you have been fully licensed ( not associate level) for 10 years, you are exempt from any additional requirements. If you have been licensed for less than 10 years you will need to document that you completed a 3 semester or 5 quarter credit hour graduate course that had diagnosing in the course content or a curriculum in diagnosing workshops. If you have not satisfied these requirements, here is where things get a little complicated primarily because the board has yet to determine the best way to enforce the educational requirements. The board could exercise discretion in the following areas: 1) The composite board does not accept diagnose continuing education as meeting the diagnose rule requirements. At least not yet. As of 5/13/2019,  the board is waiting for a decision from the Georgia attorney general’s office. This will officially establish if the board can begin to accept continuing education courses as a substitute for diagnose courses and the 45 hour curriculum offered by LPCAGA, GA NASW, GSCSW and GAMFT. 2) Accept courses that are completed after the 12/31/17 deadline as stated in board rules but prior to 9/30/18 license renewal.

PRO Tip: Would you like a personalized evaluation of diagnosing in your practice?

If you are interested in structuring your practice in an ethical manner including diagnosing, I can answer questions at any of my workshops. If you would like a comprehensive evaluation, call me and we can schedule a license consultation appointment.

4 Key Points: Rules Compliance With Diagnose and Testing

The following recommendations are based upon personal experience with many of Georgia’s other Georgia licensing boards scopes of practice violations e.g. psychology, nursing, and dental boards.

Diagnosing Mental Disorders

There is no list of mental disorders that LPCs can’t diagnose, however limit your diagnosing if possible. Usually it is not necessary for LPC SW and MFT to render highly specific diagnoses in order to carry out our work. For example, it is not inaccurate to render a more general diagnosis of recurrent major depression for a patient who a psychiatrist or psychologist has diagnosed as bipolar type I or borderline personality disorder since with all of these disorders patients may suffer from major depressive episodes. Psychiatrists and psychologists sometimes need to render more specific diagnoses. You are protecting yourself on several fronts if whenever possible you allow a psychiatrist to be the diagnosing clinician of record.

Social Workers, LPC and MFT and Psychological Testing

From reading the previous paragraph it is easier to determine which type of testing you are able to perform. Even prior to the new law, Composite Board licensees could legally administer many tests including the MMPI–clearly a psychological test. The fundamental change in this new law is that it clarifies the psychology board’s rights to perform psychology testing in an exclusive manner. The result is that it could be easier for the psychology board to issue cease and desist orders to non-psychologists for unlicensed practice of psychology. Cease and desist orders are a very serious and public disciplinary action.

Guidelines for Psychological Testing

1) The new board rules state you can administer tests that you have been properly trained to administer and interpret, but even though you have been trained in administering for example the Rorschach, it is clearly a psychological test that is usually studied in a psychology PhD program. 2) The board does not a have list of tests masters prepared psychotherapists can administer. In order to protect your license, err on the side of caution:

Suggestions To Avoid

Psychological tests that can potentially cause psychological harm to a patient if misinterpreted. For example, some IQ testing. Tests that are primarily used in psychological research. For example, the lexical decision task (LDT). Many of the common instruments used in a formal neuropsychological battery for example those used by the Social Security Administration for making determinations about psychological disability. Avoid making a determination of malingering. You can query this in your progress notes but also document either a referral or reference to a psychologist or psychiatrist needing to assess it. Avoid tests which are used to diagnose degenerative brain disorders. In fact, this potentially places you in the realm of practicing medicine.

Safe But Proceed with Caution

Questionnaires completed by the patient that render results that are a simple sum total of the items which you then interpret. Examples include the Beck Depression Inventory and the Hamilton Anxiety Rating Scale. An example of a test you can administer and interpret by virtue of training is the Dissociative Experiences Scale. Many masters level therapists are trained in trained and skilled in treating dissociative disorders and the DES renders information useful for assessment and informing treatment planning. Career and vocational tests are generally acceptable. Some psychological tests, but only if under supervision of a psychologist. Document in your record that the psychologist both interpreted the results and directed you to administer the test.

Advertising Your Testing Services

Avoid the use of any and all terms with variants of the word, “psychology” in your advertising. Examples of what to avoid are psychological assessment, career psychology assessment services and psychological and counseling testing services. “Career and vocational testing” won’t likely be challenged by either the Composite or the Psychology Board. Be clear about your testing services. As a rule, don’t attempt to push the boundaries of any of your advertising.

Information for New Licensing Applicants

It is important you learn how to submit an LPC application that is clean, concise and clear.

All 50 States Diagnose

An alphabetical listing of counselor diagnosing by state scope of practice law and regulations. I have quoted this language directly from each state’s law or regulations. georgia counselor social work diagnose rules law It’s important to understand the history of diagnosing for professional counselors, social workers, marriage and family therapists and other master’s level mental health providers. Many states have only recently added ‘diagnose’ to masters level therapists scope of practice laws. Some state boards including Georgia’s composite board have enforced masters level therapists diagnosing is legal even though the word ‘diagnose’ was not in the law. In some states, counselors have vast authority primarily due to their licensing boards lack of resources or the shortage of psychologists and psychiatrists.

Alabama

“…diagnose and develop treatment plans but shall not attempt to diagnose, prescribe for, treat, or advise a client with reference to problems or complaints falling outside the boundaries of counseling services.”

Alaska

“..may diagnose or treat, other than through the use of projective testing or individually administered intelligence tests…”

Arizona

” diagnosis and treatment of individuals, couples, families and groups.”

Arkansas

‘Diagnose’ is in the Social Workers law, however it is not in the Marriage and Family Therapists and Counselors laws.

California

“…the application of counseling interventions and psychotherapeutic techniques to identify and remediate cognitive, mental, and emotional issues…”

Colorado

(Will provide information as it becomes available.)

Connecticut

“…evaluation, assessment, analysis, diagnosis and treatment of emotional, behavioral or interpersonal dysfunction or difficulties that interfere with mental health and human development.”

Delaware

“… methods or procedures and the diagnosis and treatment of mental and emotional disorders to assist individuals in achieving more effective personal and social adjustment.”

Florida

“…practice of mental health counseling includes methods of a psychological nature used to evaluate, assess, diagnose, and treat emotional and mental dysfunctions or disorders…”

Georgia

“…utilizes counseling and psychotherapy to evaluate, diagnose, treat, and recommend a course of treatment for emotional and mental problems and conditions…”

Hawaii

“…The assessment, diagnosis, and treatment of, and counseling for, mental and emotional disorders;…”

Idaho

“…prevent, assess, and treat mental, emotional or behavioral disorders.”

Illinois

“…diagnosing for the purpose of establishing treatment goals and objectives…”

Indiana

“… to evaluate and treat emotional and mental problems and conditions in a variety of settings…”

Iowa

“…“Mental health setting” means a behavioral health setting where an applicant is providing mental health services including the diagnosis, treatment, and assessment of emotional and mental health disorders and issues…”

Kansas

“…may engage in the independent practice of professional counseling and is authorized to diagnose and treat mental disorders…”

Kentucky

“…methods, and procedures, including assessment, evaluation, treatment planning, amelioration, and remediation of adjustment problems and emotional disorders,…”

Louisiana

“…means rendering offering prevention, assessment, diagnosis and treatment…”

Maine

“…means assisting individuals, families or groups through the counseling relationship to develop understanding of intrapersonal and interpersonal problems, to define goals, to make decisions,…”

Maryland

“… methods in the diagnosis, prevention, treatment, and amelioration of psychological problems and emotional or mental conditions…”

Massachusetts

“… includes, but is not limited to, assessment, diagnosis and treatment, counseling and psychotherapy, of a nonmedical nature of mental and emotional disorders,…”

Michigan

“…a service involving the application of clinical counseling principles, methods, or procedures for the purpose of achieving social, personal, career, and emotional development…”

Minnesota

“…the implementation of professional counseling treatment interventions including evaluation, treatment planning, assessment, and referral;…”

Mississippi

“…Counseling/Psychotherapy involves diagnosis, assessment and treatment by use of the following:…”

Missouri

“…techniques, methods, or procedures based on principles for assessing, understanding, or influencing behavior…”

Montana

“…conducting assessments and diagnoses for the purpose of establishing treatment goals…”

Nebraska

“Diagnosing major mental illness or disorder except in consultation with a qualified physician, a psychologist licensed to engage in the practice of psychology…”

Nevada

“…counseling interventions to prevent, diagnose and treat mental, emotional or behavioral disorders and associated distresses…”

New Hampshire

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Can LPC’s only give diagnostic impressions?

This is false. The term “diagnostic impression” is used in many different ways, but it did not form the basis for legality of diagnosing in Georgia.

Historical Timeline

11/21/16- The 2016 Law and Pending Composite Board Rules

If you are licensed by the Composite Board, avoid the use of any form or derivative of the word “psychology” in your practice or any information you publish or advertise through print and the internet or social media unless you are also licensed by the GA State Examining Board of Psychologists. This is regardless of whether the proposed rules are passed.

2/8/17: Rule changes focusing on psychological testing

First and foremost, the board enforces our practice law–no one else. There is no way of knowing what is legal under this new law until new rules are passed. The board has significant discretion in the interpretation of this law. Your main concern at present is to be certain you are not representing yourself as a psychologist.
  • Any new diagnose course requirements which could be passed for LAPC/LPC will become partially moot when an existing rule becomes effective after 9/30/2018 requiring a course in diagnose as part of an acceptable graduate degree. In essence, you will automatically be in compliance if you have completed that course and that course is required by most CACREP and other board approved degrees.
  • There may be CEU requirements, but the law allows the board to accept experience in lieu of educational requirements. It is not known whether the board will write the rules to allow that.
  • In essence how the new law will be enforced is unknown at this time. It is possible that the Board of Examiners of Psychologists will attempt cease and desist orders with individuals who are engaging in certain activities. However, most of psychology board’s cease and desist orders on Composite Board licensees are related to advertising.
  • The Composite Board has it’s February 2017 meeting on 2/9/2017 to further discuss SB 319 and rules drafts.
  • Don’t panic. As usual, adhere to GA composite board code of ethics 135-7. Avoid the use of any form or derivative of the word “psychology” in your practice or any information you publish or advertise through print and the internet or social media unless you are also licensed by the GA State Examining Board of Psychologists. This is regardless of how the proposed rules are passed. Beside that, there is no way of knowing what you will need to do to be in compliance with this law until the Composite Board begins to enforce it and new rules are passed.

2/15/2017: Rule Changes Still in Discussion and on the March 2017 Board Meeting Agenda

The outcome of the meeting will be reflected in the minutes which should be posted within a few weeks on the Secretary of State licensing board website. I will try to post here any other updates asap.

4/10/17: Composite Board Public Rules Hearing: May 5 2017, 2:20 pm, Macon Georgia

The most recent version of the diagnose and testing rules has been confirmed by the Attorney General’s office and has been posted on the Secretary of State Professional Licensing board website.  The May 5th hearing is open to any member of the public. There have been several versions of rules drafts that the board has considered. They could be changed again. It is important to note that the board has enforcement power over our practice law and they then write rules to interpret that law. Sometimes the board will exercise discretion and enforce a rule differently than written. It is a complex and fluid process and partly why it is difficult to predict how the board will enforce any aspect of regulating our practice. The previous rules draft was scheduled for a possible vote on 3/10/17. The vote was again tabled. This partly owed to administrative and other work on the rule having not been completed. In effect, we are therefore still regulated under the old/current rules. Until rules are passed, there is nothing factual that can be stated regarding any additional licensee requirements or legality of practice activity under the new law.  All of the recent rules drafts have contained diagnose course curriculum, completion of a graduate level course which includes DSM V diagnosis for LPC SW and MFT content or exemptions for those licensed 10 years or more, and revised language addressing psychological testing, but the rules could still undergo further revisions. For now, obtain a copy of your graduate transcript, descriptions directly from the school bulletin of any courses that include diagnosing, and course syllabus. Retain these in the event the board requires you to produce them. When passed, it is not possible to know precisely how the board will enforce the new rules. The logistics of enforcement of new rules can be a challenge for board members as well as staff.

5/5/17: Board Votes Unanimously to Accept 135-12 Proposed Rules

Have the new diagnose and testing rules officially passed? Not quite–the rules will be sent to the governor who has 90 days to approve, change or veto them. They will then be sent back the the Board Executive Director and once received after 21 days will become effective. It could be August 2017 or later when the rules are official. Stay tuned for developments on how the board begins to enforce this new rule.

8/18/17: Governor Signs “Certificate of Active Supervision”

The new diagnose and testing rules have been approved and signed by the governor. They will be in effect 21 days from 8/18/17. Nathan Deal’s signed document can be viewed here.

Ethics in LPC License Training and Supervision

Ethics Demystified: Ethics LPC License Training and Supervision

Ethics in Clinical Supervision

Ethics is the foundation of professional practice as well as LPC licensure training and supervision. Ethics isn’t a component of your practice: all aspects of your practice are based upon ethics. It is the cornerstone of the practice of psychotherapy. Your practice can’t survive if you don’t have a solid grasp of what is right and wrong. Morally, clinically and legally. Without that foundation, even the most sophisticated counseling skills are of little value.

lpc licensure training and supervision

None of us are automatically ‘ethical’. You must learn it from more experienced peers. Either through consultation or professional CEU workshops. In a broader sense, LPC licensure training and supervision involves getting a license, maintaining it, and receiving/giving help to our peers.

The state of the profession is determined by those it gives birth to.

In other words, experienced therapists have an obligation to nurture the growth of those new to the counseling profession. Good license hygiene requires a mastery of ethics.

This should start from the time we begin pursuing a license. It transcends professional identity or orientation: this guide applies to everyone licensed to practice psychotherapy including psychologists.

Background

My decision to provide ethics training and supervision was based on my experience serving on the Composite Board of Professional Counselors, Social Workers and Marriage and Family Therapists.  Board members are appointed by the governor. I served for 7 years. When I departed, I wanted to share my experiences with peers. I knew I could have a positive impact on the profession. I felt a duty to share how the board evaluates ethics complaints.

Why ethics should be your top priority

Some of the most common ethical violations are found to be boundary crossings.

For therapists, the greatest job hazard is managing human contact. When our helping turns into rescuing, we have engaged in a boundary crossing. This type of boundary crossing is a common blind spot for new or inadequately trained therapists.

Sometimes therapists lack a capacity to see they have crossed a boundary. This is very concerning and it is compounded when their clinical supervisor doesn’t see it either.

Supervisors must be skilled not only in recognizing boundary crossings, but they must use those skills so together you can get your work back on track.

As you can see, you need a solid foundation in ethics in order to practice safely and fortify where you are most vulnerable. I explain this further in my approach to supervision.

What is good license hygiene

Hi-giene (ˈhīˌjēn) noun: conditions or practices conducive to maintaining health and preventing disease, especially through cleanliness. synonyms: cleanliness, sanitation, sterility, purity.

First, hygiene is prevention. As you proceed towards licensure, you should be proactive in ensuring a clean and unblemished license history. You accomplish this by incorporating a system for addressing areas where you need to strengthen your license.

There are 7 essential elements to gaining a solid grasp of ethics and good license hygiene.

7 essential elements of ethics and good license hygiene

Read the Composite Board Code of Ethics

Review the Composite Board Code of Ethics. Georgia professional counselors, social workers and marriage and family therapists are all bound by this same code. I cover it with participants line-by-line in my ethics workshop, Understanding the Composite Board Complaints and Investigations Process.

Supervision by a Well-Trained Supervisor

Having a state practice license is a serious matter.  Select your supervisor carefully. For example, if you are working with children, they need to have worked with children. They should state to you their approach to supervision.

Your supervisor should know the board rules and ethics. They need to stay on top of rule changes as well as board policies. They need to be competent in guiding you on ethical dilemmas.

There should be a ‘click’ between you. There is too much at stake to put your pursuit of licensure in the hands of someone you don’t fully trust. You are paying them for your service. They should work on your behalf and in your best interests.

Nonetheless, they should be someone who will also kindly yet bluntly challenge your work. But, if you can’t share challenging ethical situations with your supervisor, it will be difficult for you to develop as an ethical therapist.

Rethink Definitions of Boundary Crossings

We all know the obvious boundary violations. For example, we know not to engage in intimate relationships and barter with clients. However, there are subtle boundary crossings we tend to miss.

boundaries ethics therapists

Consider how this can roll down hill very quickly. The client begins work. After several months they become disgruntled with their boss who is your friend who gave you the “hook-up” on the job. At this point a breach has occurred. The client further becomes upset with you for connecting them with a job where they have a legitimate harassment case. The client files a licensing board complaint against you for the breach and unprofessional conduct.

Do you want to avoid these types of complaints? Note the following best practices:

CEU Workshops on Boundary Management

From the above illustration it is easy to see why you can never get too much education in boundaries. Research the workshops and presenters thoroughly. It is important the information you learn is accurate and comprehensive.

Presenters/trainers should be in active clinical practice. The workshops should be empowering! You shouldn’t leave with your head spinning feeling more confused and frightened.

Understand There is Always a Power Differential

Even though client relationships can be casual and relaxed, your client idealizes you. It may not be apparent, but clients hang on your every word and see you as the expert. Therefore, clients can be injured easily.

Choose your words carefully and check in with them to confirm that what you intended to convey is what they heard.

Peer Relationships That Are Friendships.

Perhaps the best way to achieve this is to carefully screen and select practice partners and office mates. Having a trusted peer on-site is invaluable.

Working through your ethical dilemmas often requires a non-judgmental third party.

Personal Psychotherapy

It is very difficult to effectively practice psychotherapy if you have not been a client in therapy. Personal therapy compliments supervision. It also helps you recognize projections and transference/countertransference. Further, your supervisor will likely confront you when they believe that personal issues are impacting your work and you need to be able to respond to your supervisor.

Putting it all together

Now you can develop a personal system to ensure good license hygiene.

1) On even numbered years, you are required to complete 35 hours of continuing education. Take plenty of ethics courses especially boundaries. 10 hours is good. Choose topics that will help correct weak areas of your practice. Approved ethics courses can be used to fulfill all of your board CEU requirements. You can the round out our requirements with elective workshops.

2) As you encounter ethical dilemmas, you have at least two resources for help: your trusted supervisor and trusted peers. Through CE training you will have skills to interact in an educated manner with your trusted peers.

3) Incorporating and sharing your personal psychotherapy can be very helpful for your development. **More often than not, struggles with a client are related to personal issues and not sheer lack of clinical skills.**

Closing Comments

I have tried to thoroughly cover ethics of LPC licensure training and supervision. If you have questions about this article, feel free to contact me by phone. If it is simple question, I am happy to offer a free phone consultation. Best wishes wherever you are in your career as a therapist!

eric- (Go Back to Top)

 

Supervision Topics : Clinical Guidance Simplified

A Fact-Based Approach to Working Through Any Supervisee Dilemma

Supervisees present us with cases that involve complex decision making. When a supervisee is overwhelmed, they can have difficulty formulating the case in a coherent manner. Often there are numerous situations converging upon the case and it can be difficult to determine which are the most important to address. We are required to reconcile these challenges in order to reach the goals of promoting clinical skills, professional development, confidence building and ethical decision making. Some of the challenges we face as clinical supervisors are:

1) these cases can present us with ethical dilemmas,
2) the case can have disastrous implications,
3) the case may be beyond the skill level and experience of the supervisee,
4) helping the supervisee prioritize interventions,
5) supervisor’s feelings of helplessness and countertransference, and
6) helping them formulate the case in a manner which is useful for problem solving.

A supervisee’s clinical dilemmas are often a result of:

1) inadequate case information,
2) faulty assumptions made about the case,
3) insufficient clinical experience, and
3) impaired insight due to intrapersonal struggles.

A Fact Based Approach: Crime Scene Investigation

Having investigated over 200 licensing board complaints, it became apparent that similar principles can be quite effectively applied to client case formulation and problem resolution. In essence, the case presentation and feedback/advice process is approached as a crime investigation:

1) facts upon initial discovery,
2) determining which direction to take the investigation,
3) discovery of more facts,
4) evaluating all information,
5) making recommendations,
6) return to step 1.

The following is an actual example of a complex case and the application of an investigative process. All identities have been concealed.

Case Vignette

The Supervisee:

27 year old female with an LAPC and 2 years of therapist licensing requirementscounseling experience. She is working in an intensive outpatient addiction program. Many are dually diagnosed with a mood disorder but rarely severe mental illness or functional psychotic disorders. Most clients are survivors of significant childhood trauma. She recently began work in a private practice setting under the direction of the owner of the counseling practice. No other work mental health work experience. Psychologically she is functioning on a scale of 1-10, about 8. No history of acute depression. Mild/moderate struggles with assertiveness, boundaries and confidence in her therapy.

The Case:

A 25 year old male. The supervisee has provided the following information: Client takes Adderal, is addicted to internet pornography, and discouraged about whether he will ever complete his bachelor degree. No suicidal ideation. Last year he was hospitalized in an inpatient psychiatric facility for 6 weeks and discharged to a intensive outpatient program that he did not attend. His stated goal is to get back into school. He does not feel he has any other problems for which he would like help.

The Dilemma:

She feels lost and does not have a clear picture of this client’s struggles. She therefore doesn’t know where to begin to help the client. She has given the client advice and helped him set goals for returning to school. After 5 months, she feels the client has made little progress.

The Investigation:

Known Facts:

Of the clients own admission, takes Adderal, was hospitalized, wants to get back in school.

Determining Direction and Evidence Collection:

We can conclude this supervisee is inexperienced particularly in clinical mental health and the spectrum of mental illness. They are new in the counseling field. They have some knowledge about addiction, depression and trauma. The supervisee is likely confused because there is a great deal of missing information; many unknowns. In other words, they have not completed a comprehensive assessment. In your opinion what are the ‘great unknowns’?

Helping the Supervisee Determine which Information/Evidence to Collect and How to Collect It

Part of being overwhelmed is that we often can’t see the forest for the trees. Your first objective should be to help them see what is most obvious. How does a supervisor accomplish that?

I often use allegory and other non-counseling metaphor and illustration in supervision:

“Imagine you are called to investigate a missing person. You identify and question witnesses. This leads you to the home of an individual who was possibly the last to see the missing person. When you arrive, the individual answers the door, you enter the home and have a brief discussion. You briefly make notice of a splatter on the wall and doorway leading to the kitchen that appears to be blood. The individual stated that another person came to the home and departed with the missing person; that they were not the last individual to see the missing person. A second elderly person appears from a bedroom in the home. She is obviously frightened and confirms the report of the missing person’s departure earlier that week. She states that according to police the person who departed with the missing person has a lengthy criminal record. She provides you the name of the individual. You call your police precinct and the elderly woman’s report is confirmed. You leave the home. What should be your next step? Which step is most likely to render the most relevant information?”

Hopefully at this point, your supervisee will conclude that inquiring about the hospitalization will render the most useful clinical information: the hospitalization is the blood splatter on the wall. Some of the questions the supervisee should ask the client are:

1) I’d like you to share with me your hospitalization last year? How did you get to the hospital? Did you drive yourself or did someone bring you?
2) Did you voluntarily admit yourself?
3) What was the hospital’s stated reason for hospitalizing you?
4) Did you express thoughts of suicide either prior to or during the hospital intake interview?
5) What did the drug test show positive for?
6) What happened immediately prior to the decision that you would go to the hospital?
7) Did you go to a general hospital emergency room? If so, were you hospitalized there?

Data Collected: The client made a suicide attempt by mixing a significant quantity of Xanax and Alcohol. They stayed in the emergency room for 48 hours prior to discharge to a psychiatric facility. The hospital said she was hospitalized for severe depression, and Xanax dependence. The drug test rendered positive results for Adderal, Xanax, and Hydrocodone. Now you have a much clearer clinical picture.

We now have more facts:

1) Confirmed substance dependence on Xanax.
2) Confirmed history of an acute and severe major depressive episode.
3) At least one prior suicide attempt which was severe enough to require medical stabilization.
4) The above make them a high risk for major depression and suicidal thoughts.

Reevaluation/Prioritization

The immediate and short-term goal of therapy should now shift from advisement on academics to stabilizing the client and reducing risk for another major depressive episode, and a comprehensive substance use assessment. Interventions aimed at increasing insight into severity of depression and substance abuse. Restating the desire to return to school as being almost entirely dependent upon first addressing substance abuse and depression.

Supervision Goals Accomplished

The supervisor now has proactive mechanisms supervision topicsin place that cover most major ethical and other concerns. It would also be prudent to recommend the supervisee seek additional work experience that will enable them to work with a population with severe clinical illness. It is important to articulate to them there is no educational substitute for that experience and the risk involved with working in a practice environment with no physician or other medical staff on-site is formidable. It is a good indicator that this supervisee is eager to learn and apply recommendations. Please follow my blog series on supervision topics. I also enjoy providing ethics in supervision workshops.

Get That LPC Application Approved

This post will help you get that lpc application approved – the first time. How do I find a qualified LPC clinical supervisor? How do I know if the board will approve my work setting? How do I know how many hours or years I need to complete? I’m sure our readers would like to know the answers to these questions.

Introduction

LPC Educational Requirements

GA Composite board rules require a graduate degree that is “…primarily counseling in content”. A masters degree in Sociology is not acceptable to the board because it is not primarily counseling in content. A degree in Professional Counseling is acceptable.

Masters in Psychology or Special Education could be eligible. It largely depends on the titles and content of the courses required. It must be a program in applied counseling not experimental or theoretical knowledge. For example, a course “Group Counseling” is acceptable whereas “Cultural Anthropology and Groups” is not. Why? The latter is not applied counseling. For more details read rules “Definitions”, paragraph 8. You also must pass a national exam further explained in “Requirements for Licensure, paragraph 3.  As you read further, you may want to read my The Art of Reading Board Rules. The page will open in a new browser window.

Years of Required Directed Experience Under Clinical Supervision

One year: 600 hours of directed experience and 30 hours of Supervision over a period of minimum 12 and maximum 20 months. 800 hours in 11 months is not acceptable. You can’t reduce or accelerate the calendar year requirement. Must be minimum 12 calendar months. You have up to 20 months to complete that one year. After September 30 2018, these requirements increase: One year is minimum 1000 hours directed experience and 35 hours Supervision. Very important: only months which you are under Direction and Supervision simultaneously will be eligible. You cannot practice if you are not under supervision.

Supervision

A: The rules state that you have until September 30th 2018 to obtain a clinical supervisor under the current requirements–generally, the supervisor must have 3 years post-licensure experience and no additional credential. In other words, any current board eligible supervisor you execute a contract with prior to that date will be acceptable throughout your supervision with them. Hypothetically, if you enter into a supervision agreement on September 30, 2018 you may stay with them as long as you like. However, if you change supervisorson October 1, 2018 that new supervisor will need either the Licensed Professional Counselors Association of Georgia Certified Professional Clinical Supervisor (CPCS) or the National Board for Certified Counselors Approved Clinical Supervisor (ACS) credential.

 

How do I Know if My Job Will be accepted by the Board

A: There are no guarantees your work setting will be accepted by the board. First, try to find a work setting or organization that has a track record with the board. Ask the director if they have had any problems with the board approving their work setting. Most employment or contract work in government settings is acceptable. Private treatment programs that have been historically accepted include Rebecca Beaton’s Anxiety and Stress Management Institute and Peachford Hospital. There are many other private treatment programs which are acceptable. Private psychiatric practices in which you receive either a W2 or 1099 are often acceptable. Smaller private practice organizations can be acceptable to the board. You CAN find that perfect therapy work site.

For any of the sites above, you must document on the duties section of the directed experience form that you are doing psychotherapy. Whether your site is acceptable to the board is very much dependent upon you demonstrating the site has structure, a comprehensive system for monitoring your work and policies/procedures for discipline and intervention with your client work. This is critical.

Can I Work in Practice Practice Psychotherapy as an LPC?

A: It is possible. Remember: In Georgia, LAPC (Licensed Associate Professional Counselor or in some states, ALPC license) and LPC are governed under the same scope of practice. The difference is that as an LAPC, you must be under direction and supervision simultaneously. That is critical.

A private practice setting in which you are working on your own without any structure or intervention, bears no resemblance to employment or you are not receiving training and administrative oversight will likely be denied as an acceptable work setting.

Q: What do you recommend for a work setting?

Where Can I Find The Best LPC Jobs and Work Settings?

A: How to find a counseling job. Your goal should be to find a site that provides clinical mental health experience. Severe mental illness. Addiction. Facilities such as Grady Memorial Hospital Psychiatry in Atlanta, Ridgeview Institute in Smyrna Georgia or a community service board are excellent training grounds. In the absence of this type of training, it may limit your skills. If you must, seek this training post-licensure. This also applies totherapist licensing requirements social workers and marriage and family therapists.

Q. How do I find a qualified supervisor?

A. Interview several. Determine if their approach provides a level structure suited to you. A supervising relationship should consist of authority, mentoring, and someone you want to learn from. Seek a supervisor that wants to help develop you clinically, personally and professionally. One of the greatest challenges of having a job where your supervisor is also your boss is that you cannot be open with them. If you have an offsite independent clinical supervisor, that conflict of interest can be eliminated.

Q.What happens in a supervision session? It seems shrouded in mystery!

A. Supervisors will highlight areas that need improvement. You being a student you will have discussions with your supervisor about your clients, and your supervisor will question you. The supervisor will give you notes and ideas and you should apply these suggestions. It should be an interactive relationship. In addition, you should be open to constructive feedback on personal issues which may be interfering with your counseling and psychotherapy. Your supervisor may inquire about childhood trauma and abuse to determine if these are unresolved and therefore negatively impacting your work. They may require you see a therapist. Generally, your supervisor should be supportive, confident, reliable and consistent.

Q. How do I know if I am cut out for this work? For example, How do I even know if I will be a qualified counselor?

A. You have to decide whether you enjoy counseling people. You will find this work frustrating if you believe clients are not changing quickly. The work will be hazardous if you become involved with a client’s matters that are outside the scope of psychotherapy. This is referred to as boundary issues. Blurred boundaries include trying to find them a job, transacting other business or any advocacy work that is not directly related to treatment. Remember: we are licensed to treat mental disorders through psychotherapy. Also, if you are not comfortable with diversity you may be more content in a different career. If you can separate your personal life from work and view it as a vocation. If you are self aware and don’t have a rigid coping style. If you understand that you can learn from other therapists–even those less experienced. If you understand that a client drives personal change- not you.

Q. Finally, what would you say to graduate level counselors pursuing state licensing on how to have a successful career?

A. Acquire and be eager to learn business skills. Be able to reconcile that even though you are helping someone, you need to seek at least the average income for counselors or social workers. Be open to learning and criticism. Seeing a therapist as a therapist is almost required. You cannot sell a product you do not believe in yourself. Find a specialty. Don’t be a generalist. Seek training in that specialty and obtain a credential. Strive to be the best at that specialty so you can become an expert in it.

If you really want to be a great therapist, cover these 3 bases:

1. Obtain solid training in clinical mental health and addiction.

2. Remember that your practice is a business.

3. Find your own therapist and work very hard. You can only help a client through their emotional struggles if you are actively working on your own struggles.

Eric Groh has worked in the mental field in Georgia or 30 years. For 16 years he has maintained a thriving Atlanta psychotherapy and ethics consultant practice. He processed over 7000 LPC applications and 200 licensee complaints while serving a 7 year governors appointment to the Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists. He specializes in the treatment of dissociative disorders and gambling disorder .

Diagnosing for Mental Health Professionals

Coming Soon!  “Ethics and DSM V: Comprehensive Assessment of Perceptual Disturbance”. This is a unique approach to diagnosing mental illness because it focuses on the common factor in all mental disorders: perceptual disturbance. Disturbance in perception is a cornerstone of diagnosing accurately. This continuing educational training also helps participants determine when to discuss the diagnosis with the patient and the hazards of ‘labeling’.

The Importance of Evaluating Perceptual Disturbance and Psychosis

Perceptual Disturbance is perhaps diagnose courses mental health professionalsthe most important clinical information to collect. In many ways it is the cornerstone of understanding mental disorders. Regardless of your psychotherapeutic approaches, the goal is change in your clients’ perception. This is true for everything from career struggles, developing self-esteem, addictions and severe mental illness. Knowing when to recommend evaluation for psychiatric medication is important. This requires an understanding of when psychosis is treatable with therapy or whether medication is required. Understanding altered perception and psychosis is fundamental to arriving at the correct diagnosis. If you have experience in the assessment of perceptual disturbance, you can diagnose many mental illnesses.

Perceptual Disturbance and Psychosis takes on many forms. Psychosis is observed in not only schizophrenia but schizoaffective, major depression, bipolar disorder, substance or drug induced, delirium, post-partum childbirth, dissociative disorders, head injury, medical disease and many others.

How do I assess non-psychotic perceptual disturbance?

Frequently, a psychosocial evaluation screens for psychotic symptoms but not a range of perceptual disturbance. Since every case is different, you will need to know when to inquire about non-psychotic perceptual problems. A great approach is to assess for perceptual anomalies and if these are significant, assess for psychotic symptoms. This is particularly true when you are in private practice or you work with populations with low rates of severe mental illness as it can facilitate your patient’s comfort with providing truthful and reliable information. Patients with histories of depressive episodes or suicidal thoughts or past attempts can be assessed using this approach.

For example, non-psychotic perceptual disturbance can also allow you to predict in advance a relapse of illness. Perhaps you have learned from experience with your patient that irrational fears, hypersensitivity to sound or other stimulation predicts the onset of a major depressive episode with severe psychosis. This also allows you to intervene proactively.

Modification of the Diagnosis

Unless your patient presents to you with a known diagnosis, you can usually only diagnose based upon current information available at the time of assessment. As you observe your patient over time and monitor symptoms this will render a clearer clinical picture. For this reason, you may later change your diagnosis of the patient. An important factor is whether the psychosis persists with treatment, whether there is partial remission or full remission. Full remission of psychosis occurs when it is substance induced. Full remission is possible with major depression. Full remission is usually not possible with schizophrenia. In this fashion, it is clear the importance of understanding psychosis in diagnosing mental disorders.

Diagnoses are often later modified for patients admitted to inpatient psychiatric treatment because the objective is to evaluate acute symptoms and proceed with admission.

Summary

This was an introduction to how developing a framework for understanding perception can be an aid in accurately diagnosing mental disorders.

nbcc approved continuing education provider georgia

Eric Groh LPC has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6921.  Programs that do not qualify for NBCC credit are clearly identified. Eric Groh LPC is solely responsible for all aspects of the programs. Programs that do not qualify for NBCC credit are clearly identified.