Can You Deliver Telemental Health Across Across State Lines.
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With few exceptions, it is illegal to practice counseling in a state you are not licensed. So you can’t deliver telemental health to a client located in a state you are not licensed. However soon through the Counseling Compact, you can practice in other participating states.
But before we go further, you’re going to need a proper Free Telemental Health Informed Consent PDF Download.
Some states, for example the Florida Counseling Board and South Carolina counseling board, issue out of state provider registrations. They only permit telemental health practice. You cannot physically practice within those state borders.
A number of states also permit limited numbers of sessions. This is usually in the interest of transitioning clients to their new state of residence.
But don’t hang your hat on these exceptions unless you are certain of the laws and fine print that permit you to practice in that state. Much thought should be given to any situations of practice in a jurisdiction where you don’t hold an official state license.
Solutions to Licensed Therapists Who Coach.
If you name your services “coaching”, you are still responsible for your license even if you don’t advertise you are licensed. Even if you aren’t doing psychotherapy. 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, then you can only coach since you are no longer licensed.
You can only have it one way. You can’t have it both ways.
Imagine this scenario. Your board asks you to respond to a client complaint of a boundary crossing. In the board interview, you explain that your informed consent makes clear you only coach. Your board will still ask you to defend your practice as a state counselor licensee.
One solution is to state in your services you are providing coaching. Be clear you will be intervening as a therapist if necessary. Absolutely advertise you are licensed. And then promote coaching as you would any subspecialty of your practice. For example, ‘Sofie McAllister LMFT. Counseling and Coaching.’
Problem solved.
Do The Online Platforms Permit Interstate Practice States.
They can’t make that decision. The counselor delivers the services and assumes full responsibility for all aspects of mental health treatment. Be thoroughly trained in telemental health and read the platform’s Terms Of Service carefully.
Seek telemental health training that is both high quality and accurate.
The revolution of electronic communication pervades our lives including how psychotherapy is delivered.
Online third party billing and credentialing providers proliferate. Their model is to enable therapists to accept insurance and receive referrals.
The Dilemma of Having Multiple Licenses.
When you have multiple licenses, you must maintain them all. Particularly, you need to understand the laws of all of those states.
By learning these laws and rules in advance you can make decisions about whether it is worth pursuing that license.
For example, the Ohio Counselor, Social Worker and Marriage and Family Therapy Board does not permit these professionals to hospitalize patients.
The Tennessee Board for Licensed Professional Counselors, Licensed Marital and Family Therapists and Licensed Clinical Pastoral Therapists requires a special license, LPC-MHSP, to diagnose mental illness. TN LPCs cannot legally diagnose.
In Georgia all can diagnose and hospitalize.
Florida’s Board of Clinical Social Work, Marriage & Family Therapy and Mental Health Counseling requires continuing education hours in HIV/AIDS.
That’s a lot to keep up with.
Short Definition of 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. Many state licensing boards require telemental health training.
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.
The Counseling Compact
The Counseling Compact will soon provide a path to practicing legally in multiple states. It is also referred to as online counseling, electronically assisted psychotherapy, teletherapy and others. Many state licensing boards require telemental health training.
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.
State Licensing and Jurisdiction
First, it’s very important to know that states can have radically different licensing laws– and you will need to know those laws and rules for each state.
For example, if you obtain a South Carolina LPC license and are delivering telemental health, you must first refer that patient to a local therapist.
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.
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.
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 the page above. The information will help protect yourself.
Considerations and Tips for Safe Telemental Health Practice
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. These types of client issues should only be addressed via telehealth if one is fully trained and experienced.
Consider carefully depth work with trauma via teletherapy.
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. Read updated privacy policies carefully.
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.
Whenever Possible Perform an Initial Face to Face Evaluation.
If you are delivering teletherapy across state lines during COVID, it may not be possible to perform a face-to-face evaluation.
Know your client by confirming their identity. Obtain a copy of an official photo ID.
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.
Frequently Overlooked Risks of Telemental Health
Your counseling interventions 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 choosing all communication and editing statements.
If you provide a service that compensates you per word of therapy, 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. Use the diagram below as a gui
Safety and Ethics Tips
1) Develop a thorough written telehealth informed consent.
2) Phone screening should include history of suicidality and suicide attempts, psychiatric and medication history, social support and family involvement, likelihood for stability, state of residence.
3) Intake paperwork should include a reliable emergency contact who can actually cause hospitalization. A copy of photo I.D. A release of information for all parties involved in client’s treatment. Clarify that you usually would not need to share the content of sessions and that the main purpose is to be able to cause action to be taken in case of emergency.
