I recently received a phone call from a former client in distress. We met for almost two years and ended our work together a few months ago because he was finishing his graduate program and moving out of state for a fellowship. It was good timing. He had been doing well emotionally for months, had transitioned off of medication with very little trouble and stayed stable, we had been meeting less frequently as a result and the upcoming move involved a great deal of excitement and happiness. He would be doing a prestigious fellowship at a well-known hospital and would be moving in with his partner after six years of long distance. As far as terminations (the therapy word for ending treatment) go, this one was a “web-gem.”
When he called last week, he was a few weeks into his fellowship, feeling very overwhelmed, afraid that he could not “cut it” in his program, was paranoid that he would make a mistake that would hurt a patient, was having trouble falling asleep, was waking up repeatedly throughout the night, and was having ongoing chest tightness. Not his best day. At the start of our conversation he stated he felt like he did when we first met, like all the work we had done flushed down the toilet and that he was back to square one. I disagreed. While he was most definitely having a flare-up of anxiety, which is pretty normal when someone with a history of anxiety makes a major change, he was not at square one. I reminded him that while physical and cognitive anxiety symptoms had returned, the coping skills (taking medication, regular exercise, talk-therapy, positive self-talk) he developed and used in the past were still in there, he just need to be reminded to use them. We discussed options, which included the possibility of finding local providers and resuming medication or talk-therapy. He was open to the medication suggestion, but was reluctant to find a new therapist, “I’m not sure I want to start over with someone else, that I could connect with someone like I did with you. Maybe we could do phone or video sessions over Skype?”
Hmm… Maybe we could do sessions over Skype? Prior to this phone call, I had met a few clinicians personally and discovered many more on-line who conduct sessions via Skype, using the video conferencing feature. I found the idea interesting, but did not consider trying it myself. When my former client suggested it, I began more actively entertaining the idea. Could we do video sessions via Skype? More importantly, should we?
The issues of ending work with a particular therapist because of moving away or moving on, client attachment issues, boundaries in the therapeutic relationship, ethical concerns, transference (the unconscious feelings in the client that are brought up and projected onto the therapist) and counter-transference (the unconscious feelings brought up within the therapist) all needed to be considered in this decision. I would do that, but before deciding whether or not I should provide psychotherapy using video-chatting over the internet I needed to find out if I could. What are the laws for social workers providing therapy via internet video chatting? Are there any? Federal? State? What does my licensing board think?
So I began to research, like the good student that I always was….. and then I fell down a legal and internet rabbit hole, involving MA and VA social work licensing boards, the National Association of Social Workers (NASW) legal counsel, the NASW Massachusetts chapter’s ethics committee, and a non-profit called the Center for Tele-Health and E-Health Law. I got a few answers, still have a few questions unanswered and was left to ask myself even more questions. I’m going wait for a few more folks to call me back, let all the new information marinate in my brain for a few days, make a decision and then post again. Stay tuned……
Lauren Schiffer, LICSW, MPH 