When I last posted, I was in the midst of an learning if I could legally provide psychotherapy ACROSS STATE LINES (I just felt the phrase needed caps for dramatic flair) via Skype and deciding if I should. My apologies for leaving readers hanging, but this question became much harder to answer than I ever imagined. Like any innovation, developing technology, or emerging field, there is little regulation and a lot of opinions.
My Google keyword search for “Skype therapy,” “psychotherapy video chat” and “online therapy” had me going in circles until I stumbled upon the word “telepsychiatry,” which then lead me to the Center for Telehealth and E-Health Law. CTeL (www.ctel.org) is a nonprofit in DC whose mission is “To overcome the legal and regulatory barriers that impact the utilization of telehealth and relate e-health services.” Jackpot! I had a chance to consult with Christa Natoli, a Harvard Law grad, who felt like a breath of informative fresh air after days of useless internet searches.
Christa explained that like our good-old Constitution, statutes are written to be flexible, and to allow room for interpretation. She explained that my specific question, “Can a social worker in Massachusetts provide therapy via video chatting to a client in Virginia?” would not be found specifically written into law and that I would have to be left interpreting something much more vague. First rule of thumb is that doctors must be licensed to practice medicine wherever the patient is. As Christa said, “If your patient is on the moon, then you must be licensed to practice on the moon.” However, things get a little confusing here, because laws pertaining to telehealth and e-health usually talk about practicing medicine, and no surprise, don’t specifically write social workers into the language of the statute.
Since licensing for social workers is regulated by states, it is the state that determines the “jurisdiction,” which means, the state (or commonwealth in my case) decides if treatment is happening where the clinician is or where the client is. Not many states have considered it enough to make laws about it. For example I now know that California believes social work treatment happens where the client is, so you must be licensed in California, whereas there aren’t any laws on Virginia that touch on this issue in anyway. When the state you live in or want to treat someone in doesn’t address the issue specifically, Christa told me it is best to go with the legal interpretation of your professional organization, in my case the National Association of Social Workers. Then she blew my mind, actually contacted the NASW legal counsel for me, and told me that….wait for it….. the NASW believes that a social worker needs to be licensed to practice in the state that the client is in to be practicing legally.
And there it is. Even if states don’t address this law, the folks who issue my license do, and I’m going to let their opinion make the decision for me. I will not provide Skype to clients who are not in Massachusetts, where I hold my only social work license. Should I ever move, or decide on a whim to hold multiple licenses from different states, I’ll reconsider.
Since I was on a roll getting Christa to answer my questions I asked her about within my own state. She told me I was good to go if I could answer yes to two questions: 1. Do you have a preexisting relationship with the client/patient? 2. Will your telehealth interaction meet the appropriate standards of care? As far as question one goes, I figured one is in the clear with an in person intake in one or two sessions. The second question came down to ethics, the rules of conduct recognized by my profession, social workers.
I contacted the NASW MA Chapter’s Ethics Committee and requested a consult. This is a great service, by the way, where a group of seasoned clinicians working a variety of social work jobs meets twice a month to discuss any issues brought to the committee. The service is free to all NASW members, but they don’t require that you give all your personal information if you’re not comfortable. Instead of staying up late at night wondering, “Could I lose my license by doing that?” or “Would other social workers think I’m crazy for doing this?” you can just call them and ask. The turn-around time is about a week or two, so that the committee members have a chance to review, conduct any necessary research, and discuss before providing consultation. Worth the wait, because one way to protect yourself from malpractice is to consult with colleagues and seek peer supervision when you have a question. One of the members called me back to let me know:
1. The NASW does not have any existing guidelines regarding video conferencing, “But it probably should.” That was a direct quote, by the way. 2. Committee members had all heard of and seen increasing numbers of clinicians using video chatting, so I would not run the risk of being a social work maverick. 3. The committee thought I should consider creating extra consent forms, addressing specific web-based confidentiality and informed consent issues. 4. They advised me to choose clients wisely when using this medium, especially to avoid clients with a history of suicidal ideation, previous suicide attempts or other unsafe or impulsive behaviors 5. They wanted me to keep in mind that, depending on the quality of a the web-cams used, important information about affect, such as blushing or sweating might not be as observable as it would be in person.
Good advice that I will certainly follow. I was disappointed, but not surprised, to find that National Association of Social Workers has not yet established formal guidelines regarding Skype, video chat or other web-based treatment. As a profession, social workers are leaders in civil rights, social welfare, policy development and advocacy. However, in my opinion, we are woefully behind when it comes to using technology, whether to assist us administratively or to market ourselves. As the ethics committee member mentioned, “they probably should” start creating guidelines for this communication tool that is not going away.
Lauren Schiffer, LICSW, MPH 