Tag: Skype

To Skpe or Not to Skype- Part Two: The Legal Verdict

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.

To Skype or Not To Skype- Part One

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……