I recently attended the Red River Institute 2015 Spring conference and was looking forward to the presentation, “The Secrets of Sustaining a Successful Clinical Practice – An Interactive Forum.” One of the first questions asked of the panel had to do with the provision of mental health services via the Internet. The ensuing discussion seemed to focus on three themes: Legal issues regarding the provision of services via the Internet (i.e., determining jurisdiction); the fact that many mental health professionals are currently providing services via the Internet and that this mode of service provision is here to stay; and the challenges and difficulties for providers in providing Internet services.
The discussion was troubling to me on a number of levels. In an effort of full disclosure, let me preface the remainder of my thoughts by stating that I have never provided mental health services via the internet; I have not reviewed current research regarding the provision of mental health services via the internet; At this time I have no desire to provide such services; As a Board-Approved Supervisor for Provisional Licensed Professional Counselors and Provisional Licensed Marriage and Family Therapists, I will not agree to supervise any PLPCs/PLMFTs who engage in this practice.
As a LPC and LMFT in the State of Louisiana, I wanted to know what position, if any, my licensing board and professional organizations took on this issue. Therefore, I went to the Louisiana LPC Board of Examiners website to look at the board's position statement. I also looked at the current AAMFT and ACA ethical codes. The position statement of the LPC Board was of little help to me, although it did address the first theme listed above. The position of the Board clearly states that the service “node” is where the client is located. (I refuse to use the word “patient” as in the Board’s position statement.) This means that if a Louisiana licensed clinician is providing services to a client in Texas via the Internet, the clinician is subject to the licensure laws and policies in Texas, which may or may not address counseling via the Internet. If the law in Texas does address this issue, the clinician may be practicing illegally if he or she is not licensed to provide such services in Texas.
One troubling opinion expressed by a panelist during the discussion was that if a clinician has a difficulty with the licensure laws or policies in other states, all that is needed is to call the service the clinician is providing something other than counseling (e.g., coaching or consultation). Louisiana law clearly defines “mental health counseling” and I would suspect that other states do the same. Although a clinician may call the service by another name, if it meets the definition as stated in law, the clinician is subject to that law. The AAMFT Code of Ethics addresses this issue by stating:
“Therapists and supervisors follow all applicable laws regarding location of practice and services, and do not use technologically-assisted means for practicing outside of their allowed jurisdictions.”
And the ACA Code of Ethics addresses the issue by stating:
“Counselors who engage in the use of distance counseling, technology, and social media within their counseling practice understand that they may be subject to laws and regulations of both the counselor’s practicing location and the client’s place of residence. Counselors ensure that their clients are aware of pertinent legal rights and limitations governing the practice of counseling across state lines or international boundaries.”
The second theme addressed in the forum with regard to mental health services via the Internet was that many clinicians are currently providing Internet services and that this is the trend of the future. An opinion expressed by one of the panelists seemed to imply that if one wants to survive as a private practitioner of mental health services, you had better jump on this bandwagon. To give the panelist credit, this opinion was being expressed in the context of a discussion on building a private practice, not on ethical implications of Internet services. However, I believe the ethical implications need to be taken into consideration. If the primary focus of the clinician is in acquiring wealth by providing services and not the quality of the service provided, the clinician will be mediocre at best.
In the book The Heart and Soul Of Change: What Works in Therapy (1999), M. Hubble, B. Duncan, and S. Miller discuss the importance of the therapeutic relationship as a catalyst for the change that occurs in the psychotherapy process. Proponents of mental health services via the Internet will argue that the quality of the service is equivalent to face-to-face interaction as the clinician and client are interacting in real time. I would counter that argument by stating my belief that it is very difficult to build that therapeutic alliance with clients via the Internet. Consider the following scenarios: It’s Christmas day and the family is getting together for the holiday meal. One family member stated that work is really busy and this day is needed to catch-up on things. However, he/she is willing to be present via Skype while the family is eating dinner. All that is needed is for the family to place an I-Pad at his/her setting at the table; A couple has decided marry and have asked a long-time family friend who is a minister to officiate the wedding. The couple has already booked the reception hall and contracted other services (e.g., photographer, limousines, musicians, etc.) paying non-refundable deposits. The minister has already committed to another service on that date and would not have enough time to travel and make it on time to the ceremony. He suggests that the wedding ceremony be performed via Skype or other Internet service; A parent of three children, ages 12, 9, and 4, receives a career opportunity of a lifetime for a temporary position (1 year) overseas. The family (spouse and children) is not able to move with the parent offered the opportunity. The parent decides to accept the opportunity and promises to be present on a regular basis during the year via telephone, email, and Skype.
In all of these scenarios, I would have a difficult time saying that the others will perceive the individual who is only able/willing to be present by electronic means as being "fully present."
The final theme addressed in the forum in regard to providing mental health services via the Internet had to do with unique difficulties clinicians and clients may experience while providing this type of service. In the psychotherapy session, the clinician is paying attention to much more than just the words that are spoken. There are nuances in body language, tone of voice, facial expression, that are all considered communication to the clinician conducting the session. Depending on the quality of the equipment being used, many of these nuances may be missed. Additionally, a client may go into crisis while the session is being conducted. With the clinician not physically present, there are limitations as to what can be done to respond to the crisis.
One final thought: It is said that technology has made our world much smaller. I will not disagree with this statement. However, I will add that today’s technology has also resulted in people becoming more disengaged from one another. We connect via electronic means and forget about the importance of having true encounters with others. In the keynote address of the RRI’s 2015 Spring Conference, Dr. Patch Adams spoke of the connection between depression and loneliness. I wonder at times if when we as clinicians are providing services via the Internet and not fully connecting with our clients, are we just perpetuating the problem?
I am not attempting to assert that providing mental health services via the Internet is never appropriate. There may be some situations in which providing mental services via the Internet is the only available option for a client to receive services. However, I will not lie to myself or to my clients in believing that providing these services is the same as a true client-therapist encounter.