Social Workers and e-Therapy

Introduction

More than one hundred years after the invention of the telephone, its use in clinical treatment is still being debated by mental health professionals, including social workers.  The re-emergence of technology debates has been fueled by an increase in research as to the efficacy of counseling services delivered via various electronic modes, the lack of services in rural areas, the push for low-cost forms of delivering health care, and the ever-expanding uses of the Internet in modern society.  This Legal Issue of the Month article will review developments in law, practice standards, and social work practice and marketing related to electronic communications and service delivery.

Electronic Modalities of Treatment

Telephone therapy or counseling sessions are offered to clients in a wide range of treatment approaches.  In some clinical social work practices, telephone sessions are offered as an adjunct to a primarily face-to-face therapeutic relationship, available when transportation or life emergencies prevent clients from attending their scheduled office visits.  In other settings, a social work practice may offer telephone therapy as the primary mode of treatment for specified clients, such as the mobility-impaired, or rural clients with transportation barriers, while continuing to provide office sessions to other clients.  Some social workers may provide telephone counseling as case management or for psychosocial education on matters related to primary healthcare diagnosis and treatment, such as diabetes or cancer.  In such situations, the telephone sessions may be used for information sharing, problem solving, and support, rather than mental health diagnosis and psychotherapy. 

Telemedicine and telehealth, as structured by the Medicare regulations requires the use of designated sites that provide videoconferencing capabilities (Coleman, 2002).  Thus, a rural patient would need to come to a local site at an appointed time to access the services provided by the professional who is available electronically at a remote location.  This process is more structured than either telephone therapy or online therapy, but is required for Medicare reimbursement.

Internet, online or e-therapy is conducted with a range of methods, which have not all been subjected to the rigors of scientific research as to their efficacy.  These include scheduled electronic “chat” sessions which consist of real time information exchanged via a computer keyboard, structured email exchanges, and group online “chat” sessions that are accessible only to approved members of the group, or open chat sessions moderated by a therapist.  Online self-help groups for various mental and physical health conditions are too numerous to catalog here, but health care researchers are exploring the efficacy of these interventions as well.

Research

Health research on telemedicine and electronic therapy offers a vast array of professional journal articles indicating few limitations on the potential scope of telemedicine.  Although the mental health professions may have qualms about distance counseling, physical medicine is pushing the boundaries of remote care by providing services across long distances using electronic technology for procedures such as monitoring blood pressure and fetal heart rates, evaluating wounds, overseeing dental treatment, providing teleradiology, and robotic surgery, to name a few. 

A search of the professional health literature available through the National Center for Biotechnology Information at the U.S. National Library of Medicine (“NLM”) on the topic “telemedicine” returned 8,715 results, with 795 from January 2006 – March 2007 alone (NLM, 2007).  A scan of the 2006 – 2007 titles shows the use of telemedicine across the most remote portions of the globe, into areas of military conflict, and into outer space.  Research addresses the use of telemedicine in localities as diverse as Afghanistan, Chechnya, the Amazonian rainforest, Iceland, South India, China, Japan, Korea, Jordan, Ecuador, Singapore, and manned space stations outside of Earth’s atmosphere, as well as rural areas of the United States, such as Appalachia and the Dakotas.

Social Work Practice Standards

The National Association of Social Workers (“NASW”) & Association of Social Work Boards (“ASWB”) Standards for Technology and Social Work Practice (“Technology Standards”), published in 2005, provide guidance for the use of technology-mediated social work practice.  The Preface indicates that the Standards should apply to “the use of technology as an adjunct to practice, as well as practice that is exclusively conducted with technology.”  Specific issues addressed include:

  • social work advocacy for technology access by clients with special needs or limited access
  • compliance with applicable laws and regulations in all states where the social work services are provided
  • appropriate matching of online methods, skills and techniques to the cultural and ethnic characteristics of the treatment population
  • accurate marketing practices and verification of client identity
  • privacy protection requirements
  • knowledge about appropriateness of certain types of online technologies for specific clients
  • development of security policies and procedures, as well as contingency plans for electronic failures or emergencies
  • retention of technology consultants.

 Far from repudiating the use of technology in social work practice, the Standards remind social workers that high practice standards are particularly required when the lack of face-to-face contact may increase the “potential for harm or abuse of vulnerable people.”  In addition, social workers “should advocate for both themselves and for clients to resolve access [to technology] problems.”

An informal review of online social work services available to the public offers a snapshot of creative means of addressing best practices requirements. For example:
 

  • requiring pre-session information from new clients to save time and reduce clients costs, such as a personal history, or answering a brief questionnaire related to treatment needs;
  • providing nationwide services by making licensed practitioners available in each state;
  • requiring clients to provide identifying information and emergency contacts;
  • providing electronic links to a wide range of supportive resources; and
  • providing clear payment policies, treatment expectations and limitations, and privacy policies on the therapist’s Web site in easy to understand language.

A variety of questionable social work practices is also displayed to the public online, such as making unfounded claims of successful outcomes; use of unprofessional photographs; failure to identify the professional by name and licensure status; single-state therapy practices providing “nationwide” therapy services without indicating licensure in the states where the clients are located; providing services to “anonymous” clients; and permitting public Internet posting of client’s comments where confidentiality is not assured.

State Social Work Law and Regulation
A primary legal issue regarding electronic social work practice is defining the location where services occur, when services are provided across state lines.  The ASWB Model Social Work Act (“Model Act”), Section 301 (e), defines social work services as those provided to an individual in the state where the client is located.  At least one state, Oklahoma, has adopted the ASWB provision as written:  “The provision of social work services to an individual in this state, through telephonic, electronic or other means, regardless of the location of the social worker, shall constitute the practice of social work and shall be subject to regulation” (Oklahoma, 2007). The ASWB commentary to this section points out that “practice other than in-person service is limiting to both the practitioner and client” and advises “extreme caution” in offering electronic services.  It also calls for further study.

Consistent with the Model Act, the Technology Standards admonish social workers to “abide by all regulation of their professional practice with the understanding that their practice may be subject to regulation in both the jurisdiction in which the client receives services as well as the jurisdiction in which the social worker provides services,” (NASW & ASWB, 2005). This highlights the requirement that social work practices that operate in more than one state must review and interpret the laws and regulations for social work practice in each state and determine how the practice should be structured to avoid conflicting requirements and afford clients the greatest level of protection from unregulated practice.

The California Board of Behavioral Sciences is seeking clarification as to the applicability of medical practice standards for “telemedicine” to social work and other mental health licensees through its committee process, according to a statement on its Web site.  The relevant provision of California law does not apply to telephone conversations with clients nor e-mail communications, but does apply to interactive audio, video, or data communications in real time or near real time transfer of information. Detailed standards for offering such services are provided in the California Business and Professions Code Section 2290.5, including:

  • advance written consent to treatment from the patient or patient’s legal representative
  • description of risks, consequences and benefits of telemedicine
  • applicability of existing confidentiality protections
  • applicability of existing laws regarding medical records and copies of records.

(California Board of Behavioral Sciences, 2006).

Texas authorized the creation of a pilot program to offer telehealth or telemedicine services for mental health services to certain Medicaid recipients; however, it was primarily limited to professional consultations between non-physician providers and physicians, (Vernon’s Texas Code Annotated, 2006).
South Carolina law makes it clear that a South Carolina social work license is required in order to provide social work services via telephone or electronic means to any residents of that state. (Code of Laws of South Carolina 1976 Annotated, 2006).  Minnesota law requires social workers who provide services through electronic means to “take the steps necessary, such as consultation or supervision, to ensure the competence of the social worker’s work and to protect clients from harm.” (Minnesota Statutes Annotated, 2007).

Other Health Professions

Other health professions have responded to the provision of services across state lines by various means. Within nursing, twenty states have joined the Nurse Licensure Compact, whereby participating states pass legislation permitting recognition of licensure in one state for purposes of practicing in another state or states (National Council of State Boards of Nursing, 2007).  Although this has been received with conflict within the nursing profession, it provides one model for assuring that interstate licensure concerns are addressed in telemedicine.

The Federation of State Medical Boards (FSMB) adopted the Model Act to Regulate the Practice of Telemedicine Across State Lines in 1995. At least 10 states have passed the Model Act by statute or regulation (FSMB, 2007). The American Medical Association (AMA), in a review of physician licensure trends, identified several other possible alternatives to facilitate interstate telemedicine (Robertson, 2005). These include medical consulting, endorsement, mutual recognition, reciprocity, registration, limited licensure, and national licensure. Robertson confirmed the AMA’s clear preference for state-based licensure and opposition to a national licensure approach.

Analysis and Conclusions

Practice is ahead of legislation and regulation in the area of electronic therapy services. For the most part, telephone services have in the past been used in a limited manner, in conjunction with in-person client contacts. Several states have exceptions to licensure requirements that would permit brief contact with clients across state lines (e.g. Indiana, Montana, Wyoming). The expanded use of the Internet in everyday society has pushed the boundaries of traditional uses of information technology beyond previous conceptions, including new uses for “old” technologies, such as the telephone. Research on technology-mediated counseling services is continuing at a fast pace; however, much of the research addresses telephone and cyber counseling as an adjunct to other medical services, as social support, psycho-education, or case management, rather than comparing traditional face-to-face psychotherapy with a solely electronic counseling modality. Thus, the historic understanding that face-to-face therapy is the most effective modality for providing counseling has not been refuted. 

Social workers who provide services electronically should apply the practice standards available from the profession when making decisions about how to present their practice online, and when developing office policies and procedures. Social workers need to carefully assess the licensure requirements for each state where clients will receive services. Many state licensing boards do not have the authority to discipline unlicensed practitioners. Thus, current law or regulation may not provide effective remedies for consumers participating in electronic therapy across state lines. Social work leaders may need to consider new regulatory or legislative alternatives to effectively protect consumers, recognizing that telehealth, cybertherapy or telephone counseling may be the only access to mental health treatment for some clients, or that it may serve as an initial linkage for clients who would otherwise never engage in a therapeutic relationship. 

References
California Board of Behavioral Sciences (2006). Notice to licensees regarding psychotherapy on the Internet. [Online]. Available at http://www.bbs.ca.gov/psyonlin.htm
Code of Laws of South Carolina 1976 Annotated (2006). § 40-63-30.  
Coleman, M. (2002). Medicare telehealth provisions for the clinical social worker.  National Association of Social Workers, Clinical Social Work Practice Update. [Online].  Available at http://www.socialworkers.org/practice/clinical/csw0402.pdf
Federation of State Medical Boards of the United States (1996).  Model act to regulate the practice of telemedicine across state lines, Report of the Ad Hoc Committee on Telemedicine. [Online].  Available at  http://www.fsmb.org/pdf/1996_grpol_regulate_medicine_practice.pdf
Federation of State Medical Boards of the United States (2007). Telemedicine overview by state [Online].  Available at http://www.fsmb.org/pdf/grpol_telemedicine_licensure.pdf
Minnesota Statutes Annotated (2007). § 148D.200 Subdivision 1: (b).
National Association of Social Workers & Association of Social Work Boards (2005).  Standards for technology and social work practice. [Online].  Available at http://www.socialworkers.org/practice/standards/NASWTechnologyStandards.pdf
National Council of State Boards of Nursing (2007). Participating states in the NLC. [Online].  Available at https://www.ncsbn.org/158.htm
Oklahoma.Statutes Annotated (2007). Title 59 § 1270 B. 4.
Robertson, J., American Medical Association (2005). Physician licensure: An update of trends, [Online].  Available at http://www.ama-
assn.org/ama/pub/category/print/2378.html
U.S. National Library of Medicine (NLM) (2007), PubMed, available at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed
Vernon’s Texas Code Annotated, Government Code (2006). § 531.02175.
Resources
Coleman, M.F. (2000). Online therapy and the clinical social worker. National Association of Social Workers, Clinical Practice Update [Online].  Available at https://www.socialworkers.org/practice/clinical/online.asp (last visited April 3, 2007).
Robb, M. (2004). The “distance counseling” cyberfrontier, part I, National Association of Social Workers Insurance Trust, Practice Pointer.[Online]. Available at http://www.naswinsurancetrust.org/understanding_risk_
management/pointers/PP%20%20Distance%
20Counseling%20I%20Final.pdf
(last visited April 3, 2007).
Robb, M. (2004). The “distance counseling” cyberfrontier, part II, National Association of Social Workers Insurance Trust, Practice Pointer. [Online]. Available at http://www.naswassurance.org/understanding_
risk_management/pointers/PP%20%20Distance%
20Learning%20II%20Final.pdf
(last visited April 3, 2007)

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