We all know this scene: you do months or years of great work with a great client. They are growing, changing, and you have a fantastic working relationship with them. Then, they decide they need to move out of state.
“I don’t want to have to build up this relationship again with another therapist,” they say, “can you do Skype therapy?”
Can you? The simple answer to the question of cross-state mental health practice is, at this time in history, “only with a fair amount of logistical work and a dash of good luck.”
This doesn’t make sense. I am licensed in my state. Isn’t that enough?
Consider the purpose of a licensing board. Boards are there to protect consumers from clinicians acting poorly or in bad faith. They are not there to serve clinicians or to help us do better work. Some may choose to do so, but that is not usually their mission.
When you work with a client in a foreign state, your work is in both that state and your state. The purpose of the licensing board(s) in the client’s state is to regulate who is working with that client. Thus, they don’t take kindly to outsiders who “Skype in” willy-nilly.
Yes, this state of affairs creates some mighty odd outcomes. For example, I work with English-speaking folks in Japan via videoconferencing. Most of my clients are Americans who live and work in the land of the rising sun, where mental health counseling is unregulated (caution: licensing issues are far from being the only concern around international telemental health practice.) When those clients return to the States, however, we have to terminate therapy — unless they move to Oregon, of course.
Is there no way to be able to work in multiple states?
Some clinicians are licensed in more than one state.
Here in Portland, Oregon, for example, we sit just across the Columbia River from Washington. A lot of therapists around these parts hold licenses in both states so that they can have a reasonable amount of portability.
Assuming telemental health practice is legal in all states where you are licensed, and the client’s state allows practice by therapists who are outside of the state at the time of sessions, having multiple licenses will increase your flexibility and reach.
That said, working across state lines based on multiple licensure still requires a bit of thought and diligence.
As an example to work with: around March of 2014, attorney and professional counselor Eric Strom compiled licensure requirements and rules regarding telemental health for counseling licensure boards in all 50 states.
Strom noted that the rules governing licensees across states don’t always agree. For example, counselors, MFTs and clinical social workers in some states are legally allowed to use the word “psychotherapy” to describe their practice. In other states, that word is reserved only for psychologists. An MFT, for example, who lists herself as a “psychotherapist” based on the rules of the state where she resides, may violate the rules of another state where she has recently gained licensure. She may be violating the rules of one license while following the rules of another.
As such, it is wise to perform the same due diligence regarding licensed practice in foreign states as you would in your home state, and to specifically look out for conflicts.
Of course, you also need to consider the challenges of attaining licensure in a new state where you don’t reside.
In cases where therapists don’t wish to hang a shingle in a foreign state, but rather wish to help an existing client who recently moved to that foreign state, there could be a simpler solution than seeking a new license. Some states allow clinicians in foreign states to practice temporarily so as to help existing clients transition to the new state. Strom reported that as of March 2014, there were 19 states that offered such programs, with differing specific rules. So when the need for temporary allowance comes up, it could pay to contact the licensing board in that foreign state and ask if and when they allow it.
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What if I call it “coaching” instead of “counseling” or “psychotherapy”?
Many experts simply advise against this practice, stating that your status as a licensed professional follows you wherever you go. Rather than make a blanket statement like that, however, I offer an analysis of associated risks:
1. Are you a coach? Do you have training or certification indicating that you practice coaching? Do or did you practice coaching in other contexts?
If you are claiming to be a coach, on what do you base that claim? In most states, this would not be a significant issue for a layman. Coaching generally isn’t regulated by government.
For a licensed clinician, however, there arises a reasonable doubt as to why your practice is “coaching” as opposed to the profession in which you are licensed. Even if clients sign an agreement that they understand the difference, there is no way to guarantee that licensing boards and other applicable authorities will be swayed.
2. How do you differentiate the scope of practice for a coach from that of a counselor, social worker, psychologist, etc.? Can you demonstrate that what you practice online is coaching and not mental or behavioral health care?
Sara Kashing, a staff attorney for the California Association of Marriage and Family therapists, wrote in 2015:
According to the IFC, a coach is responsible for discovering, clarifying, and aligning with what the client wants to achieve;… coaching often relates to career development, achievement, and advancement. While these definitions are instructive to a degree, the lack of a [government] regulated scope of practice could make the boundaries of a coaching relationship somewhat nebulous.
What we see here is that it even with growing self-regulation among the coaching profession, the lack of a legal scope of practice for coaches creates a new risk scenario.
Therapists who claim to be working within the coaching scope of practice could potentially have a hard time proving what that scope is. Since everything that coaches do is within the legal scope of the licensed mental health professions, inability to legally demonstrate that what you practice is purely “coaching” would leave authorities with no other choice but to regard what you’re doing as part of the profession under which you are licensed. If you are practicing in a state where you aren’t legal to practice, this bad risk outcome would likely result in prosecution of some kind.
As a side note: Kashing also makes a good point about advertising:
The practice of coaching and the practice of psychotherapy are clearly distinct and, as such, it is recommended the practices be advertised separately to avoid confusing and/or misleading clients regarding the scope of work performed as a coach and/or psychotherapist. When practicing both professions, the best practice would be to have different business names, separate letterhead, business cards, promotional materials, and websites.
3. What do you do if a remote client’s needs go beyond the scope of coaching practice? Do you have a procedure for this situation? Have you documented it?
Is it ethical or legal to transition to a therapeutic relationship if the need arises? If not, how do you manage situations where therapeutic interventions become an emergency necessity? Remember that if the client is in a state where it’s not legal for you to practice as a therapist, performing those therapeutic interventions would likely be illegal.
Regardless of how you approach it, I would recommend investigating laws and board rules in every state where you wish to work with clients. Consulting with lawyers who know telemental health law is a safe bet. But don’t be discouraged by this advice. With some proper diligence and elbow grease, expanding beyond your own state borders is a real possibility.
And one last thing about Skype: I use “Skype” as my example in this article because it is recognizable. However, I don’t recommend you use it for telemental health for a number of reasons. If you’d like more options, including more full-featured telemental health platforms, check out Jay Ostrowski’s Telemental Health Comparisons website.
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11 Legal-Ethical
Thank you for this very informative article, Roy! I have a client whose father recently passed away and so she has moved home with her mother temporarily to help take care of her. Her new state doesn’t allow teletherapy unless I’m licensed in that state (which I’m not). But two questions have a arisen from the client: she plans to visit Portland frequently until she moves back. Can she come in for a session when she is back in Portland? This made me wonder about the ethics of seeing someone from another state, even if they are visiting you in your office. Second, because she is not actually becoming a resident of the new state (not getting her own place, drivers license, voter regististration), is it possible she is still a resident of OR and we can continue working together? This seems to be getting into the fuzzy area of determining what is residency.
Thank you for your helping clearing up these murky waters for everyone!
Hi Melinda,
People can come seek out therapy wherever they want. Should be no problems there.
The question of how her state’s board decides on jurisdiction may not hang on her actual residency in the sense of having a local driver’s license, etc. It may easily be a much looser definition. You’ll have to ask them about it.
Good luck!
Very helpful information. Just setting up telehealth workshops in the UK and your information is invaluable…thank you
Sure thing. Good luck with the workshops!
This is a most informative introduction to the currently developing field of telehealth. I do have clients who Skype with me when traveling. I have considered online therapy sessions for the future as part of my practice.
Roy, can you please point me to the section of the OBLPCT Code of Ethics, or the Oregon Administrative Rules (OAR) that specifically addresses the practice of teletherapy across state lines? I can’t seem to find anything in either document that speaks to this.
Thanks,
John Benassu
Hi John,
It’s Divison 90: http://arcweb.sos.state.or.us/pages/rules/oars_800/oar_833/833_090.html
A hypothetical.
A patient has been in psychoanalysis with a psychiatrist who also prescribes medication. Patient is away in another state for 3months to a year in another state (most likely at an academic institution).
They engage in online therapy and psychiatrist 1 continues to do most of the evaluations for meds. A psychiatrist in state 2 sees the patient in person and writes the prescriptions. The patient has been stable for a long time and no changes are made. Psychiatrist 1 and Psychiatrist 2 speak on the phone.
Assume that the patient is paying his old psychiatrist out-of-pocket. If psychiatrist 2 is willing to assume legal liability, is this kosher?
Depends on the laws of those states. :)
I think I’m probably in a unique situation – I have been practicing in California, licensed, for about 25 years. I now reside in Ecuador and practice teletherapy, or any of the many names it has. Under Ecuadorian Law, I am a legal, card-carrying resident with government permission to practice psychology. So if I am an Ecuadorian psychologist can’t I just practice with whoever wants me? There may be some very serious restriction of international trade were someone in Ohio be prohibited from receiving services by a psychologist licensed in another country. Is it even legal? And should that not be the patient’s choice?
It’s simply an issue of how we license professionals. The licensing boards in any jurisdiction reserve the right to prosecute those who practice their covered activity in their jurisdictions.
It definitely creates nonsensical outcomes, but it is still standing, unfortunately.
Thanks for the information! What about a situation when students at an American university are currently having telecounseling while they study abroad in a different country? I’m having trouble finding information on that, and any help would be appreciated.
I am a licensed clinical social worker in Maryland, but I currently live in Louisiana where I do not yet have my advanced clinical license. Can I practice online therapy with clients in Maryland?
Can you say more about your international practice and/or how you went about setting it up? Are there resources out there that you can suggest?
Hi Kay,
Well, that is a pretty long story. :) For international work, I recommend anyone be aware of ISMHO (http://ismho.org) and internationally and locally-oriented professional orgs in the areas they serve.
If anyone is interested in consulting on international practice, that is a service we offer here: https://dev-personcenteredtech.com/web-consulting-services-and-fees/consulting-for-mental-health-professionals/
Wondering if any of this information has changed since NCC came out with Distance Counseling Certification.
This was written well after the DCC was available, actually. It doesn’t have much if any impact on cross-state licensure issues.
Who should I contact to find out if I can be licensed in Florida and Alabama as a mental health counselor
Hi Karen,
You should contact the licensing boards in those states.
-Roy
Thanks so much for the information! I have been wanting to develop an online/phone therapy practice that allows me an RV lifestyle but it seems like it could be more complicated than I was hoping.
If you want to work across state lines, then sure, it would be. But people to use telehealth to manage the RV lifestyle.
I actually talked about exactly that (doing telehealth while traveling) in my last Office Hours session. You have to subscribe to our Person-Centered Tech Support service to view Office Hours sessions. But for those who are subscribed, the recording of that session is here: https://dev-personcenteredtech.com/office-hours-session/december-28th-2015/
Hi Roy,
Thank you for the very informative article. I have been interested in working with an online provider that signs up therapists and then everything is done through their portal and app (text, video, etc). Their way around this issue is to inform the client of the state of the licensed provider, then the client must agree that the services are being conducted in the state of the licensed therapist. A novel workaround, sure, but would this hold up if there was an issue? Seems a little flimsy to me, because even if a client “agrees” that he is receiving online services in a different state than his own, he is still actually receiving online services in his home state. Would appreciate any thoughts you have on this.
Hi Rudy,
This is a really good question!
You certainly need to be satisfied that you are performing therapy ethically and legally and it is your responsibility to ensure that. I can say that for sure and that may impact how you approach this.
This is the kind of question we work really with at our Office Hours. You should check it out: https://dev-personcenteredtech.com/person-centered-tech-support/#oh-videos
I’m searching for information of Respiratory Therapist via Skype guidelines. Any suggestions of where I might find such guidelines?
Hi Sheryl: we work with mental health here, so I couldn’t tell you. You may want to inquire with your professional org.
I can tell you, though, that Skype is no good for anyone who is a HIPAA covered entity, regardless of profession.
If you’re asking because you’re looking for what software to use, you’ll find this article very useful: Free Online Therapy Software Compared: Usefulness, Ease, Security, Support, & HIPAA
Hi Roy,
I am licensed in the State of New York, LMHC and in California LPCC. I am wondering if I can provide telemental health to individual’s in New York even when in California? I have not seen yet if New York has adopted it yet, I think it is in process. But when they do, would that be an option? I am in network for Optum and Cigna both of which are reimbursing for such depending on the clients individual plan
Hi Donna,
I can’t tell you about each state’s specific laws or licensing board’s rules — they change all the time! You’ll need to inquire with those bodies to find out more. If you’re hoping for consultation on the subject, Eric Strom is an attorney and professional counselor who has a lot of knowledge of different states’ rules regarding distance counseling: http://www.strom-consulting.com/
Kay – I was able to set up a teletherapy practice – Dr. William I. Perry, Online Psychologist, through references from various attorneys, doctors, and even a judge. It was just easier for them and the patient and myself to know that there need not be any worry about getting there on time, traffic, parking, etc. And having been slandered by a psychotic custody litigant in a weekly San Francisco phone sex rag it became difficult to feel comfortable just staying in San Francisco. I had also wanted to move to South America for years, and met my wife there, so everything just fell into place. In terms of “setting it up” it’s no different than setting up any private practice, with the bonus of being able to let people know that they don’t have to go anywhere in order to get help. It’s working out great for me, and more importantly my patients.
Hi, I see you are in the UK. Good luck firstly with your workshops. I live in London, and would like to start therapy with a counsellor in the US, who is highly trained in a specific field. They have an Oregon License. Do you know how I could find out if it would be legal per UK law for me to have Skype sessions with her?
Thanks in advance!
All the best,
Corinne
Hi Roy,
I live in London, and would like to start therapy with a counsellor in the US, who is highly trained in a specific field. They have an Oregon License. Do you know how I could find out if it would be legal per UK law for me to have Skype sessions with her? Actually, per any international law? Or is it totally restrictive? I don’t know if I’m asking the right questions, but I also saw a commenter saying that they work via an online entity where the client signs an agreement staying that they know therapy is being given under the state laws of the licensee. Would this be of help and kosher in my situation?
Thanks in advance!
Hi Corinne,
Thanks for your messages. Our best advise is to contact the counselor you desire to work with and ask them to see if it is permissible; ultimately, they will have to determine if it is legal and ethical. There are many variables that effect the situation, so we cannot give definitive guidance.
Best of luck!
Would be interesting to know what would happen if the sabbatical were in Canada. Tougher to figure out.
I have a practice in California. I am licensed in California. I want to move to Hawaii and keep my California license, clients and practice. Just switch to providing my couples counseling services via video conference.
Is that possible?
Hello Fiachra,
Great question. As Roy responded to a previous asker, we can’t tell you about each state’s specific laws or licensing board’s rules — they change all the time! You’ll need to inquire with those bodies to find out more. If you’re hoping for consultation on the subject, Eric Strom is an attorney and professional counselor who has a lot of knowledge of different states’ rules regarding distance counseling: http://www.strom-consulting.com/
Best of luck!
Hi Roy-
I’m currently an outpatient LCSW in Montana. My husband and I will be moving to Belize in 3-4 yrs. and opening a bed and breakfast. While I’m not planning on continuing individual therapy, I am becoming certified in a specialized couples counseling intervention and am interested in providing intensive couples retreats throughout the year at our B & B. How would the licensing issue work with that? Belize is a developing country and there does not appear to be any type of licensing regulations. [My potential clients would most likely be Americans]. Thanks for any info!-Kristin
Hi Kristin,
Ooh, running a B&B in Belize sounds delightful! Your question is a great one; it’s so specific to your particular circumstances that it isn’t something that we’ve addressed the particulars of in our existing resources. However, Roy does offer individual consultation and would be happy to provide information and guidance around the consideration. If you would like more information on individual consultation with Roy, please click here.
SKYPE is not hipaa compliant at all. There are options such as DOXY which is free for the provider and easy for your client to use as well on their phone or computer. However, at least in state of VA and most all states the therapist is at their office only when these sessions take place for many insurance companies to reimburse or consider legal/ethical. Consult your insurance provider portal etc as well as your board to know the exact laws. Also emails without security is also a big Hipaa consideration.
No you must only practice where you are licensed as an LCSW. NASW AND your state chapter will show you the regulations. You can have dual license in both states depending on the reasons etc. I’m an LCSW outpatient therapist as well. Hope this helps!
You need to go to your health professions website of your board and look at the laws. Example NASW OF NEW JERSEY, etc. or whatever board you are under. Most recently Only psychiatrists have been approved (some cases/states) but not therapists. Including information from your insurance panels rules such as teletherapy can only be given in an office (whether you have a home office that is known to the insurance companies along w having a business license for your home as certain regulations even apply to this. Hope this helps but your board will easily address all of this:)
Hi Corrine, I’m guessing you’ve got this sorted out by now, but for other potential UK folks with similar questions, here’s what we know:
a. We’re not in any way experts on UK law! Unfortunately, we don’t know of anyone there who is doing quite the same thing we are.
b. The Data Protection Act appears to be the overarching privacy regulation that applies to everyone in the UK. NHS also has guidelines re: data protection for practitioners who work with NHS.
c. I have not come across anything that says a UK citizen can’t receive therapy from a non-UK therapist, but I haven’t found anything that says they can either. I think getting in touch with the NHS is probably going to be your best bet for getting that question (and the follow up of whether you can get the therapy paid for) answered.
d. If you investigate and determine that there is no legal barrier from the UK side, then the US therapist will need to check with their state board to see if they are allowed to do international therapy. In the case of Oregon, I do know that Licensed Professional Counselors (LPC) can perform therapy for international clients because that’s what Roy is and he does so.
For the more generic question of “I have license type X in state Y or Z, live in state Y, and want to do telementalhealth with a client in state Z,” the answer is almost always going to be: “Check with the type X licensing board in Y and Z.”
Hi, I am curious to know if a therapist licensed in CA, but moving to MI, can legally and ethically do Skype or FaceTime therapy with clients they used to see in CA….the clients still live in CA and the therapist is keeping her license in CA, even though moving to MI. She may also gain licensure in MI, but that won’t happen immediately.
Hi Jennifer,
There are 2 parts to the answer. First, we can’t tell you about each state’s specific laws or licensing board’s rules — as they change all the time! You’ll need to inquire directly with those bodies to find out more. If you’re hoping for consultation on the subject, Eric Strom is an attorney and professional counselor who has a lot of knowledge of different states’ rules regarding distance counseling: http://www.strom-consulting.com/. Secondly, neither Skype or FaceTime are HIPAA secure and therefore can’t legally be used by HIPAA covered entities; however, there are several good, free and HIPAA secure videoconferencing platforms — you can see information about two of those options in Roy’s article on “Free Online Therapy Software Compared: Usefulness, Ease, Security, Support & HIPAA” Another good option is Regroup Therapy.
Additionally, we offer a lot of guidance and resources to those launching and establishing an online therapy practice through our Person Centered Tech Support service. I invite you to check it out and to please let us know if you have any questions about the ways in which it could meet your specific needs. You can reach us at [email protected] or 503-893-9717.
Best of luck with your move!
This is all really helpful. In the next year I am due to move to the USA to be with my partner. I am a BACP (UK)qualified counsellor, but understand that that won’t enable me to practice in the State of Illinois.
Does anyone know that once I get my green card, if I can continue to counsel UK clients from Illinois?
It’s all really confusing!
Hi Lee,
It is complicated. I think you’ll find Roy’s article on “International Online Therapy: What to Know Before You Go (and Start Doing It)” helpful for your current considerations.
Best of luck on your move to the US!
Hello, I’m a licensed MFT in California. I have a client that will be going to Washington for college. She would like to see me when she returns to California during her school breaks. Is this legal?
Hi Tamara. Great question! As with most inter-state telehealth questions, the first place to start is to check with each respective licensing board. Above and beyond that, we would be more than happy to provide guidance and input on these considerations. We have two means of getting that direct input and guidance; individual consultation with Roy, or our wonderful support service that includes regular access to consultation time with Roy — in addition to many other wonderful resources, including 11.5+ APA and NBCC approved CEs, which is currently 20% off this month as a New Years special. If you would like to discuss individual consultation or our support service, I invite you to call 503-893-9717 or email [email protected] and we can arrange a free 10-minute resource consultation.
Normally if you have a license in a state to practice you could do online therapy with clients from that state. However it may not be possible for you to Bill their insurance companies since many of those do not allow online therapy.
So one of the things that I am understanding by reading Mr Huggins article is that if you are living in South America and you want to counsel people in the United States, you better have a license to practice in the states that your clients live. Because it is not only the laws of your South American country but also the laws governing the states that your clients live in the US that determine whether your practice is legal. I recommend that many of you considered transitioning from Mental Health therapy into life coaching which is not regulated typically anywhere.
So just to be clear state laws and insurance rules are two totally different things. Normally it’s a little easier to work across state lines with teletherapy if you are licensed in both States than it is to Bill Insurance in the state that you are in when the client is in the other state. There are very few insurance companies that allow billing for teletherapy at this time. But I do believe the two you mentioned allow that. Unfortunately they are some of the lowest reimbursement rates.
Normally Most states to allow you to do teletherapy with residents of their states if you have a license to practice in their state. However you would definitely want to check to make sure it’s okay in California. Also just to be clear again most insurance companies won’t allow billing for that. But if they are private pay clients that would be much easier. There are also ethics around making sure that clients who are experiencing emergency situations have support in their local area and you may have to refer some of these clients to Mental Health Services in their area if you cannot provide them directly and in person. If your clients have severe mental health issues it may not be ethical to practice with them at a distance. However if they have issues that are less severe and you are doing more like coaching with them, you might consider transitioning your practice to coaching and get around all of the legal issues.
I have a question, I could potentially be moving to NY state, I’m an LPC in Colorado and will not be able to get license in NY right away. Am I able to see Colorado clients using teletherapy while living in New York?
Hello Jacquelyn, Thanks so much for reaching out with your question. Person Centered Tech offers membership and consultation services if you are looking to get your specific questions answered. Find out more here!
Hi Victoria,
This sounds like a really frustrating a stressful situation. We’re sorry you are going through it. The best way to assure any clinician is following professional ethics and laws is to contact their board directly. So depending on the license of the therapist in question (LCSW, LPC, LMFT, etc) you can search profession + board of examiners Kentucky and that will point you in the direction you need to go. There is generally a section on each board site that allows a complaint to be filed if that is the route you’d like to take. Best wishes on this journey in healing.