“European commerce during the Dark Ages was limited and stifled by the existence of a multitude of small kingdoms that were independently regulated and who suppressed the movement of goods across their borders through a confusing and inconsistent morass of taxation, tariff, and regulation. This forced merchants to find another solution to move their goods, one that would avoid the strangulation that resulted from this cumbersome regulatory model. These merchants chose to move their goods by sea without being subject to the problems that were created by this feudal and archaic design, a move that changed the world. The little kingdoms took hundreds of years to catch up.”

–Harris, E., & Younggren, J. N. Risk management in the digital world.

Keeping up with policy is not my favorite thing:  But if I am to continue to be a consultant to therapists building their business and an educator on integrating technology into social work practice, it is part of the prep work.  So when a recent client asked me a question about licensure and online therapy in our Commonwealth of Massachusetts I surfed on over to our Division of Professional Licensure to take a look.  Good thing I did, and a lesson for all of you thought leaders and innovators out there, regardless of what state you live in.

There wasn’t much about technology, except for the interesting fact that the past several Board Meeting minutes made mention of a Committee discussion open to the public on “E-practice policy.”  I assumed (correctly it turns out) that this meant that the Social Work Board was formulating a policy, so I reached out to the Division and asked some general questions about what it was going to look like.  The answer was prompt and pretty scary.

The representative stated in her email to me that the “Board ​feels ​as ​if ​the ​use ​of ​electronic ​means ​should ​be ​employed ​as ​a ​last ​resort ​out ​of ​absolute ​necessity ​and ​it ​is ​not ​encouraged. ​The ​social ​worker ​would ​have ​the ​burden ​of ​proof ​that ​electronic ​means ​were ​employed ​as ​a ​last ​resort ​out ​of ​absolute ​necessity.”

I have several concerns about this.

Before elaborating on them, I want to explain that my concerns are informed by my experience as a clinical social worker who has used online therapy successfully for several years, as well as an educator nationwide on the thoughtful use of technology and social work practice.  I have had the opportunity to present on this topic at a number of institutions including Harvard Medical School and have created the first graduate course on this topic for social workers at Boston College.  In short, this issue is probably the most defining interest and area of study in my career as a social work clinician, educator and public speaker.

I also am a believer in regulation, which is why I have been licensed by the Board of Licensure in Oregon, and am in process of similar applications in several states, including CA, and NY, so that I may practice legitimately in those jurisdictions. I am a very concerned stakeholder in telemedicine and here are only a few of my concerns about a policy of “extenuating-circumstances-only-and-be-ready-to-prove-it:”

1. E-Therapy is an evidence-based practice.  It has been found to be extremely efficacious in a number of peer-reviewed studies, over 100 of which can be found at  http://construct.haifa.ac.il/~azy/refthrp.htm .  In fact, telemedicine has been found to have comparable efficacy to in-office treatment of eating disorders (Mitchell et al, 2008,) childhood depression (Nelson et al, 2006,) and psychosocial case management of diabetes (Trief et al, 2007) among others.   To limit an efficacious modality of treatment by saying it needs to be used only in an “extenuating” circumstance or as a last resort which is discouraged would be a breathtaking reach and troublesome precedent on the part of the Board, which has not been done with any other treatment modality to the best of my knowledge.  Telemedicine was also endorsed by the World Health Organization 3 years ago.  And as I wrote this post, the University of Zurich released research showing online therapy is as good as traditional face-to-face therapy, and possibly better in some cases (Birgit, 2013.)
2. To place and require a burden on the individual social worker to account for why this treatment modality is justified by necessity of extenuating circumstances also raises the issues of parity and access.  Providers familiar with the issue of mental health parity will hopefully see the parallels here.  Clinical social workers for example may become more reluctant to work with patients requiring adaptive technology if they realize that they could be held to a higher level of scrutiny and documentation than their counterparts who do not use online technology.  Even though the Board would possibly deem those circumstances “extenuating” it would require an extra layer of process and bureaucracy that could have the side effect of discouraging providers from taking on such patients.
3. Insurers such as Tricare and the providers in the military are increasingly allowing for reimbursement for telemedicine; and videoconferencing software is  becoming more encrypted and in line with HIPAA.  While these should not be the reasons that drive telemedicine in social work, we should consider that a growing segment of the population finds it a reputable form of service delivery.
4. Such policies require input from people with expertise in clinical practice, the law,  technology, and the integration of the three.  When I asked about whether any members of the Board had experience with the use of different newer technologies in clinical practice or how to integrate them, I was informed that “the ​Board ​is ​comprised ​of ​members ​with ​diverse ​backgrounds. ​They ​have ​reviewed ​the ​policies ​and ​procedures ​for ​electronic ​means ​for ​many ​other ​jurisdictions ​as ​well ​as ​the ​NASW ​and ​ASWB ​Standards ​for ​Technology ​and ​Social ​Work ​Practice ​in ​addition ​to ​the ​policies ​set ​forth ​for ​Psychologists, ​LMHC’s ​and ​LMFT’s ​in ​MA.”

The NASW policy which I believe she is referring to was drafted 8 years ago in 2005.  For context, it was drafted 5 years before the iPad in 2010, 2 years before the iPhone in 2007, and 4 years before the HITECH act in 2009.  In fact, the policy I reference says nothing about limiting technology such as online therapy to “last resort;” rather it encourages more social workers and their clients to have access to and education about it. That professional organizations may be lagging behind the meaningful use and understanding of technology is not the Board’s fault.  But to rely on those policies in the face of recent and evidence-based research is concerning.  If the Board does wish to be more conservative than innovative in this case, I’d actually encourage it to consider the policy adopted by the Commonwealth’s Board of Allied Mental Health Professionals at http://www.mass.gov/ocabr/licensee/dpl-boards/mh/regulations/board-policies/policy-on-distance-online-and-other.html which in fact does not make any mention of setting a criteria of extenuating circumstances or potentially intimidate providers with the requirement of justification.

I hope the Board listens to my concerns and input of research and experience in the respectful spirit that it is intended. I am aware that I am commenting on a policy that I have not even seen, and I am sure that the discussions have been deep and thoughtful, but I know we can do better.  As a lifetime resident of Massachusetts, I know we take pride in being forward thinkers in public policy.  Usually we set the standard that other states adopt rather than follow them.  I invited the Board to call upon me at any time to assist in helping further the development of this policy, and reached out to state and national NASW as well.  I hope they take me up on it, but I am not too hopeful.  I had to step down from my last elected NASW position because I refused to remove or change past or future blog posts.

If you practice clinical social work or psychotherapy online, it’s 3:00 AM:  Do you know what your licensing boards and professional organizations are doing?  Are they crafting policies which are evidence-based and value-neutral about technology, or are they drafting policies based on the feelings and opinions of a few who may not even use technology professionally?

This is a big deal, and you need to be involved, especially if you are pro-technology.  The research from Pew Internet Research shows that people age 50-64 use the internet 83% of the time, about 10% less than younger people; and only 56% of people 65 or older do. These older people and digital immigrants are often also the decision-makers who are involved in policy-making and committees.

If you don’t want to practice online, you may bristle at this post.  Am I saying that older people are irrelevant? No.  Am I saying that traditional psychotherapy in an office is obsolete? Absolutely not.  But I am saying that there is a backlash against technology from people who are defensive and scared of becoming irrelevant, and fear does not shape the best policy.  Those of us with experience in social justice activism know that sometimes we need to invite ourselves to the party if we want a place at the table.

And with government the table is often concealed behind bureaucracy and pre-digital “we posted notice of this public hearing in the lobby of the State House” protocols.  My local government is relatively ahead of the curve by posting minutes online, but I look forward to the day when things are disseminated more digitally, and open to the public means more than showing up at 9:30 AM on a work day.  If they allow videoconferencing or teleconferencing I will gladly retract that.

At its heart, divisions of professional licensure are largely about guildcraft:  They regulate quality for the good of the whole guild and the consumers who purchase services from guild members.  They establish policies and sanction members of the guild as part of establishing and maintaining the imprimatur of “professional” for the entire guild.  They develop criteria both to assure quality of services and to regulate the number of providers allowed in the guild with a certain level of privileges at any time:  LSWs, LCSWs, and LICSWs are the modern-day versions of Apprenctice, Journeyman and Master Craftsman.  This is not to say guilds are bad, but it is to say that we need more of the senior members of the guild to advocate for technology if they are using it.

Too often the terms “technology” and “online therapy” get attached to term “ethics” in a way that implies that using technology is dangerous if not inherently unethical.  That’s what I see behind the idea that online therapy should only be used as a “last resort.”  We thought something similar about fire once:  It was mysterious to us, powerful and scary.  So were books, reading and writing at one point:  If you knew how to use them you were a monk or a witch.

Technology has always been daunting to the keepers of the status quo, which is why you need to start talking to your policymakers.  Find out what your licensing boards are up to, advocate, give them a copy of this post.  Just please do something, or you may find your practice shaped in a way that is detrimental to your patients and yourself.

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References

Birgit, W., Horn, A. B., & Andreas, M. (2013). Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. Journal Of Affective Disorders, doi:10.1016/j.jad.2013.06.032

Funderburk, B. W., Ware, L. M., Altshuler, E., & Chaffin, M. (2008). Use and feasibility of telemedicine technology in the dissemination of parent-child interaction therapy. Child Maltreatment, 13(4), 377-382.

Harris, E., & Younggren, J. N. (2011). Risk management in the digital world. Professional Psychology: Research And Practice, 42(6), 412-418. doi:10.1037/a0025139

Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., Crow, S., Lancaster, K., Simonich, H., et al. (2008). A randomized trial comparing the efficacy of cognitive–behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face. Behaviour Research & Therapy, 46(5), 581-592.

Nelson, E., Barnard, M., & Cain, S. (2006). Feasibility of telemedicine intervention for childhood depression Routledge.

Trief, P. M., Teresi, J. A., Izquierdo, R., Morin, P. C., Goland, R., Field, L., et al. (2007). Psychosocial outcomes of telemedicine case management for elderly patients with diabetes. Diabetes Care, 30(5), 1266-1268.