Jay Ostrowski, Traci P. Collins
Telemental health—also known as online counseling or online therapy—has become a solution for increasing the public’s access to mental health care. Mental health state licensure boards have lacked consistency in the adaptation of laws and the use of language within these laws. Policies are examined from the mental health state licensure boards in all 50 U.S. states for counselors, psychologists, marriage and family therapists and social workers. The determination of whether a policy existed was made. If so, the terminology was compared across professions. Results indicated that fewer than half of mental health licensure boards included telemental health-related terminology in their policies, indicating the absence of telemental health policies. Future research, implications for counselors and limitations are discussed.
Keywords: state licensure boards, policies, telemental health, online counseling, health terminology
Mental health care professional shortage areas fall across the United States (Rural Assistance Center, 2015). According to the Health Resources and Services Administration, there is an immediate need for approximately 4,000 mental health providers nationwide (Kaiser Family Foundation, 2014). According to the Bureau for Labor Statistics (2014), the mental health counselor workforce is not distributed in proportion to the need. The National Institute of Mental Health (2014) estimated 43.6 million adults aged 18 or older in the United States suffered from some form of mental illness in the past year. Many individuals’ mental health needs go untreated due to gaps in resources or delivery of services (Brown, 1998; Gibson, Morley, & Romeo-Wolff, 2002; Modai et al., 2006).
The U.S. government has demonstrated a strong commitment to the development, promotion and integration of technology-assisted care into the U.S. health care system through ongoing work in telemental health (Godleski, Nieves, Darkins, & Lehmann, 2008; National Center for Telehealth & Technology, 2011, 2015; Pruitt & Woodside, 2015). In addition, the government has issued numerous grants for telemental health and other health services for license reciprocity (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2015), established the Office for the Advancement of Telehealth, and published the 2015 Treatment Improvement Protocol (Substance Abuse and Mental Health Services Administration, 2015).
Pruitt, Luxton, and Shore (2014) stated that “home-based telemental health has several important benefits for both patients and clinical practitioners including improved access to services, convenience, flexibility, and potential cost savings” (p. 340). Policymakers and advocates view telehealth technology as particularly promising given the continuing shortage of mental health clinicians and long travel distances to obtain care (Lambert, Gale, Hansen, Croll, & Hartley, 2013).
With advancements in technology and the availability of the Internet, mental health care providers have sought new ways to integrate technology into practice (Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2005), including implementing technology in scheduling appointments, distributing assessments and providing treatment services. Using Internet-based videoconferencing, mental health care providers can easily connect with clients without requiring in-office meetings (Baker & Bufka, 2011). Some individuals will not or cannot seek mental health services when in-person services are needed; therefore, the in-person treatment process becomes a treatment barrier (Bensink, Hailey, & Wootton, 2006). According to Brown (1998), some individuals fail to seek mental health services due to geographical restrictions. Other individuals may struggle with physical health restrictions, preventing them from seeking traditional, in-office services. Mental health conditions such as panic disorder (Klein, Richards, & Austin, 2006), agoraphobia and eating disorders (Zabinski, Celio, Wilfley, & Taylor, 2003) may restrict individuals from receiving traditional services. Using Internet-based services, mental health practitioners can reach clients who are in rural locations, who are seriously ill or who do not seek traditional counseling.
While the use of technology increases access to care, the technology itself creates new, unique challenges and potential risks for mental health providers (Baker & Bufka, 2011). Fifteen years ago, Riemer-Reiss (2000) discussed utilizing distance technology in mental health practice, listing foreseeable concerns for practitioners. More recent publications (Barnett & Kolmes, 2016a, 2016b) present similar concerns and questions for mental health providers. Counselors must attain competency in working with special populations or in specific practice areas, including the use of telemental health services (Baker & Bufka, 2011; Barnett & Kolmes, 2016a, 2016b). Yet, counselors are faced with a lack of clear guidance on ethical, legal and regulatory requirements for telemental health services, including security, assessments and best practices (Ostrowski, 2014).
A Brief History of Telemental Health
In September 1997, the National Board for Certified Counselors (NBCC) became the first organization to adopt standards for telemental health (Shaw & Shaw, 2006). At that time, NBCC called telemental health WebCounseling, defined as “the practice of professional counseling and information delivery that occurs when client(s) and counselor are in separate or remote locations and utilize electronic means to communicate over the Internet” (NBCC, 1997, p. 3). In October 1999, the American Counseling Association (ACA) released the Ethics Standards for Internet Online Counseling in order to “establish appropriate standards for the use of electronic communications over the Internet to provide online counseling services, [which] should be used only in conjunction with the ACA Code of Ethics and Standards of Practice” (p. 1). For psychologists, the American Psychological Association (APA) released a statement in 1997 regarding the use of services by telephone, teleconferencing and the Internet, urging psychologists to use the existing APA Ethics Code and the appropriate licensure board rules for services provided (Shaw & Shaw, 2006). The Clinical Social Work Federation (CSWF) issued a position paper in 2001 on Internet text-based therapy, stressing that practitioners must follow their CSWF code of ethics and all state licensing laws (Lonner, 2001; Shaw & Shaw, 2006).
Nearly 20 years have passed since NBCC broke ground by providing initial guidance for Web-based counseling. The ethical guidance for mental health professionals has continued to evolve as the body of research is growing and telemental health services are becoming more prominent. Several studies have discussed the ethical codes for mental health practice for counselors, psychologists, social workers, and marriage and family therapists (Alleman, 2002; Barnett & Scheetz, 2003; International Society for Mental Health Online, 2000; Mallen, Vogel, & Rochlen, 2005; Manhal-Baugus, 2001; Midkiff & Wyatt, 2008; Recupero & Rainey, 2005). However, while most major mental health organizations have released ethical guidelines for telemental health practice, counselors also must seek guidance from state mental health licensing boards to comply with state licensure laws. Competency requires more than familiarity with state licensure laws; counselors must understand the guidelines and be able to correctly apply the guidelines to clinical practice. As Pabian, Welfel, and Beebe (2009) discovered, 76.4% of surveyed clinicians were misinformed about their state laws concerning duty to warn. If the majority of counselors did not fully understand their state guidelines for practice on this single issue, there are serious concerns about ethical telemental health practice regarding numerous licensure issues across state lines. These concerns highlight the need for clarity and understanding on licensure guidelines. For the purposes of this paper, the authors examine the current telemental health terminology used in state licensure laws located on their Web sites.
Telemental Health Terminology
As telemental health technology has become a promising option, new descriptive terminology has been developed. Several major organizations use the term telemental health. The U.S. Department of Veterans Affairs describes telemental health as “behavioral health services that are provided using communication technology” (U.S. Department of Veterans Affairs, 2015, para. 3.). The U.S. Department of Health and Human Services’ Health Resources and Services Administration Office for the Advancement of Telehealth funds 14 Telehealth Resource Centers located across the United States (Telehealth Resource Centers, 2015). Telehealth Resource Centers use the terms telemental health and telebehavioral health. The National Center for Telehealth and Technology uses the term telemental health in the Department of Defense Telemental Health Guidebook (National Center for Telehealth & Technology, 2015). The American Telemedicine Association, a primary force of the telemedicine industry, uses the term telemental health (American Telemedicine Association, 2015). Thus, the term telemental health is used henceforth to broadly describe using the Internet to provide mental health care.
In the professional and academic literature and on the Internet, numerous terms are used to describe technology- or Internet-based mental health care including: online counseling, online therapy, video therapy, telemental health, telebehavioral health, e-therapy, cybertherapy, telepsychology, telecounseling, Internet therapy, Internet counseling, video counseling, video chat, e-mail therapy, clinical video therapy and Web therapy (Backhaus et al., 2012; Barak, Klein, & Proudfoot, 2009; Castelnuovo, Gaggioli, Mantovani, & Riva, 2003; Center for Substance Abuse Treatment, 2009; Day & Schneider, 2002; Maheu et al., 2005; Suler, 2004; Yellowlees et al., 2010). Some terms describe the medium used (e.g., e-mail therapy, clinical video therapy), while other terms describe the broad use of mental health services over the Internet (e.g., telemental health, online therapy).
Inconsistent terminology among organizations or state licensure boards can lead to a number of problems for mental health providers, as well as researchers, educators and other mental health workers. Using varying terminology, mental health providers must identify and follow state laws regarding telemental health practice, in addition to ethical guidelines. The purpose of this research was to (a) determine whether individual mental health state licensure boards (counseling, psychology, social work, and marriage and family therapy) have a policy or service provision regarding telemental health services, (b) identify the terminology used in the state licensure board policies, and (c) compare the differences in terminology used in licensure board policies across mental health professions.
Method
Procedure
Various terms, such as online therapy, telemental health and online counseling, were searched on the Internet and in the professional literature. We identified related terms in the search results and in the citations of articles; these additional terms were searched until no more semantically-related terms could be found. The initial generated list and the accumulated terms were compiled and used to begin data collection.
We searched state mental health licensure board Web sites (N = 151) in all 50 states for the counseling, marriage and family therapy, psychology and social work professions. State licensure boards’ Web sites were accessed and we reviewed telemental health-related laws, statutes, rules, policies (which will all be referred to as policies henceforth) and newsletters. In addition, the first author called and sent e-mails to state licensure board personnel to verify whether telemental health policies existed when policies were not located on the Web site. All terms related to telemental health services were collected and added to the initial list, resulting in a final list of 42 terms. We broadly defined the presence or existence of telemental health policies as the use of one or more of the 42 terms. Research assistants searched each state licensure board Web site with the final list of terms to ensure a thorough search.
We collected the terms used on each state board Web site to examine the consistency in term usage across all state licensure boards. Next, we categorized the terms used on all state licensure boards’ Web sites by mental health profession (counseling, marriage and family therapy, psychology and social work). The data was then analyzed for themes.
Results
State Board Policies
We analyzed the data collected from state mental health licensure board Web sites. We identified the state mental health licensure boards with telemental health policies. Sixty-five mental health licensure boards had specific telemental health policies. In the following 14 states, not one of the licensure boards had issued a policy about telemental health: Connecticut, Florida, Idaho, Illinois, Indiana, Kansas, Maine, Minnesota, Mississippi, Missouri, New Jersey, Rhode Island, Washington and Wyoming.
Next, we examined the data across mental health professions. The existence of state board policies varied widely for each profession within most states. The number of state licensure boards that had issued telemental health policies for each profession was nearly evenly represented among the first three disciplines as follows: counseling (n = 22), psychology (n = 22), social work (n = 21), and marriage and family therapy (n = 1). We found that only 14 states had telemental health policies for all mental health professions: California, Colorado, Kentucky, Louisiana, Nebraska, New Hampshire, New York, North Carolina, North Dakota, Ohio, Pennsylvania, South Carolina, Utah and West Virginia.
State Terminology Used for Telemental Health
We identified the terms found on state licensure board Web sites. The following 19 unique terms were used across the 65 state licensure boards that had issued policies: distance counseling, distance therapy, electronic-assisted counseling, electronic means, electronic practice, electronic telepractice, electronic transmission, Internet counseling, Internet practice, online counseling, online psychotherapy, remotely, technology-assisted, teleconferencing, telehealth, telemental health, telepractice, telepsychology and teletherapy.
E-mails were sent to 40 state board personnel because telemental health-related laws or policies were not located on the state licensing board Web site. In these cases, 16 state licensure board staff members provided guidance that conflicted with policies published on their Web site or in their newsletter. For instance, many state board personnel who were contacted indicated that telemental health services were permitted as long as state laws were followed. In all 16 cases, the licensure board staff added information not available publicly. This information was excluded from the data, as it was not representative of an official, public policy. Only one state, New Mexico, explicitly prohibited professional counselors from providing mental health services online.
Lastly, we compared the terms used in state licensure board policies across mental health professions. The term used most often by counseling (n = 7) and social work (n = 8) state licensure boards was electronic counseling or therapy (n = 7). The term most prevalent among psychology state licensure boards was telehealth (n = 6).
Discussion
With only 43% of mental health state licensure boards issuing at least a minimal policy regarding the use of telemental health services, mental health professionals are left without clear guidelines for acquiring proper training, educating clients and following sound procedures for using telemental health services to work with clients. Support and education may be warranted for licensure boards whose members may not have the time or expertise to craft policies based on evidence-based practice or best practice guidelines.
Among the states that do have policies, the data demonstrate that state licensure boards’ policies differ in terminology. With 19 telemental health-related terms identified in state licensure boards’ policies, the mental health profession lacks consensus as telemental health services have grown over the last decade. Agreement or consistency is needed for effective conversations among researchers, educators and mental health providers to ultimately provide clear guidance to clinicians and clinicians-in-training.
Mental health providers seeking to identify state policies regarding telemental health may search for online therapy, when their state uses one of 19 broader terms such as electronic means. The average mental health provider is likely unaware that nearly 20 different terms are used among state licensure boards, let alone aware of which term may be used to identify the laws in their respective state. Researchers, educators and state licensure board staff members should consider selecting the terms they use to include the common language of mental health providers. By narrowing the use of terms, state licensure boards would ensure mental health providers greater access to policies.
Inconsistent terminology leads to a number of problems. Since telemental health has grown over time and been through several iterations of research and development, some terms may be associated with one or more periods of development. Employers posting jobs in telemental health may identify the position with one term (e.g., telebehavioral health therapist) while a job seeker may use another search term (e.g., online counselor). Researchers also may have difficulty finding related research on telemental health services when there are many terms used for the same concept (e.g., cyberpsychology, Internet therapy, online counseling, Web therapy, e-counseling). Inconsistent terminology could hinder the development and dissemination of the body of research supporting telemental health services.
In addition, state licensure boards may consider how restrictions meant for one mode of services (e.g., text-based counseling) will impact another mode (e.g., video-based counseling). State licensure boards may use language to be as inclusive as possible, yet the specific types of telemental services permitted may be unclear to mental health providers. When identifying policies in different states, mental health providers may be confused when state licensure boards use the same terminology to refer to different services. For example, practitioners may use telephone, e-mail, text, smartphone apps, or interactive videoconferencing to provide counseling services and be unaware that certain formats are permitted where others are not. Implementing changes in terminology will assist mental health providers in finding the policies pertaining to telemental health as well as reduce confusion and hesitancy to provide services via the Internet.
Future Research
Future research is recommended to identify competencies for telemental health services for adults, children and special populations. Guidelines and ethical standards have been developed using reviews of the literature and consensus among a limited number of professionals in their respective associations (American Association for Marriage and Family Therapy, 2015; ACA, 2014; American Mental Health Counselors Association, 2015; APA, 2013; National Association of Social Workers, Association of Social Work Boards, 2005; NBCC, 2016). No formal study has yet to be conducted on the competencies of a telemental health provider or on the effects of counselor competency training on providing telemental health services. Professional communities and independent continuing education providers around the United States provide training services for counselors, and some graduate counseling programs offer students an elective course in technology and counseling. While these efforts provide counselors with training, research and advocacy are needed to identify competency areas related to ethical telemental health practice. Counselors may be extremely skilled in in-person counseling, yet unable to successfully transfer these skills to an online environment (Mallen et al., 2005). Established professional competencies in telemental health would inform educators and policymakers in future endeavors.
It is important for telemental health training to draw from outcome studies, lending direction for best practices in telemental health regarding ethical and therapeutic guidelines. Ford, Avey, DeRuyter, Whipple, and Rivkin’s (2012) survey provided insights into the biggest successes and challenges of integrating telemental health services into practice. They noticed the success of being able to reach an underserved population. They echoed the need for outcome research to inform practices and ethics, as well as a need for outcome research to inform sound cultural and contextual practice for counselors. In addition to counselor educators and researchers, it is important that clinicians currently engaged in telemental health practices inform colleagues of benefits and challenges through professional publications (Sude, 2013). Once further research outcome data are acquired and proposed counselor training competencies are in place, state licensure boards will have comprehensive best practice guidelines for creating more detailed information for licensees, leading to improved counseling practices and better results for clients.
Implications for Counselors
Counselors should be aware that their licensure board policies and ethical codes may include different telemental health terms than those with which they are familiar. Identifying the telemental health terms is a counselor’s first step toward locating telemental health guidelines, understanding the specific policies and developing beginning competencies for an online, electronic practice.
Counselors are encouraged to consult ethical guidelines for practice before engaging in telemental health activities. Important ethical considerations include duty to warn, scope of practice, confidentiality, record keeping and marketing (Mallen et al., 2005), among others. Other considerations that are unique to telemental health practice include legal and ethical requirements for training, protocols for emergency services, location and identity verification, and an informed consent process that is specific to telemental health (NBCC, 2016). Some state licensure boards require documentation of informed consent in addition to other security requirements, such as identifying the client’s local emergency services and verifying the client’s identity and age. Barnett and Kolmes (2016a, 2016b) discussed the risks associated with telemental health practices based on two cases and provided suggestions for practice, including specific competencies in telemental health, technology, general telemental health, multicultural practice, clinical practice for telemental health (e.g., assessing client’s appropriateness for telemental health), process of informed consent (e.g., fees, confidentiality, verification of legal consent), licensing issues, ethical issues (e.g., duty to warn, reporting abuse), and adequate liability insurance coverage. The number of telemental health competencies and concerns, including the use of technology (e.g., encryption), indicates a need for counselors to seek telemental training and guidance before engaging in telemental health services. In a recent survey, Ford et al. (2012) discovered that clinicians reported the need for training on equipment use as one of the biggest challenges for effective service delivery.
With sound training and competencies in place, counselors can take advantage of the benefits of telemental health by providing care for people who are not able to seek face-to-face counseling services (e.g., rural and frontier clients). Mental health professions are increasing the capability to reach the underserved through technology and telemental health practices. As technology and policies change, professional counselors are encouraged to become and stay literate in the efficacy and best practices for telemental health services.
Professional counselors are challenged to be aware that telemental health in general is growing rapidly, and the dynamics of the profession (e.g., laws, ethics, technology and reimbursement) are increasing counselors’ capability to serve the underserved through technology. Counselors who do not incorporate telemental health services into their practice may limit their practice as clients may seek accessible online providers in the near future (Myers & Turvey, 2013). Also, counselors who adopt telemental health services will capture more market share as the medical community heeds the incentives to make electronic service referrals and integrate telehealth and telemental health into medical practice.
Conclusion
Telemental health is no longer something of the future (Mallen et al., 2005). Telemental health is occurring now and rapidly expanding. Professional counselors, counselor educators, leaders in the counseling profession and state licensure boards are encouraged to consider the terminology used when creating regulations and how these decisions may impact the application of counseling services. Also, licensure boards may feel compelled to use all-inclusive language to cover future possibilities of telemental health practice. Broad terms such as electronic may be all-inclusive but are not aligned with common vernacular among practitioners and do not reflect the research or terminology used by associated entities (e.g., insurance companies that reimburse for services).
However, common terminology such as telemental health and online counseling could be used to help counselors identify these policies within professional codes of ethics, state licensure laws, and other documents. In addition, researchers must consider the terminology used within publications to increase understanding among readers and minimize confusion in the profession.
Professional counselors, counselor educators and counseling leaders are challenged to forge ahead, advocating for clear guidelines from their state licensure boards, debating what is sufficient for training guidelines and advocating to use technology to reach underserved clients with professional counseling services. Without exposure to research and best practices, licensure boards may be led to create overly restrictive regulations that prevent the benefits of telemental health from being possible and unintentionally limit access to mental health care for people who cannot seek face-to-face counseling. There is a need for specific communications about telemental health practices between different functional components of the counseling profession (i.e., practitioners, educators, leaders, state board personnel). For example, state licensure boards and counselors who are grounded in telemental health research and best practices can work together to form clear, all-encompassing information for licensees.
As mental health professions forge ahead with telemental health practice, counselors should continue to develop this important treatment medium to capture the clientele and referrals from the participating medical community. Failure to do so may leave counselors at a disadvantage in the marketplace. As the U.S. government moves forward to meet the mental health treatment needs of millions of Americans, counselors are encouraged to take a leadership role in this movement to reach the underserved with professional counseling services.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Jay Ostrowski, NCC, is Director of Product and Business Development at the National Board for Certified Counselors, Inc. and Affiliates, and the CEO of Behavioral Health Innovation. Traci P. Collins, NCC, is a professional counselor at Triad Counseling & Clinical Services, LLC in Greensboro, NC, and a doctoral candidate at North Carolina State University.
