Setting Ethical Limits: For Caring and Competent Professionals ______________________________________
LEGAL AND ETHICAL CONSIDERATIONS The challenges of online therapy lead to legal and ethical concerns associated with the delivery of mental health services via the Internet. Those opposed to online or distance therapy worry about licensure issues related to doing therapy across jurisdictional boundaries, legal responsibility in the event of a crisis, and the appropriateness of client anonymity [94]. Providing services across state lines is one of the biggest unresolved issues. Although communication technologies allow counselors to reach clients anywhere, state licensing laws generally do not permit out-of-state counselors to provide services via these methods. Some states offer guest licensure provisions, but most states require that the counselor hold a license in his or her own state and in the client’s state. Providing distance therapy within one’s own state is simpler, and it allows mental health professionals to reach people who would not otherwise have access to services (e.g., rural residents, people with certain disabilities) as well as those who want to receive services from home. To confidently provide distance services [95]: • Abide by all applicable licensing requirements and professional standards of care. • Understand the technology being used. • Periodically check your state legislature’s website for the latest telehealth laws and regulations. • Check for a board policy statement that provides guidance on telepractice. • Check whether your state licensing board has issued policies related to telepractice. • Confirm that telehealth services (both in-state and across jurisdictional lines) are covered under your malpractice policy. The COVID-19 public health emergency increased demand for mental and behavioral health services while driving most of those services to telehealth platforms. In response to this, in 2020, the APA led a campaign to maximize the availability of telepsychology services [96]. In March 2020, the federal government designated psychologists as critical, essential workers, and the Centers for Medicare and Medicaid Services (CMS) improved access to care for Medicare beneficiaries. CMS issued further guidance to waive key telehealth requirements. Because the new legislation cannot supersede state licensing laws (e.g., those that prohibit psychologists from using telehealth to provide services across state lines), the APA drafted letters to governors in all 50 states urging them to temporarily suspend state licensing laws and regulations regarding telepsychology services to ensure continuity of care. Within weeks of receiving the APA letter [96]: • 12 states issued executive orders calling for expansion of telehealth service rates. • 14 states issued executive orders allowing patients to receive telehealth services in their own homes.
• 16 states temporarily lifted licensing requirements. • 22 states either expanded their policies for out-of-state providers to temporarily practice in their states or instituted emergency expedited registration for out-of- state providers. However, the COVID-19 public health emergency ended in August 2023, and professionals offering telehealth services must use fully HIPAA-compliant software. Some options include Skype for Business, Updox, VSee, Zoom for Healthcare, and others [97]. More information can be found at https://www. hhs.gov/hipaa/for-professionals/security/laws-regulations/ index.html [98]. The APA also advises professionals to review individual payer’s policies to confirm what telehealth services are covered and to determine the requirements for coding and billing telehealth services. Depending on the state, telehealth services may be limited to videoconferencing or include asynchronous communications or audio-only phone. It is also important to determine if there are originating site restrictions for where the patient may receive services or if coverage of telehealth services is limited to in-network providers or telehealth-only providers [97]. Emergency licensing provisions enacted during the COVID-19 pandemic have also ended. SOCIAL MEDIA With the advent of social media, clients can now search for and find the Facebook or Twitter page of their counselor, if one exists. Counselors who accept a client’s “friend request” are in essence agreeing that the counselor and client are now friends, creating a multiple relationship. As discussed, when clients have access to their counselor’s social media sites, both intentional and unintentional self-disclosures can occur. Modern social networking systems (e.g., Facebook, Instagram) exemplify intentional self-disclosure without a particular client focus. In contrast, Internet search engines (e.g., Google, LexisNexis) may allow unintended disclosure of personal details of the professional’s life. Professionals should be aware and cognizant of social media involvement, including what information is public. Many sites offer ways to post minimal information if a connection to other professionals is desired. Avoid posting a profile photo that includes your family or other personal details, as these are public [86]. CONCLUSION Competent counselors are well-educated and well-versed in the ethics of their profession. They understand that trust is built over time in the therapeutic relationship, with the help of limits and boundaries, and that it is reinforced by empathic response. Competent, compassionate professionals are both self- and other-aware and able to seek appropriate supervision and consultation when necessary. They establish self-care boundaries in order to protect their own compassionate, empathic response as well as their physical, emotional, and spiritual well-being. This enables counselors to most effectively help their clients.
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