C OMPETENCY AND S COPE OF P RACTICE

In addition to technological and liability concerns online, an important dilemma that therapists face is how to practice within their scope of training in a fi eld that is too new to have outcome-based criteria for training. At this point, most professional organizations lean on the law as it now stands in determining a clinician’s duty and standard of care in the electronic delivery of mental health services. Clearly, the Internet, either as an adjunct to offi ce practice or as a stand-alone cyber-experience, has great potential to provide mental health interventions. Most professionals erroneously assume that they can transfer existing skills to the Internet rather than fi rst becoming familiar with Internet communication constructs, the culture of cyberspace, and cyber psychology (Glueckauf et al., 2003).

Koocher and Morray (2000) surveyed state attorneys general, asking how different jurisdictions regulated telepsychology. Their fi ndings have been adapted by the California Board of Psychology in their January 2005 newsletter. Before engaging in the remote delivery of mental health services via electronic means, the California Board of Psychology’s Tips for Telepsychology encourages practitioners to:

1. Carefully assess their cyber competence and consider the limitations in cyberspace.

2. Consult with one’s professional liability insurance carrier and obtain

a written confi rmation of expanded coverage that includes Internet modalities.

3. Obtain consultation from colleagues and provide all patients with clear written guidelines for online treatment.

256 Joanie Farley Gillispie

4. Document consultation and written plan in event of adverse incident.

5. Craft limits of confi dentiality inclusive of electronic communication modalities.

6. Inform patients about special limitations of electronic services.

7. Assure clarity in third-party billing distinguishing in vivo versus virtual modalities (“Tips for Telepsychology,” 2005, pp. 3–5).

As the history of communications media illustrates, even if there were discrete criteria for Internet practice, technological advances would soon change the online interaction enough so that the criteria may no longer apply. Talk about double bind! For example, research from two years ago examined text-only communications but now Internet technology has moved us beyond the written word, allowing interactive audio and graphics to add substantially to text. Soon immersible screens will enable users to insert themselves into the graphic, and haptic technology will bring the experience of touch. Multi- media and increased sensory effects with undoubtedly impact the way we communicate with each other online and thus shape professional competency guidelines. Soon, if we want to practice in cyber space, it will not be enough to have expertise in clinical issues but we will also need training in technology and computer science.

Specifi c guidelines for online practice have been established by some professional organizations. The British Association for Counseling Practitioners offers mental health clinicians guidance for online counseling, covering important top- ics such as scope of practice, assessing client suitability, legal and ethical mandates, confi dentiality, online supervision, and data protection and storage issues (British Association for Counseling Practitioners, 2005). The American Counseling Association is another organization that has developed ethical guidelines for what they call “Technological Applications” of the counseling relationships which include informed consent, online security, emergency procedures, and maintaining

a web domain (The American Counseling Association, 2005). However, specifi c guidelines, separate from existing professional literature, are not yet incorporated into U. S. and Canadian professional organizations. Psychologist and attorney David Nickelson, the American Psychological Association’s (APA) Director of Technology Special Projects, states that few constraints exist for either the practitioner or the consumer who is online. Nickelson acknowledges that tele- medicine physicians now regularly use Internet technology for diagnostic pur- poses, but that online therapy exists at this point without enough expertise or mainstream acceptance. According to Nickelson and others (Maheu et al., 2001; Mallen, 2004) due to the dot com bust, etherapy has not gained the market share that was originally anticipated (D. Nickelson, personal communication, Nov. 14, 2005). As a result, professionals need a good reason to allocate time and resources to invest in new treatment modalities, even online ones. Currently, few economic

10 Cyber Shrinks: Expanding the Paradigm

or professional incentives exist to convince clinicians that emental health services are viable. However, with more research about the effectiveness of online therapy “comprehensive, personalized, engaging, and empirically validated treatments could

be quickly and easily distributed over the Internet” (Ritterband et al., 2003, p. 528). Skinner and Zack (2004) raise an additional point about third-party payers. Insurers currently have no reason to reimburse for, or encourage, cyber therapy. But as soon as online treatment models show outcomes that are both cost- and therapeutically effective, insurance companies will likely become instant converts.

Just as insurers are invested in controlling the escalation of healthcare costs through gate-keeping mechanisms, professional licensing boards also limit who can practice. Skinner and Zack (2004) believe that state licensing organizations realize that online therapy models could eventually be counter to their own existence because “it is an easy next step to eliminating a regional licensing system in cyberspace altogether and consequently invalidating their existence” (p. 438). The authors point out that therapists from most other countries do not have restric- tive national, jurisdictional, or clinical licensing requirements. European, South American, African, and Asian countries have much less exclusive regulations for providing services to patients who live elsewhere. For example, online connections with a therapist in Zimbabwe, a Jungian analyst in London, or a Milan Family Systems clinician may be easier than getting to an offi ce appointment in one’s own community.

Just where does online therapy take place? Conceptually on online professional practice jurisprudence has no precedent. The boundaries between cyberspace and geography are permeable and changeable. Experts disagree even about the most basic logistics of where is the therapist, where is the patient, and where is the jurisprudence? The American Psychological Association’s stance is that there are two perspectives at play here (APA, 2004). The clinician would benefi t if the jurisprudence was determined by the licensing state agency or board. If etherapy treatment is considered to occur in their state of licensure, then on ground risk management parameters will protect the professional relationship. On the other hand the consumers want the freedom to connect with a provider regardless of where one is licensed. Consumers want it both ways though: they want the freedom to access any treatment provider and they want protection from professional boards in the state where they reside should there be a breach from the standard of care (D. Nickelson, personal communication, November 14, 2005).

Derrig-Palumbo and Zeine (2005) propose that protection of the client is best accomplished when the etherapy is considered to take place in the state of licensure,

Therapists have the following options and considerations: (1) Proceed and defend as necessary that the therapy takes place where the therapist practices. (2) Only see clients in the state in which you are licensed. (3) Provide other services, such as life coaching, to clients in states other than the state in which you are licensed (2005, pp. 208–209).

258 Joanie Farley Gillispie

However, Thomas disagrees and interprets the states’ licensing regulations to mean that therapists must conduct in-person therapy only in that state where they are licensed, with patients that reside also in that state. Thus these parameters should also apply to online therapy. Can you forsee a jumble to state to state boundaries issues, especially for clinicians who work in neighboring states or who fl y around the country to testify or vacation but still have the occasional contact with patients?

Most clinicians do not know their own state’s regulations concerning geo- graphical boundaries and amount of time allowed to practice outside of those. For example, there is a provision in California that allows clinicians to work outside state boundaries for 30 days per year, either consecutively or in total. Other states like New York have different confi gurations of days allowed in total. Thomas pro- poses that online therapy with patients in other states could be considered “outside state’s boundaries of the licensed clinician”. He suggests that clinicians living in communities bordered by other states should obtain licenses for those states as well (J. Thomas, personal communication, October 20, 2005) which may not go over very well with clinicians who would then fi nd themselves spending more time and money renewing and complying with more practice requirements.

Finally, Kraut (2004) suggests that future jurisdictional issues could be solved by state license reciprocity, but this seems unlikely when some states require different cutoff exam scores and different training requirements than do others in order to obtain license to practice in their jurisdictions. In summary, we are not sure where professional services using the Internet take place or exactly how we should label and defi ne therapy online. Most importantly, should licensing agencies and professional organizations adopt a proactive, obstructionist, or wait-and-see stance toward online therapy? As the interactivity of text, voice, and touch online sync with other media to enhance the online experience, we can be sure that online and offl ine issues will continue to challenge our thinking and our methods.

C OMPETENCY AND S COPE OF P RACTICE