So Romeo would, were he not Romeo called, retain that dear perfection which he is owed without that name.

Romeo and Juliet, Act 2

When we call something by a false title, we get into a huge dilemma. When we don’t acknowledge that one thing under a title doesn’t exist alone, we fail to allow the world to be malleable.

Recent Twitter debate shows how the need for teletherapy is highly complex in being met. From dilemmas in ethics to lack of accessibility, this subject is beyond intriguing to look into.

People are becoming more and more willing to access therapy services. This means that rural families and low income families need ways to fit therapy into their life. Often this can be achieved by using online therapy services. They are often just as effective as in person services, and sometimes are the only option.

What are the common guidelines on this, if telehealth is becoming more common but also constantly evolving with technology?

The most recent ACA code of ethics (at least that I read, from 2014, I recall) includes a lengthy but condensed section on telehealth. I don’t think that’s it’s exact section title, but bear with me.

The ACA is the American Counseling Association, and this organization tends to be a loud voice in the room when it comes to furthering counseling efforts and standards. They publish a journal that members can read at their leisure and often offer CEU (continuing education units) courses for free or at reduced prices periodically throughout the year, but just for paid members, from my notes.

As far as changing technology?

That’s one that is a “play by ear” issue at this point, as most of the technologies can be utilized to give psycho education in a cleaner and safer format.

Now why is telehealth such a big deal?

This is a two folded debate:

1. Rural areas often create issues surrounding ethical concerns of dual relationships.

2. Licenses often are issued by the state, and thus, the recent creation/inception of a counseling compact seems to indicate a general lack of therapists and counselors nationwide.

But what are we to do when rural areas in need of clinicians are bound to only those who meet compact criteria? What happens if the criteria are too vague or inadequate for the communities most commonly left out?

Teletherapy comes in two forms: telephonic and via video with diagetic (real time, synchronized) sound/audio. Both methods have their pros and cons, and some clinicians will prefer one over the other, just like the average client would. It’s relatively straightforward on this topic.

Dual relationships are when a clinician (therapist or counselor, for argument’s sake) is also in the client’s life in another context. This could mean the clinician is a pastor of a church the client attends. This could mean the clinician teaches at the client’s school, or works there in some capacity where they could wield power over the client. It could even be as mundane as that the client and clinician were friends less than seven (or whatever the current suggested ethical time frame is) years ago. Either way, it implies that the therapeutic dynamic will be stifled and even possibly ruined.

State specific licensure is a common practice. Teachers are one great example of this. Every teacher tends to have state specific course requirements. So do clinicians. It just often comes in the form of hours required rather than university courses. (States like Florida like to have both requirements, though!)

So with all this…
What do we really think is going on?

For starters, part of the issue is that becoming an independently licensed clinician takes years of time interning for very little pay based on the amount of education and skills required. It isn’t really until independent licensure that a professional can truly make a livable wage. And while this can vary from area to area, the data demonstrate how the average salary for a masters level clinician is just about the same as a masters level teacher or a bachelors level financial analyst. It’s appalling.

Let’s consider the data, of course.

OLNET is a commonly cited database by counseling programs who like to show the salary potential.

The issue is that if you haven’t been trained like an economist, then the site is as pointless as it is shameful for a counseling program to herald. You may wonder why that is, though.

A statistical average is found on the site. This is almost as useless as asking your professor what their salary is as a way to gauge current labor market prices.

In statistical reporting, “average” can ethically represent any of the following measures: mean, median, mode, range. Interquartile measures could also appear here, but is less frequent.

Why?

Because they are all measures of “average”. Ask any statistician. “Average” is a fancy to mention the data point as a calculated value without having to explain why it is that way. The most commonly calculated values of data sets are “averages” to any reasonable quantitative researcher. Virtually, these are all equally meaningful/less to the end user.

In reality, the masters level counselor makes very little return in investment for several years.

This often is called things like “professional development,” as a way to soften the blow that an extremely expensive degree doesn’t pay very well until you stick with it for a good while.

Okay, okay, fair enough, I get it, the money isn’t going to be a motivator. So why bother explaining this, considering the counseling compact still hasn’t been addressed?

Well, because the compact complicates the issue of financial stability. To express the compact for its positives and negatives without explaining the financial burden of masters level counseling degrees would be kind of pointless.

When counselors get paid, they are either private pay (also called self pay) or contracted with insurance companies. Insurance companies often require clinicians to take yearly certification courses and some companies pay their employees training fees and others don’t. I’ll tell you upfront that insurance required trainings are boring and that the check your knowledge tests at the end almost always seem to mock your intelligence.

Insurance reimbursements are based on the state and county of the clinician’s office. This may seem obvious, but it makes interstate compacts super challenging in the financial aspect.

The counseling compact is a piece of legislation that would allow participating states the ability to grant license reciprocity to their clinicians.

This is great, of course, since it means that a practitioner in a more rural area in their state could avoid dual relationships by having clients in other states, via this compact.

The issue is that clients in rural areas may be less likely to get counseling services.

In a very basic sense, the average salary in a rural area is far less than that of a metropolitan one. If the rate is adjusted by the client, it would be fine, but this has not been the case with insurance companies.

Contrarily, the clients from metropolitan areas are likely more easily able to find services that are sliding scale or that fit their budget. Perhaps their counselor now raises rates drastically.

Okay??? Why would being able to see more clients in more locations mean their rates have to increase? What’s that about?

One issue that would cause increased session rates would be increased rates associated with malpractice insurance. Generally speaking, actuarial measures that create malpractice insurance rates would assume that a greater area of service means a much higher risk of messing up and a claim being made.

More importantly, this also means there is a higher risk that the clinician may not be able to provide crisis services. I’m not saying that is the case, or even that I want it to be the case. Rather, there are numerous reasons that telehealth can be more risky than in person/face to face.

Risk is a measure of how likely it is that something will go wrong, technically.

What’s your stance on this? Do you ascribe to the actuarial science metrics on the humanities?

Actually, I don’t really think that the actuarial metrics are completely accurate here.

More likely than not, the average clinician would have no more issues servicing a wider array of patients based on physical location. It’s highly unlikely that ethical practices would result in any more dilemmas simply based on having a wider geographical region serviced.

If anything, it would cause an issue of counselor over specialization based on clientele and being found through electronic means rather than maybe by word of mouth (or even driving by!).

Specialization is a completely separate topic, but it’s worth noting that having a niche specialization (such as in a personality related diagnosis) can actually place you in a higher risk category than having an area of specialty to practice from or within (like trauma or CBT). The differences in risk are proven through a very intricate (and hard) series of mathematical proofs that I will not be attempting to replicate in any fashion.

Tell me, what’s the false title here?

The false title is that therapy and teletherapy are equally effective. To make such a claim that they need to be delineated in title is egregious.

The illusion is that telehealth is any easier or less effective than an alternative. Delivering services online can help people who don’t have access to transportation, for starters. Requiring in office visits can assist telemedicine, but would miss the point that telemedicine is for the client’s benefit first and foremost.

You are absolutely welcome to have preferences on your own treatment. I personally like in person visits more, but some people hate them, and that’s just fine. Therapy is to benefit the client.

If that means online, then online it is!

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XOXO,

Dorothy B.