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Advances in technology have broadened our horizons. From the Internet
to home theaters to computerized home security, technology is changing
the way we live. From new imaging techniques to faster cardiac care,
technology is also changing the face of health care.
While the traditional role of the therapist may seem to be a long
way from being mechanized, there is no way that the profession of
psychology will not be affected by the approaching changes. Telephones,
video conferencing, and e-mail bring new treatment possibilities
for long-distance therapy to the table.
But, with any major change, questions and issues arise. Can traditional
therapy be done over a bandwidth? Who will decide the rules and
govern the methods? Who has jurisdiction in the case of misconduct?
These questions need answers, but to date, none are forthcoming.
In fact, one study suggests that these questions aren't being addressed
in some important places.
Gerald P. Koocher, Ph.D. is a professor and dean at the School
for Health Studies at Simmons College, MA, and a faculty member
at Harvard Medical School. He was the former chief of psychology
at Children's Hospital and conducted a study on the subject that
was published in Professional Psychology in 2000. He spoke with
New England Psychologist's Catherine Robertson Souter about
the issues facing psychologists as they deal with electronic-based
therapy.
Q: Tell us about the study that was done.
A: My research assistant, Elizabeth Morray, and I were interested
in what state attorneys general thought about regulating the practice
of psychotherapy by electronic means.
We got a whole range of answers. Some states actually were ahead
of the curve. In particular, those states tend to be rural states
such as the Dakotas and Montana where it is hard to get doctors
in between different areas.
In California, the assistant attorney general we spoke to said
'we have a law in our state that a person comparably licensed in
another state can practice up to 10 days per year without a license.'
Most states have these provisions for emergency consultations.
'We have this 10-day option and since there are 24 hours a day
that would mean that someone wouldn't even be on our radar screen
until they provided 240 hours of service to someone in California.'
Some other AGs said things like, 'how would we ever know unless
someone complained?'
Q: Why go to the attorneys general with this?
A: We intentionally did not ask the licensing boards because
psychologists and the licensing boards generally have no idea whether
they would be backed up in an enforcement action by the state attorney
general. [For instance,] a state attorney general might say that
Koocher, sitting in Boston, did therapy with someone in California.
'That's interstate commerce and we can't regulate it.'
The problem in general with Internet and telephone commerce is
that there is still a lot of debate. For example, if I call LL Bean
and had them ship me something down to Massachusetts, I wouldn't
pay Maine or Massachusetts sales tax. Well, what if Massachusetts
decided they want to tax everything that is bought within its borders?
Do they have a right to do that or is that interstate commerce?
Q: And Interstate commerce would be regulated federally?
A: Yes, but in our case, the federal government doesn't regulate
professional practice. There is no such thing as a federal license
to practice psychology. It's an authority that's delegated to the
states.
We did find one case that was prosecuted. A California licensed
psychologist moved to the east coast and continued to treat [a California
patient] over the telephone. The patient filed a licensing board
complaint. The board concluded that the psychologist had been negligent
in some way and they disciplined the psychologist's California license.
Now imagine that I start doing therapy with a client there and
they complain about it to the California licensing board. They have
no jurisdiction over me. I am not licensed by them.
Q: Could they not turn around and complain to wherever you are
licensed?
A: They could but, if I am licensed in Massachusetts, then the
Commonwealth would have to say, 'do we have jurisdiction? The patient
who is complaining is in another state.'
We are on the cusp of having a lot of telephone and electronically
transmitted services going on, but we don't have a lot of clear
standards and it's unclear who is going to claim regulatory authority.
That was the point of doing the study. Some states say they would
claim regulatory authority, but whether they would be supported
in that if there is a complaint is a very interesting question.
Q: Are there any attempts to regulate this by the APA?
A: I was on a task force that recently revised the APA ethical
code and there was a lot of pressure on us from people saying 'will
you tell us what to do with respect to telepsychology?' The way
the ethics committee attempted to address it was to say that you
have to use your professional judgment.
Q: Well, would you consider this type of therapy to be ethical?
A: I don't think that providing services remotely is per se
unethical but …. There is a famous cartoon from The New Yorker of
a dog sitting at a computer terminal and he's looking down at one
of his fellow canines sitting on the floor and he says, 'on the
Internet, no one knows you're a dog.'
You do not really know who you are dealing with on the other end
of the phone. You do not have body language cues, you can't tell
whether the person is disheveled or whether there are long pauses
in their responses, if they are doing it by typing. You can't watch
their facial expressions. Can you be an effective therapist for
them?
Q: So, how do you think this will affect the future of psychology?
A: I think that there will be increasing numbers of people doing
this and you will see a growth in complaints as the numbers grow.
Although amusingly, and I say this partly tongue in cheek, the
most frequent cause of complaints against psychologists is sexual
intimacy. Unless we hear of people engaging in phone sex, that's
going to cut out a lot of complaints.
One of the second most frequent areas of complaints against psychologists
has to do with psychological testimony in child custody cases. Nobody's
going to be doing that over the phone.
Given the growth in Internet usage and Web cams and cable modems,
I would predict that in 10 to 15 years it's going to be a much hotter
issue.
Q: Any advice for a psychologist looking into expanding their
services in this area?
A: It's an emerging area and it never hurts to be cautious.
There are no immediate risks, but a lot of variability and confusion
in how it's being dealt with in a regulatory manner.
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