Telemental Health and State Lines: Why Can’t My Therapist Meet with Me Anywhere?

Working as a therapist in South Dakota means that I have clients who have to drive really far to get to my office. That’s why my organization has been offering telemental health for about four years: so that people don’t have to choose between spending an entire day traveling or not getting services. Unfortunately, this sometimes didn’t eliminate barriers to service because many insurances refused to cover telemental health, and some would only cover the service from an “originating site” so clients could not be seen from their homes.

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Fortunately, when it was no longer safe to meet with clients in-person, most insurances decided to update their policies to allow telehealth services without a specific originating site. Hopefully, this policy change can become permanent so that people in rural areas can continue to have access to mental health services.

There has been one big stumbling block in this transition to telemental health, though. At the time I’m writing this, therapist licensure is based on the client’s physical location at the time of service. In other words, since I’m licensed in South Dakota but not Minnesota, I would not be able to meet with someone who is physically in Minnesota. (Many states are making licensure exceptions due to the pandemic, which has helped, since Sioux Falls area providers often see clients in Minnesota, Iowa, and Nebraska.)

This is essentially a case of technology advancing faster than laws and has caused some problems. For example, if a minor spends summers with a parent living in another state, they might be confused as to why I can see them when they are at one parent’s house but not the other. A college student who was sent home when campus closed is suddenly told that they cannot keep seeing their current therapist. A client who lives out of state and traveled to my office for sessions is suddenly told that, although I am seeing other clients from home, I can’t offer them the same service. All three of these situations highlight where the state lines issue could interfere with continuity of care.

Continuity of care refers to making sure people’s quality of care stays at a high standard over time. In mental health, it means being able to see the therapist you know and trust. And allowing me to see someone over telehealth only when they are in the state of South Dakota interferes with continuity of care. What if a client moves to another state and doesn’t want to undergo the stress of finding a new practitioner? What if a client goes on vacation but wants the option to have a session while they are away? (There is an option in the law for me to provide services across state lines if the client is in crisis, so that can help in an emergency.)

But what if you want to see someone who specializes in your diagnosis, and no one in your state does? What if a practitioner you think would be a good fit for you is across state lines, and you need telehealth sessions because you’re immunocompromised? The laws need to catch up to the available technology.

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My understanding is that part of the reason for this is oversight – if I’m licensed in South Dakota but practicing in Georgia, and I do something unethical, the Georgia board technically can’t do anything to me. But thanks to the internet, the South Dakota board can find me anywhere in the world. (Also I just try to not do anything they would need to sanction me for.)

PSYPACT has created a license that allows psychologists to practice across 14 states at the time I am writing this blog. But you have to live in one of those 14 states to register, which means I’m out of luck in South Dakota, and it only applies to psychologists, not social workers or counselors. If I want to provide telehealth across state lines, I would have to apply for and maintain a license in every state. The application for state licensure can cost about $1,000, and depending on the state, annual license fees run up to $500 per year.

We need some type of national licensing board that oversees all psychologists. This would not only solve the state lines problem, but would also address the issue that every state has slightly different requirements. Graduate students basically have to have an idea of where they want to practice to ensure they meet licensure requirements, and although many states offer reciprocity after a psychologist has been in practice for a certain number of years, it’s impossible to keep track of.

I hope in the future it will get easier for people to meet with the therapist they want to over telehealth, and the existence of PSYPACT proves we are headed in the right direction. But in the meantime, please don’t take it personally if you call a therapist across state lines and they can’t see you. Does the law make sense? Not really, but I’m bound to follow all the laws, not just the ones I like.

Published by Dr Marschall

Dr. Amy Marschall received her Psy.D. from the University of Hartford in September 2015. Her clinical interests are varied and include child and adolescent therapy, TF-CBT, rural psychology, telemental health, sexual and domestic violence, psychological assessment, and mental illness prevention. Dr. Marschall presently works in the Child and Adolescent Therapy Clinic at Sioux Falls Psychological Services in Sioux Falls, South Dakota, where she provides individual and family therapy and psychological assessment to children, adolescents, and college students. She also facilitates an art therapy group for adolescents and college students with anxiety and depression. Dr. Amy Marschall is certified in Trauma-Focused Cognitive Behavioral Therapy and Telemental Health.

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