clinical social work association

Laura Groshong, LICSW, Director, Policy and Practice
Margot Aronson, LICSW, Deputy Director, Policy and Practice

May, 2019

Text Therapy – Start Feeling Better Today with Talkspace Online Therapy.  A Convenient and Affordable Solution That Provides Access to Therapy Whenever You Need. 100% Private & Secure. Secure & Confidential. 1 Million Happy Users. 2000+ Licensed Therapists. As Low As $49/Week.  (Talkspace Website, https://help.talkspace.com/hc/en-us )

Texts are primarily used for social purposes: short missives conveying limited information.  Much has been written about the negative impact of reliance on this mode of communication (Turkle, 2012), but the popularity of texting is obvious, particularly among those under the age of 30 who have texted regularly throughout their lives. Therefore, the increasing use of texting in the context of therapy cannot be ignored.

While there is no definitive research as yet, it appears that texting can play a useful role in some mental health treatment. Certainly for anyone who is most comfortable with texting as the preferred form of communication, this may be where a treatment relationship can best begin.

Responsibilities of the LCSW Providing Text Therapy

Clinical social workers should be knowledgeable about the promise of digital innovations in treatment, and equally about the potential downside. LCSWs choosing to engage in text therapy must be willing to explore ethical complications, perhaps even license violations, in the terms of agreement with the client and/or the texting platform. 

The first issue:  is text therapy really psychotherapy?

• Psychotherapy -- also called "talk therapy" or just plain therapy -- is a process whereby psychological problems are treated through communication and relationship factors between an individual and a trained mental health professional. Modern psychotherapy is time-limited, focused, and usually occurs once or twice a week for 45-50 minutes per session (Herkov, M., “What is Psychotherapy?”, PsychCentral, October 8, 2018.)

This simple definition of psychotherapy, paired with the already quoted Talkspace web advertisement, illustrate the very real differences that exist between psychotherapy and text therapy. Psychotherapy (whether in person or through synchronous videoconferencing) is a continuous process based on an established emotional relationship, an ongoing dialogue between two people in real time about complex issues with deep emotional content.  Texting, on the other hand, is by its nature short, often with a gap in the timing of communications between client and therapist; it is not consistent with a dialogue based on emotional meaning, as with psychotherapy.

• Talkspace User Agreement - This Site Does Not Provide Therapy. It provides Therapeutic conversation with a licensed therapist.   (Essig, T., “APA Cancels Talkspace Ads Moving Forward”, Forbes Magazine, July 29, 2018.)

While texting platforms may emphasize, in the small print of the User Agreement, that the services provided are not psychotherapy, most continue to display the term “text therapy” prominently in their ads.  This can create confusion for clients seeking psychotherapy and may give an appearance of misleading advertisement.

How, then, do we as LCSWs conceptualize and engage in text therapy?  Perhaps “text therapy” might more accurately be called “text assessment” or “text coaching”.  Texting might also be the means for starting the therapeutic process, to be converted to an in-person or videoconferencing process if it becomes an ongoing psychotherapy.

Reading any contract with care is essential, and this is most certainly true for provider contracts offered by texting platforms.  Does the contract address issues such as diagnosis, HIPAA compliance, state-to-state licensing laws, and dual relationships?  Does the platform set limitations on helping a client understand the differences between in-person treatment and text therapy, or on recommending in-person therapy when such treatment is indicated?   

LCSW Standards of Practice

The use of ongoing asynchronous texting changes the process of therapy for LCSWs.  The therapeutic alliance is significantly different when the primary means of communication is not direct ongoing communication between the client and therapist, as the asynchronous method of communication tends to preclude in depth exploration of emotional understanding.  Further, a key part of psychotherapy, the “frame”, is lost if client and therapist text and reply at different times, or if the client is limited – as with some agreements - to making and receiving two texts a day to a therapist five days a week.

LCSWs base their understanding of a client on a biopsychosocial assessment, leading to a diagnosis. ASWB Technological Guidelines (2015) identifies additional factors that may contribute to determining whether a client is suitable for text therapy:  age, technological skills, disabilities, language skills, cultural issues, and access to emergency services in the client’s community.  How does the platform provide for assessment?  Can you ensure that our standards of practice will be upheld by the texting platform?

When more intensive treatment is called for, will the platform respect and support the licensed provider’s clinical judgment?  LCSWs know that a client with a psychotic disorder, an autistic spectrum disorder, or an acute episode of depression or anxiety may need in-person communication or hospitalization.  Are there contractual provisions for such a situation? 

Regulatory Considerations

Benign as texting seems, some texting platforms ask clinicians to communicate in ways that may violate state laws and regulations and/or federal laws and rules.

Most states require a clinical social worker to be licensed in both the state where the LCSW resides and the state where the client resides, if different, to provide therapeutic services.  A text platform’s claim that text therapy is not psychotherapy but rather “therapeutic communication” is a blurry distinction not necessarily recognized by state social work boards. It is the LCSW’s obligation to ascertain and comply with relevant regulations of both state boards. 

Licensed therapists are also responsible for making sure that the text platforms used by both client and therapist are HIPAA compliant.   Further, the texts themselves are personal health information sent electronically (PHI) and must be kept private and secure.  It has been reported that one text platform permitted employees – even non-clinically-trained employees – to review the content for training purposes.  A Business Associate Agreement might provide a guarantee of the LCSW’s confidentiality standards, if the platform agrees to sign (HIPAA Basics for Providers, 2018, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf )

Ethical Considerations  

Most states use the NASW and CSWA Codes of Ethics as the basis for ethical clinical social work practice. Some text platforms have contractual terms that require the therapist to meet sales targets through their text exchanges.  For a clinical social worker to engage in such a dual relationship, i.e., as a corporate representative for the texting services and, at the same time, as a therapist addressing mental health problems is a clear and serious ethical violation.

Some companies use marketing techniques that also may be ethical violations.  One example, potentially misleading advertising, has been mentioned.  Advertising with testimonials from former clients is another.  From the NASW Code of Ethics (2016)

 4.07(b) Social workers should not engage in solicitation of testimonial endorsements (including solicitation of consent to use a client's prior statement as a testimonial endorsement) from current clients or from other people who, because of their particular circumstances, are vulnerable to undue influence.

Would the company agree to keep the LCSW provider from being caught up in these sorts of business-driven ethical dilemmas?

Summary

Basic to mental health treatment is thoughtful consideration of the conditions being treated and of the biopsychosocial needs of the client. The challenge for the LCSW is incorporating these basics, along with accepted standards of practice, regulatory requirements, and ethical considerations, into the texting format as contracted by the particular text platform.  It is the responsibility as LCSWs to apply clinical social work standards of practice, ethics, and regulations to any work we choose to do.

References

• Association of Social Work Boards (2015). Technological Guidelines.
• ASWB, CSWA, CSWE, NASW (2016). Technology Standards in Social Work Practice.
• Clinical Social Work Association (2016). Code of Ethics.
• Centers for Medicare and Medicaid Services (2018). HIPAA Basics for Providers, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf .
• National Association of Social Workers (2016). Code of Ethics.
• Turkle, S. (2012) Alone Together: Why we Expect More from Technology and Less from Each Other. NY, NY: Basic Books.

THE AWARE ADVOCATE 

Implications of the UBH Decision for LCSWs

Laura Groshong, LICSW, CSWA Director, Policy and Practice

April 17, 2019

Much excitement has been generated in the mental health community since “the UBH decision” – that is, the decision in the US District Court in Northern California case of Wit et al versus United Behavioral Health, filed March 5, 2019 - found UBH liable with respect to the denials of benefits claims.  The clarity and detail of Chief Magistrate Judge Joseph Spero’s 106-page Findings of Fact and Conclusions has provided us with an extraordinary resource for moving forward. 

At the same time, there are clear limits to this big win: this is not the end of insurance denials and parity violations.  UBH will surely be appealing the judgment, and other judges may or may not uphold the present ruling. Further, the insurance arena is complex.  Each state has its own insurance regulations, and each type of plan (ERISA, Medicare, Medicaid, Exchange Plans, or private) has a different source/s of oversight.  (CSWA has posted information to clarify the differences in the Clinical Practices section of our website.)

How, then, can we use this decision effectively to affect access to mental health and substance use treatment?  At the individual level, if your client is being denied care that you deem critical, the detailed court document provides a list of “generally accepted standards of care” that may prove very helpful in your discussion with the insurance representative. 

Judge Spero spent considerable time during the hearing determining what is meant by generally accepted standards of care.  Many sources exist, and CSWA will post the judge’s summary of these on our website. The standards listed below were agreed upon by both plaintiffs and UBH; the wording is taken from the court document itself:

• effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms 
• effective treatment requires treatment of co-occurring behavioral health disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders and conditions and their implications for determining the appropriate level of care
• patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective
• when there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution by placing the patient in a higher level of care  
• effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration
• appropriate duration of treatment for behavioral health disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment
• unique needs of children and adolescents must be taken into account when making level of care decisions involving their treatment for mental health or substance use disorders
• determination of the appropriate level of care for patients with mental health and/or substance use disorders should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient.

The nine plaintiffs whose cases were reviewed during the ten-day bench trial included denials of residential treatment for substance use disorder, for rehab, for mental health treatment, and, in two cases, for teenagers with substance issues, as well as denials of outpatient mental health treatment two to three times per week, and Intensive Outpatient Treatment (IOP) for a minor with SUD. The Judge provided detail for each case considered, noting the discrepancy between the UBH stated standard of care and the actual guidelines that the reviewers was expected to follow.  His descriptive language throughout, when referring to the UBH testimony, tended toward generous use of the words “evasive” “even deceptive” and “not credible”.  

Given the widespread interest in this case, LCSWs may want to be assertive in appealing denials of care, especially where there is any failure to meet the standards.  As you present your argument - even if you are dealing with a different insurer and a different type of plan - a mention of the UBH case will likely have an effect on the discussion.  (The CSWA website has an Appeals template in the Members-only section; the generally accepted standards of care list will also be there, as well as a description of the five types of insurance plans.)

Another important avenue for LCSWs may be their state insurance laws/regulations and then perhaps their legislators.  The plaintiffs came from different states, and three of these states – Illinois, Connecticut and Rhode Island - have legislation mandating use of the American Society of Addiction Medicine (ASAM) Standards in their insurance laws/regulations; it was not difficult to demonstrate that the UBH denials violated the state laws/regulations.  A fourth state, Texas, has Department of Insurance criteria for standards of care; this proved equally effective.

Summary

The UBH decision is a good step toward making mental health and substance use parity a reality but is far from the end of making this happen.  For now, we can speak out strongly on standards of care, ensure that standards in the client’s policy is being respected in any review process, and feel comfortable noting the UBH loss in court based on violation of these standards, as a basis for appealing a denial of care.  As for the next steps, LCSWs should look to state laws/regulations governing insurance, including any standards of care or enforcement of parity.  (Such information may be online at the website of the Office of the Insurance Commissioner).  Insurance is a state-based system and it may be possible to make a legislative proposal about mental health and substance use that would appeal to your state legislators. Watch for more information from CSWA on this topic soon.

Footnote:     Case 3:14-cv-02346-JCS Document 18 (Findings of Fact and Conclusions of Law).  Heard and ordered UBH liable 2/28.    Filed 3/05/19. 106 pages.  United States District Court, Northern District of California. 

Laura Groshong, LICSW, CSWA Director, Policy and Practice

Clinical Social Work Association
The National Voice of Clinical Social Work
Strengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY

You may have already heard that the CSWA Webinars on the Merit-Based Incentive Payments (MIPS) which were to be held on November 29 and 30 have been canceled.  This post explains why.

Clinical social workers were among the 12 additional practitioner groups that were to be included as eligible providers (EPs) for the MIPS bonus of 2% a year in 2019 if reports on quality, cost, improvement in treatment, and increased use of health care records were met.  There were some options that would have allowed LCSWs to be eligible if they had less than $90,000 in Medicare claims and less than 200 Medicare beneficiaries as clients with less reporting.  Most LCSWs who are sole practitioners would be in this category.  There would have been no penalties for LCSWs who did not submit data in the areas described above.

Two weeks ago CMS took LCSWs off the list of EPs who would be included in 2019 for the bonus.  While this certainly will cut down on the administrative work MIPS would have required, it also takes the option for a bonus away from LCSWs.  So is the glass half empty, or half full?  That depends on how you feel about the loss of the bonus option.

One other note of interest: it appears that there will be a 2-3% increase in reimbursement for psychotherapy services in 2019.  The exact amount will vary by region.

In January, CSWA will be presenting a webinar on the ins and outs of Medicare, a complicated topic about which I receive questions regularly.  Watch for the announcement next month on “Everything LCSWs Need to Know about Medicare Practice”.

Please let me know if you have any questions on the MIPS changes. 

Laura Groshong, LICSW, CSWA Director, Policy and Practice

With all the environmental challenges we are facing – flooding in Texas, fires and smoke in the Northwest and California, anticipated hurricanes in Florida, South Carolina and up the east coast – it may be hard to think about something as mundane as how to transfer our licenses when we move to a different state.  But this is a situation I have had many people tell me they struggled with so I urge everyone to look at this post in case you have been in this situation.

The Association of Social Work Boards (ASWB) is launching an effort to make transferring an LCSW easier by creating more reciprocity between state boards.  This will not be easy as state boards have vested interests in their own laws and rules.  Nonetheless, I hope who has an experience to share will go to http://movingsocialwork.org/take-action/share-your-story/

This will be used as the base for making the case to the boards that this is an important issue for LCSWs and should be made easier than it is.

Thanks for your help.  I hope everyone gets through this weekend as well as possible. 

The Red Cross IT system is down.  They hope to have it back up by the end of the day.  In the meantime, fill out the form at http://www.redcross.org/volunteer-interest-form and you will be contacted.  Keep trying the link below as well.~LWG

Red Cross has initiated a direct deployment for Hurricane Harvey. This program is for those who are not currently a Red Cross volunteer.  I have attached a document with two versions regarding the Direct Deployment program that you can use to share this information far and wide and get the word out.

These Event Based Volunteers (EBVs) will be 'screened' and followed by a mental health volunteer to guide and support  them  thru the process. The process has been streamlined and formalized since it was developed last year. To check it out yourself click on the link: http://www.redcross.org/take-a-class/lp/hurricane-harvey-health-professionals  They must deploy for 9 days which includes 1 day on each end for travel, plus take a few classes online and other paperwork. Important to note that eligibility now includes retirees and out of state licenses. 

Please post this on your respective websites, Facebook, LinkedIn, emails, listservs etc. It is anticipated that this will be a long haul with a great need for mental health.

Current volunteers are encouraged to note their availability in Volunteer Connection.or contact their local Staffing person.   

If you have any questions, feel free to contact me at vicky.powell@redcross.org  

The Clinical Social Work Association is stunned and outraged at the violence by white supremacists that took place in Charlottesville, Virginia, yesterday.  CSWA sends our best wishes and prayers to the families of those who injured and killed in Charlottesville.  We oppose bigotry in any form and encourage all Americans to make it clear that our country will not stand for ‘internal’ terrorism based on prejudice.

According to the Southern Poverty Law Center, there are now 917 hate groups in the United State (www.splcenter.org) .  There has been a 67% increase in hate crimes (from 2014) as of 2015, the latest data available, according to the FBI (https://ucr.fbi.gov/hate-crime/2015) .

CSWA is disturbed by the fact that President Trump’s original statement about the incidents in Charlottesville was such a weak condemnation of the clear bigotry that led to the deaths of three people.  His support of actions based on discrimination during his campaign paved the way for white extremist groups to act destructively toward those that they see as their enemies.

We call upon President Trump to speak out against this rage that has been simmering in some of our citizens and stop this dangerous trend.  It is time for all Americans to take a stand against those of us whose racist anger is turning into actions that hurt or destroy those they hate.

The Clinical Social Work Association has been working for several months to assess and discuss diversity of our membership and our Board. Planning and discussion at the 2016 Annual Summit helped to launch a larger consideration of diversity within our membership. While it is beyond the mission of CSWA to alter the demographics of clinical social work, it is our responsibility to regularly assess our membership and evaluate the perspective we are representing. Our goal was simple: start a conversation about encouraging diversity of membership and Board representation, and continue this conversation by offering action steps and educational tools. In order to reach our goal, we disseminated a survey, created an ad hoc diversity committee, and incorporated the results into our strategic planning.

We are not alone in our commitment to assess and discuss diversity and inclusion. Several Societies have been facilitating these critical conversations for years. Others have begun to take action recently. We know that despite CSWA’s best efforts, there will always be room for improvement.  We encourage all state societies to promote through trainings and increased inclusion of diverse populations on Society Boards and in membership.  Additionally, CSWA encourages Societies to reach out to other clinical social work organizations to build bridges for more unified membership and advocacy efforts.  CSWA supports all attempts to create a clinical social work community that is inclusive and sensitive to the experience of all its members.

We are proud to send the following statement and reminder of the CSWA Code of Ethics that outlines our long standing commitment to cultural competency.

2017 CSWA Diversity Statement

The Clinical Social Work Association has long supported the values of diversity and inclusion. During these troubling times it is vital we create a welcoming and supportive environment for all our members and the people we serve. We firmly believe that we can best promote excellence within our profession by offering educational tools for dialogue and professional development, assessing our membership, and promoting our strong code of ethics regarding cultural competency standards. Further, we recognize the responsibility for excellence, diversity and inclusion lies within each of us who make up the clinical social work profession. CSWA encourages all members and affiliated societies to promote increased awareness of the meaning of diversity to all.

Melissa Johnson, CSWA President, July, 2017

The Clinical Social Work Association has been working for several months to assess and discuss diversity of our membership. Several Societies have begun to develop programs to promote diversity awareness. Based on their work, below are some suggestions.

Define your terms. Everyone has a different idea about what diversity means. Beyond race and gender, it can also include but is not limited to considerations of age, ethnicity, sexual orientation, mental and physical capabilities, gender identity, family status, language, opinions and experience. 

Assess. Review your bylaws and clauses that define diversity standards; check for any institutional bias or exclusionary language. Start a conversation about diversity and inclusion with Board members and within your Society. Be prepared to have difficult conversations.  Collect rich data; the goal of a survey is not just a head count, but rather the beginning of an education process.

Listen and affirm. Ask about the experiences of your members. Do not make assumptions about how people view this complicated issue. Encourage all Board members to evaluate their own perspective. Don’t scold or shame those who are struggling with understanding.    

Learn, share, educate.  Offer trainings; invite speakers; build coalitions with other associations; plan a conference on diversity and inclusion.  Identify all of the ways you can define diversity and how inclusion is experienced within your society and the profession. Embed these principles in your leadership and others will follow. 

Contact Melissa Johnson, CSWA Board President or any of the board members if you want to discuss these concepts with other Societies or find experts to conduct trainings.  It helps to not have to reinvent the wheel.  CSWA wants all its members and Societies to be self-aware about what healthy understanding and acceptance of diversity means to them and others.

Four major national social work organizations - NASW, CSWA, CSWE, and ASWB - have been developing draft Social Work Technology Standards for the past two and a half years.  These standards will cover every area in clinical social work practice that may be affected by the use of technology including clinical practice, record-keeping, education, and macro social work.  Many thanks to Laura Groshong, CSWA Director of Policy and Practice, who served as CSWA's representative on the Task Force that put in hundreds of hours on this project.

These standards have been posted for public comment until July 20, 2016.  They are available at the following link with instructions on how to submit comments:   http://www.socialworkers.org/practice/naswstandards/TechnologyStandardsInSocialWorkPractice/CommentSubmission.aspx Another way to obtain the draft standards is to go to www.socialworkers.org. To the right, look for the “What’s New” box.  Scroll down and click on “Draft Technology Standards in Social Work Practice.” 

Comments must be submitted by July 20, 2016 to be considered.  After consideration of the changes by the Task Force, the draft technology standards will be submitted for review and approval to the NASW Board of Directors in September, 2016 and the other organization Boards (CSWA will meet in October).

The goal is to have these standards published by the end of 2016.

CSWA is proud to have been a participant in this important project and encourages all members to review the draft standards and send comments.

Clinical Social Work Association
The National Voice of Clinical Social Work
Strengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY

Dear CSWA Members, 

It is hard to accept the massacre of LGBTQ people in Orlando and the hate it represents.   

There have been some good summaries of how to think about it, including one by Glenda Russell (attached).  A PDF version is available online at http://drglendarussell.com/wp-content/uploads/2016/06/Responding-to-Orlando.pdf. Please feel free to share with others.

"Give an Hour" is making the thousands of therapists who give an hour of treatment to veterans available to the Orlando LGBT community - to join go to http://www.giveanhour.org/ForProviders.aspx .  To read their press release, go to http://bit.ly/1YnkaTl  .  

We can never stop insisting on the right of everyone to live their lives regardless of color, sexual orientation, gender or any identity that has been demonized. Please re-read the CSWA Statement on Discrimination (attached).  The hate being legalized against trans people in the states mentioned is a contributing factor to the terrible loss in Orlando.  Speak out against all forms of hate."

Susanna Ward, PhD, LCSW
President & CEO, Clinical Social Work Association
(606) 923-0944
cswapres@gmail.com

Melissa Johnson, LCSW
President-Elect, Clinical Social Work Association
mjohnson@clinicalsocialworkassociation.org

Laura Groshong, LICSW
Director, Policy and Practice
lwgroshong@clinicalsocialworkassociation.org

 attachment:  Russell - RespondingtoOrlando - 6-16.pdf

CSWA - "The National Voice for Clinical Social Work"
Strengthening IDENTITY, Preserving INTEGRITY, Advocating PARITY