[Editors Note: Since this post was written, the Quill decision has been overturned in South Dakota v. Wayfair, however, that ruling was overturned over issues relating to sales tax fairness and not over the core jurisdictional issues inherent in the Interstate Commerce Clause. In short, the Wayfair case doesn’t change the fundamental legal reasoning in this post.]

First, let’s start with a disclaimer. While we are experts in the laws surrounding online therapy and we’ve been working with online therapists since 2010, the following article is not intended to be legal advice. If you have any legal questions, we advise you to seek qualified legal representation from a professional attorney with experience in these issues.

That being said, the internet is not the expert when it comes to telehealth across state lines. There is so much misinformation about online counseling, state lines, licensing boards, state and federal laws that it can be dizzying! The purpose of this article is not to be the definitive, final word on interstate commerce and telehealth, but merely to serve as an introduction to the arguments as well as a springboard for an informed discussion. This post will be controversial and it will definitely challenge strongly-held beliefs, however believing something to be true and it actually being true are two different things. We’re going to be mentioning relevant laws, court cases as well as logical arguments. You are encouraged to follow the links and dive deeper yourself and use your own judgment as a guide for your therapy practice. This article is focused on psychologists and other non-MD mental health practitioners, however, this analysis should still hold for medical doctors as well, because the arguments are identical.

Can I practice across state lines?

This is the million dollar question, isn’t it? Before we answer that, let’s look into the US Constitution and what it has to say.

Article I, Section 8, Clause 3

[The Congress shall have Power] To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes.

In Gonzales v. Raich, 545 U.S. 1 (2005), the Supreme Court opinion stated:

…the primary use of the Clause was to preclude the kind of discriminatory state legislation that had once been permissible.

Which means that the Commerce Clause was designed to prohibit a state passing laws that discriminated against other states in terms of interstate commerce.

The Sherman Antitrust Act, which was enacted to prevent monopolies, says this:

Every contract, combination in the form of trust or otherwise, or conspiracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal.

Telehealth and the Commerce Clause

What does that mean to you? The Sherman Antitrust Act clearly establishes that to restrict trade or commerce between the states is illegal. Which, in plain language means that California can’t restrict the therapy practice of someone in Montana. The licensing boards can’t enact barriers that restrict trade between the states. No matter how much they might wish it to be so, in fact, any “ban” on cross-state practice is a violation of Sherman and it should go without saying, the Commerce Clause as well.

Aren’t “learned professions” exempt from the Sherman Antitrust Act?

There have been cases that suggest that the “learned professions” such as law or medicine were exempt from the Sherman Act, however, in Goldfarb v. Virginia State Bar, 421 U.S. 773, 792 (1975), the Supreme Court specifically reversed the lower court decision that stated that the “learned professions” were exempt from Sherman. In fact, the Supreme Court specifically stated that Congress did not intend any sweeping “learned profession” exclusion from the Sherman Act. What does that mean for therapists? A state licensing board can’t regulate trade between the states. They can only regulate trade within their borders. In fact, Article X of the Constitution allows states to regulate the professions within their borders, however, they can not regulate trade across their borders.

Is health care interstate commerce?

Health care across state lines is considered interstate commerce. Arizona v. Maricopa County Medical Soc’y., 457 U.S. 332 (1982) established that health care is covered by federal antitrust law and by extension, covered under the Commerce Clause. The Maricopa County case was concerned with price fixing, however, the implication of that case provides the precedent that a medical board is subject to the same antitrust laws as any other industry, which means, they can’t restrict interstate commerce.

Maine v. Taylor, however, does cast a bit of uncertainty because the Supreme Court decided that discriminatory laws may be upheld only if they serve “legitimate local purposes that could not adequately be served by available nondiscriminatory alternatives.” What that means is that interstate trade can be restricted if those goods are particularly likely to harm the health and safety of the state’s citizens. The Taylor case was specific to a type of fish that carried a parasite that could have potentially harmed local waters. However, it would be highly improbable to establish that a Montana therapist’s qualifications were such that they could “significantly harm” a person living in Oregon. The state licensing requirements in the United States are all rigorous. It would be a very difficult legal argument to prove the potential for “significant” harm.

What about federal law?

There are no federal laws prohibiting cross-state online therapy. There are no federal laws prohibiting telehealth across state lines. California does not have jurisdiction in Texas. The state licensing board of North Carolina can’t prohibit someone living in North Carolina from seeing a practitioner in Georgia. A Georgia practitioner can’t be prosecuted or punished for seeing a patient from North Carolina unless the practitioner is physically present within the borders of North Carolina. However, let’s explore this concept more deeply.

Physical presence and interstate online therapy

There was a case in Pennsylvania (Abraham v. Bureau of Professional and Occupational Affairs, Board of Psychology) where an Israel-based therapist was prosecuted by the Pennsylvania courts because he was offering services in Pennsylvania without being licensed there. However, this case is interesting because the legal argument against him wasn’t the issue of transnational therapy. It was the fact that the doctor in question had a physical presence in Pennsylvania. In fact, he listed a Pennsylvania address and phone number. The court ruled that this physical presence made him subject to Pennsylvania licensing laws; he was considered a resident of Pennsylvania by the courts. Here’s an article about that case. The entire basis of that case was the Pennsylvania residency, not that he was foreign licensed. Had he not had a physical presence within the state, he would not have been in violation of the law.

Quill Corp. v. North Dakota, 504 U.S. 298 (1992) is one of the most important cases that are especially relevant to the online therapist. In this case, the Supreme Court ruled that a business must have a physical nexus in a state in order to be subject to sales taxes by that state. This case established that a business that has no physical presence in the state is not subject to the jurisdiction of that state. What does this mean to the therapist? A therapist is not subject to the state laws of a state in which they have no physical presence. Another earlier case, National Bellas Hess v. Department of Revenue, 386 U.S. 753, 87 S.Ct. 1389 (1967) established that a mail order company not located within a state is not “physically present” in that state, despite doing business with people in that state. In our internet connected era, a “mail order” company is analogous to an “internet” company. The key point is that a therapist who isn’t in a state isn’t subject to regulation by that state no matter how badly that state may wish it to be so.

The bottom line

You should make your own decisions about cross-state practice, however, make those decisions based on the law and the relevant court decisions. In terms of ethics, at iCouch, we recommend that your informed consent make it clear to your client that you are licensed in “State X” and practice under the laws of “State X.” If you make it clear to the client and never misrepresent your qualifications or jurisdiction, then everybody wins. Your client can get the online counseling they need and they’re fully informed as to the “product” they are receiving. That’s really what it comes down to: letting the client decide what’s best for them. State lines should never be a barrier to finding the perfect therapist. Practice your profession transparently, with full the full consent and knowledge of your patients.

A note on medication

If you’re a psychiatrist prescribing medication, we recommend an abundance of caution. Our official position on medication is that it should require an in-person visit before medication is ever prescribed — regardless of what the law may or may not allow. We strongly feel that it’s inappropriate to prescribe medication without an in person consultation. However, follow-on appointments could certainly be appropriate for online consultations. Our opinion in this regard is ethical more than legal and we certainly are not promoting or encouraging an online consultation when it’s not in the best interest of the patient. Follow the law of course, but remember, the higher “law” of the health professions is to always think of what’s best for the patient first and foremost. First, do no harm!

What about Skype therapy?

It’s interesting when some US-based therapists refuse cross-state clients, yet use Skype or Google Hangouts to conduct therapy sessions. The irony is that cross-state practice is not illegal, while using Skype for mental health consultations is illegal. Read our article about Skype and HIPAA compliance to learn more about why therapists should never use Skype. If you are interested in learning how to legally add online counseling to your therapy practice, read our our post about it here.

Published by Brian Dear

Brian is the cofounder and CEO of iCouch, Inc. He has an extensive background in software engineering, inbound marketing and mental health practice management.

Join the Conversation

24 Comments

  1. Oh my. While I appreciate the intent of this article, I suggest that all licensed professionals reading this content stop and ask themselves a few questions:
    1. Why has the US federal government (through the Office for the Advancement of Telehealth) given millions of dollars every three years to national professional associations AMA (through the Interstate Medical Licensure Compact (IMLC) http://www.imlcc.org/) and the APA (through the the Psychology Interjurisdictional Compact (PsyPACT https://asppb.site-ym.com/mpage/legislative) as well as others to conduct research and develop successful models of interjurisdictional practice?
    2. Why did counselors just celebrate the release of the “the The National Counselor Licensure Endorsement Process ” If practicing over state lines were even “arguable”?

    As I have been writing and training about this particular issue for the last 22 years, I highly recommend that anyone with questions about their licensure ONLY direct those questions to their board, and to do so in writing. Email is often the best approach, as most licensing boards will respond to email in a matter of days. If I will also add that I would be very careful to abide by the response of the licensing board in all matters related to licensing, as the board has the power to interfere with a professional’s ability to practice one’s profession not only in their own state, but also in others.

    1. The National Counselor Licensure Endorsement Process ought to be irrelevant for Telehealth. If you’re in Texas, you’re in Texas. And subject to Texas law. Your client, if they happen to be in another state, they are the ones subject to the laws in another state — not the practitioner. Look up any of the Supreme Court cases mentioned in this article. There is a body of precedent that supports that assertion. Show me a federal law that allows a state to regulate practitioners in another state. You can’t because it doesn’t exist. I’m sure you’ve been training people for a long time — so you should know: there isn’t a federal law prohibiting cross-state practice and there IS a federal law prohibiting states from blocking interstate commerce.

      It’s a fact that one state can’t legislate the activities of someone in another state, yet that’s exactly what states attempt to do. The licensing boards are even worse. They claim to want to protect patients, but how is it protecting a patient when they can’t get care? I get calls and emails all the time from primary care doctors in rural Utah, Wyoming, Idaho who can’t find a suitable therapist for one of their patients anywhere within 150 miles. Yet with cross-state telehealth, We could have 50 qualified practitioners available to them instantly. But instead, because of this institutionalized stupidity, those practitioners are ostensibly not allowed to help because they aren’t licensed in Utah, etc.

      Great. Let’s deny care to people because someone in Sacramento feels that cross-state practice is somehow “harmful.” It’s a cartel designed to protect not patients, but the monopoly power of a particular state’s practitioners. If I’m in San Francisco and can’t afford $200 per hour, California has made it illegal for me to see a Reno practitioner at $85 per hour — because apparently I need “protection” against those unsafe heathen licensed in Nevada. Or, perhaps, because California wants to protect California therapists from the dangers of competition. Ironic because an undocumented worker can pick fruit or work in a restaurant (and even practice law) in California without fear from the state, while a qualified, fully documented therapist in Reno is considered unsafe because they are licensed in Nevada and not California.

      It’s morally wrong. It’s illogical. It’s bad for patients. It’s bad for the mental health of Americans.

      A practitioner should be allowed to see any patient they want as long as they are practicing within the scope of their qualifications and the patient is provided with an informed consent making it clear the laws under which their treatment will be governed.

      We are DENYING CARE to people because of ridiculous, byzantine licensing boards that are acting like it’s the 1950s. Yes, we need licensing requirements. However, the internet has changed the world and it gives us power like never before to provide care to those who aren’t getting it. Rather than supporting the status quo, we should be kicking the barriers down. The ACA literally spent more ink complaining about the Tennessee “therapist bill” than they ever have complained about licensing boards attempting to restrict cross-state telehealth. Yet more people are harmed from being denied care because of geography than were harmed by the Tennessee law.

      The people that support this nonsensical concept that you’re practicing at the patient’s location aren’t doing a thing to actually bring care to underserved areas. How many of the practitioners making these rules have spent time in rural Montana? How many have spent time in Appalachia? They talk about “caring” for patients, but then they do nothing to actually care for patients that need it the most. They need to be plucked from their ivory towers and deposited in a farming community in rural Alabama or at a remote Native American village in Alaska. They won’t do that. But WE CAN. With telehealth. We have the technology. It works. There are thousands of qualified practitioners that would love to be able to make a difference — if the licensing cartels would get out of the way and actually let them.

      Show me some case law that states you’re “in” the location of your patient. There isn’t any. You can’t be in two places at once. If you’re physically in Texas, those are the laws that apply and that’s the licensing board under which you are subject.

      The so-called “experts” are promoting an outdated system that ignores the fact that the internet makes distances less relevant. It’s ok for a Texas therapist in Houston to see an El Paso patient. But an El Paso therapist can’t see a New Mexico patient? That’s just ridiculous. The argument of being close in order to intervene in an emergency doesn’t hold water when it’s “ok” for a Houston therapist to see a patient 750 miles away but it’s not ok for a El Paso therapist to see a patient 5 miles away, across the boarder in New Mexico.

      We should be fighting this cross-state restrictive orthodoxy instead of bolstering it.

      I respect that you’ve been in this field much longer than I have, but it doesn’t take much experience to see that licensing boards restricting cross-state Telehealth are absolutely wrong — both from a Constitutional law perspective as well as a moral one.

      We’re fighting the wrong battle. We should be abolishing geographic restrictions on telehealth. As long as you are licensed within your jurisdiction and practicing within the scope of your qualifications, practitioners should not be prohibited from seeing out of state patients solely because of their geography. Once the mental health practitioner shortages have been solved, then perhaps I might care about licensing boards and their provincial, Luddite attitudes. People are literally suffering all over the country right now and that problem isn’t going to get solved unless we start to think different.

      1. Per the Alabama Board of Examiners in Counseling 6/12/18, the laws that determine and cover the therapy are “where the client lives”.

        1. However, does Alabama have jurisdiction over a practitioner not in Alabama? Of course not. That’s the point — Boards of Examiners attempt to exert jurisdiction across state lines — when they just don’t have that authority. As far as where the patient lives — does that mean that a person visiting Birmingham, but lives in Texas can’t legally see a practitioner? That’s ridiculous — if a person where hit by a car in Mobile, but they lived in Mississippi, that would imply that doctors could treat that person.

          The Alabama Board of Examiners is wrong. I don’t doubt what they say, but they are acting unconstitutionally.

          What happens if someone lies and says they live in Alabama and they don’t? The rules simply say “resident” of a state. But how do you prove that? Is ID required? Perhaps a phone bill? What about the indigent who can’t prove residency? What’s the proper way to handle that?

          State licensing boards should be sued out of existence and a unified federal licensing system should be implemented. They are directly responsible for shortages of care across the country. Alabama, of all places ought to reevaluate the value of their Board of Examiners’s position. Alabama has a huge shortage of practitioners. http://www.alabamapublichealth.gov/ruralhealth/Mental%20HPSA%20Map%20-%20October%202017.pdf

  2. As an attorney and LMHC I am aware that many professionals are banning together to form interstate compacts. Professional counselors need to do this and promote national certification for telehealth. We seem to be falling behind in this regard. I would like to know who is doing legislative work in this area.

    1. I would love to know who is doing legislative work in this area too! The national mental health professional associations don’t seem to care — they seem determined to extend the status quo. At iCouch, we are in contact with relevant members of Congress on a regular basis trying to get some action on both enforcing existing interstate-commerce law as well as explicit legislation invalidating the cross-state restrictions promoted by some state licensing boards. But it’s a long road and there aren’t too many people in the mental health community that seem to care.

      National certification is an excellent idea. The paramedic field has a similar concept with the National Registry of Emergency Medical Technicians.

  3. There is so much BS going on with this. State licensing boards are making money, impeding care to clients, all to make a buck or two, and give the illusion of protecting the public. There is NO reason that the whole counseling profession can’t have simple reciprocity across state lines. Applying to various state boards takes time, financial resources, and interpretation of some rather sketchy laws (in some states). Uniformity could help. In order for me to be licensed in every state (if I want to do telemental health in my very small niche), it would cost me somewhere between $7,000 and $10,000 annually in fees alone. I am willing and able to meet up with people to form a coalition to take on this mess. I’m close enough to DC (a day’s drive) to talk to whomever. Also, Greensboro, NC is about 3 hours from me, and this could help.

    1. We completely agree. One of our big questions is why organizations such as the APA and the American Counseling Association aren’t taking more of a lead in pushing this. This is the single most effective way to make an immediate impact in serving the vast areas of underserved people in the United States. Arizona v. Maricopa County Medical Soc’y., 457 U.S. 332 (1982), as I mentioned in the article, is likely a precedent that might have a serious impact on the current cartel-like behavior of state licensing boards. The basic concept is this: If the licensing board of State A prevents their practitioners from seeing patients from State B, despite being otherwise legal to practice, it follows that the licensing board is enacting restrictions on interstate commerce — which is an indisputable violation of federal anti-trust law. If state licensing boards are actually colluding on preventing cross-state practice, that’s a crime under the Sherman Act, but also the Clayton act might apply. The Constitution as well as over a century of case law is very unambiguous on states restricting interstate commerce.

      I’m baffled why the American Counseling Association would present strong policy statements against the Tennessee “Therapist Law” — a law that would allow practitioners to potentially discriminate against clients based on “deeply held beliefs.” The issue of Tennessee is a separate issue except the reasoning the ACA used for opposition was that it would result in the denial of care to vulnerable populations. However, that line of reasoning is IDENTICAL to why we oppose the prohibitions by some licensing boards of cross-state practice. Our argument is a simple one: If the ACA really cares about access to care and preventing practitioner shortages, then why the heck aren’t they screaming from the rooftops against licensing boards that are effectively colluding to deny care to the underserved?

      As a company, it’s politically “safe” for iCouch to just sit on the sidelines and not comment, however this issue cuts to the core of why we started this company; we want to elevate the therapy profession, make it easier for practitioners to deliver care as well as for potential patients to receive it. Of course, our business isn’t just online therapy — that’s just one part of it, but for us it’s a moral issue. We have record rates of opioid addition, we have large swaths of the country that are dangerously underserved by mental health professionals and organizations such as the ACA literally have spent their time writing policy statements about the latest immigration controversy. I’m not suggesting that the Tennessee law situation or current immigration issues aren’t important — however, if an organization is to be an advocate for the profession and patients, then they really ought to get on board and start putting some muscle behind challenging the fiefdoms of state licensing boards.

      We could end these cross-state restrictions tomorrow — it just takes a court case. Ultimately someone is going to have to sue a licensing board. However, such lawsuits require legal standing, so until there’s a “harmed” party, there’s nothing to sue over. Unfortunately we can’t sue on behalf of people not able to receive care.

      To clarify my position: I fully support the licensing process. It’s vital that mental health professionals be completely qualified and vetted. With that, there is no debate. However, where I vehemently stand in opposition is when a state line becomes relevant in terms of who can get care and who can’t. A California driver’s license is perfectly legal in Arizona, why aren’t behavioral health licenses? Under the Full Faith and Credit clause of the Constitution, therapist licenses should be recognized.

      Full Faith and Credit shall be given in each State to the public Acts, Records, and judicial Proceedings of every other State.

      But of course, just as the Interstate Commerce Clause is violated, so it the Full Faith and Credit clause.

      This is a long road upon which we travel, but I’m looking forward to the day we get the Supreme Court decision slamming the prohibition of cross-state practice — or at the very least a federal law that ends such prohibitions.

    2. YES! Thank you all for this excellent discussion! Brian, this is the best summary I’ve found! And Kathleen I agree it is ridiculous and it creates unnecessary burdens and barriers to not have reciprocity between states!

  4. So if one is offering therapy across state lines and the client submits a superbill to their insurance showing that the therapist is located in a different state will there be a problem?

    1. The question is really up to the insurance company, however a simple way to know the answer — if that client had driven to your office in person and received your services, would insurance cover that? I can’t speak for insurance policies, but “out of network” doesn’t generally have anything to do with the state in which services are received. As an example, if you were to travel to Alaska and get hurt hiking and visited a doctor there — would insurance cover that visit? Mental health care is logically no different — the state in which one gets care has little to do with reimbursement, assuming out-of-network is normally covered.

      However, we certainly don’t provide legal advice, so it’s best for the client to simply ask their insurance company: “Does out-of-network reimbursement cover practitioners not in my state?” I’m betting it does, but I’m definitely not the final word on that.

  5. I am curious whether anyone has tried this restraint of trade argument in court. Are you aware of any lawsuits to this effect? Also, do you have any comments regarding the California Board of Behavioral Health’s recommendation that therapists check with other states before even engaging in a phone call with a patient traveling to another state? I’m surprised that hasn’t gotten more attention.

    1. This is strictly my opinion, however the reason I don’t think this is getting more attention is that mental health practitioners are not generally the type to rock the boat. Meaning — whatever comes down from the licensing board is the “law” and it’s generally considered infallible. Also, given the way that supervision happens, new practitioners fall into the traditions of the profession rather quickly — their supervisor taught them the “rules” and thus those “rules” are generally unquestioned, despite, as I’ve argued in this (and other) articles, the high likelihood that these sorts of “cartel” rules are restraint of trade. There hasn’t been much incentive for practitioners to take these rules to court because — in order to sue, you have to have standing and, unless a practitioner actually gets harmed (i.e. they have their license revoked,) they aren’t going to have standing. There aren’t too many practitioners out there that want to be the test case for this issue since they’d be risking their livelihood.

      Regarding that California Board of Behavioral Health recommendation — that’s just ridiculous. If we accept the premise that a California licensed therapist is qualified to see a patient in Fresno, then that same exact patient in Reno is somehow not able to be treated by the same practitioner they’ve already been seeing? Do qualifications actually end at the state line? The theory, as was presented to me by a practitioner who served on a licensing board (in another state,) was that Nevada might have different rules on things such as data disclosures, etc. However, this issue is solved with an informed consent that clearly explains to a client or potential client the rules/laws under which treatment will be conducted.

      Here’s an interesting case out of PA where the state court actually ruled against a therapist who wasn’t PA licensed who was from out of state. However, the interesting thing about that case is that the defendant’s business address was listed as Pennsylvania. So given he has a “physical nexus” within the state — THAT was the reason he lost the case. It’s clear from the legal opinion that without that physical nexus, there would have been no case.

      I’m just frustrated that organizations such as the American Counseling Association don’t scream about this. This issue is fundamental to access to care. However, the ACA is a de facto enforcer of the status quo, so they don’t have any particular incentive to take on this issue.

      My position is that cross-state mental health treatment restrictions are bad for patients and increase the effects of provider shortages. I wrote another post on this subject that goes into greater detail about this issue of cross-state restrictions and the damaging effects on American mental health. Please visit that article if you have the chance!

  6. Hello,
    I have an interesting question regarding telemedicine and Medicare reimbursement. I am licensed as a clinical psychologist in VA and see clients in nursing homes as an independent contractor. The company I work for has told me that when I temporarily travel overseas (recently a funeral), I am not allowed to see my clients because Medicare will not reimburse because “Medicare requires that you be in the U.S. (this is the requirement of the government related to privacy and international communications security).” I called Medicare and they do not know of any such rule. All they require is that the beneficiary is in the required state (in this case Virginia). I know that VA does not allow cross-licensing, but that is not the issue here. All I want is to be able to provide services t0 my clients while I am here for two weeks. Does anyone know an answer to this?

  7. I’ve been trying to get answers to a simple question and can’t find any info on this. I am an LCSW licensed in California. I am will be living in Canada for a couple of years and want to know if I can do therapy sessions with California clients from there. Anyone knows the answer to this?

  8. Good luck all. Just don’t cross the Oregon board…they will hunt you. Those that are looking for safe harbor? visit HARBR.org which is a group of practitioners against these evil, trade restricting licensure boards who operate without oversight and ruin careers in the process. Not to be trifled with, but the arguments here are very good – but guess what, the boards dont follow laws, they make them up a they go! Administrative law is baked with the politics in your state. Beware.

  9. Hi Brian, thank you for this article. I live in Ohio and work for a teletherapy company. I am a Speech Language Pathologist licensed in Ohio and California. I am never physically in California, as I work from home in Ohio. I pay Ohio state taxes. Do you know if the California out of state tax laws apply to a person in my situation? Please help if you can. I do not know where to get the answer. The company I work for will be taking the money out of my 1099 pay. The company I work for is a Georgia company.

    1. California tax laws don’t apply unless you are either a resident of California or derive income from a California company. In the case of California-sourced income, you could be liable for tax on the California part of that income. But in your case, it seems very unlikely that you would have any California tax liability. I’m not a tax lawyer, but I certainly would not file a California tax return if I were in your case. But, I am NOT a tax professional and this does not constitute legal or tax advice!

  10. Bravo, and thanks for your investments to uncover the facts here. You’ve done a good amount to validate what’s obvious to anyone who’s run a business. Licensing, and the attempt to regulate licensure is clearly an attempt to monopolize a revenue stream. I’m a founder who happens to be a therapist -so I’ve seen this snowballing around telehealth for years. I knew there’d by a power grab by the states. What’s always been interesting to me is that therapists, the one’s impacted the most by these fluff laws, often fight the hardest to support them. Perhaps this is just a symptom of fear, as they stand to lose the most. But it plain just doesn’t make sense. People work years to get a degree and earn the right to serve and earn what barely amounts to a lower-middle class salary, and an external board exercises authority about how and where money can be made? What’s worse, as you stated, the choices of the people who need the services the most are taken away. So everybody but the state wins, and for what?… What’s the point of restricting the rights and freedoms of people who care enough to live a life of service and the needs of people suffering the most? The claim that restrictions are imposed to protect the innocent is plainly ludicrous, as you aptly demonstrated. It’s not only silly, it’s the earmark of entitlement and disrespectful. It’s also a proxy to unnecessary complication. For instance, the barriers of yearly fees associated with state licensing boards- and the price breaks offered for practitioners who are members of “official” but privately run industry associations? And the price breaks on yearly continuing education courses?.. And liability insurance – the lists go on and on. This is just business for business sake. Why not be more direct and offer Groupons? In truth most independent psychotherapists and therapist in general aren’t wealthy, but still they are paying more in yearly fees than MD’s and dentists in many states? They are be milked. We need to abandon sentimentality and fear here and just call this stuff out. Nobody seems to be to blame here, as it’s just another case of blind ambition gotten out of control. Telehealth is a land grab and that’s human and understandable. But it has clearly gotten out of control. Having to practice in fear of losing the right to do what you’ve spent years of your life training for (and paying for) – seems like the criminal act – at least to me it does. Thanks again for your work in the field, keep it coming. You are appreciated here. 😊

  11. What about a therapists from outside of the US (for example from the UK), can they offer online therapy to people in the US?

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