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There are legal and ethical issues as well. Many therapists who are using electronic therapy have unwittingly violated confidentiality guidelines and state licensure requirements. Because electronic therapy can cross state lines, Maheu says therapists should know not only their own state licensing requirements, but the licensing rules of the client’s state as well. Some states expressly prohibit their therapists from practicing out of state, so doing therapy with someone who lives in another state can earn a hefty fine in certain situations. For instance, a California therapist who does therapy with someone in Utah can get fined by both states. When doing therapy with a client in another state, says Maheu, therapists should always contact the licensing board in the other state and ask for permission prior to treatment. Failure to do so can technically lead to criminal conviction and subsequent nullification of malpractice insurance, although the licensing boards are only recently mobilizing to take action on such licensing violations.

Many forms of electronic therapy aren’t HIPAA-compliant, including Gmail, which isn’t sufficiently encrypted and passes through junctions where other people could conceivably read or archive the e-mails. Skype, often therapists’ platform of choice, may be free, but it’s not nearly as secure as other services and may not be HIPAA-compliant, warns Maheu. Services such as will set up more secure connections for a nominal charge, but the field is in such flux that Maheu recommends that therapists make sure that any service they use clearly states that it’s HIPAA-compliant, not simply that it’s “secure.”

Therapists can learn more about how to develop online therapy skills and understand the legalities involved at Nagel’s Online Therapy Institute and Maheu’s TeleMental Health, which feature a range of information and resources.


Climate: American Psychologist 66, no. 4 (May/June 2011); Ro Randall, “Hope, Despair, and 4° Celsius,” May 30, 2011, Termination: Professional Psychology: Research and Practice 42, no. 2 (April 2011): 160-68; William Doherty, Psychotherapy Networker Webcast, “The Ethics of Termination,”

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