State-by-state licensure is anachronistic in the age of teletherapy, providers say

Thanks to the pandemic’s teletherapy expansion, a patient living in Kansas can virtually connect with their therapist in Kansas without friction. However, let’s say that patient gets a new job in Missouri or Texas or Wyoming. Even if they’ve met with their therapist virtually for years now and are in the middle of processing a specific traumatic event, unless their therapist happens to have a license in the state they’re moving to, that relationship will end.

Nearly three-quarters of therapists (70%) reported having this experience, according to a survey by therapist support platform Alma.

After performing a survey of 200 therapists regarding nationwide licensure, Harry Ritter, Alma's CEO, told Fierce Healthcare that he was most surprised by the number of therapists who had lost a client to an out-of-state move.  

“My main concern has been having to end relationships with long-established clients who moved to other states for various reasons,” a provider reported anonymously in the survey performed by Alma. “This has been a very tough transition for those who have developed a trusting relationship with me and where we both feel like there is more work to be done. That has happened multiple times, especially during this pandemic where people were forced to move back to living with family.”

Providers in the U.S. benefited from generous licensure policies during the COVID-19 pandemic that enabled cross-state care but many states are now beginning to roll those policies back. 

The vast majority—a whopping 89% of therapists—responded to Alma’s survey stating that they wanted their license to allow for nationwide care. Alma also found that after the pandemic, 70% of therapists planned to maintain an entirely virtual practice, up from 41% a year ago.

Ritter emphasized that without cross-state licensure, patients from marginalized communities or with unique mental health conditions struggle to find a therapist who can understand their experience.

“The more unique the need is, whether it's because of the clinical identity of that person's condition, or their gender or sexual identity, their racial or religious identity, their immigrant status, for those people, being able to open the aperture and look for providers that may be either located regionally or nationally has the biggest impact,” Ritter told Fierce Healthcare.

Currently, therapists are able to hold multiple licenses but must apply to each separately. According to Alma’s survey, this is a process that can take anywhere from one month to a year. Some therapists reported associated costs as high as $1,000 with the majority reporting $250-$500.

Therapists stated that they were deterred from entering the process most significantly due to the time the process demands, financial cost and the lack of easily accessible information about the application process.

Ritter attributes the maintenance of state-by-state licensure despite the widespread use of teletherapy to the revenue gained from state governments for license applications along with state responsibility to ensure the legitimacy of providers. Legitimacy and some of that revenue could be maintained, he said, if the states established reciprocity with other states through standardized applications.

This is the model followed by the Psychology Interjurisdictional Compact (PSYPACT). 

Of the 26 states who are participating in the compact, 18 have passed PSYPACT legislation formally adopted by the compact’s governing body. Psychologists practicing in these states may then apply to the PSYPACT Commission to gain the ability to practice interjurisdictional teletherapy.

“As a bicultural, bilingual trauma therapist, I would be able to work with folks who may not have the same access to my specialties in their states,” an anonymous therapist responded to Alma’s survey. “And as a brown immigrant woman, I know the importance of having someone who understands you and your background.”

Nearly half of respondents to the Alma survey, 48%, said they were pursuing cross-state licensure to maintain a connection with a current client who had moved.

Therapists also reported pursuing licensure in another state to grow their client base (58%), because teletherapy is more widely accepted (54%) and it allowed flexibility to split time between states (41%).

While not all therapists say they will continue exclusively in digital spaces, 98% say they have had positive experiences with the technology and 30% actually reported that teletherapy has made their relationships with patients stronger.  

Ritter said that when he first started working with Alma, he was hesitant about virtual psychotherapy, concerned that some ineffable quality of care would be lost in the digital ether. Now, he has changed his tune.

“You see lower no-show rates. It makes it a lot easier for folks who have demanding jobs, especially folks who are in hourly jobs or have long commutes," Ritter said. "So, the ability to access virtually just makes it so much easier, reduces the friction so much. It allows you to open the aperture on available providers. People actually respond differently by being in their own home.”

He doesn’t think in-person therapy will ever disappear entirely. For patients living with roommates or an abusive partner, visiting an office may be necessary for them to be able to speak openly. For children or teens especially, in-person options may be better to account for limited attention spans.

But, for a country of people that tend to move, he thinks therapy options should be thought of as “an ‘and’ option, not an ‘or.’ There should be in-person and virtual and there's no reason that we should limit the virtual because of where the provider happens to be.”