Alabama Administrative Code Chapter 536-X-8 — Standards of Conduct of Marriage and Family Therapists

536 Alabama Board of Examiners in Marriage and Family Therapy

Ala. Admin. Code r. 536-X-8-.01 Responsibility To Clients

Marriage and family therapists advance the welfare of families and individuals. They respect the rights of those persons seeking their assistance, and make reasonable efforts to ensure that their services are used appropriately.

(1) Marriage and family therapists provide professional assistance to persons without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, or relationship status.

(2) Marriage and family therapists obtain appropriate informed consent for therapy or related procedures and use language that is reasonably understandable to clients. When persons, due to age or mental status, are legally incapable of giving informed consent, marriage and family therapists obtain informed permission from a legally authorized person, if such substitute consent is legally permissible. The content of informed consent may vary depending upon the client and treatment plan; however, informed consent generally necessitates that the client: (a) has the capacity to consent; (b) has been adequately informed of significant information concerning treatment processes and procedures; (c) has been adequately informed of potential risks and benefits of treatments for which generally recognized standards do not yet exist; (d) has freely and without undue influence expressed consent; and € has provided consent that is appropriately documented.

(3) Marriage and family therapists are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of such persons. Therapists recognize within communities there is potential for multiple relationships to exist with a client. Marriage and family therapists accept that multiple relationships add to the complexity of the professional relationship and work to ensure clarity of professional judgment and avoid exploitation of the client.

(4) Sexual intimacy with current clients is prohibited.

(5) Sexual intimacy with current clients or with known members of the client’s family system is prohibited.

(6) Sexual intimacy with former clients is prohibited for five years following the termination of therapy or the last professional contact. Sexual intimacy with known members of a former client’s family system is prohibited for five years following the termination of therapy or the last professional contact.

(7) Marriage and family therapists shall not provide clinical services to an individual with whom the marriage and family therapist has had a prior sexual relationship.

(8) Marriage and family therapists shall not sexually harass clients. Sexual harassment includes sexual solicitation, requests for sexual favors, unwanted sexual advances or physical harassment of a sexual nature.

(9) Marriage and family therapists comply with applicable laws regarding the reporting of alleged unethical conduct.

(10) Marriage and family therapists do not use their professional relationships with clients to further their own interests.

(11) Marriage and family therapists respect the rights of clients to make decisions and help them to understand the consequences of these decisions. Therapists clearly advise the clients that they have the responsibility to make decisions regarding relationships such as cohabitation, marriage, divorce, separation, reconciliation, custody, and visitation.

(12) Marriage and family therapists continue therapeutic relationships only so long as it is reasonably clear that clients are benefiting from the relationship.

(13) Marriage and family therapists assist persons in obtaining other therapeutic services if the therapist is unable or unwilling, for appropriate reasons, to provide professional help.

(14) Marriage and family therapists do not abandon or neglect clients in treatment without making reasonable arrangements for the continuation of such treatment.

(15) Marriage and family therapists obtain written informed consent from clients before videotaping, audio recording, or permitting third-party observation.

(16) Marriage and family therapists, upon agreeing to provide services to a person or entity at the request of a third party, clarify, to the extent feasible and at the outset of the service, the nature of the relationship with each party and the limits of confidentiality.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed November 15, 2000; effective December 20, 2000. Amended: Filed March 21, 2005; effective April 25, 2005. Amended: Filed July 10, 2006; effective August 14, 2006. Repealed and New Rule: Filed December 22, 2009; effective January 26, 2010. Amended: Filed February 8, 2012; effective March 14, 2012. Amended: Filed June 19, 2019; effective August 3, 2019.
• Editor's note: Chapter 536-X-7 was renumbered to Chapter 536-X-8 as per certification filed July 10, 2006; effective August 14, 2006.

Ala. Admin. Code r. 536-X-8-.02 Confidentiality

Marriage and family therapists have unique confidentiality concerns because the client in a therapeutic relationship may be more than one person. Therapists respect and guard the confidences of each individual client.

(1) Marriage and family therapists disclose to clients and other interested parties, as early as feasible in their professional contacts, the nature of confidentiality and possible limitations of the clients’ right to confidentiality. Therapists review with clients the circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. Circumstances may necessitate repeated disclosures.

(2) Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law. When providing couple, family or group treatment, the therapist does not disclose information outside the treatment context without a written authorization from each individual competent to execute a waiver. In the context of couple, family or group treatment, the therapist may not reveal any individual’s confidences to others in the client unit without the prior written permission of that individual.

(3) Marriage and family therapists use client and/or clinical materials in teaching, writing, consulting, research, and public presentations only if a written waiver has been obtained in accordance with Subprinciple 2.2, or when appropriate steps have been taken to protect client identity and confidentiality.

(4) Marriage and family therapists store, safeguard, and dispose of client records in ways that maintain confidentiality and in accord with applicable laws and professional standards.

(5) Subsequent to the therapist moving from the area, closing the practice, or upon the death of the therapist, a marriage and family therapist arranges for the storage, transfer, or disposal of client records in ways that maintain confidentiality and safeguard the welfare of clients.

(6) Marriage and family therapists, when consulting with colleagues or referral sources, do not share confidential information that could reasonably lead to the identification of a client, research participant, or other person with whom they have a confidential relationship unless they have obtained the prior written consent of the client, research participant, or other person with whom they have a confidential relationship. Information may be shared only to the extent necessary to achieve the purposes of the consultation.

(7) Marriage and family therapists provide clients with reasonable access to records concerning the clients. When providing couple, family, or group treatment, the therapist does not provide access to records without a written authorization from each individual competent to execute a waiver. Marriage and family therapists limit client’s access to their records only in exceptional circumstances when they are concerned that such access could cause serious harm to the client. The client’s request and the rationale for withholding some or all of the record should be documented in the client’s file. Marriage and family therapists take steps to protect the confidentiality of other individuals identified in client records

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed December 22, 2009; effective January 26, 2010. Amended: Filed February 8, 2012; effective March 14, 2012. Amended: Filed June 19, 2019; effective August 3, 2019.

Ala. Admin. Code r. 536-X-8-.03 Professional Competence And Integrity

Marriage and family therapists maintain high standards of professional competence and integrity.

(1) Marriage and family therapists pursue knowledge of new developments and maintain competence in marriage and family therapy through education, training, or supervised experience.

(2) Marriage and family therapists maintain adequate knowledge of and adhere to applicable laws, ethics, and professional standards.

(3) Marriage and family therapists seek appropriate professional assistance for their personal problems or conflicts that may impair work performance or clinical judgment.

(4) Marriage and family therapists do not provide services that create a conflict of interest that may impair work performance or clinical judgment.

(5) Marriage and family therapists, as presenters, teachers, supervisors, consultants and researchers, are dedicated to high standards of scholarship, present accurate information, and disclose potential conflicts of interest.

(6) Marriage and family therapists maintain accurate and adequate clinical and financial records.

(7) While developing new skills in specialty areas, marriage and family therapists take steps to ensure the competence of their work and to protect clients from possible harm. Marriage and family therapists practice in specialty areas new to them only after appropriate education, training, or supervised experience.

(8) Marriage and family therapists do not engage in sexual or other forms of harassment of clients, students, trainees, supervisees, employees, colleagues, or research subjects.

(9) Marriage and family therapists do not engage in the exploitation of clients, students, trainees, supervisees, employees, colleagues, or research subjects.

(10) Marriage and family therapists attend to cultural norms when considering whether to accept gifts from or give gifts to clients. Marriage and family therapists consider the potential effects that receiving or giving gifts may have on clients and on the integrity and efficacy of the therapeutic relationship.

(a) Follow state employee guidelines in receiving gifts of substantial value AND

(b) Do not receive gifts that impair the integrity or efficacy of the therapeutic relationship.

(11) Marriage and family therapists do not diagnose, treat, or advise on problems outside the recognized boundaries of their competencies.

(12) Marriage and family therapists, because of their ability to influence and alter the lives of others, exercise special care when making public their professional recommendations and opinions through testimony or other public statements, especially with regards to diagnosis and treatment of mental, behavioral, and emotional disorders.

(13) Marriage and family therapists conduct analysis of the risks to their practice setting, telecommunication technologies, and administrative staff, to ensure that client data and information is accessible only to appropriate and authorized individuals.

(14) Marriage and family therapists encrypt confidential client information for storage or transmission; and utilize such other secure methods as safe hardware and software and robust passwords to protect electronically stored or transmitted data and information. It is the responsibility of the therapist to ensure that session logs stored by 3rd party locations are secure.

(15) Marriage and family therapists when documenting the security measure utilized, should clearly address what types of telecommunication technologies are used (e.g., email, telephone, text, and videoconferencing), how they are used, whether teletherapy services used are the primary method of contact or augments in-person contact.

(16) Marriage and family therapists plan for the professional retention of records and availability to clients in the event of the therapist’s incapacitation or death.

(17) Marriage and family therapists make efforts to prevent the distortion or misuse of their clinical and research findings.

(18) Marriage and family therapists, because of their ability to influence and alter the lives of others, exercise special care when making public their professional recommendations and opinions through testimony or other public statements.

(19) To avoid a conflict of interests, marriage and family therapists who treat minors or adults involved in custody or visitation actions may not also perform forensic evaluations for custody, residence, or visitation of the minor. The marriage and family therapist who treats the minor may provide the court or mental health professional performing the evaluation with information about the minor from the marriage and family therapist’s perspective as a treating marriage and family therapist, so long as the marriage and family therapist does not violate confidentiality.

(20) Marriage and family therapists are in violation of this Code and subject to termination of membership or other appropriate action if they:

(a) are convicted of any felony;

(b) are convicted of a misdemeanor related to their qualifications or functions;

(c) engage in conduct which could lead to conviction of a felony, or a misdemeanor related to their qualifications or functions;

(d) are expelled from or disciplined by other professional organizations;

(e) have their licenses or certificates suspended or revoked or are otherwise disciplined by regulatory bodies;

(f) continue to practice marriage and family therapy while no longer competent to do so because they are impaired by physical or mental causes or the abuse of alcohol or other substances; or

(g) fail to cooperate with the Board at any point from the inception of an ethical complaint through the completion of all proceedings regarding that complaint.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed December 22, 2009; effective January 26, 2010. Amended: Filed February 8, 2012; effective March 14, 2012. Amended: Filed June 19, 2019; effective August 3, 2019.

Ala. Admin. Code r. 536-X-8-.04 Responsibility To Students And Supervisees

Marriage and family therapists do not exploit the trust and dependency of students and supervisees.

(1) Marriage and family therapists are aware of their influential positions with respect to students and supervisees, and they avoid exploiting the trust and dependency of such persons. Therapists, recognize that potential for multiple relationships with students exist. Marriage and family therapists accept that multiple relationships add to the complexity of the professional relationship and work to ensure clarity of professional judgment and avoid exploitation of the student.

(2) Marriage and family therapists do not provide therapy to current students or supervisees.

(3) Marriage and family therapists do not engage in sexual intimacy with undergraduate or graduate students or supervisees during the evaluative or training relationship between the therapist and student or supervisee. Should a supervisor engage in sexual activity with a former student or supervisee, the burden of proof shifts to the supervisor to demonstrate that there has been no exploitation or injury to the student or supervisee.

(4) The marriage and family therapist shall not sexually harass students or supervisees. Sexual harassment includes sexual solicitation or requests for sexual favors.

(5) Marriage and family therapists do not permit students or supervisees to perform or to hold themselves out as competent to perform professional services beyond their training, level of experience, and competence.

(6) Marriage and family therapists take reasonable measures to ensure that services provided by supervisees are professional.

(7) Marriage and family therapists avoid accepting as supervisees or students those individuals with whom a prior or existing relationship could compromise the therapist’s objectivity. When such situations cannot be avoided, therapists take appropriate precautions to maintain objectivity. Examples of such relationships include, but are not limited to, those individuals with whom the therapist has a current or prior sexual, close personal, immediate familial, or therapeutic relationship.

(8) Marriage and family therapists do not disclose supervisee confidences except by written authorization or waiver, or when mandated or permitted by law. In educational or training settings where there are multiple supervisors, disclosures are permitted only to other professional colleagues, administrators, or employers who share responsibility for training of the supervisee. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law.

(9) Marriage and family therapists providing clinical supervision shall not enter into financial arrangements with supervisees through deceptive or exploitative practices, nor shall marriage and family therapists providing clinical supervision exert undue influence over supervisees when establishing supervision fees. Marriage and family therapists shall also not engage in other exploitative practices of supervisees.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed December 22, 2009; effective January 26, 2010. Amended: Filed February 8, 2012; effective March 14, 2012. Amended: Filed June 19, 2019; effective August 3, 2019.

Ala. Admin. Code r. 536-X-8-.05 Responsibility To Research Participants

Investigators respect the dignity and protect the welfare of research participants, and are aware of applicable laws and regulations and professional standards governing the conduct of research.

(1) Investigators are responsible for making careful examinations of ethical acceptability in planning studies. To the extent that services to research participants may be compromised by participation in research, investigators seek the ethical advice of qualified professionals not directly involved in the investigation and observe safeguards to protect the rights of research participants.

(2) Investigators requesting participant involvement in research inform participants of the aspects of the research that might reasonably be expected to influence willingness to participate. Investigators are especially sensitive to the possibility of diminished consent when participants are also receiving clinical services, or have impairments which limit understanding and/or communication, or when participants are children.

(3) Investigators respect each participant’s freedom to decline participation in or to withdraw from a research study at any time. This obligation requires special thought and consideration when investigators or other members of the research team are in positions of authority or influence over participants. Marriage and family therapists, therefore, make every effort to avoid multiple relationships with research participants that could impair professional judgment or increase the risk of exploitation.

(4) Information obtained about a research participant during the course of an investigation is confidential unless there is a waiver previously obtained in writing. When the possibility exists that others, including family members, may obtain access to such information, this possibility, together with the plan for protecting confidentiality, is explained as part of the procedure for obtaining informed consent.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed December 22, 2009; effective January 26, 2010.

Ala. Admin. Code r. 536-X-8-.06 Responsibility To The Profession

Marriage and family therapists respect the rights and responsibilities of professional colleagues and participate in activities that advance the goals of the profession.

(1) Marriage and family therapists remain accountable to the standards of the profession when acting as members or employees of organizations. If the mandates of an organization with which a marriage and family therapist is affiliated, through employment, contract or otherwise, conflict with the AAMFT Code of Ethics, marriage and family therapists make known to the organization their commitment to the AAMFT Code of Ethics and attempt to resolve the conflict in a way that allows the fullest adherence to the Code of Ethics.

(2) Marriage and family therapists assign publication credit to those who have contributed to a publication in proportion to their contributions and in accordance with customary professional publication practices.

(3) Marriage and family therapists do not accept or require authorship credit for a publication based on research from a student’s program, unless the therapist made a contribution (significant participation in the design of research, collection of data, data analysis, and writing of findings in the article).

(4) Marriage and family therapists who are the authors of books or other materials that are published or distributed do not plagiarize or fail to cite persons to whom credit for original ideas or work is due.

(5) Marriage and family therapists who are the authors of books or other materials published or distributed by an organization take reasonable precautions to ensure that the organization promotes and advertises the materials accurately and factually.

(6) Marriage and family therapists participate in activities that contribute to a better community and society, including devoting a portion of their professional activity to services for which there is little or no financial return.

(7) Marriage and family therapists do not fabricate research results. Marriage and family therapists disclose potential conflicts of interest and take authorship credit only for work they have performed or to which they have contributed. Publication credits accurately reflect the relative contributions of the individual involved.

(8) Marriage and family therapists who are the authors of books or other materials that are published or distributed do not plagiarize or fail to cite persons to whom credit for original ideas or work is due.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed December 22, 2009; effective January 26, 2010. Amended: Filed February 8, 2012; effective March 14, 2012. Amended: Filed June 19, 2019; effective August 3, 2019.

Ala. Admin. Code r. 536-X-8-.07 Financial Arrangements

Marriage and family therapists make financial arrangements with clients, third-party payers, and supervisees that are reasonably understandable and conform to accepted professional practices.

(1) Marriage and family therapists do not offer or accept kickbacks, rebates, bonuses, or other remuneration for referrals; fee-for-service arrangements are not prohibited.

(2) Prior to entering into the therapeutic or supervisory relationship, marriage and family therapists clearly disclose and explain to clients and supervisees:

(a) all financial arrangements and fees related to professional services, including charges for canceled or missed appointments;

(b) the use of collection agencies or legal measures for nonpayment; and

(c) the procedure for obtaining payment from the client, to the extent allowed by law, if payment is denied by the third-party payer. Once services have begun, therapists provide reasonable notice of any changes in fees or other charges.

(3) Marriage and family therapists give reasonable notice to clients with unpaid balances of their intent to seek collection by agency or legal recourse. When such action is taken, therapists will not disclose clinical information.

(4) Marriage and family therapists represent facts truthfully to clients, third-party payers, and supervisees regarding services rendered

(5) Bartering for professional services may be conducted only if:

(a) the supervisee or client requests it,

(b) the relationship is not exploitative,

(c) the professional relationship is not distorted, and

(d) a clear written contract is established.

(6) Marriage and family therapists may not withhold records under their immediate control that are requested and needed for a client’s treatment solely because payment has not been received for past services, except as otherwise provided by law.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed December 22, 2009; effective January 26, 2010. Amended: Filed February 8, 2012; effective March 14, 2012.

Ala. Admin. Code r. 536-X-8-.08 Advertising

Marriage and family therapists engage in appropriate informational activities, including those that enable the public, referral sources, or others to choose professional services on an informed basis.

(1) Marriage and family therapists accurately represent their competencies, education, training, and experience relevant to their practice of marriage and family therapy.

(2) Marriage and family therapists ensure that advertisements and publications in any media (such as directories, announcements, business cards, newspapers, radio, television, Internet, and facsimiles) convey information that is necessary for the public to make an appropriate selection of professional services. Information could include:

(a) office information, such as name, address, telephone number, credit card acceptability, fees, languages spoken, and office hours;

(b) qualifying clinical degree (see subprinciple 8.5);

(c) other earned degrees (see subprinciple 8.5) and state or provincial licensures and/or certifications;

(d) AAMFT clinical member status; and

(e) description of practice.

(3) Marriage and family therapists do not use names that could mislead the public concerning the identity, responsibility, source, and status of those practicing under that name, and do not hold themselves out as being partners or associates of a firm if they are not.

(4) Marriage and family therapists do not use any professional identification (such as a business card, office sign, letterhead, Internet, or telephone or association directory listing) if it includes a statement or claim that is false, fraudulent, misleading, or deceptive.

(5) In representing their educational qualifications, marriage and family therapists list and claim as evidence only those earned degrees:

(a) from institutions accredited by regional accreditation sources recognized by the United States Department of Education,

(b) from institutions recognized by states or provinces that license or certify marriage and family therapists, or

(c) from equivalent foreign institutions.

(6) Marriage and family therapists correct, wherever possible, false, misleading, or inaccurate information and representations made by others concerning the therapist's qualifications, services, or products.

(7) Marriage and family therapists make certain that the qualifications of their employees or supervisees are represented in a manner that is not false, misleading, or deceptive.

(8) Marriage and family therapists do not represent themselves as providing specialized services unless they have the appropriate education, training, or supervised experience.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed December 22, 2009; effective January 26, 2010.

Ala. Admin. Code r. 536-X-8-.09 Technology-Assisted Training/Education Requirements of Profession

(1) Marriage and family therapists who conduct teletherapy within the state of Alabama must be accountable to education and training standards for teletherapy prior to initiating services.

(2) Therapists may only advertise and perform those services they are licensed and trained to provide. The anonymity of electronic communication makes misrepresentation possible for both therapists and clients. Because of the potential misuse by unqualified individuals, it is essential that information be readily verifiable to ensure client protection.

(3) Therapists shall review their discipline’s definitions of “competence” prior to initiating teletherapy to assure that they maintain recommended technical and clinical competence for the delivery of care. Therapists shall have completed basic education and training in suicide prevention in relation to electronic communication. Marriage and family therapists inform clients of the protocol if suicide is an imminent threat.

(4) Therapists shall assume responsibility to continually assess both their professional and technical competence when providing teletherapy services.

(5) Minimum 12 hours initial training required in teletherapy. Telehealth training do not need to award continuing education credits (although they may, and those would be counted toward annual CE requirements) as long as the training covers the required content areas outlined below. After initial training, licensees must demonstrate continued competence in major content areas (see below; e.g. encryption of data, HIPAA compliant connections). Areas to be covered in the training must include, but not limited to:

(a) Appropriateness of Teletherapy

(b) Teletherapy Theory and Practice

(c) Modes of Delivery

(d) Legal/Ethical Issues

(e) Handling Online Emergencies

(f) Best Practices & Informed Consent

(6) In order for an MFT Intern to practice teletherapy, the Intern must be actively supervised for one (1) hour for every five (5) clinical hours, by an AAMFT Approved Supervisor, AAMFT Supervisor Candidate, ABEMFT Approved Supervisor, or ABEMFT Supervisor Candidate trained in teletherapy and telesupervision. Supervision must include discussion specifically related to the practice of teletherapy, whether that supervision is virtual or in person. The intern must also complete the minimum required 12 hours of training or one (1) credit course (15 classroom hours) in teletherapy.

(7) In order for a Licensed MFT Associate to practice teletherapy, the Associate must be actively supervised for one (1) hour for every ten (10) clinical hours, by an AAMFT Approved Supervisor, AAMFT Supervisor Candidate, ABEMFT Approved Supervisor or ABEMFT Supervisor Candidate trained in teletherapy and telesupervision. Supervision must include discussion specifically related to the practice of teletherapy, whether that supervision is virtual or in person. The associate must also complete the minimum required 12 hours of training or one (1) credit course (15 classroom hours) in teletherapy if not completed previously as an intern.

(8) In order for a Licensed MFT to practice teletherapy, the licensee must have completed a minimum of 12 hours initial training. This requirement is met for LMFT’s who completed the 12 hours of teletherapy training or one (1) credit course (15 classroom hours) in teletherapy as an LMFT Intern or LMFT Associate.

(9) In order for an AAMFT Approved Supervisor, AAMFT Supervisor Candidate, ABEMFT Approved Supervisor, or ABEMFT Supervisor Candidate to be considered trained to provide telesupervision or telesupervision training, the Supervisor must have three (3) additional hours of training in telesupervision beyond the minimum required training to practice teletherapy.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed June 19, 2019; effective August 3, 2019. Amended: Published January 31, 2022; effective March 17, 2022.

Ala. Admin. Code r. 536-X-8-.10 Technology-Assisted Professional Services

(1) Adhering to Laws and Rules in Each Jurisdiction

(a) Marriage and Family Therapists are authorized to practice teletherapy within the boundaries of the state of Alabama. Marriage and family therapists are licensed to practice in Alabama serving the citizens of Alabama. The practice location is derived from the client geographical location. The burden resides with the marriage and family therapists concerning legal and ethical practice behaviors and client care no matter where the client resides.

(b) Marriage and family Therapists and supervisors follow all applicable laws regarding location of practice and services, and do not use technologically-assisted means for practicing outside of their allowed jurisdictions.

(c) Treatment, consultation, and supervision utilizing technology-assisted services will be held to the same standards of appropriate practice as those in traditional (in-person) settings.

(2) Identity Verification of Client

(a) An appropriate therapeutic relationship has not been established when the identity of the therapist may be unknown to the client or the identity of the client(s) may be unknown to the therapist. An initial face-to-face meeting, which may utilize HIPAA compliant videoconferencing, is highly recommended to verify the identity of the client. If such verification is not possible, the burden is on the therapist to document appropriate verification of the client.

(b) A therapist shall take reasonable steps to verify the location and identify the client(s) at the onset of each session before rendering therapy using teletherapy.

(c) Therapists shall develop written procedures for verifying the identity of the recipient, his or her current location, and readiness to proceed at the beginning of each contact. Examples of verification means include the use of code words, phrases or inquiries. (For example, “is this a good time to proceed?”)

(3) Establishing the Therapist-Client Relationship

(a) A therapist who engages in technology-assisted services must provide the client with his/her license number and information on how to contact the board by telephone, electronic communication, or mail, and must adhere to all other rules and regulations in the state of Alabama.

(b) The relationship is clearly established when informed consent documentation is signed. Therapists must communicate any risks and benefits of the teletherapy services to be offered to the client(s) and document such communication. Clients, whether contracting for services as individuals, dyads, families, or groups, must be made aware of the risks and responsibilities associated with technology-assisted services. Therapists are to advise clients in writing of these risks, and of both the therapist’s and clients’/supervisees’ responsibilities for minimizing such risks.

(c) Screening for client technological capabilities is part of the initial intake processes. (Ex. This type of screening could be accomplished by asking clients to complete a brief questionnaire about their technical and cognitive capacities).

(d) Teletherapy services must have accurate and transparent information about the website, owner/operator, location and contact information, including a domain name that accurately reflects the identity.

(e) The therapist and/or client shall use connection test tools (e.g., bandwidth test) to test the connection before starting their videoconferencing session to ensure the connection has sufficient quality to support the session.

(4) Cultural Competency

(a) Therapists shall be aware of the limitations of teletherapy and recognize and respect cultural differences (e.g. when therapist is unable to see the client, non-verbal cues).

(b) Therapists shall select and develop appropriate online methods, skills, and techniques that are attuned to their clients’ cultural, bicultural, or marginalized experiences in their environments.

(c) Client perspectives of therapy and service delivery via technology may differ. In addition, therapists shall know the strengths and limitations of current electronic modalities, process and practice models, to provide services that are applicable and relevant to the needs of culturally and geographically diverse clients and members of vulnerable populations.

(d) Therapists shall consider cultural differences, including clarify of communications.

(e) Sensory deficits, especially visual and auditory, can affect the ability to interact over a videoconference connection. Therapists shall consider the use of technologies that can help with visual or auditory deficit. Techniques should be appropriate for a client who may be cognitively impaired, or find it difficult to adapt to the technology.

(5) Informed Consent/Client Choice to Engage in Teletherapy

(a) The therapist must document the provision of consent in the record prior to the onset of therapy. The consent shall include all information contained in the consent process for in-person care including discussion of the structure and timing of services, record keeping, scheduling, privacy, potential risks, confidentiality, mandatory reporting and billing.

(b) This information shall be specific to the identified service delivery type and include considerations for the particular individual.

(c) The information must be provided in language that can be easily understood by the client. This is particularly important when discussing technical issues like encryption or the potential for technical failure.

(d) Alabama laws regarding verbal or written consent must be followed. If written consent is required, electronic signatures may be used if they are allowed by Alabama requirements.

(e) In addition to the usual and customary protocol of informed consent between therapist and client for face-to-face counseling, the following issues, unique to the use of teletherapy, technology, and/or social media, shall be addressed in the informed consent process:

1. confidentiality and the limits to confidentiality in electronic communication;

2. teletherapy training and/or credentials, physical location of practice, and contact information;

3. licensure qualifications and information on reporting complaints to appropriate licensing boards;

4. risks and benefits or engaging in the use of teletherapy, technology, and/or social media;

5. possibility of technology failure and alternate methods of service delivery;

6. process by which client information will be documented and stored;

7. anticipated response time and acceptable ways to contact the therapist;

(i) agreed upon emergency procedures;

(ii) procedures for coordination of care with other professionals;

(iii) conditions under which teletherapy services may be terminated and a referral made to in-person care;

8. cultural and/or language differences that may affect delivery of services;

9. possible denial of insurance benefits;

10. social media policy;

11. specific services provided, and

12. information collected and any passive tracking mechanism utilized.

(f) Therapists must provide clients clear mechanisms to:

1. access, supplement, and amend client-provided personal health information;

2. provide feedback regarding the site and the quality of information and services; and

3. register complaints, including information regarding filing a complaint with the applicable state licensing board(s).

(6) Working with Children

(a) Therapists must determine if a client is a minor and, therefore, in need of parental/guardian consent. Before providing teletherapy/therapy services to a minor, therapist must verify the identity of the parent, guardian, or other person consenting to the minor’s treatment.

(b) In cases where conservatorship, guardianship or parental rights of the client have been modified by the court, therapists shall obtain and review a written copy of the custody agreement or court order before the onset of treatment.

(7) Acknowledgement of Limitations of Teletherapy

(a) Therapists must: (i) determine that teletherapy is appropriate for clients, considering professional, intellectual, emotional and physical needs; (ii) inform clients of the potential risks and benefits associated with teletherapy; and (iii) ensure the security of the communication medium.

(b) Clients must be made aware of the risks and responsibilities associated with teletherapy. Therapists are to advise clients in writing of these risks and of both the therapist’s and clients’ responsibilities for minimizing such risks.

(c) Therapists shall consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the therapy process. Therapists shall educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.

(d) Therapists shall be aware of the limitations of teletherapy and recognize and respect cultural differences (e.g. when therapist is unable to see the client, non-verbal cues).

(e) Therapists shall recognize the members of the same family system may have different levels of competence and preference using technology. Therapists shall acknowledge power, dynamics when there are differing levels of technological competence within a family system.

(f) Before therapists engage in providing teletherapy services, they must conduct an initial assessment to determine the appropriateness of the teletherapy services to be provided for the client(s). Such an assessment may include the examination of the potential risks and benefits to provide teletherapy services for the client’s particular needs, the multicultural and ethical issues that may arise, and a review of the most appropriate medium (e.g., video conference, text, email, etc.) or best options available for the service delivery. It may also include considering whether comparable in-person services are available, and why services delivered via teletherapy are equivalent or preferable to such services. In addition, it is incumbent on the therapist to engage in a continual assessment of the appropriateness of providing teletherapy services throughout the duration of the service delivery.

(8) Confidentiality of Communication

(a) Therapists utilizing teletherapy must meet or exceed applicable federal and state legal requirements of health information privacy including HIPAA/HiTECH.

(b) Therapists shall assess carefully the remote environment in which services will be provided, to determine what impact, if any, there might be to the efficacy, privacy and/or safety of the proposed intervention offered via teletherapy.

(c) Therapists must understand and inform their clients of the limits to confidentiality and risks to the possible access or disclosure of confidential data and information that may occur during service delivery, including the risks of access to electronic communications.

(9) Professional Boundaries Regarding Virtual Presence

(a) Reasonable expectations about contact between sessions must be discussed and verified with the client. At the start of the treatment, the client and therapist shall discuss whether or not the provider will be available for phone or electronic contact between sessions and conditions under which such contact is appropriate. The therapist shall provide a specific time frame for expected response between session contacts. This must also include discussion of emergency manage3ment between sessions, along with fee structure related to the different types of services.

(b) To facilitate the secure provision of information, therapists must provide in writing the appropriate ways to contact them.

(c) Marriage and family therapists are discouraged from engaging personal virtual relationships with clients (e.g., through social and other media). A. Therapists shall document any known virtual relationships with clients; B. Documentation of therapeutic intent is required; and C. The burden of proof is on the therapist to ensure that the virtual relationship does no emotional or psychological harm to the client(s).

(d) Therapists shall discuss and document, and must establish, professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the counseling relationship (e.g., lack of confidentiality, circumstances when not appropriate to use).

(10) Social Media and Virtual Presence

(a) Therapists shall develop written procedures for the use of social media and other related digital technology with clients. These written procedures, at a minimum, provide appropriate protections against the disclosure of confidential information and identify that personal social media accounts are distinct from any used for professional purposes.

(b) In cases where therapists wish to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles shall be created to clearly distinguish between the two kinds of virtual presence.

(c) Therapists must respect the privacy of their clients’ presence on social media unless given consent to view such information.

(d) Therapists must avoid the use of public social media sources (e.g., tweets, blogs, etc.) to provide confidential information.

(e) Therapists shall refrain from referring to clients generally or specifically on social media, blogs or social networking sites.

(11) Sexual Issues in Teletherapy

(a) Treatment and/or consultation utilizing technology-assisted services must be held to the same standards of appropriate practice as those in face to face settings.

(b) Therapists must be aware of statues and regulations of relevant jurisdictions regarding sexual interactions with current or former clients or with known members of the client’s family system.

(c) Marriage and family therapists shall not solicit through social media or in video conferencing sexual favors, participate in online sexual behaviors including sending or receiving sexual pictures, or making sexual advances with a current client or family member of a current client or with a former client.

(12) Documentation/Record Keeping

(a) Synchronous and asynchronous client-related electronic communications, shall be stored and filed in the client’s medical record, consistent with traditional record-keeping policies and procedures.

(b) Written policies and procedures must be maintained at the same standard as face-to-face services for documentation, maintenance, and transmission of the records of the services using teletherapy technologies.

(c) Services must be accurately documented as remote services and include dates, place of both therapist and client(s) location, duration, and type of service(s) provided.

(d) Requests for access to records require written authorization from the client with a clear indication of what types of data and which information is to be released.

(e) Marriage and family therapists must inform clients on how records, including audiovisual session data are maintained electronically. This includes, but is not limited to, the type of encryption and security assigned to the records, and if/for how long archival storage of transaction records is maintained.

(f) Marriage and family therapists cannot release audiovisual session data without notarized client written authorization indicating specifically that audio/video communications are to be released.

(g) Therapists must create policies and procedures for the technologies used to create, store, and transmit data and information and about the secure destruction of data.

(h) Clients must be informed in writing of the limitations and protections offered by the therapist’s technology.

(i) The therapist must obtain written permission prior to recording any/or part of the teletherapy session. This authorization can be a part of an informed consent agreement signed at the beginning of therapy, and must be re-evaluated throughout therapy.

(13) Payment and Billing Procedures

(a) Prior to the commencement of initial services, the client shall be informed of any and all financial charges that may arise from the services to be provided. Arrangement for payment shall be completed prior to the commencement of services.

(b) All billing and administrative data related to the client must be secured to protect confidentiality. Only relevant information may be released for reimbursement purposes as outlined by HIPAA.

(c) Therapist shall document who is present and use appropriate billing codes when treatment requires.

(d) Therapist must ensure online payment methods by clients are secure.

(14) Emergency Management

(a) Marriage and family therapists are required to know the involuntary hospitalization and duty-to-notify laws outlining criteria and detainment conditions. Professionals must know and abide by the rules and laws in the jurisdiction where the therapist is located and where the client is receiving services.

(b) At the onset of the delivery of teletherapy services, therapists shall make reasonable effort to identify and learn how to access relevant and appropriate emergency resources in the client’s local area, such as emergency response contacts (e.g., emergency telephone numbers, hospital admissions, local referral resources, a support person in the client’s life when available and appropriate consent has been authorized).

(c) Therapists must have clearly delineated emergency procedures and access to current resources in each of their client’s respective locations, including in-person services which can offer support; simply offering 911 may not be sufficient. Also, marriage and family therapists make reasonable effort to discuss with and provide all clients with clear written instructions as to what to do in an emergency.

(d) If a client experiences crises/emergencies suggestive that in-person services may be appropriate, therapists shall take reasonable steps to refer a client to a local mental health resource or ensure a referral for in-person services are made including follow-up by the therapists.

(e) Therapists shall prepare a plan to address any lack of appropriate resources, particularly those necessary in an emergency, or other relevant factors which may impact the efficacy and safety of said service. Therapists shall make reasonable effort to discuss with and provide all clients with clear written instructions as to what to do in an emergency (e.g., where there is a suicide risk). As part of emergency planning, therapists must be knowledgeable of the laws and rules of the jurisdiction in which the client resides, as well as document all emergency planning efforts.

(f) In the event of a technology breakdown, causing disruption of the session, the therapists must have a backup plan in place. The plan must be communicated to the client prior to commencement of the treatment and may also be included in the general emergency management protocol.

(15) Synchronous vs. Asynchronous Contact with Client(s)

(a) Communications may be synchronous with multiple parties communicating in real time (e.g., interactive videoconferencing, telephone) or asynchronous (e.g., email, online bulletin boards, storing and forwarding information). Technologies may augment traditional in-person services (e.g., psychoeducational materials online after an in-person therapy session), or be used as stand-alone services (e.g., therapy provided over videoconferencing). Different technologies may be used in various combinations and for different purposes during the provision of teletherapy services. The same medium may be used for direct and non-direct services. For example, videoconferencing and telephone, email, and text may also be utilized for direct service while telephone, email, and text may be used for nondirect services (e.g., scheduling). Regardless of the purpose, marriage and family therapists shall be aware of the potential benefits and limitations in their choices of technologies for particular clients in particular situations. Therapists will ensure that all communications are secure and confidential, and that clients know the potential limitations of confidentiality with any mode of communication.

(16) HIPAA Security, Web Maintenance, and Encryption Requirements

(a) Videoconferencing applications must have appropriate verification, confidentiality, and security parameters necessary to be properly utilized for therapeutic purpose.

(b) Video software platforms must not be used when they include social media functions that notify users when anyone in contact list logs on (skype, g-chat).

(c) Capability to create a video chat room must be disabled so others cannot enter at will.

(d) Personal computers used must have up-to-date antivirus software and a personal firewall installed.

(e) All efforts must be taken to make audio and video transmissions secure by using point-to-point encryption that meets recognized standards.

(f) Videoconferencing software shall not allow multiple concurrent sessions to be opened by a single user.

(g) Session logs stored by 3rd party locations must be secure.

(h) Therapists ensure that client data and information is accessible only to appropriate and authorized individuals.

(i) Therapists must encrypt confidential client information for storage or transmission, and utilize secure software and robust passwords to protect electronically stored or transmitted data and information.

(j) When documenting the security measures utilized, therapists shall clearly address what types of telecommunication technologies are used (e.g., email, telephone, videoconferencing, text), how they are used, whether teletherapy services used are the primary method of contact or augments in-person contact.

(17) Archiving/Backup Systems

(a) Therapists shall retain copies of written communications with clients. Examples of written communications include email/text messages, instant messages, and histories of chat-based discussions.

(b) PHI and other confidential data must be backed up to or stored on secure data storage location.

(c) Therapists must have a plan of the professional retention of records and availability to clients in the event of the therapist’s incapacitation or death.

(18) Testing/Assessment

(a) Marriage and family therapists do not provide assessments or testing through videoconferencing or teletherapy, except for exploratory questionnaires (e.g., depressive symptoms, symptom distress, suicidality, relationship satisfaction). Marriage and family therapists refer clients to professionals who can assess, evaluate, and diagnosis in-person.

(19) Telesupervision

(a) Therapists must hold supervision to the same standards as all other technology-assisted services. Telesupervision shall be held to the same standards of appropriate practice as those in in-person settings. All supervision requirements apply to telesupervision.

(b) Before using technology in supervision, s shall be competent in the use of those technologies. Supervisors must take the necessary precautions to protect the confidentiality of all information transmitted through any electronic means and maintain competence.

(c) The type of communications used for telesupervision shall be appropriate for the types of services being supervised, clients and supervisee needs. Telesupervision is provided in compliance with the supervision requirements of the relevant jurisdiction(s). Marriage and family therapists have direct knowledge of all clients served by his or her supervisees.

(d) Supervisors of marriage and family therapy ensure that they are well trained and competent in the use of all chosen technology-assisted professional services. Careful choices of audio, video, and other options are made in order to optimize quality and security of services, and to adhere to standards of best practices for technology-assisted services. Furthermore, such choices of technology are to be suitably advanced and current so as to serve the professional needs of clients and supervisees.

(e) Supervisors shall: (a) determine that telesupervision is appropriate for supervisees, considering professional, intellectual, emotional, and physical needs; (b) inform supervisees of the potential risks and benefits associated with telesupervision, respectively; (c) ensure the security of their communication medium; and (d) only commence telesupervision after appropriate education, training, or supervised experience using the relevant technology. Supervisees shall be made aware of the risks and responsibilities associated with telesupervision. Supervisors are to advise supervisees in writing of these risks, and of both the supervisor’s and supervisee’s responsibilities for minimizing such risks.

(f) Supervisors must be aware of statutes and regulations of relevant jurisdictions regarding sexual interactions with current or former supervisees.

(g) Communications may be synchronous or asynchronous. Technologies may augment traditional in-person supervision, or be used a stand-along supervision. Supervisors shall be aware of the potential benefits and limitations in their choices of technologies for particular supervisees in particular situations.

(h) Supervisors of marriage and family therapy should not render services using technology-assistance without verifying the location and identifying the requesting supervisees, to the most reasonable extent possible, at the outset of supervision.

(i) Supervisors of marriage and family therapists are discouraged from knowingly engaging in a personal virtual relationship with supervisees (e.g., through social and other media). Supervisors of marriage and family therapists document the rational for any known virtual relationship with supervisees.

(j) Supervisors of marriage and family therapy should not render services using technology-assistance without verifying the location and identifying the requesting supervisees, to the most reasonable extent possible, at the outset of supervision.

(k) Supervisors of marriage and family therapy document the rationale for any known virtual relationships with supervisees. It is the responsibility of the supervisor to ensure that the virtual relationship is not exploitive.

(l) Supervisors of marriage and family therapists shall not sexually harass supervisees. Sexual harassment includes sexual solicitation, requests for sexual favors, unwanted sexual advances, or physical harassment of a sexual nature.

(m) Supervisors of marriage and family therapists shall not solicit through social media or in videoconferencing sexual favors, participate in online sexual behaviors including sending or receiving sexual pictures, or making sexual advances with a current supervisee.

History

• Author: The Alabama Board of Examiners in Marriage and Family Therapy
• Authority: Code of Ala. 1975, §§34-17A-1 thru 34-17A-26.
• New Rule: Filed June 19, 2019; effective August 3, 2019.