Scott Cohen is a former President of the Massachusetts Association for Marriage & Family Therapy. Scott served for 15 years on the Allied Board of Mental Health as a representative for MFTs, and he’s currently the Treasurer of the Association for Marriage & Family Therapy Regulatory Board.

This is a transcription from the interview conducted by Jeremiah Gibson, Executive Director of the New England Association for Family & Systemic Therapy (NEAFAST), with Scott Cohen on July 27, 2020. Watch the full interview here.

Jeremiah Gibson: Scott and I are talking today about online continuing education option called Tales from the Licensing Board: Ethical Issues Facing Couple & Family Therapists. And this is a home study event that’s being done in conjunction with the Couple & Family Institute of New England (CFINE). For more information, you can get on their website: coupleandfamilyinstitute.com. So Scott, one of the things that I’m curious about when we talk about the program is how did you get interested in the ethical processes of marriage and family therapy? 

Scott Cohen: Well, Jeremiah, I’ve been a longtime marriage and family therapist, for the last 40 or so years. And I was, as you said, President of the Marriage & Family Therapy Association, I got involved in lots of different things with AAMFT and the Massachusetts Association for Marriage & Family Therapy. And after my term as President and Past President, there was an opening on the Allied Board of Mental Health Division of Registration. So it’s something that I gravitated towards, and I became a Board Member probably in 1990 or thereabouts. And I served my first term there for about 8 years. And I was sort of the second generation of Board of Registration Board Members. The first generation were those folks who actually put together and implemented the law licensing Marriage & Family Therapists as well as Mental Health Counselors and the other professions on the Board. And so I served, as I said, for about 7 or 8 years there, and then I left the Board of Registration only to find myself coming back on the Board of Registration another 8 years later, and served another 7 years, and actually just left the Board within the last couple months. So the Board of Registration’s tasks—really it is a governmental appointee—and the task, the legislative task, is really consumer protection. It is a Board that issues licenses to Marriage & Family Therapists as well as Mental health Counselors, Educational Psychologists, Behavior Analysts, and Rehab Counselors. It propagates the requirements for licensure, and it peers ethical cases when people run a file for some of the ethics of our profession. So it’s something that I drifted over to after my time at AAMFT and as I said, I’ve been on the Board for about 15 years, and hopefully I’ve learned an awful lot about ethics myself in that process. 

JG: I can imagine that reading through some of the ethics complaints, reading through some of the paperwork, that you’ve learned a lot about what not to do, as well as how to ethically and effectively practice couple and family therapy. I’m curious, Scott, in the video presentation, what are some of the ethical issues you talk about?

SC: So the presentation is actually a 5 ½ hour CE event and we talk about informed consent, responsibility with treating minors in the state of Massachusetts, we go over the AAMFT code of ethics, we talk about how to make a professional will which I don’t think many of us have at all. One of the interesting things, as you said is that I’ve learned a lot about what not to do. I’ve always thought of myself as a pretty ethical person, but I was really struck often by some of the cases we heard, and some of the times where I thought to myself, ‘”Oh boy, I have to really be careful.” And then at the end of the presentation, we spend the last hour and a quarter or so talking about cases. Now, these are not verbatim cases, obviously, due to confidentiality issues. But they are a compilation of interesting case material that I’ve put together. So in my presentation I say, "You be the Board of Registration and you tell me if you think there are ethical violations here, and if so, what would you do?" 

JG: Scott, my understanding is that MFTs in Massachusetts aren’t required to do a CE set in ethics like other licenses are or like other MFTs in other states are, so I’m curious what makes it really important—specifically for Marriage & Family Therapists but really for anyone who practices couple and family therapy—to do a workshop like this in the ethics of couples and family therapy?

SC: So, first of all, I think it’s ethically required of each individual to pay attention to ethics. Ethics can be kind of a dry topic but I think we need to look at our own ethics. It’s interesting you mention it’s not required right now in the statute of regulation—one of the things that I did before I left the Board, in concert with the current Board Member Jacqueline Gagliardi, we’re actually in the process of rewriting the regulations, and we actually have already presented them to the Board; they have to go through a public hearing. And one of the new requirements is in fact to have 3 CEs every licensing cycle in ethics. As you said, many many other states have it. As I sit on the Association for Marriage & Family Therapy Regulatory Board and I go to the annual conference—where, generally, 30 or so other states are represented at any given time—I hear what all the other states are doing, and a lot of them have a requirement in ethics. This last cycle, as you know, there was a requirement to have 2 CEs in domestic violence. In addition, some states require CEs in teletherapy—and we’ll talk a little bit more about that because that’s one of the issues right now, especially with COVID.

JG: You mentioned COVID-19 and I’m really curious what ethical considerations you see coming up with COVID-19, particularly as more therapists are moving into teletherapy. 

SC: It’s really very interesting, the whole concept of what’s going on with COVID-19, because at this point, very few clients are being seen face-to-face; they’re all being seen with telehealth. And telehealth is the big new way. And we’ve sort of let the genie out of the bottle that telehealth is here to stay. But the difficulty is, in this day and age of COVID, the insurance companies and even the licensing boards across the nation have basically waved HIPAA requirements for doing telehealth/teletherapy. With telehealth we can use any platform, whether it be HIPAA compliant or not, and the rules and regulations are thrown out the window. And there’s no requirement for any level of training in teletherapy. So I think that since we as a profession and the world have experienced teletherapy, as I said, the genie’s out of the bottle: teletherapy is here to stay. We will be doing a lot more work in telehealth and teletherapy. However, one of the things that I know I’m pushing for—and I’ve made a proposal to the Board of the Allied Mental Health of Massachusetts—is that they do institute some level of teletherapy guidelines. There is a document that is in the bibliography called the Association of Marriage and Family Therapy’s Regulatory Board Teletherapy Guidelines. One of the parts of this training does include this MFTRB. Two years ago when we did this training I included in it some of the difficulties of doing teletherapy. Rght off the get-go: how do you get informed consent when you’re doing teletherapy? Then there’s the question of whether therapy is synchronous or asynchronous. Synchronous means that it’s what we’re doing right now: having an interaction in real-time, whether that be in a video or on the telephone. Other therapy you do through email. So email is asynchronous; you get an email and then some time expires in between before you respond to someone. Text can be synchronous or asynchronous. But there are issues in terms of how you are conducting your therapy. In Massachusetts, one of the issues as well is where the therapist is. For instance, in Massachusetts, the regulations clearly state that therapy takes place where the client is; the therapist can be anywhere. So as a teletherapist, if I want to see someone, even a college student, for instance, up in New Hampshire or Colorado, I would have to be licensed in that state.

JG: Even if that person has a residential address in Massachusetts?

SC: That’s correct. Because in theory, the therapy takes place where the client is. One of the things we talk about in MFTRB is how wonderful it would be to have a national certification that was accepted in every state to do teletherapy. Failing that, another avenue for that is a compact—inter-state compact—and the most well-known type of inter-state compacts is driver’s licenses. So you might have a driver’s license in Massachusetts but you can drive anywhere else in the country and they honor the Massachusetts license. And that’s a legislative issue. So if the legislature were to agree to a national compact—and I know the nurses, probably about half the states, belong to a nurses compact… So there are a lot of issues in teletherapy: that legal part, liability is an issue, that whole issue of if you’re not doing face-to-face, are you seeing the person you think you’re seeing? We’ve heard all about all these scams with people posing as other people, mostly for devious means. And then the issue of diagnosis: well, if you’re not seeing the person face-to-face and on the telephone, there’s a really severe limit of what you can see and how you can do it. Text-based therapy has severe limitations. And even face-to-face like this, I only see your face, Jeremiah, I can’t see the rest of your body language. So you might be making all sorts of obscene gestures at me and I can’t even see it. So, these are some of the issues we talk about in teletherapy and the limitations of it as well as how it’s regulated, how secure, how encrypted a server might be…I mean we’re doing a Zoom call right now, Jeremiah, but I’m sure you’ve heard the stories of how people have been Zoom-bombed. So right now in our world, we’re allowing a lot because of COVID, but I think that in the future we’re going to be pulling back and I know a lot of states that are talking about it are talking about teletherapy guidelines that have to be HIPAA compliant.

JG: I’m curious, when you think about teletherapy, what are other ethical considerations that you don’t have to consider as much in face-to-face therapy?

SC: So again, is your server encrypted? Is it secure? Are you protecting the confidentiality of your client? And depending on how it is, does someone else have access to their email? All of that stuff is really important. It takes a skill set to conduct teletherapy. Not everyone has the skill set; certainly not many people have training. In Massachusetts we don’t have teletherapy regulations right now. Some states do; most states do not. It is something that will be coming up, I think, for most every state. Everyone’s been thrown into it; people are learning how to do it. But I think there certain skill sets and training that we should have. 

JG: What are other important ethical gaps that people miss that you talk about in the Tales from the Licensing Board presentation?

SC: We go over the AAMFT code of ethics, which is the code of ethics Licensed Marriage and Family Therapists have to adhere to. That’s actually one of the answers of the CE questions, so I’m giving it right now to you. And we talk about working with minors. Working with minors especially is difficult because in the commonwealth of Massachusetts, best practices require you to have the consent of both parents, even though they might be divorced and separated—especially, I guess, if they’re divorced or separated. And there are many, many, many cases that we hear about with therapists getting complaints filed against them because one party says, “I did not give you permission to treat my children. And my ex hired you, but I did not give you permission, and I think you’re badly influencing the kids against me because you’re allied with my ex.” So knowing custodial arrangements. Certainly in divorced and separated issues, being able to review legal custody documents is an important element of it. That’s some of the stuff we talk about it.

Another thing we talk about is developing a professional will. That’s really kind of interesting because it’s nothing that I would have known about had I not served on the Board and investigated some of this. So a professional will is really what happens when you as a therapist retire or die suddenly: who takes care of the records? Who do you transfer all of your professional information to? We’ve had certainly a number of cases where therapists have died suddenly and the client is left not even knowing where to turn. Spelling it out in advance—and that is part of informed consent. So we talk about informed consent and different informed consent forms and what they should include. And one of them is: if you should as a therapist should die suddenly, what access does the client have to their records and where would the records go? What does a good intake sheet have? What is informed consent and what is the degree to which—the depth, I guess, more than the degree—the depth to which what you have to look at in informed consent in some ways is actually really scary? I made the acknowledgment [in my presentation] that my informed consent isn’t as deep as I’m talking about—but it’s a really important issue.

JG: I’d be curious, those that are watching the video, how many folks have heard of professional wills. I, for one, have not so thank you for sharing that and so much other valuable information about how to do the work ethically and also inform our clients to the utmost extent.

SC: I’ll tell you the last thing the presentation goes over: it goes over the Board of Registration, it goes over the makeup of the Board of Registration, and it also talks a little bit about what happens when a complaint gets filed and what is the process when a complain gets filed: what the Board then does, what the Board responsibility is do to, how it then gets investigated. And then the very last piece is going over cases.

JG: What are other ways that folks can stay engaged in best ethical practices?

SC: Ethics is generally thought of as a pretty dry topic. And I always in my practice was fearful of the dryness of ethics. But as I got into it and began to understand it more…to keep on eye on things like confidentiality: we all know that stuff; first do no harm: we all know that; that’s how we were trained. But just to be aware of the ethical considerations. And I think the 3 CEs every cycle, every two years, of ethics is actually pretty important because there are so many different elements of ethics: use of self best ethics: how much do you disclose, how much do you not disclose—I don’t talk about that in this training but these are some of the other issues of ethics.

JG: Again, Tales from the Licensing Board: Ethical Issues Facing Couple & Family Therapists. You can find this online at coupleandfamilyinstitute.com. It’s $85; $65 for folks who work in agencies. And this has been approved for LMFTs, social workers, mental health counselors, and Licensed Psychologists. Scott, thank you so much for taking the time today to talk with me about a really important topic of ethics and best practice for doing couples and family therapy.

SC: Thank you, Jeremiah. I appreciate the time spent with you and your insight and questions as well.