Technology is an awesome tool that can enhance psychological services if done by a knowledgable therapist. For many years I’ve enjoyed working with a lot of people from around the world but it’s not for everybody.
Below I provide the basic notes outlined after a popular talk I give to behavioral health professionals interested in the ins and outs of using the modality of telepsychology in their practice.
[Click here for a pdf with hyperlinks to useful articles, information and resources on this subject. Tele-Psychology handout]
Telepsychology is a big fat subject. For the sake of organization and saving a few brain cells, this talk is divided into four parts that overlap here and there:
I. Introduction & History
II. Why do it? With Whom?
III. Ethical & Legal Considerations
IV. How Do You Do It?
Let’s start with a definition of telepsychology: The provision of psychological services given remotely using telecommunications technology.
Email, texting, faxing, telephone and video conferencing all fall in to this category. Here I mainly focus on video for direct service and email/texting for indirect service (scheduling).
Personally, I am not comfortable with the idea of providing therapeutic service in an email conversation or an instant messaging chat. There is too much opportunity for written words to be misread. I prefer telephone and video. This is a personal choice.
Even though I do believe face-to-face is best, tele-sessions can be a good-enough alternative.
Tele-sessions are very enjoyable and effective. People report satisfaction in the quality of counseling they receive via video chat. When it’s done well it can feel as if the client/patient is in the room with you.
There aren’t a lot of reliable studies that I could find but what I did find suggested that for certain situations video sessions can be as effective for long term symptom relief as face-to-face counseling.
Technology is a gift and like any gift can work for us if we have the wisdom to know how to use it, when to use it and when not to. There are incredible positives to being able to help your clients when they cannot come into the office. There are negatives which we will cover here but over all I believe having the ability to use tele-sessions as an added value to your practice and can be rewarding for you and for your clients.
Telemedicine has been around for a long time. The authors of a book on the history of telemedicine would argue that it started as far back as the 1920s when an enterprising doctor in the Netherlands used a radio transmission to submit questionable heart rhythms of a patient to an expert in a city center for review.
The early twentieth century experienced a tech explosion similar to what we are experiencing now. Radio, popular use of the telegram, the invention of the telephone made it possible for doctors to help people who were isolated. People traveling on ships could consult with their land bound physicians for instance or soldiers on the battlefield needing instruction to help a wounded comrade.
When astronauts went into space NASA figured out a way to keep a medical eye on them remotely. From that telemedicine grew by leaps and bounds. In the 1990s psychology began to get in the game.
Today as a profession we are in a crazy, ambivalent relationship with the Internet. The technology and the desire to use it by both providers and consumers is huge while the comfort level may be iffy.
One telepsychology expert described it as a new Wild West. Another said, regarding regulation of telepsychology the tail is wagging the dog. Cohesive regulation has not yet caught up with Internet use.
There are people with questionable credentials out there promoting their “online therapy practice” without any concern for ethical or legal issues. They don’t have a license to live up to or to lose.
Parody’s of online therapy, such as Lisa Kudrow’s “Web Therapy”, let us know it’s out there, whether we like it or not.
Last year a very popular article in the New York Times pointed out a lot of the pit falls and advantages of video sessions. It starts out with the image of a young woman mixing a mojito, settling down on a chaise lounge poolside and calling up her therapist on Skype. It was horrifying on so many levels I could hardly get through the rest of the article.
But none of that should cause us to throw the baby out with the bath water.
II. Why Do It?
Starting out with the premise that office bound face-to-face sessions are generally the best service delivery environment, why would anyone want to use tele-sessions for their psychological care?
➢ Live in a remote place where counseling services are not available.
➢ Are living overseas for school or for business.
➢ Live in a small community where everyone knows you, making privacy and confidentiality a challenge.
➢ Their work or lifestyle requires them to travel a lot making a commitment to therapy difficult.
➢ Finding a local therapist with the qualifications they require is tough.
➢ You have a relationship with a therapist and want to keep working with them despite distance.
As a professional you may want to provide continuity of care and/or expand the reach of your practice beyond the bricks and mortar of your office.
In deciding who is a good candidate for tele-sessions do your psychologist thing. Triage the Tele-Session Client.
a. You know the client well because you have already worked with them in your office or you have the opportunity to do an in office assessment.
b. No severe mental illness or high risk.
c. As soon as you know this person needs an on site therapist you do everything you can to link that person with local help.
d. CBT vs psychodynamic. Supportive. Nothing in depth or deeply invasive.
e. Simple, well-defined goals, e.g. lower anxiety, reduce stress.
g. Only Individuals
h. Only adults.
III. Ethics and Legality
Back to the Wild West. Last year psychologists at the APA at the request of the membership and the Board of Directors, took up the challenge of distilling all the issues around tele-practice down to some useful guidelines.
These guidelines were developed by a task-force made up of representatives from American Psychological Association, the Association of State and Provincial Psychological Boards and the APA Insurance Trust.
The taskforce leaned heavily on relevant standards and guidelines already in effect: the APA Ethics Code, the Record Keeping Guidelines, “Guidelines on Multicultural Training, Research, Practice and Organizational Change for Psychologists”
“these guidelines are informed by professional theories, evidence-based practices and definitions to offer the best guidance in the practice of tele-psychology.”
Throughout the guidelines two important components are identified:
➢ The psychologist’s knowledge of and competence in the use of the technology being utilized.
➢ The need to ensure the client/patient has a full understanding of the increased risk to loss of security and confidentiality when using those technologies.
Guideline 1: Competence of the Psychologist. Psychologists who provide telepsychology services strive to take reasonable steps to ensure their competence with both the technologies used and the potential impact of the technologies on clients/patients, supervisees or other professionals.
➢ Only provide services within the boundaries of competence.
➢ Continually assess competence.
➢ Psychologists make every effort to consider cultural, linguistic, socio-economic and other characteristics that may impact effective use of technologies.
➢ Make every effort to identify and learn how to access emergency resources in the client/patient’s local area.
➢ If using telepsychology to provide supervision/consultation consult with others with knowledge of unique issues involved.
Guideline 2: Standards of Care in the Delivery of Telepsychology Services. Psychologists who provide telepsychology services strive to take reasonable steps to ensure their competence with both the technologies used and the potential impact of the technologies on clients/patients, supervisees or other professionals.
➢ Psychologists are encouraged to carefully examine the unique benefits relative to the unique risks.
➢ Consider some initial in-person contact.
➢ Be aware of other factors that may be relevant to assessing the appropriate use of telepsychology: geographic location, medical conditions, mental status, stability, psychiatric diagnosis, current or historic use of substances, treatment history and therapeutic needs.
➢ Monitor and assess regularly the progress of their client/patient.
Guideline 3: Informed Consent. Psychologists make every effort to obtain and document written informed consent that specifically addresses the unique concerns related to the telepsychology services they provide. When doing so, psychologists are cognizant of the applicable laws and regulations, as well as organizational requirements that govern informed consent in this area.
➢ Obtain written and documented informed consent.
o Security conditions
o Inherent risks (disruption in video feed)
o Service limitations
o Billing procedures & documentation
➢ Obtaining informed consent sets stage for telepsychology relationship.
➢ Informed consent makes clear the boundaries of telepsychological services as well as procedures for telecommunications. E.g. If emailed by a patient when should they expect a response?
➢ Psychologists are cognizant of pertinent laws and regulations with respect to informed consent in their jurisdiction and the client/patient’s.
Guideline 4: Confidentiality of Data and Information. Psychologists who provide telepsychology services make every effort to protect and maintain the confidentiality of the data and information relating to their clients/patients and inform them of the potentially increased risks to loss of confidentiality inherent in the use of the telecommunication technologies, if any.
➢ Understand the limits of confidentiality and risks to possible access or disclosure of data.
➢ Aware of ethical & practical implications of researching online personal information about clients/patients. Risks to boundaries of appropriate conduct.
➢ Psychologists encouraged to review and educate themselves about use of social media, utilization of privacy settings when appropriate and be mindful that any electronic communication can have high risk of public discovery.
Guideline 5: Security and Transmission of Data and Information. Psychologists who provide telepsychology services take reasonable steps to ensure that security measures are in place to protect data and information related to their clients/patients from unintended access or disclosure.
➢ Conduct a risk analysis of their practice setting from which telepsychology is being conducted.
➢ Consult with relevant experts.
➢ When possible encrypt confidential client/patient data for storage or transmission.
➢ Use secure methods such as robust password protection, safe hardware & software, protected networks and devices.
➢ Secure back-up of data.
➢ With email, online messaging consider preserving of actual data for client records.
Guideline 6: Disposal of Data and Information and Technologies. Psychologists who provide telepsychology services strive to dispose of data and information and the technologies used in a manner that facilitates protection from unauthorized access and accounts for safe and appropriate disposal.
➢ Develop policies and procedures for destruction of data.
➢ Strive for secure disposal that insures confidentiality and security.
➢ Clean data and images from storage media as well as hardware.
➢ Document your procedure for disposing of data.
Guideline 7: Testing and Assessment. Psychologists are encouraged to consider the unique issues that may arise with test instruments and assessment approaches designed for in-person implementation when providing telepsychology services.
➢ Know that test results may be compromised, interfere with validity and reliability.
➢ Distractions could effect performance.
➢ Consider trained assistant on site with client/patient.
➢ Be ready to address limitations and potential impact of procedures.
➢ Strive to use test norms derived from actual telepsychological administration if available.
Guideline 8: Interjurisdictional Practice. Psychologists are encouraged to be familiar with and comply with all relevant laws and regulations when providing telepsychology services to clients/patients across jurisdictional and international borders.
➢ Be aware of laws and regulations that specifically address telepsychology within and between jurisdictions.
➢ Be aware of any opinion or declaratory statement issued by relevant regulatory bodies i.e. practitioner licensing boards.
➢ Psychologists strive to keep abreast of developments.
IV. How Do You Do It?
1. Hardware that has video chat ability.
c. Sound input and output. Built in mic/headphones.
d. Pedestal with adjustable height.
a. Skype has been deemed not secure enough by the APA.
b. Secure Telehealth, Jabber, Vidyo, Vsee are all used by institutions that practice tele-health.
c. Both the therapist and patient need to have access to the same program to connect.
3. Internet connectivity
a. A good Internet connection.
b. Password protected.
c. Device specific.
4. Get comfortable being on camera. Practice with friends & family. If you’re self-conscious you are not attending to your client.
a. Set up as if the person were in your office.
b. Keep the camera at arms length at least. No floating head.
c. Eye contact. Look at camera frequently.
d. Close/reduce the look back window.
e. Remember earbuds/mic if you tend to yell. Get used to them.
f. The visual should be professional. Check out what’s behind you. Door closed. Quiet. Secure.
g. Lighting. No back lighting. Indirect, diffused, sunlight is best
h. Home office. Same rules apply. Be aware of ambient noise. Dog barking.
5. Instruct your client what is best from their end.
b. Free from distraction
6. Getting paid.
a. Consider giving initial consult free of charge
b. For now tele-sessions are generally fee for service.
c. Have ability to allow clients to pay with PayPal or Credit card.
d. If your client can only pay by check, get paid before hand like a retainer.
e. Third party payors will occasionally pay for tele-sessions. You would need to check with each individual payor for CPT codes and amount of payment/reimbursement provided.
Be aware of time zones when scheduling.
Let the client initiate the call whenever possible.
Assuming you are a trained, educated, credentialed, behavioral health professional you have the qualifications to use this new medium with responsibility, clinical sensitivity and ethical awareness.
Part of our responsibility as professionals is to always be abreast of new knowledge as it relates to best practices through continuing education. This is particularly important in this new frontier of telepsychology.
If you have anything that would be helpful to share on telepsychology or have any questions please write your thoughts in the comments section. Click the Comments tab just under the title and to the right. I will do my best to address any concerns you may have.