Telemental health has grown in popularity over the last decade as a way for therapists to offer their services via an online or a virtual setting through live interactive video conferencing. This type of online therapy is referred to by different names:
- distance therapy
- behavioral telehealth
- internet therapy
- web therapy
- virtual therapy
- online counseling
Many different disciplines have since started using teletherapy as a model for their practice, refining it as technology improves. It is now being used in private practices, schools, clinics, and hospitals for all ages and ranges of clients.
With telemental health therapy, you and your client log into an online “room” or portal of some kind, much like you would if you were video conferencing or video chatting, to attend the therapy session. You can see each other face-to-face and communicate live, just as you would in an office.
With most video conferencing platforms, you are also able to share your screen, so any worksheets, activities, or sites you want to use during your session, you can share with your client.
Therapy offered via these modes of service should be of equal quality to the therapy that would be provided in person. Each state has its own specific rules and regulations surrounding telemental health.
There are HIPAA compliance and legal issues, with specific variations from state to state. This course will:
- Define telemental health and list the various names for this mode of therapy.
- Explain the benefits of telemental health.
- Explain the possible drawbacks and risks of telemental health.
- Discuss the necessary screening of appropriate clients for telemental health therapy.
- Explore the ethics of teletherapy.
Define Telemental Health
Just as telehealth refers to health care services provided from a distance—whether through online messaging, telephone, or video chat—telemental health is mental or behavioral health services provided through technology. As mentioned above, we can’t all seem to agree on a name…or guidelines and reimbursement, but these are all changing and falling into place rapidly.
It offers mental health care providers a way to practice with their patients even when they move across the country or work with shut-ins who find it difficult or impossible to leave their homes. It also offers patients a way to get the treatment they need with the convenience (and often affordability) they need in their busy lives.
History of Telemental Health
Videoconferencing has been used since the 1950s when the Nebraska Psychiatric Institute was using early video conferencing to provide group therapy, long-term therapy, consultation-liaison psychiatry, and medical student training at the Nebraska state hospital in Norfolk in 1959. Clinicians have been using the telephone as a means to provide mental health support as early as the 1960s. In addition, there have been multiple mental health forums, advice columns, and podcasts throughout the years. We are referring to telemental health, where a client and a clinician meet in a virtual office for therapy seems to have begun around 1995, when Dr. Sommers created online therapy with continual dialogue and a private therapeutic relationship. In the same year, therapist Ed Needham launched Cyberpsych Counseling and charged $15 for each hour-long session he provided. Needham was the first therapist to exclusively use chat rooms to work with clients. In 1997 mental health professionals formed the International Society for Mental Health Online [ISMHO]. Its mission has been to promote and advance online mental health treatments, including online therapy. During the 2000s, online therapy gradually became more popular and widespread. Businesses and therapy practices began trying to expand so they could treat thousands of clients at once. In 2012 Oren and Roni Frank launched Talkspace, an online therapy platform that quickly evolved to offer unlimited messaging therapy. It wasn’t the first company to provide chat rooms for therapists and clients to work together. It did, however, provide online therapy on a historic scale. Even in its earlier stages, the platform gave clients a more robust experience than simply exchanging emails with a therapist. By using the app on their smartphones, clients could send text, video, and voice messages all in the same room, any time they wanted, and without limit. Talkspace has largely defined the online therapy landscape in the 2010s, and many similar companies have followed.
Congress passed the Health Insurance Portability and Accountability Act [HIPAA] in 1996. Since then, HIPAA has been a major factor in determining whether an online health service is ethical and compliant with the law. It is a complicated law with many areas people are still determining how to interpret. At its core, however, is the simple push to ensure health providers keep patient information private and secure.
Ethical controversy emerged as more therapists began practicing online therapy and working with clients outside the states they lived in. Even before online therapy became more popular, state licensing boards forbade mental health professionals from practicing outside the state or states in which they were licensed. Nonetheless, it was not clear whether these state rules applied to online therapy. HIPAA did not necessarily restrict practicing online therapy between states either.
Some therapists believed prohibiting or even frowning upon interstate treatment defeats the purpose of online therapy. Others strictly abided by ethical recommendations and strict interpretations of both HIPAA and state licensing board regulations.
Telemental health is growing by leaps and bounds in 2020 with the outbreak of the Corona Virus COVID-19. Most individuals are self-quarantining during a time of extreme stress. The need for mental health services is increasing. The need for this service mode that enables clients to be safe and seen is at an all-time high.
Benefits of Telemental Health
Telemental health has been shown to be equivalent to in-person care in diagnostic accuracy, treatment effectiveness, and patient satisfaction; it often saves time, money, and other resources.
The use of video-based telemental health is increasing in response to consumer demand for convenient, inexpensive, and readily-accessible services. Technology is no longer a major barrier.
There are pros and cons for both the therapist and the client about telemental health services.
Let’s first take a look at the pros and cons for clinicians.
Pros for Clinicians
- You aren’t tied down to an office, and it can reduce overhead costs not having an office.
- There is a greater ability to expand your reach and help more clients.
- If you provide online counseling out of your home, you can write off a portion of your expenses.
- You can create your ideal schedule to align with your dream lifestyle and private practice.
- You can work just about anywhere, as long as you have a computer and wifi.
- It is convenient.
- You can practice wherever and whenever you want. As long as you are licensed in the state the client resides.
Pros for clients:
- Clients can be treated by the best of the best, regardless of where they live.
- It is convenient.
- There is less stress with getting to and from appointments.
- It is more anonymous in that clients will not sit in lobbies worrying about who will see them, which eases stigma.
- The client remains in the comfort of their own home.
- It is more flexible for their schedule.
- It can be a good option for those with physical limitations.
In addition to convenience and reaching remote populations, there are also two other areas where telemental health can be particularly useful: treating people with an autism spectrum disorder and with severe anxiety disorders.
People with autism spectrum disorder may find it much easier to connect with someone over the phone, where there are fewer “signals” for them to read, like body language and facial expressions.
Further, those with severe anxiety can receive the care they need without having to navigate a potentially triggering commute to the provider’s office, waiting in an uncomfortable waiting room, and interacting with the myriad people they may see on their way to and from their appointment.
Drawbacks of Telemental Health
While online therapy can potentially be very helpful for people in certain situations, at this point, it does not come without some risks or disadvantages over traditional therapy options.
- Some insurance companies will not cover telemental health sessions
- Some states do not allow out-of-state providers
- Concerns about confidentiality and privacy
- Concerns about unreliable technology
- Online therapists cannot respond to crises
- Online Therapy Is Not Appropriate for Those With Serious Psychiatric Illnesses
- There is a loss of body language, vocal signals, and facial expressions
- Lacks intimacy and the intricacy that real-world interactions possess
- Online therapy eliminates geographic restraints, making the enforcement of legal and ethical codes difficult
Many therapists do not like the transition from life to online counseling. I have heard comments from colleagues such as, “I”m not loving it,” “online sessions are EXHAUSTING!” and “I canceled all of my couples sessions. They just didn’t feel effective”. Some will adjust and continue to move forward. Some will find this is not a service mode they work best in.
This method of service delivery has been growing over the last decade but even more so in the early part of 2020 during the Covid-19 virus peak with the period when so many are in self-quarantine with an increase in stress, depression, anxiety, not to mention being in close quarters with family members 24/7. The need is there, but is the reimbursement?
Some states have laws that require, in some form or another, for private insurers and/or that state’s Medicaid program to cover telehealth services. In states without these requirements, insurers may cover it anyways, but not always and sometimes not at the same rate or without additional forms and approvals.
A growing number of private insurers require professionals to perform additional paperwork before they can bill for telemental health sessions. This additional paperwork usually requires the professional to give attestations regarding their telemental health practice procedures. There is not a uniform procedure in place across these companies and states as of the date of this course. Unfortunately, this leaves the mental health professionals needing to contact all the insurers with whom they are paneled to find out what processes they require and seek any necessary assistance from there. That is not a quick or easy process.
It would be wise to inquire with private insurers regarding telemental health coverage rather than simply performing remote sessions and hoping the insurance company will decide to cover them. That has sometimes worked in the past but is becoming increasingly unlikely to work. What’s worse is that it could work at first, but then you could find yourself having to return funds once the insurer realizes they paid for sessions they did not want to pay for.
As for Medicare: it is one of the largest payers for telehealth services, especially those delivered to Medically Underserved Areas (MUAs.)
Ethics of Telemental Health
Almost every behavioral health clinician uses some form of technology in providing services or in their business operations. Technology is part of the industry, whether it is a mobile phone, online scheduling or billing program, online platform for a test, or videoconferencing platform.
Every behavioral health professional association addresses the ethical use of technology. This section will take a glimpse into what the APA, NBCC, NASW, ACA, and AAMFT, say regarding telemental health. If one of these does not pertain to you, then just skim through the section.
American Psychological Association (APA)
Telepsychology is defined, for these guidelines, as the provision of psychological services using telecommunication technologies. Telecommunications is the preparation, transmission, communication, or related processing of information by electrical, electromagnetic, electromechanical, electro-optical, or electronic means (Committee on National Security Systems, 2010). Telecommunication technologies include but are not limited to telephone, mobile devices, interactive videoconferencing, email, chat, text, and Internet (e.g., self-help websites, blogs, and social media). The information that is transmitted may be in writing or include images, sounds, or other data. These 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 or leadership development provided over video conferencing). Different technologies may be used in various combinations and for different purposes during the provision of telepsychology services. For example, videoconferencing and telephone may also be utilized for direct service, while email and text are used for non-direct services (e.g., scheduling). Regardless of the purpose, psychologists strive to be aware of the potential benefits and limitations in their choices of technologies for particular clients in particular situations.
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.
Psychologists have a primary ethical obligation to provide professional services only within the boundaries of their competence based on their education, training, supervised experience, consultation, study, or professional experience. As with all new and emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists utilizing telepsychology aspire to apply the same standards in developing their competence in this area. Psychologists who use telepsychology in their practices assume the responsibility for assessing and continuously evaluating their competencies, training, consultation, experience, and risk management practices required for competent practice.
Psychologists assume the responsibility to continually assess both their professional and technical competence when providing telepsychology services. Psychologists who utilize or intend to utilize telecommunication technologies when delivering services to clients/patients strive to obtain relevant professional training to develop their requisite knowledge and skills. Acquiring competence may require pursuing additional educational experiences and training, including but not limited to, a review of the relevant literature, attendance at existing training programs (e.g., professional and technical), and continuing education specific to the delivery of services utilizing telecommunication technologies. Psychologists are encouraged to seek appropriate skilled consultation from colleagues and other resources.
Psychologists are encouraged to examine the available evidence to determine whether specific telecommunication technologies are suitable for a client/patient, based on the current literature available, current outcomes research, best practice guidance, and client/patient preference. Research may not be available in the use of some specific technologies, and clients/patients should be made aware of those telecommunication technologies that have no evidence of effectiveness. However, this, in and of itself, may not be grounds to deny providing the service to the client/patient. A lack of currently available evidence in a new area of practice does not necessarily indicate that a service is ineffective. Additionally, psychologists are encouraged to document their considerations and choices regarding the use of telecommunication technologies used in service delivery.
Psychologists understand the need to consider their competence in utilizing telepsychology as well as their client’s/patient’s ability to engage in and fully understand the risks and benefits of the proposed intervention utilizing specific technologies. Psychologists make reasonable efforts to understand how cultural, linguistic, socioeconomic, and other individual characteristics (e.g., medical status, psychiatric stability, physical/cognitive disability, personal preferences), in addition to, organizational cultures may impact the effective use of telecommunication technologies in service delivery.
Psychologists who are trained to handle emergencies in providing traditional in-person clinical services, and are generally familiar with the resources available in their local community to assist clients/patients with crisis intervention. At the onset of the delivery of telepsychology services, psychologists make a reasonable effort to identify and learn how to access relevant and appropriate emergency resources in the client’s/patient’s local area, such as emergency response contacts (e.g., emergency telephone numbers, hospital admissions, local referral resources, clinical champion at a partner clinic where services are delivered, a support person in the client’s/patient’s life when available). Psychologists prepare a plan to address any lack of appropriate resources, particularly those necessary in an emergency, and other relevant factors which may impact the efficacy and safety of said service. Psychologists make reasonable efforts to discuss with and provide all clients/patients 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, psychologists are encouraged to acquire knowledge of the laws and rules of the jurisdiction in which the client/patient resides and the differences from those in the psychologist’s jurisdiction, as well as document all their emergency planning efforts.
In addition, as applicable, psychologists are mindful of the array of potential discharge plans for clients/patients when telepsychology services are no longer necessary and/or desirable. If a client/patient recurrently experiences crises/emergencies suggestive that in-person services may be appropriate, psychologists take reasonable steps to refer a client/patient to a local mental health resource or begin providing in-person services.
Psychologists using telepsychology to provide supervision or consultation remotely to individuals or organizations are encouraged to consult others who are knowledgeable about the unique issues telecommunication technologies pose for supervision or consultation. Psychologists providing telepsychology services strive to be familiar with professional literature regarding the delivery of services via telecommunication technologies, as well as competent with the use of the technological modality itself. In providing supervision and/or consultation via telepsychology, psychologists make reasonable efforts to be proficient in the professional services being offered, the telecommunication modality via which the services are being offered by the supervisee/consultee, and the technology medium being used to provide the supervision or consultation. In addition, since the development of basic professional competencies for supervisees is often conducted in person, psychologists who use telepsychology for supervision are encouraged to consider and ensure that a sufficient amount of in-person supervision time is included so that the supervisees can attain the required competencies or supervised experiences.
Guideline 2: Standards of Care in the Delivery of Telepsychology Services
Psychologists make every effort to ensure that ethical and professional standards of care and practice are met at the outset and throughout the telepsychology services they provide.
Psychologists delivering telepsychology services apply the same ethical and professional standards of care and professional practice that are required when providing in-person psychological services. The use of telecommunication technologies in the delivery of psychological services is a relatively new and rapidly evolving area, and therefore psychologists are encouraged to take particular care to evaluate and assess the appropriateness of utilizing these technologies before engaging in, and throughout, telepsychology practice to determine if the modality of service is appropriate, efficacious and safe.
Telepsychology encompasses a breadth of different psychological services using a variety of technologies (e.g., interactive videoconferencing, telephone, text, email, web services, and mobile applications). The burgeoning research in telepsychology suggests the effectiveness of certain types of interactive telepsychological interventions to their in-person counterparts (specific therapies delivered over video teleconferencing and telephone). Therefore, before psychologists engage in providing telepsychology services, they are urged to conduct an initial assessment to determine the appropriateness of the telepsychology service to be provided for the client/patient. Such an assessment may include the examination of the potential risks and benefits to provide telepsychology services for the client’s/patient’s particular needs, the multicultural and ethical issues that may arise, and a review of the most appropriate medium (e.g., video teleconference, 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 telepsychology are equivalent or preferable to such services. In addition, it is incumbent on the psychologist to engage in a continual assessment of the appropriateness of providing telepsychology services throughout the service delivery.
When providing telepsychology services, considering client/patient preferences for such services is important. However, it may not be solely determinative in the assessment of their appropriateness. Psychologists are encouraged to carefully examine the unique benefits of delivering telepsychology services (e.g., access to care, access to consulting services, client convenience, accommodating client special needs, etc.) relative to the unique risks (e.g., information security, emergency management, etc.) when determining whether or not to offer telepsychology services. Moreover, psychologists are aware of such other factors as geographic location, organizational culture, technological competence (both psychologist and client/patient), and, as appropriate, medical conditions, mental status and stability, psychiatric diagnosis, current or historic use of substances, treatment history, and therapeutic needs that may be relevant to assessing the appropriateness of the telepsychology services being offered. Furthermore, psychologists are encouraged to communicate any risks and benefits of the telepsychology services to be offered to the client/patient and document such communication. In addition, psychologists may consider some initial in-person contact with the client/patient to facilitate an active discussion on these issues and/or conduct the initial assessment.
As in the provision of traditional services, psychologists endeavor to follow the best practice of service delivery described in the empirical literature and professional standards (including multicultural considerations) that are relevant to the telepsychological service modality being offered. In addition, they consider the client’s/patient’s familiarity with and competency for using the specific technologies involved in providing the particular telepsychology service. Moreover, psychologists are encouraged to reflect on multicultural considerations and how best to manage any emergency that may arise during the provision of telepsychology services.
Psychologists are encouraged to 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 telepsychology. Such an assessment of the remote environment may include a discussion of the client’s/patient’s situation within the home or within an organizational context, the availability of emergency or technical personnel or supports, risk of distractions, the potential for privacy breaches, or any other impediments that may impact the effective delivery of telepsychology services. Along this line, psychologists are encouraged to discuss fully with the clients/patients their role in ensuring that sessions are not interrupted and that the setting is comfortable and conducive to making progress to maximize the impact of the service provided since the psychologist will not be able to control those factors remotely.
Psychologists are urged to monitor and assess regularly the progress of their client/patient when offering telepsychology services to determine if the provision of telepsychology services is still appropriate and beneficial to the client/patient. If there is a significant change in the client/patient or the therapeutic interaction to cause concern, psychologists make a reasonable effort to take appropriate steps to adjust and reassess the appropriateness of the services delivered via telepsychology. Where it is believed that continuing to provide remote services is no longer beneficial or presents a risk to a client’s/patient’s emotional or physical well-being, psychologists are encouraged to thoroughly discuss these concerns with the client/patient, appropriately terminate their remote services with adequate notice and refer or offer any needed alternative services to the client/patient.
Guideline 3: Informed Consent
Psychologists strive to obtain and document 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.
The process of explaining and obtaining informed consent, by whatever means obtained, sets the stage for the relationship between the psychologist and the client/patient. Psychologists make a reasonable effort to offer a complete and clear description of the telepsychology services they provide, and seek to obtain and document informed consent when providing professional services (APA Ethics Code, Standard 3.10). In addition, they attempt to develop and share the policies and procedures that will explain to their clients/patients how they will interact with them using the specific telecommunication technologies involved. It may be more difficult to obtain and document informed consent in situations where psychologists provide telepsychology services to their clients/patients who are not in the same physical location, or with whom they do not have in-person interactions. . Moreover, there may be differences concerning informed consent between the laws and regulations in the jurisdictions where a psychologist who is providing telepsychology services is located and the jurisdiction in which this psychologist’s client/patient resides. Furthermore, psychologists may need to be aware of how cultural, linguistic, socioeconomic characteristics, and organizational considerations may impact a client’s/patient’s understanding of, and the special considerations required for, obtaining informed consent (such as when securing informed consent remotely from a parent/guardian when providing telepsychology services to a minor).
Telepsychology services may require different considerations for and safeguards against potential risks to, confidentiality, information security, and comparability of traditional in-person services. Psychologists are thus encouraged to consider appropriate policies and procedures to address the potential threats to the security of client/patient data and information when using specific telecommunication technologies and appropriately inform their clients/patients about them. For example, psychologists who provide telepsychology services consider addressing with their clients/patients what client/patient data and information will be stored, how the data and information will be stored, how it will be accessed, how secure the information communicated using a given technology, and any technology-related vulnerability to confidentiality and security by creating and storing electronic client/patient data and information.
Before providing telepsychology services, psychologists are aware of the importance of obtaining and documenting written informed consent from their clients/patients that specifically addresses the unique concerns relevant to those services that will be offered. When developing such informed consent, psychologists make a reasonable effort to use language that is reasonably understandable to their clients/patients, in addition to, evaluating the need to address cultural, linguistic, and organizational considerations and other issues that may impact a client’s/patient’s understanding of the informed consent agreement. When considering for inclusion in informed consent those unique concerns that may be involved in providing telepsychology services, psychologists may include the manner in which they and their clients/patients will use the particular telecommunication technologies, the boundaries they will establish and observe, and the procedures for responding to electronic communications from clients/patients. Moreover, psychologists are cognizant of pertinent laws and regulations with respect to informed consent in both the jurisdiction where they offer their services and where their clients/patients reside (see Guideline on Interjurisdictional Practice for more detail).
Besides those unique concerns described above, psychologists are encouraged to discuss with their clients/patients those issues surrounding confidentiality and the security conditions when particular modes of telecommunication technologies are utilized. Along this line, psychologists are cognizant of some of the inherent risks a given telecommunication technology may pose in both the equipment (hardware, software, other equipment components) and the processes used for providing telepsychology services, and strive to provide their clients/patients with adequate information to give informed consent for proceeding with receiving the professional services offered via telepsychology. Some of these risks may include those associated with technological problems and those service limitations that may arise because the continuity, availability, and appropriateness of specific telepsychology services (e.g. testing, assessment, and therapy) may be hindered as a result of those services being offered remotely. In addition, psychologists may consider developing agreements with their clients/patients to assume some role in protecting the data and information they receive from them (e.g. by not forwarding emails from the psychologist to others).
Another unique aspect of providing telepsychology services is that of billing documentation. As part of informed consent, psychologists are mindful of the need to discuss with their clients/patients what the billing documentation will include prior to the onset of service provision. Billing documentation may reflect the type of telecommunication technology used, the type of telepsychology services provided, and the fee structure for each relevant telepsychology service (e.g., video chat, texting fees, telephone services, chat room group fees, emergency scheduling, etc.). It may also include a discussion about the charges incurred for any service interruptions or failures encountered, responsibility for overage charges on data plans, fee reductions for technology failures, and any other costs associated with the telepsychology services that will be provided.
Guideline 4: Confidentiality of Data and Information
Psychologists who provide telepsychology services make a reasonable 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 telecommunication technologies if any.
The use of telecommunications technologies and the rapid advances in technology present unique challenges for psychologists in protecting the confidentiality of clients/patients. Psychologists who provide telepsychology learn about the potential risks to confidentiality before utilizing such technologies. When necessary, psychologists obtain the appropriate consultation with technology experts to augment their knowledge of telecommunication technologies in order to apply security measures in their practices that will protect and maintain the confidentiality of data and information related to their clients/patients.
Some of the potential risks to confidentiality include considerations related to uses of search engines and participation in social networking sites. Other challenges in this area may include protecting confidential data and information from inappropriate and/or inadvertent breaches to established security methods the psychologist has in place, as well as boundary issues that may arise as a result of a psychologist’s use of search engines and participation on social networking sites. In addition, any Internet participation by psychologists has the potential of being discovered by their clients/patients and others and thereby potentially compromising a professional relationship.
Psychologists both understand and inform their clients/patients 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 (e.g. telephone, email) between the psychologist and client/patient. Also, psychologists are cognizant of the ethical and practical implications of proactively researching online personal information about their clients/patients. They carefully consider the advisability of discussing such research activities with their clients/patients and how information gained from such searches would be utilized and recorded as documenting this information may introduce risks to the boundaries of appropriate conduct for a psychologist. In addition, psychologists are encouraged to weigh the risks and benefits of dual relationships that may develop with their clients/patients, due to the use of telecommunication technologies, before engaging in such relationships (APAPO, 2012).
Psychologists who use social networking sites for both professional and personal purposes are encouraged to review and educate themselves about the potential risks to privacy and confidentiality and consider utilizing all available privacy settings to reduce these risks. They are also mindful of the possibility that any electronic communication can have a high risk of public discovery. They, therefore, mitigate such risks by following the appropriate laws, regulations, and the APA Ethics Code (APA, 2010) to avoid disclosing confidential data or information related to clients/patients.
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.
The use of telecommunication technologies in the provision of psychological services presents unique potential threats to the security and transmission of client/patient data and information. These potential threats to the integrity of data and information may include computer viruses, hackers, theft of technology devices, damage to hard drives or portable drives, failure of security systems, flawed software, ease of accessibility to unsecured electronic files, and malfunctioning or outdated technology. Other threats may include policies and practices of technology companies and vendors such as tailored marketing derived from email communications. Psychologists are encouraged to be mindful of these potential threats, and take reasonable steps to ensure that security measures are in place for protecting and controlling access to client/patient data within an information system. In addition, they are cognizant of relevant jurisdictional and federal laws and regulations that govern the electronic storage and transmission of client/patient data and information and develop appropriate policies and procedures to comply with such directives. When developing policies and procedures to ensure the security of client/patient data and information, psychologists may include considering the unique concerns and impacts posed by both intended and unintended use of public and private technology devices, active and inactive therapeutic relationships, and the different safeguards required for different physical environments, different staff (e.g. professional versus administrative staff), and different telecommunication technologies.
Psychologists are encouraged to conduct an analysis of the risks to their practice setting, telecommunication technologies, and administrative staff, to ensure that client/patient data and information is accessible only to appropriate and authorized individuals. Psychologists strive to obtain appropriate training or consultation from relevant experts when additional knowledge is needed to conduct an analysis of the risks.
Psychologists strive to ensure that policies and procedures are in place to secure and control access to client/patient information and data within information systems. Along this line, they may encrypt confidential client/patient data 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. If there is a breach of unencrypted electronically communicated or maintained data, psychologists are urged to notify their clients/patients and other appropriate individuals/organizations as soon as possible. In addition, they are encouraged to make their best efforts to ensure that electronic data and information remain accessible despite problems with hardware, software, and/or storage devices by keeping a secure backup version of such data.
When documenting the security measures to protect client/patient data and information from unintended access or disclosure, psychologists are encouraged to clearly address what types of telecommunication technologies are used (e.g., email, telephone, video teleconferencing, text), how they are used, whether telepsychology services used are the primary method of contact or augments in-person contact. When keeping records of email, online messaging, and other work using telecommunication technologies, psychologists are cognizant that preserving the actual communication may be preferable to summarization in some cases depending on the type of technology used.
Guideline 6: Disposal of Data and Information and Technologies
Psychologists who provide telepsychology services make reasonable efforts 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.
Consistent with APA Record Keeping Guidelines (2007), psychologists are encouraged to create policies and procedures for the secure destruction of data and information and the technologies used to create, store and transmit the data and information. The use of telecommunication technologies in the provision of psychological services poses new challenges for psychologists when they consider the disposal methods to utilize in order to maximally preserve client confidentiality and privacy. Psychologists are therefore urged to consider conducting an analysis of the risks to the information systems within their practices in an effort to ensure full and complete disposal of electronic data and information, plus the technologies that created, stored, and transmitted the data and information.
Psychologists are encouraged to develop policies and procedures for the destruction of data and information related to clients/patients. They also strive to securely dispose of software and hardware used in the provision of telepsychology services in a manner that insures that the confidentiality and security of any patient/client information are not compromised. When doing so, psychologists carefully clean all the data and images in the storage media before re-use or disposal consistent with federal, state, provincial, territorial, and other organizational regulations and guidelines. Psychologists are aware of and understand the unique storage implications related to telecommunication technologies inherent in available systems.
Psychologists are encouraged to document the methods and procedures used when disposing of the data and information and the technologies used to create, store, or transmit the data and information, as well as any other technology utilized in the disposal of data and hardware. They also strive to be aware of malware, cookies, etc., and dispose routinely of them on an ongoing basis when telecommunication technologies are used.
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.
Psychological testing and other assessment procedures are an area of professional practice in which psychologists have been trained and are uniquely qualified to conduct. While some symptom screening instruments are already being administered online frequently, most psychological test instruments and other assessment procedures currently in use have been designed and developed originally for in-person administration. Psychologists are thus encouraged to be knowledgeable about, and account for, the unique impacts, suitability for diverse populations, and limitations on test administration and on test and other data interpretations when these psychological tests and other assessment procedures are considered for and conducted via telepsychology. Psychologists also strive to maintain the integrity of the application of the testing and assessment process and procedures when using telecommunication technologies. In addition, they are cognizant of the accommodations for diverse populations that may be required for test administration via telepsychology. These guidelines are consistent with the standards articulated in the most recent edition of Standards for educational and psychological testing (American Educational Research Association, American Psychological Association, and the Council on Measurement in Education).
When a psychological test or other assessment procedure is conducted via telepsychology, psychologists are encouraged to ensure that the integrity of the psychometric properties of the test or assessment procedure (e.g., reliability and validity) and the conditions of administration indicated in the test manual are preserved when adapted for use with such technologies. They are encouraged to consider if modifications to the testing environment or conditions are necessary to accomplish this preservation. For example, access to a cell phone, the Internet or other persons during an assessment could interfere with the reliability or validity of the instrument or administration. Further, if the individual being assessed receives coaching or such information as potential responses or the scoring and interpretation of specific assessment instruments because they are available on the Internet, the test results may be compromised. Psychologists are also encouraged to consider other possible forms of distraction that could affect performance during an assessment and which may not be obvious or visible (e.g., sight, sound, and smell) when utilizing telecommunication technologies.
Psychologists are encouraged to be cognizant of the specific issues that may arise with diverse populations when providing telepsychology and make appropriate arrangements to address those concerns (e.g., language or cultural issues; cognitive, physical, or sensory skills or impairments; or age may impact assessment). In addition, psychologists may consider the use of a trained assistant (e.g., proctor) to be on-premise at the remote location in an effort to help verify the identity of the client/patient, provide needed on-site support to administer certain tests or subtests, and protect the security of the psychological testing and/or assessment process.
When administering psychological tests and other assessment procedures when providing telepsychology services, psychologists are encouraged to consider the quality of those technologies that are being used and the hardware requirements that are needed in order to conduct the specific psychological test or assessment approach. They also strive to account for and be prepared to explain the potential difference between the results obtained when a particular psychological test is conducted via telepsychology and when it is administered in person. In addition, when documenting findings from evaluation and assessment procedures, psychologists are encouraged to specify that a particular test or assessment procedure has been administered via telepsychology, and describe any accommodations or modifications that have been made.
Psychologists strive to use test norms derived from telecommunication technologies administration if such are available. Psychologists are encouraged to recognize the potential limitations of all assessment processes conducted via telepsychology and be ready to address the limitations and potential impact of those procedures.
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.
With the rapid advances in telecommunication technologies, the intentional or unintentional provision of psychological services across jurisdictional and international borders is becoming more of a reality for psychologists. Such service providers may range from the psychologists or clients/patients being temporarily out-of-state (including split residence across states) to psychologists offering their services across jurisdictional borders as a practice modality to take advantage of new telecommunication technologies. Psychological service delivery systems within such institutions as the U.S. Department of Defense and the Department of Veterans Affairs have already established internal policies and procedures for providing services within their systems that cross-jurisdictional and international borders. However, the laws and regulations that govern service delivery by psychologists outside of those systems vary by state, province, territory, and country (APAPO, 2010). Psychologists should make a reasonable effort to be familiar with and, as appropriate, to address the laws and regulations that govern telepsychology service delivery within the jurisdictions in which they are situated and the jurisdictions where their clients/patients are located.
It is important for psychologists to be aware of the relevant laws and regulations that specifically address the delivery of professional services by psychologists via telecommunication technologies within and between jurisdictions. Psychologists are encouraged to understand what the laws and regulations consider as telehealth or telepsychology. In addition, psychologists are encouraged to review the professional licensure requirements, the services, and telecommunication modalities covered, and the information required to be included in providing informed consent. It is important to note that each jurisdiction may or may not have specific laws which impose special requirements when providing services via telecommunication technologies. The APAPO (2010) has found that there are variations in whether psychologists are specified as a single type of provider or covered as part of a more diverse group of providers. In addition, there is wide diversity in the types of services and telecommunication technologies that are covered by these laws.
At the present time, there are a number of jurisdictions without specific laws that govern the provision of psychological services utilizing telecommunication technologies. When providing telepsychology services in these jurisdictions, psychologists are encouraged to be aware of any opinion or declaratory statement issued by the relevant regulatory bodies and/or other practitioner licensing boards that may help inform them of the legal and regulatory requirements involved when delivering telepsychology services within those jurisdictions.
Moreover, because of the rapid growth in the utilization of telecommunication technologies, psychologists strive to keep abreast of developments and changes in the licensure and other inter-jurisdictional practice requirements that may be pertinent to their delivery of telepsychology services across jurisdictional boundaries. Given the direction of various health professions, and current federal priorities to resolve problems created by requirements of multi-jurisdictional licensure, (citations e.g., FCC National Broadband Plan, 2010, Canadian Agreement on Internal Trade 1995), the development of a telepsychology credential required by psychology boards for inter-jurisdictional practice is a probable outcome. For example, nursing has developed a credential that is accepted by many US jurisdictions that allow nurses licensed in any participating jurisdiction to practice in person or remotely in all participating jurisdictions. In addition, an ASPPB Task Force has drafted a set of recommendations for such a credential.
It is important to note, that it is not the intent of these guidelines to prescribe specific actions, but rather, to offer the best guidance available at present when incorporating telecommunication technologies in the provision of psychological services. Because technology and its applicability to the profession of psychology is a dynamic area with many changes likely ahead, these guidelines also are not inclusive of all other considerations and are not intended to take precedence over the judgment of psychologists or applicable laws and regulations that guide the profession and practice of psychology. It is hoped that the framework presented will guide psychologists as the field evolves.
National Board of Certified Counselors (NBCC)
The National Board for Certified Counselors (NBCC) is a not-for-profit organization dedicated to the
identification of counselors who have voluntarily met national standards based on research in the profession.
NBCC’s mission also includes the promotion of quality assurance and professionalism in counseling practice.
In connection with the mission to promote quality assurance, NBCC recognized the potential impact of
computers on the counseling profession decades ago. After conducting research with experts in the field, NBCC
adopted the Standards for the Ethical Practice of WebCounseling in 1997, the first of such standards in the
mental health profession. Given the evolution of the technology in this area, the NBCC Board of Directors has
regularly reviewed these standards and adopted revised policies such as The Practice of Internet Counseling.
The most recent review of the practice of internet counseling supports a revision in the standards, and the
resulting information demonstrated the following fundamental concepts:
1. Counseling through distance means presents unique ethical dilemmas to professional counselors.
2. Related technology continues to advance and be used more by increasing numbers of professional
3. Use of technology by counselors continues to evolve.
In light of this information, the policy regarding internet counseling has been revised, and this document, the
NBCC Policy Regarding the Provision of Distance Professional Services replaces previous editions.
One of the most recognizable differences in this policy is the use of the term “distance professional services.”
Rather than focusing only on the provision of “internet counseling,” this policy expands the terminology to
include other types of professional services that are starting to be used more in distance formats.
Other key terms with regard to this policy include:
Face-to-face refers to services that involve the synchronous interaction between an individual or groups
of people using what is seen and heard in person to communicate.
Distance professional services involve the use of electronic or other means (e.g., telephones or
computers) to provide services such as counseling, supervision, consultation, or education.
Counseling is a professional relationship that empowers diverse individuals, families, and groups to
accomplish mental health, wellness, education, and career goals.
Supervision is a contracted, hierarchical relationship between two or more professionals. The intended
focus of supervision is on the augmentation of a supervisee’s professional services.
Consultation is a deliberate agreement between two or more professionals to work together to increase
the effectiveness of professional services in relation to a specific individual (client, student, or supervisee).
Common methods for the provision of distance professional services include the following:
• Telephone-based refers to the synchronous distance interaction in which information is received only
through audio means.
• Email-based refers to the asynchronous distance interaction in which information is received through
written text messages or email.
• Chat-based refers to the synchronous distance interaction in which information is received through
• Video-based refers to the synchronous distance interaction in which information is received via video
and audio mechanisms.
• Social network-based refers to the synchronous or asynchronous distance interaction in which
information is exchanged through social networking mechanisms.
All of the above-mentioned examples of distance professional services may be conducted with individuals,
couples, families, or group members.
The NBCC Policy Regarding the Provision of Distance Professional Services identifies specific actions National
Certified Counselors (NCCs) must take when providing distance services. NBCC recognizes that some counselors
provide a combination of face-to-face and distance services even in the context of one particular client or
supervisee; therefore, the standards described in this policy supplement the directives identified in the National
Board for Certified Counselors (NBCC) Code of Ethics.
STANDARDS FOR DISTANCE PROFESSIONAL SERVICES
1. NCCs shall adhere to all NBCC policies and procedures, including the Code of Ethics.
2. NCCs shall provide only those services for which they are qualified by education and experience.
NCCs shall also consider their qualifications to offer such service via distance means.
3. NCCs shall carefully adhere to legal regulations before providing distance services. This review
shall include legal regulations from the state in which the counselor is located as well as those from
the recipient’s location. Given that NCCs may be offering distance services to individuals in different
states at any one time, the NCC shall document relevant state regulations in the respective record(s).
4. NCCs shall ensure that any electronic means used in distance service provision are in compliance
with current regulatory standards.
5. NCCs shall use encryption security for all digital technology communications of a therapeutic
type. Information regarding security should be communicated to individuals who receive distance
services. Despite the use of reasonable security safeguards, distance service recipients shall be
informed of the potential risks of distance communications. Not the least of these considerations
is the warning about entering private information when using a public access or computer that is on a
shared network. NCCs shall caution recipients of distance services against using “auto-remember”
user names and passwords. NCCs shall also inform recipients of distance services to consider
employers’ policies relating to the use of work computers for personal communications.
6. To prevent the loss of digital communications or records, NCCs who provide distance services
shall maintain secure backup systems. If the backup system is also a digital mechanism, this too
shall offer encryption-level security. This information shall be provided to the recipient of
7. NCCs shall screen potential distance service recipients for appropriateness to receive services via
distance methods. These considerations shall be documented in the records.
8. During the screening or intake process, NCCs shall provide potential recipients with a detailed
a written description of the distance counseling process and service provision. This information shall
be specific to the identified service delivery type and include considerations for that particular
individual. These considerations shall include the appropriateness of distance counseling in relation
to the specific goal, the format of service delivery, and the associated needs (i.e., computer with
certain capabilities, etc.), the limitations of confidentiality, privacy concerns, the possibility of
technological failure, anticipated response time to electronic communication, alternate service
deliveries, and any additional considerations necessary to assist the potential recipient in reaching a
determination about the appropriateness of this service delivery format for their need(s). NCCs shall
discuss this information at key times throughout the service delivery process to ensure that this
method satisfies the anticipated goals, and if not, the NCC will document the discussion of
alternative options and referrals in the client’s record.
9. Because of the ease in which digital communications can inadvertently be sent to other individuals,
NCCs shall adopt behaviors to prevent the distribution of confidential information to unauthorized
individuals. NCCs shall discuss actions the recipient may take to reduce the possibility that they will
send information to other individuals by mistake.
10. NCCs shall provide recipients of distance professional services with information concerning their
professional credentials and links to the respective credentialing organization websites.
11. NCCs, either prior to or during the initial session, shall inform recipients of the purposes, goals,
procedures, limitations, potential risks, and benefits of services and techniques. NCCs also shall
provide information about rights and responsibilities as appropriate to the distance service. As a
part of this type of service provision, NCCs shall discuss with recipients the associated challenges
that may occur when communicating through distance means, including those associated with
privacy and confidentiality.
12. In the event that the recipient of distance services is a minor or is unable to provide legal consent,
the NCC shall obtain a legal guardian’s consent prior to the provision of distance services.
Furthermore, NCCs shall retain copies of documentation indicating the legal guardian’s identity in
the recipient’s file.
13. NCCs shall avoid the use of public social media sources (e.g., tweets, blogs) to provide
confidential information. To facilitate the secure provision of information, NCCs shall provide in
writing the appropriate ways to contact them.
14. NCCs shall discuss with recipients the importance of identifying recipient-named contacts in the
event of identified emergency situations. As a part of this discussion, NCCs will identify the
circumstances in which the individuals will be contacted and what information will be shared
with emergency contacts. NCCs will provide recipients of distance services with specific written
procedures regarding emergency situations. This information shall include emergency responders
near the recipient’s location. Given the increased dangers intrinsic to providing certain distance
professional services, NCCs shall take reasonable steps to secure reasonable referrals for recipients
15. NCCs shall develop written procedures for verifying the identity of the recipient, his or her current
locations, 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
16. NCCs shall limit the use of information obtained through social media sources (e.g., Facebook,
LinkedIn, Twitter) in accordance with established practice procedures provided to the recipient
at the initiation of services or adapted through an ongoing informed consent process.
17. NCCs shall provide information concerning locations where members of the public may access the
Internet free of charge or provide information regarding the location of complimentary web
communication services. In such cases, the informed consent process shall include the required
discussion items, including how this affects confidentiality and privacy.
18. NCCs shall retain copies of all written communications with distance service recipients. Examples
of written communications including email/text messages, instant messages, and histories of chat-
based discussions even if they are related to housekeeping issues such as change of contact
information or scheduling appointments.
19. At a minimum, NCCs shall retain distance service records for a minimum of five years unless
state laws require additional time. NCCs shall limit the use of records to those permitted by law,
professional standards, and as specified by the agreement with the respective recipient of distance
20. NCCs shall develop written procedures for the use of social media and other related digital
technology with current and former recipients. These written procedures shall, at a minimum,
provide appropriate protections against the disclosure of confidential information and the creation
of multiple relationships. These procedures shall also identify that personal accounts are distinct
from any used for professional purposes.
National Association of Social Workers (NASW)
Social workers should become familiar with a number of key additions to the NASW Code of Ethics. The most significant updates to the code include the following:
• Encourage social workers to discuss with clients policies concerning use of technology in the provision of professional services. Clients should have a clear understanding of the ways in which social workers use technology to deliver services, communicate with clients, search for information about clients online, and store sensitive information about clients.
• Encourage social workers who plan to use technology in the provision of services to obtain client consent to the use of technology at the beginning of the professional-client relationship.
• Advise social workers who use technology to communicate with clients to assess each client’s capacity to provide informed consent.
• Advise social workers to verify the identity and location of clients they serve remotely (especially in case there is an emergency and to enable social workers to comply with laws in the client’s jurisdiction).
• Alert social workers to the need to assess clients’ ability to access and use technology, particularly for online and remote services. They also encourage social workers to help clients identify alternate methods of service delivery if the use of technology to deliver services is not appropriate.
• Advise social workers to obtain client consent before conducting an online search for information about clients, as a way to respect clients’ privacy (unless there are emergency circumstances).
• Highlight the need for social workers to understand the special communication challenges associated with electronic and remote service delivery and how to address these challenges.
• Advise social workers who use technology to comply with the laws of both the jurisdiction where the social worker is regulated and located and where the client is located (given that social workers and clients might be in different states or countries).
• Advise social workers to be aware of, assess, and respond to cultural, environmental, economic, disability, linguistic, and other social diversity issues that may affect delivery or use of services.
• Discourage social workers from communicating with clients using technology for personal or nonwork-related purposes, in order to maintain appropriate boundaries.
• Advise social workers to take reasonable steps to prevent client access to social workers’ personal social networking sites and personal technology, again to avoid boundary confusion and inappropriate dual relationships.
• Suggest that social workers should be aware that posting personal information on professional websites or other media could cause boundary confusion, inappropriate dual relationships, or harm to clients.
• Remind social workers to be aware that clients may discover personal information about them based on their personal affiliations and use of social media.
• Suggest that social workers should avoid accepting requests from or engaging in personal relationships with clients on online social networks or other electronic media.
• Advise social workers to take reasonable steps (such as use of encryption, firewalls, and secure passwords) to protect the confidentiality of electronic communications, including information provided to clients or third parties.
• Advise social workers to develop and disclose policies and procedures for notifying clients of any breach of confidential information in a timely manner.
• Advise social workers to inform clients of unauthorized access to the social worker’s electronic communication or storage systems (e.g., cloud storage).
• Advise social workers to develop and inform clients about their policies on the use of electronic technology to gather information about clients.
• Advise social workers to avoid posting any identifying or confidential information about clients on professional websites or other forms of social media.
• Advise social workers using technology to facilitate evaluation or research to obtain clients’ informed consent for the use of such technology. They also encourage social workers to assess clients’ ability to use the technology and, when appropriate, offer reasonable alternatives.
American Association of Marriage and Family Therapists (AAMFT)
STANDARD VITECHNOLOGY-ASSISTED PROFESSIONAL SERVICES
Therapy, supervision, and other professional services engaged in by marriage and family therapists take place over an increasing number of technological platforms. There are great benefits and responsibilities inherent in both the traditional therapeutic and supervision contexts, as well as in the utilization of technologically-assisted professional services. This standard addresses basic ethical requirements of offering therapy, supervision, and related professional services using electronic means.
6.1 Technology Assisted Services.
Prior to commencing therapy or supervision services through electronic means (including but not limited to phone and Internet), marriage and family therapists ensure that they are compliant with all relevant laws for the delivery of such services. Additionally, marriage and family therapists must: (a) determine that technologically-assisted services or supervision are appropriate for clients or supervisees, considering professional, intellectual, emotional, and physical needs; (b) inform clients or supervisees of the potential risks and benefits associated with technologically-assisted services; (c) ensure the security of their communication medium; and (d) only commence electronic therapy or supervision after appropriate education, training, or supervised experience using the relevant technology.
6.2 Consent to Treat or Supervise.
Clients and supervisees, 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 and supervisees in writing of these risks, and of both the therapist’s and clients’/supervisees’ responsibilities for minimizing such risks.
6.3 Confidentiality and Professional Responsibilities.
It is the therapist’s or supervisor’s responsibility to choose technological platforms that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology.
6.4 Technology and Documentation.
Therapists and supervisors are to ensure that all documentation containing identifying or otherwise sensitive information which is electronically stored and/or transferred is done using technology that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology.
6.5 Location of Services and Practice.
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.
6.6 Training and Use of Current Technology.
Marriage and family therapists 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 best serve the professional needs of clients and supervisees.
American Counseling Association (ACA)
The ACA devotes a separate section (Section H) to “Distance Counseling, Technology, and Social Media” where it spells out guidelines regarding limitations, access, informed consent, use of the Web, and more, regarding telehealth and related issues.
ACA Code of Ethics, 2014
B.3.e Transmitting Confidential Information
Counselors take precautions to ensurethe confidentiality of all information transmitted through the use of any medium.
Section H. Distance Counseling, Technology, and Social Media
Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attemptto protect confidentiality and meet any legal and ethical requirements for the use of such resources.
H.1. Knowledge andLegal Considerations
Counselors who engage in the use of distance counseling, technology, and/or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (e.g., special certifications, additional course work).
H.1.b. Laws and Statutes
Counselors who engage in the use of distance counseling, technology, and social media within their counseling practice understand that they may be subject to laws and regulations of both the counselor’s practicing location and the client’s place of residence. Counselors ensure that their clients are aware of pertinent legal rights and limitations governing the practice of counseling across state lines or international boundaries.
H.2. Informed Consent and Security
H.2.a. Informed Consent and Disclosure
Clients have the freedom to choose whether to use distance counseling, social media, and/or technology within the counseling process. In addition to the usual and customary protocol of informed consent between counselor and client for face-to-face counseling, the following issues, unique to the use of distance counseling, technology, and/or social media, are addressed in the informed consent process:
- distance counseling credentials, physical location of practice, and contact information;
- risks and benefits of engaging in the use of distance counseling, technology, and/or social media;
- possibility of technology failure and alternate methods of service delivery;
- anticipated response time;
- emergency procedures to follow when the counselor is not available;
- time zone differences;
- cultural and/or language differences that may affect delivery of services; possible denial of insurance benefits; and
- social media policy.
H.2.b. Confidentiality Maintained by the Counselor
Counselors acknowledge the limitations of maintaining the confidentiality of electronic records and transmissions. They inform clients that individuals might have authorized or unauthorized access to such records or transmissions (e.g., colleagues, supervisors, employees, information technologists).
H.2.c. Acknowledgment of Limitations
Counselors inform clients about the inherent limits of confidentiality when using technology. Counselors urge clients to be aware of authorized and/or unauthorized access to information disclosed using this medium in the counseling process.
Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements. Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means.
H.3. Client Verification
Counselors who engage in the use of distance counseling, technology, and/or social media to interact with clients take steps to verify the client’s identity at the beginning and throughout the therapeutic process. Verification can include, but is not limited to, using code words, numbers, graphics, or other nondescript identifiers.
H.4. Distance Counseling Relationship
H.4.a. Benefits and Limitations
Counselors inform clients of the benefits and limitations of using technology applications in the provision of counseling services. Such technologies include, but are not limited to, computer hardware and/or software, telephones and applications, social media and Internet-based applications and other audio and/or video communication, or data storage devices or media.
H.4.b. Professional Boundaries in Distance Counseling
Counselors understand the necessity of maintaining a professional relationship with their clients. Counselors discuss and 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, times when not appropriate to use).
When providing technology-assisted services, counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client. Counselors verify that clients understand the purpose and operation of technology applications and follow up with clients to correct possible misconceptions, discover appropriate use, and assess subsequent steps.
H.4.d. Effectiveness of Services
When distance counseling services are deemed ineffective by the counselor or client, counselors consider delivering services face-to-face. If the counselor is not able to provide face-to-face services (e.g., lives in another state), the counselor assists the client in identifying appropriate services.
Counselors provide information to clients regarding reasonable access to pertinent applications when providing technology-assisted services.
H.4.f. Communication Differences in Electronic Media
Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.
H.5. Records andWeb Maintenance
Counselors maintain electronic records in accordance with relevant laws and statutes. Counselors inform clients on how records 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.
H.5.b. Client Rights
Counselors who offer distance counseling services and/or maintain a professional website provide electronic links to relevant licensure and professional certification boards to protect consumer and client rights and address ethical concerns.
H.5.c. Electronic Links
Counselors regularly ensure that electronic links are working and are professionally appropriate.
H.5.d. Multicultural andDisability Considerations
Counselors who maintain websites provide accessibility to persons with disabilities. They provide translation capabilities for clients who have a different primary language, when feasible. Counselors acknowledge the imperfect nature of such translations and accessibilities.
H.6. Social Media
H.6.a. Virtual Professional Presence
In cases where counselors wish to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles are created to clearly distinguish between the two kinds of virtual presence.
H.6.b. Social Media as Part of Informed Consent
Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media.
H.6.c. Client Virtual Presence
Counselors respect the privacy of their clients’ presence on social media unless given consent to view such information.
H.6.d. Use of Public Social Media
Counselors take precautions to avoid disclosing confidential information through public social media.
There are many, many more codes of ethics regarding elemental health services.
It is important to obtain consent for treatment from a client before beginning with them. Depending on where you are in the world, you may have more than one type of consent that is required. You probably have standard forms and a process that you use to get it signed. Easy right? Well, yes, if the client is sitting in your waiting room.
What are the requirements for informed consent in your jurisdiction? And, working virtually, just how do you get it signed? These are the dilemmas that telehealth therapists have to work through.
It is important to remember:
- Even when working virtually and need formal consent
- You cannot use your standard consent form for both your in-person and telehealth clients
SAMPLE INFORMED CONSENT:
You want to fully understand your legal and ethical responsibilities as a clinician. If you are seeing clients in other states, find out what that state’s requirements are. Some states require you to be licensed in both the state you are in and these state the client is in. Some states required that you register to do elemental health with someone in the state if you are licensed in a different state.
When it comes to clients and consent, you have to be sure that your consent forms provide all of the necessary information for a client to make an informed decision about care. In fact, if you’re in practice already, you probably have one. But does it address telemental health?
Just as with in-person therapy, there are limits and risks inherent to technology and telemental health. There are issues with:
- the use of technology
- protection of PHI and confidentiality
- Internet security
- connectivity and more
It is your ethical (and maybe legal) obligation to make sure your client fully understands what therapy in a virtual setting is and is not. These unique aspects of telemental health need to be in your informed consent document.
Obtaining consent is another issue to think through. Except in maybe a very rare emergent situation, verbal consent will not suffice. Written consent ensures that you can prove that the client was fully informed and provided consent. This protects you, and it protects the client. Some counselors email forms and require them to be scanned and sent back. Some have technology platforms that offer templates and electronic signing.
Screening For Appropriate Clients For Telemental Health Services
Telemental health is especially effective with respect to the treatment of PTSD, mild depression, and ADHD in team-based environments, and with some patients, groups may be more effective than in-person care. However, it is not appropriate for significantly depressed or suicidal clients.
Screening prospective and current clients for fit for your behavioral health services can significantly impact their safety and treatment outcomes. It is crucial to assess whether or not an individual is likely to be a fit for behavioral health services, whether they will receive services at your office, through video conferencing, a phone session, or secure messaging.
When moving a client to a fully telemental health model or a hybrid model:
- Consider the patient’s cognitive capacity, cooperativeness with treatment professionals, current and past difficulties with substance abuse, and history of violence or self-injurious behavior.
- Consider the geographic distance to the nearest emergency medical facility, the efficacy of the patient’s support system, and their current medical status.
- Keep in mind that the patient’s consent must include discussions of circumstances around session management and that services may be discontinued if the patient can no longer be managed through distance technology.
- Consider whether any medical aspects of care would require an in-person examination.
Preparations for Providing Telemental Health Services
Do a test of the software beforehand for your own peace of mind and to be sure it will work and verify that you have your client’s contact information.
Find a place in your office or home office where privacy is possible. The sessions should not be overheard or interrupted.
Recommend earbuds for your client so they have better sound quality.
Have your screen on a stable surface since excessive movement can create a feeling of seasickness for your client.
Try to have the top of your head near the top of your video screen rather than in the bottom half of the screen. That way, when they’re looking at your face, they’ll be looking more or less into their camera (assuming it’s at the top of their computer), so it will feel like they’re looking at you.
Be sure to close email and turn off notifications that could be distracting and dilute the experience. You’ll want to have your full attention focused on the session just as if you were in a face-to-face session.
Also, close programs that could slow down your computer’s processing ability and interfere with the quality of the video.
You may also need to work out payment arrangements with your client if they generally pay in person.
Telemental health is not the same as face-to-face counseling; it is not for all counselors or clients. It has many positives that should be considered.