Division 29 (Society for the Advancement of Psychotherapy) of the American Psychological Association has embarked on establishing practice recommendations for telepsychotherapy. This document was developed by a taskforce of Division 29 board members with the hope of providing a set of recommendations for psychologists providing therapeutic services using electronic media.
According to the American Psychological Association (2010), the term “telehealth” is an encompassing term used to describe services that include all interactions that are not in person between health care professionals and their patients. However, there are numerous terms used to describe the provision of mental health services using technology, with no universally agreed-upon nomenclature.
In this document, the term “telepsychotherapy” will describe the use of electronic media via telephone (i.e., landlines and cellular phones) and videoconferencing to deliver psychotherapeutic services. Although other electronic media may be used, this document specifically excludes the use of Internet services via email, instant messaging, text messaging, facsimile, chat, blogging, video blogging, webinars, blackboards, social or professional networking or web pages. Additional recommendations may be needed to address these methods when used alone or as an adjunct to psychotherapy; however, in the interest of brevity, we will limit this first document to real-time psychotherapy sessions with clients via phone and video.
Why We Need Telepsychotherapy Recommendations
For many psychologists, face-to-face psychotherapy has been their preferred and only mode for delivering clinical services until recently, when modern technology has made it possible to increase access to mental health care. Telepsychotherapy has the potential of improving services and reducing risks for substandard practice in the treatment of patients; however, without clear and defined guidelines for this type of practice, psychologists may be putting themselves at ethical and legal risk and may not provide clients with optimal psychotherapy services.
To date studies are showing that such services are as effective as face-to-face services (Barak et al., 2008; Folen at al., 2010). Indeed, studies concerning the effectiveness of telepsychotherapy have shown favorable findings, providing scientific support for the use of such technologies in practice in areas of pain, depression (Kroenke et al., 2010), post-traumatic stress disorder, and anxiety (Guay, 2010). Studies have also shown no differences between telephone-delivered psychotherapy and face-to-face delivery in the perception of the therapeutic relationship, post-session mood, or general satisfaction with services (Morgan, Patrick, & Magaletta, 2008).
It should be noted that telepsychotherapy is not for everyone. We believe that telepsychotherapy should not be a substitute for regular in-person psychotherapy when possible and should not be used only for the sake of convenience. Indeed, there should be a compelling reason for doing this kind of work. The advantages of practicing remotely are clear where access to care is an issue, such as in rural areas with limited or no public transportation, or where the client is disabled or house-bound. Telepsychotherapy is efficient in terms of time for both client and psychotherapist, and it provides ease of access.
PRACTICING TELEPSYCHOTHERAPY IN STATE
Most psychologists are already familiar with provision of services over the telephone, as when conducting an intake screening with a prospective client or handling questions or crises that may emerge during the course of psychotherapy. In the first case, this is the initial contact with the client and obviously little is known at that time. It may mark the beginning of the professional relationship. In the second, psychologists are speaking with known clients who are engaged in ongoing treatment. The provision of an entire course of psychotherapy over the phone is, however, relatively new to most psychotherapists accustomed to the face-to-face, in-office setting. The increasing availability of facilities for videoconferencing provides psychologists and clients with a broader range of possibilities for psychotherapy.
It would be important for psychologists to check with their state laws and regulations to ensure that there is no prohibition against the provision of telepsychotherapy in that jurisdiction. Most states are silent on the matter, and psychologists who choose to use these methods are expected to provide the usual standard of care and to act as any reasonable and ethical practitioner would (APA, 2010).
PRACTICING TELEPSYCHOTHERAPY ACROSS STATE LINES
Statutory problems are not new to the practice of psychology. The profession is largely regulated by state licensing boards that have different regulations impacting out of state practice. Some state licensing boards allow limited out of state practice without registration, some require registration, and others prohibit such practice. The psychologist who chooses to do telepsychotherapy needs to know that some licensing boards have opined that the regulatory authority for this type of activity is not determined by the physical location of the psychologist but, rather, where the client is. Thus, those who choose to practice in this manner can run afoul of state boards that might consider this practice to be illegal and even criminal, that is, practicing psychology without a license in that jurisdiction.
Psychologists who provide telepsychotherapy need to check whether the state where the patient is located allows for this activity. In addition, if the state has administrative requirements regarding this type of practice, these must be complied with. APA has developed a chart that summarizes a 50 state review describing temporary and guest licensure. The report cautions that one still must check with the individual state licensing board. The APA chart is available at APA Practice Central: apapracticecentral.org/advocacy/state/telehealth-slides.pdf.
If a psychologist wishes to gain permanent licensure in another state, the National Register (NR) of Health Service Providers in Psychology credentials psychologists who meet requirements for education, internship, and experience as health care professionals. The NR expedites licensure mobility for psychologists in 47 jurisdictions in the US and Canada as well as internationally. Its website (www.nationalregister.org) provides the psychologist with a listing of states that accept NR credentials. For psychologists who seek licensure in other states, the National Register can be quite helpful and saves considerable time and effort.
The Association of State and Provincial Psychology Boards (ASPPB) also offers possible solutions to those who choose to engage in interstate practice like telepsychotherapy. First, they offer the Certificate of Professional Qualification in Psychology (CPQ). This is a program that promotes mobility for licensed doctoral psychologists in the United States and Canada. The CPQ documents that the individual holding the certificate has met specific requirements in licensure, education, examination and training and has never had disciplinary actions taken against his or her license. Those who possess this credential do not have to submit further credentials to meet the requirements for licensure in that state (http://www.asppb.net/i4a/pages/index.cfm?pageid=3451).
In addition, ASPPB has also recently developed the Interjurisdictional Practice Certificate (IPC). This is a mechanism for licensed psychologists to practice temporarily in another jurisdiction more easily. Those who possess this certificate will be able to practice in ASPPB member jurisdictions. It will offer the boards in those states better oversight and regulation of licensed psychologists wishing to practice temporarily in their state, province or territory. According to ASPPB, “the concept behind the IPC is one of notification and temporary permission to practice rather than full licensure” (http://www.asppb.net/i4a/pages/index.cfm?pageid=3459). While this certificate is currently in development, it potentially offers a good solution to those who choose to practice temporarily in another state when they do not possess a credential to do so. Currently five states accept the IPC as meeting their licensure requirements for temporary practice, and two are in the process of so doing.
A final comment should be made about temporary, unlicensed practice under reasonable circumstances. Psychologists who provide telepsychotherapy must remember that all that can be expected of them is “reasonable” conduct. In that spirit, there may be strong legal and professional arguments that allow for temporary interstate practice without licensure under unique circumstances. For example, if a long-term psychotherapy patient was traveling in another state, or was going to reside there briefly, it seems impractical to require a psychologist to refer that individual to another licensed professional who would see her/him until s/he returned or to require the psychologist to obtain temporary licensure in that state. Clearly, such administrative requirements run afoul of continuity of care and good practice standards. Thus, remaining in contact with a patient who is in another jurisdiction may be consistent with the APA Ethics Code and the standard of care. That being said, this concept has not been tested legally.
GENERAL PRACTICE RECOMMENDATIONS
Assuming that a psychologist is providing telepsychotherapy in a jurisdiction in which one holds a license (permanent or temporary, if practicing across state lines), many issues should be considered. Following is a brief discussion of some such issues and related practice recommendations.
In a decision to hold psychotherapy sessions electronically, the informed consent should include issues unique to the medium, such as privacy, confidentiality, fees, reimbursement, security and reliability of video or phone connection, limits of communication, record keeping, termination, availability for emergencies, and cancellation policy.
With regard to confidentiality, the chosen medium may offer more or less privacy. The most private and secure medium is a landline telephone call. Clients should be informed that cell phone calls do not have the security of a landline contact so that they can make informed decisions about whether to speak about confidential matters on a cell phone.
The Internet is not regulated and not currently protected by privacy laws. Skype, for example, is not an encrypted site and is, therefore, not a confidential means of communication. Providing psychotherapy on unencrypted sites is ill advised and thus, informed consent is important. Clients may prefer to meet via Skype and express no concern about the absence of encryption. Therefore, we suggest that clients be made fully aware of the confidentiality concerns, and if they choose to meet through this medium, that the decision be documented by the psychologist.
Psychologists should check with their malpractice insurance carriers for coverage. Malpractice insurance carriers generally provide coverage as long as the practice is legal.
Psychologists should check with the applicable licensing board(s) to ensure that the practice of telepsychotherapy is approved. For example, when planning to provide services to someone across state lines where the psychologist is not licensed, it is important to contact that state licensing board to determine how to temporarily practice there.
For practitioners, billing for telepsychotherapy services can be problematic; however, as the practice increases, we believe many insurers will be turning their attention to reimbursement for this type of psychotherapy. Psychologists need to check with the insurance carrier for each prospective client to be sure that there is a proper provision for reimbursement.
Types of Clients
Our preference is for telepsychotherapy to be performed with ongoing clients with whom one already has an established psychotherapy relationship rather than starting a new relationship electronically. However, we recognize that exceptions may be possible and that for some people because of location, disability, or diagnosis, starting a course of psychotherapy in this manner is perhaps preferable.
We recommend this type of work only with clients who are not considered high risk. Some clients who are not at risk, however, become at risk. For this reason, if psychotherapy will be provided at a distance, it is important that the treating psychologist establish clinical support in the patient’s geographic location in case of emergency so that standards of care can be met.
Volume control, video quality, phone quality, and reliability are all important to consider (Folen et al., 2010), and a back-up care plan should be made for potential technical failure. Folen et al. (2010) note that psychologists and patients both adapt well even to relatively distorted visual presentation but that deviation in sound quality was not well-tolerated. A stand-by phone may be recommended.
Training in Telepsychotherapy Skills
It is vital that psychologists acquire the necessary skill sets to manage not only the technological issues of telepsychotherapy, but also the more subtle interpersonal aspects of providing psychotherapy remotely.
Addressing the Experience of Telepsychotherapy.
The psychologist and client can discuss:
- Agreement on the frequency and length of treatment (short term vs. open ended), willingness to continue if the modality is effective and to discontinue if the modality is not working.
- Management of technical problems in the sessions.
- Their assessment of the effectiveness of the psychotherapy via phone or web conferencing. This would ensure a consistent evaluation of the effectiveness of the modality.
If at all possible, scheduling intermittent in-person sessions with the client is recommended. This will allow for monitoring and evaluation of the telepsychotherapy for effectiveness.
FREQUENTLY ASKED QUESTIONS
In this document, we present a small number of FAQs below, recognizing that a multitude of questions about the practice of telepsychotherapy exists.
l. I am engaged in telepsychotherapy with a client who lives out of state. Last night the client called me to say he is suicidal. He asked if he should drive the three hundred miles to see me in person.
Response: Your first action should be a referral to a qualified mental health professional in the client’s home town. It is recommended that psychologists who do telepsychotherapy arrange for emergency backup prior to initiating this type of treatment. For example, it would be important to know about local resources, such as hospital emergency rooms, crisis hotlines, and the like. Also, one should know the phone number for the local police department or emergency response team in the client’s jurisdiction in case it is needed.
2. I am a licensed psychologist. Do I need to be licensed in the state where my client lives before starting telepsychotherapy?
Response: In many jurisdictions it is assumed that therapy occurs in the state where the client lives. You need to check with your licensing board and the licensing board in the state where your client lives.
3. How would I know if I am providing the acceptable standard of care in my state whenever I provide telepsychotherapy?
Response: You should look carefully at the APA Ethical Principles of Psychologists and Code of Conduct (APA, 2002) as well as the laws and regulations of psychology in the jurisdiction(s) you are practicing in. You should also review the information provided to your client about limits of confidentiality, including the limits of the technology that you are using.
4. Do I have to keep record of what goes on during telepsychotherapy?
Response: Yes. Telepsychotherapy does not exempt you from record keeping. All professional services provided should be documented similarly regardless of the medium.
5. Will my malpractice insurance cover telepsychotherapy?
Response: The APA Insurance Trust covers all legitimate forms of psychotherapy. The American Professional Agency notes that “tele-media psychotherapy services are not excluded. However, the Program Administrator would review the application based upon the percentage of time this type of psychotherapy services are being provided for acceptability” (email correspondence with Lucile Kaleck, January 2011). We believe that one should still contact his/her malpractice insurance carrier in order to obtain further information. Remember: if such practice is considered criminal, it is likely not covered by the malpractice insurance carrier.
6. How do I handle payment of fees?
Response: As in face-to-face therapy, this is a matter that you and your patient have to discuss prior to providing telepsychotherapy. This should include discussion of canceled appointments and rescheduling of appointments. Medicare pays for some telehealth activities in areas designated as rural health professional shortage areas and counties not in a Metropolitan Statistical area. Your patient should check with third-party payers concerning coverage.
As we noted in our preamble, we believe this is the time to assist our Division 29 members in thinking about telepsychotherapy. In this electronic age, our graduate students, early career psychologists, and seasoned psychologists will need to think about possible new avenues for providing psychotherapy. We noted that telepsychotherapy is not for every practitioner, nor is it suitable for every client. Future research will provide additional help, and as telehealth continues to develop, telepsychotherapy will follow closely.
We recognize that these recommendations may well need to be further refined and modified in the future. Indeed, we believe strongly that the next revision of APA’s Ethical Principles of Psychologists and Code of Conduct will need to include more explicit ethical guidance concerning telepsychotherapy and telehealth. The recommendations we have presented here will hopefully provide steps in that direction.