“Telehealth,” “Telepsychology,” “E-Health,” “E-Therapy;” whatever you call it, when you integrate various technologies into psychotherapy and other professional services you provide (such as clinical supervision) there are a range of important issues that each mental health clinician should be aware of and consider.
While much more information is included in the accompanying downloadable Powerpoint presentation from workshops I provide on this topic, this brief article provides essential information needed to be able to utilize various technologies in clinical practice ethically, legally, and effectively.
Just Which Technologies Are We Speaking of and How Might They Be Used?
In general, various technologies can be used for either administrative or clinical purposes.
Administrative purposes include:
- Scheduling appointments with clients.
- Typing reports and letters.
- Reproducing reports and letters.
- Sending letters, reports, and other materials.
Clinical purposes include:
- Conducting interviews and clinical assessments.
- Providing psychotherapy and counseling services.
- Providing clinical supervision.
- Seeking or offering consultation to colleagues.
- Monitoring client status, progress, and outcomes.
A range of technologies may be used for either of these purposes. For example a psychotherapist may:
- Schedule or change a client’s appointment by telephone, e-mail, or via your website.
- Type a client’s report on a computer.
- Record and store treatment session notes on one’s computer or in “The Cloud”.
- Forward a report to a colleague or referral source by fax or e-mail.
- Provide crisis intervention to a client via the telephone.
- Offer counseling sessions or clinical advice to clients by e-mail.
- Utilize videoconferencing to conduct an assessment or to provide treatment.
- Monitor client data and progress with apps that send the information to you via text message.
Technologies such as telephone, fax, photocopying, e-mail, text messaging, and websites can each be used for administrative purposes to help run your practice more smoothly and effectively. They may also help you to be more accessible to clients and to be able to respond to them in a timely manner. When utilizing various technologies for clinical purposes, a number of potential benefits and risks arise.
Potential Benefits of the Clinical Use of Technologies
- Increased access to needed clinical services for those who are homebound, live in a remote or isolated area, or who might not seek out needed services in-person due to stigma.
- Ability to continue a client’s treatment when the client travels for work, is away on vacation, or otherwise out of town.
- To respond to client crises when not in the office (by telephone, e-mail, text messaging, or even video conferencing).
- To provide or receive clinical supervision and consultation with expert colleagues who are located out of your local geographic area.
- To monitor client functioning and be able to respond rapidly when needed (see slides 38-42 for a clinically relevant example).
Potential Risks and Drawbacks of the Clinical Use of Technologies
- With certain technologies such as telephone, e-mail, and text messaging, the absence of visual cues such as facial expression may make it difficult to discern emotions or intonation.
- With e-mail and text messaging the absence of visual and auditory cues.
- Difficulty confirming the identity of with whom you are communicating.
- Appropriately and effectively responding to client emergencies and crises.
- Technological limitations and interruptions.
- Technology competence issues for psychotherapists.
- Client expectations for responsiveness such as expecting you to respond to their e-mails immediately.
- Cultural and other diversity differences and nuances may be missed or misunderstood.
- Not all clients and not all treatment issues are amendable for treatment via each of these technologies (e.g., suicidal clients).
Important Ethics and Legal Issues You Must Address
- You must be able to guarantee each client’s confidentiality regardless of the therapeutic medium used. This can include the use of encryption for e-mails, virus and malware protection for your computer, and the use of HIPAA-compliant software when using videoconferencing. Be sure all electronic devices with client information stored on them (e.g., smart phones, tablets, lap tops) are password protected and that their hard drives are encrypted (See Barnett & Scheetz, 2004, for a more detailed review of ethics and legal issues relevant to integrating various technologies into clinical practice).
- In addition to the usual issues typically addressed in the informed consent process for in-person psychotherapy, all additional issues applicable to providing the clinical services via the medium used must be addressed as well. Examples include steps to take if an interruption in the transmission occurs during a session, what the costs are for online services, how payment is accepted, and expectations for responsiveness to clients’ communications.
- Be sure you can know the identity of who you are interacting with each time and that the individual is legally authorized to consent to the treatment being offered. It is not unheard of that a minor will use his or her parent’s credit card without permission to purchase online services.
- Knowledge of mental health resources in the client’s local area is essential so that referrals can be made and emergency services can be accessed in a timely manner. These should be researched and known from outset of the professional relationship.
- When clients are out of your state, province, or territory be sure to research from the outset local laws relevant to providing clinical services to your clients. For example, you should know the specifics of laws such as reporting requirements for the suspicion of abuse or neglect of minors and the elderly or vulnerable adults along with mandatory reporting requirements when clients make threats to harm identifiable others (Tarasoff reporting requirements). Additionally, you should know the licensing laws in the jurisdiction from which you are providing the clinical service as well as in the jurisdiction in which the client is receiving the clinical service. Many jurisdictions require you to be licensed in both, or at least to obtain a temporary exemption to practice in the state where the client is located even if the clinical services are being provided via electronic means and not “in person.”
Using Social Media in Clinical Practice
We definitely live in a time in which many individuals participate in various social media such as FaceBook, Twitter, LinkedIn, and many others (see slides 42-60). In fact, for some individuals (see the YouTube videos on digital immigrants and digital natives on slide 53) various social media are integral for how they establish and maintain relationships as well as a primary means of how they communicate with others in their daily lives.
Thus, psychotherapists are likely to have clients who contact them via social media, such as by sending “friend” requests, offers to connect on LinkedIn, and the like. It is therefore important that you give thought to how you will respond to such requests before they occur. Key issues to consider and important points to keep in mind include:
- When using social media, the personal and the professional easily may comingle. Consider how much personal information you are comfortable clients having access to. Consider also how this may impact clients clinically. Having access to your personal life and private information may not be in many clients’ best interests clinically.
- View participation in social media with clients as a form of self-disclosure. Keep in mind that self-disclosure can be intentional and relevant to a client’s treatment, but it may also be unintentional or inadvertent and may not be appropriate for clients or desired by psychotherapists. For a more detailed discussion of self-disclosure in psychotherapy see Barnett (2011).
- See accepting “friend requests” as a boundary/multiple relationship issue. If you wouldn’t become friends outside the office with a client you treat in-person, then why would you accept a “friend request” from a client, whether an in-person or online client?
- Even with the highest security settings, personal information can be shared. Social media participants in your online network may easily find out who the others in your network are (to include other clients).
- Develop a social media policy that is included in your informed consent process with every client. See slides 58-84 for more information about the use of social media, accepting friend requests from clients, and developing and using a social media policy.
Key Recommendations for the Practice of Telepsychology
- Be knowledgeable of and follow applicable guidelines for telepsychology practice. Visit http://www.apapracticecentral.org/ce/guidelines/telepsychology-guidelines.pdf for APA’s telepsychology guidelines.
- Remain aware of the relevant standards in the APA Ethics Code, available at http://www.apa.org/ethics
- Get training to use the technologies you plan to use to provide telepsychology.
- Utilize a comprehensive informed consent with each client from the outset that addresses all issues relevant to the clinical services being provided. Be sure to address how emergencies and crises will be handled as well as technology failures.
- Ensure that fees and payment issues are addressed from the outset. Do not assume that insurance companies will provide reimbursement or coverage for these services.
- Take necessary precautions to protect each client’s confidentiality.
- Know all applicable laws in the jurisdiction where the client is receiving the service you are providing. When unsure, check with the licensing board in that jurisdiction.
- Be sure to check with your malpractice insurance carrier to ensure that you remain covered regardless of the medium used for providing professional services.
- Do not assume that all clinical issues and client presentations are amendable to treatment via all technologies (e.g., e-mail therapy for suicidal clients).
- Be familiar with the relevant telepsychology literature to know which technology media have been demonstrated as potentially effective for which disorders and presenting problems (See slides 23-26 for examples and see Godine & Barnett, 2013 for a detailed review of this literature). Just because a disorder is amenable to an in-person treatment, that doesn’t guarantee that it will also be effective if administered via a technology.
- Attend to language, culture, and other diversity issues that may affect effective communication. While telepsychology can enable you to have access to clients around the world, this may stretch your multicultural competence beyond acceptable limits.
- Be cautious about your participation in social media and develop a social media policy that you include in your informed consent process with clients. See slides 58-84 for more information about the use of social media, accepting friend requests from clients, and developing and using a social media policy.
- Follow the 11 steps listed in slides 86-89 for protecting and securing confidential health information when using a mobile device.
Cite This Article
Barnett, J. E. (2014, October). Integrating technology into practice: Essentials for psychotherapists. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/integrating-technology-into-psychotherapy-practice.
American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics
American Psychological Association. (2013). Guidelines for the practice of telepsychology. Retrieved from http://www.apapracticecentral.org/ce/guidelines/telepsychology-guidelines.pdf
Barnett, J. E. (2011). Psychotherapist self-disclosure: Ethical and clinical considerations. Psychotherapy, 48(4), 315-321.
Barnett, J. E., & *Scheetz, K. (2003). Technological advances and telehealth: Ethics, law, and the practice of psychology. Psychotherapy: Theory/Research/Practice/Training, 40, 86-93.
Godine, N., & Barnett, J. E. (2013). The use of telepsychology in clinical practice: Benefits, effectiveness, and issues to consider. International Journal of Cyber Behavior, Psychology, and Learning, 3(4), 70-83.