Clinical Impact Statement: This article provides essential information to psychotherapists planning to, or who are presently providing, telepsychology services. Key ethical and legal issues relevant to the practice of telepsychology are addressed and their impact on the clinical effectiveness of telepsychology services is highlighted.
The use of telepsychology by psychotherapists has increased in recent decades (Glueckauf et al., 2018). It provides greater access to psychotherapy, such as for those who live in areas where needed treatment services are not available and for those who are homebound or who lack access to adequate transportation. It also can be more cost-effective than in-person psychotherapy for both clients and psychotherapists alike.
In response to the onset of the COVID-19 pandemic, online clinical practice quickly increased from 7.1% of psychotherapists to 85.5% of psychotherapists in the United States (Pierce et al., 2020). This rapid shift from in-person to online psychotherapy was an appropriate response to safety concerns caused by the pandemic. It helped ensure that those who were in treatment at the time of the onset of COVID would not have their treatment abruptly ended and those in need of psychotherapy (a need that has increased since the start of the pandemic) would have access to it.
The rapid transition to providing online psychotherapy to clients likely caught many psychotherapists feeling unprepared and raised many questions and challenges for them (Khatib et al., 2021). These include:
- Knowing what ethics standards and guidelines are available to help guide psychotherapists toward ethical and competent telepsychology practice,
- knowing which hardware and software are needed and how to effectively use them,
- knowing how to transition effectively from in-person to online services to include knowing what fees to charge for the services provided,
- understanding and addressing confidentiality and common threats to privacy in the online environment,
- knowing how to modify the informed consent process to address issues relevant to online services,
- being familiar with the most current literature on the effectiveness of various psychotherapy treatments via different online media and making informed decisions about who may be appropriately treated online,
- planning for timely and relevant responses when clients experience a crisis,
- and knowledge of laws relevant to the practice of telepsychology in one’s own state, province, or territory, and those relevant to inter-jurisdictional practice.
While safety concerns secondary to the COVID-19 pandemic have driven psychotherapy into the online environment, this may not be a temporary situation, even if in-person treatment becomes viable again. Many individuals are finding the ease and convenience of online psychotherapy to be beneficial to them. Likewise, many psychotherapists also find online psychotherapy to be a great convenience and report viewing it positively and being open to its future use (Békés & Aafjes-van Doorn, 2020). This brief article offers an introduction to the legal, ethical, clinical, and practical issues relevant to the provision of telepsychology services.
The practice of telepsychology brings with it several important legal issues. By definition, telepsychology means that the psychotherapist and client are not in the same location. While many clients live locally and were previously treated in-person, telepsychology’s expanded reach enables psychotherapists to treat clients across state lines. This interjurisdictional practice brings with it several challenges. Since the practice of psychology is regulated by each state, unless one is granted an exception, one must be licensed where the psychotherapist is located and where the client is located. At the beginning of the pandemic many states loosened this restriction and allowed health professionals licensed in any state to provide professional services in their state, both in-person and virtually. These allowances were time limited and many of them have expired, so it is important to check the website of the psychology licensing board in the client’s state to see if this exception still exists.
It is recommended that psychotherapists always confirm with potential clients where they are located to determine if the psychotherapist is legally authorized to provide this treatment. Fortunately, the Association of State and Provincial Psychology Boards (ASPPB) has developed PsyPACT, an interjurisdictional practice credential that at present allows a psychologist licensed in one state to practice (in-person or virtually) in 27 other states, with additional states likely to be included in this interstate compact in the near future. See https://psypact.site-ym.com/page/psypactmap for more information about PsyPACT and the states currently participating in it. For psychologists licensed in one of these states, participation in PsyPACT offers a cost-effective means of practicing virtually in numerous other states without needing to go through the time consuming and expensive process of becoming licensed in each of these other states individually.
Even if one has the legal authority to provide psychotherapy in another state there are additional legal issues to consider. Of greatest importance is knowledge of laws in the client’s state relevant to mandatory reporting requirements. States typically have laws that require breaching confidentiality under certain circumstances such as to report the suspicion of abuse or neglect of minors and of older adults or vulnerable adults, and when clients disclose an intent to harm an identifiable victim or group of victims, yet laws vary by state. It is recommended that psychotherapists ensure their familiarity with relevant laws in the states where their clients are located and follow them as is required. When conflicts between state laws arise, consultation with colleagues with legal expertise is recommended.
Before Treating Clients
Prior to offering telepsychology services psychotherapists should familiarize themselves with telepsychology options. A wide range of software options exist for video conferencing, each offering different features. Reading reviews of these options, discussing preferences with colleagues, and trying out options and assessing them for ease of use may be helpful prior to selecting one. It is essential to ensure that the option selected is HIPAA-complaint and that the vendor provides you with a Business Associates Agreement in which HIPAA compliance for protecting confidential client information is stated (HIPAA Journal, 2022).
It is important to become skilled with any technology used, to include developing comfort utilizing all its features. Conducting practice sessions with a colleague can be helpful in this regard. Many clients may not have familiarity with the technology being used and may need instruction by the psychotherapist at the outset of treatment as well as assistance should technology-related difficulties occur over the course of treatment. Thus, in addition to one’s clinical competence, technological competence is important to possess as well.
Numerous online treatments for a wide range of clinical presentations have been studied and new studies are published daily. Psychotherapists should familiarize themselves with this literature, staying current with it, to ensure that treatment offered have the needed research evidence.
Informed Consent to Telepsychology
As with in-person treatment it is important to engage in a comprehensive informed consent process with clients “as early as is feasible in the therapeutic relationship” (APA, 2017). In addition to all issues typically addressed, issues specific to the provision of telepsychology should be included as well. Be sure to address which technologies may be utilized for which purposes (e.g., administrative versus clinical purposes). For example, one might limit clinical interactions to video conferencing and telephone and only use e-mail and text messaging for administrative purposes such as scheduling and changing appointments. Additionally, the level of responsiveness from you they can anticipate should be addressed. For instance, if you only respond to voicemail messages, e-mails, and text messages during certain hours, this should be clearly stated so that clients do not have unrealistic expectations about responsiveness. Many today expect near-instantaneous responses to text messages, something not reasonable to expect of their psychotherapist. Psychotherapists should also inform clients about financial policies to include if e-mail exchanges and phone calls in-between sessions are billed separately or included in the fee paid for each treatment session. The possibility that lapses in the technology being used may occur during online treatment sessions should be addressed as well so that clients and psychotherapists will have an agreed upon plan should loss of connectivity occur during a psychotherapy session (e.g., having the client call the psychotherapist’s cell phone number).
Numerous resources exist to assist psychologists to modify and update their informed consent practices to ensure they include issues relevant to the practice of telepsychology. Several sample documents are available on the website of The Trust (https://www.trustinsurance.com/). These include a sample Telepsychology Informed Consent document and a sample Electronic Communication Policy (https://parma.trustinsurance.com/Resource-Center/Document-Library-Quick-Guides). Further, it is recommended that psychotherapists, whether practicing online or in-person, include a Social Media Policy in their informed consent process. One excellent sample policy is available on the website of Dr. Keely Kolmes at https://drkkolmes.com/writing/social-media-policy/.
Social Media Interactions with Clients
Clients who participate in social media in their personal lives may naturally assume that they will be able to interact with their psychotherapist in this manner as well. Psychotherapists should consider social media interactions with clients carefully (e.g., accepting friend requests from clients) and think of online relationships as similar to in-person ones. Social media interactions with clients should be considered as boundary and multiple relationship issues, with particular attention being paid to the potential for inappropriate self-disclosure on the psychotherapist’s part. Younggren and Gottlieb (2004) provide the following questions to ask oneself when considering if entering into a second relationship with a client is advisable:
- Is entering into a relationship in addition to the professional one necessary, or should I avoid it?
- Can the dual relationship potentially cause harm to the patient?
- If harm seems unlikely or avoidable, would the additional relationship prove beneficial?
- Is there a risk that the dual relationship could disrupt the therapeutic relationship?
- Can I evaluate this matter objectively?
It is recommended that psychotherapists consider such issues prior to them arising. Developing a social media policy and reviewing it with each client at the beginning of treatment will help establish appropriate boundaries and expectations from the outset.
Assessing and Responding to Clients’ Treatment Needs
As with in-person treatment, it is important to assess each new client’s treatment needs and ensuring that we possess the needed clinical competence to assist each client. Additionally, we want to confirm that how we are providing treatment will be consistent with their treatment needs. This includes the use of telepsychology. Not all clients can be effectively treated via telepsychology; some may need inpatient or another level of treatment that cannot be offered virtually. Some clients may be better treated via one telepsychology modality over another, and the most appropriate option should be recommended (e.g., video conferencing, telephone, e-mail, or text messaging). Of course, access to the recommended technology must be considered as well. While videoconferencing may be optimal for a particular client, if that client does not have access to the Internet, this will not be a viable option and the use of the telephone may be an option to consider.
Confirming each client’s location at the beginning of the professional relationship is important for several reasons. In addition to confirming licensing requirements, there are clinically relevant issues to consider as well. Psychotherapists should be prepared for possible client crises during the course of treatment. While some crises may be addressed directly with the client online, knowledge of resources in the client’s local community is essential. Since some online clients will not be located in one’s local community, some research will need to be done at the outset of treatment to learn of emergency resources in their community.
Psychotherapists should use all available means of protecting each client’s confidentiality. This includes using virus, malware, and firewall protections and keeping them up to date. Further, when notified of the presence of an update to the operating system one is using, it should be downloaded immediately. Often, these updates are fixes to gaps found in the system’s security and are essential for protecting confidentiality.
Educate clients about threats to confidentiality associated with telepsychology. This includes technological issues and the physical setting where they will be during sessions. Ensure that each client is in a location where privacy can be maintained during the treatment session and where the risk of interruptions will be minimized. It may be helpful to have the client scan the room with their video camera so you can see the setting in which they are located during the psychotherapy session. When working with children and adolescents, it may be especially important to do this to ensure that family members are not present but off-screen during the session.
Clients should also be informed of the risks inherent in the use of public WiFi for their internet connection. It is strongly recommended that password protected WiFi be used due to the lack of security with public WiFi. When using e-mail to communicate with clients, encryption is recommended due to security risks associated with e-mail use. At a minimum, each psychotherapist’s electronic devices should be password protected. Beyond this, the use of multi-level authentication is recommended where after entering one’s password there is a multidigit code sent to one’s cellphone or through one’s e-mail that also must be entered. Further, all treatment records must be stored securely and similarly protected from unauthorized access.
Mobile mental health applications (apps) for smartphones and tablets are widely used, with more than 10,000 of them available at present (Marshall et al., 2020). Many clients may be utilizing them prior to entering psychotherapy and at times psychotherapists will want to recommend their use to clients as an adjunct to psychotherapy. But not all apps are created equally and very few have been studied for their usefulness or effectiveness, with many not providing intended results and some being counterproductive to treatment goals (Wasil et al., 2021). One recent study found that only 2.08% (21/1009) of available psychosocial wellness and stress management apps have published, peer-reviewed evidence of feasibility and/or efficacy (Lau et al., 2020). It is recommended that psychotherapists ask each client about any app use and for those used by clients, to download the app, try it out to assess its relevance and usefulness, and see what research, if any, exists to support its use. Psychotherapists should endeavor to recommend apps to clients that have empirical evidence for their use and that that are likely to support the work being done in treatment.
Telepsychology has many potential benefits, to include providing clients with access to needed psychotherapy they might not otherwise have been able to receive. It also presents several challenges to include the technology, ethics, legal, and other issues addressed above. While the APA Ethics Code is being revised, at present it does not specifically address telepsychology other than stating that the Ethics Code applies to all professional services provided regardless of the medium used. Psychologists are referred to the APA Telepsychology Guidelines (APA, 2013) for additional guidance on the issues addressed in this brief article. An additional useful resource is the APA’s Office and Technology Checklist for Telepsychological Services (APA, 2020).
Cite This Article
Barnett, J. E., & Jokhadar, N. (2022). The practice of telepsychology: Ethical, legal, and clinical issues. Psychotherapy Bulletin, 57(3), 6-11.
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American Psychological Association. (2020). Office and technology checklist for telepsychological services. Available at https://www.apa.org/practice/programs/dmhi/research-information/telepsychology-services-checklist.pdf
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