If your idea of psychology practice is treating clients in an office, day in and day out, it may be time to expand that vision. Psychologists today aren't just seeing clients in face-to-face visits; they are counseling them via phone, text, email and video media, including Skype.
A significant number of psychologists are now providing this type of practice, known collectively as telehealth. According to a 2010 APA study of psychology health service providers (PDF, 145KB), about 87 percent provided such services.
But as the practice grows locally and globally, so do questions about how it works for psychologists and their clients. "There are so many nuances when you start getting into these practices," says Ron Palomares, PhD, assistant executive director of governance operations in APA's Practice Directorate. Top among those nuances are privacy, confidentiality and the technological glitches that can arise with electronic gadgets.
That's why over the last year APA's Joint Telepsychology Task Force has proposed Guidelines for the Practice of Telepsychology, recommendations to help psychologists navigate some of the stickier issues that can come with a telepsych practice. These include what to do if the phone connection fails or how to respond to a faraway emergency.
"The joint task force's first goal was to lay out some answers to the bigger issues, and then fine-tune them in the years to come," says Palomares, who heads APA's staff support for the task force with representatives from the Association of State and Provincial Psychology Boards (ASPPB) and the American Psychological Association Insurance Trust.
APA's Council of Representatives approved the guidelines in August, and they will be published in American Psychologist within the next year. In the meantime, here's an overview of what they recommend.
Ensure confidentiality, privacy and informed consent
The potential risks of treatment are more complicated with telepsychology than in a traditional practice. With in-person visits, providers can be more confident of a secure environment. "But when you move into cell phones, land lines, video conferencing and Internet, these media all allow for eavesdroppers," says Palomares.
One way to mitigate these risks is to have detailed discussions with your clients at the outset of teletherapy so that clients understand the potential risks to privacy. For example, if a client is having the telepsychology session from home, family members may be able to overhear the therapy, posing a confidentiality risk. Similar breaches can occur if a client is in a public place — at work, in a coffee shop or even a park. Make sure the client clearly understands these risks, then have him or her sign an informed consent form, says Palomares.
But informed consent isn't always enough, adds Deborah Baker, JD, director for legal and regulatory policy in APA's Practice Directorate. Skype and some other technologies do not seem to comply with the requirements under the Health Insurance Portability and Accountability Act (HIPAA), which is overseen by the U.S. Department of Health and Human Services' Office for Civil Rights. And yet health-care providers are still responsible for protecting their patients' and clients' personal health information — and liable should a breach of confidentiality occur. "Anything that's electronically created through a telehealth encounter is subject to HIPAA," says Baker.
She recommends that psychologists who want to practice telepsychology think twice about using Skype or other free Web-based platforms. Instead, psychologists ought to consider investing in audio-video conferencing programs designed with HIPAA compliance in mind, she says. Though APA doesn't endorse any one software vendor in particular, the American Telemedicine Association website, which has a section featuring various companies that create the programs, might be a good place to start in researching secure videoconferencing options.
Know the licensing requirements
Practicing telepsychology across state lines comes with great potential — and great confusion. Laws vary from state to state, with some states having specific statutes or administrative rules relating to telepsychology and others having none. Some state psychology licensing boards, says Baker, have issued advisory opinions on providing psychological services remotely or practicing across state lines, evidencing how the boards might apply the licensing laws to telehealth in the event of a licensing complaint. And others haven't addressed the subject at all.
"Always check with your state's psychology licensing board," Baker says.
One of the sticky points is that in addition to being licensed in the state you're in, a number of states take the perspective that the provider ought to be licensed in the state where the client is. One psychologist, for example, licensed in Ohio, planned to spend six months of the year in Florida and wanted to continue treating his clients in Ohio remotely while in Florida. The Florida board opined that his providing psychological services via telehealth to his Ohio clients constituted the practice of psychology in Florida as well as Ohio. It required him to be licensed in Florida, too.
Some states allow for temporary practice for a fixed number of calendar days per year under a temporary or guest practice provision that might facilitate telehealth practice across state lines. Before you engage in telepractice, it is recommended that you contact your state psychology licensing board to understand what your state's policies are. If you anticipate telehealth practice across state lines, it is equally important to understand what the other state's policies are regarding telepractice and the practice of psychology generally.
In addition to the telepsychology guidelines, APA's Joint Telepsychology Task Force is hoping to create some consistency across states by drafting model language for how to best regulate telepsychology. The task force is also supporting the creation of the e.passport, a mechanism developed by ASPPB that would facilitate telepsychology across state lines while maintaining the protection of the public.
"The concept is that if you're licensed in one state and have an e.passport, you could then practice in any state that's also signed on to it," says Palomares.
Of course, states have to be signed on first — a process that may take years, or decades.
Get in touch with your inner techie
Technological glitches are common, and someone practicing telepsychology has to have a backup plan for all contingencies. For example, if you're in the middle of a video session, what do you do if your Internet service fails? How do you bill if your patient's cell phone dies? If you're using email for communication of personal information, is it encrypted?
Also, as noted above, confidentiality is critical. "One thing is that you really have to understand whether the technology you're using is secure," says Baker. "Our guidelines don't actually say, 'This technology is good, and this one's not good.'" The Department of Health and Human Services doesn't do this either, she says, so the burden is on the practitioner.
Palomares says telepsychology practitioners should know how to clear their computers' cookies, which save their browsing history and log-in information and could potentially compromise confidentiality. He also endorses carefully reading over the user agreement with any program or app that will be used in audio-video conference or to chat online. With Skype, for example, clicking "I accept," gives the company that owns Skype the right to all conversations. "The likelihood that Skype will broadcast your client's session is tiny, of course, but it's still a risk to confidentiality," he says. This is where technology and legal issues intersect — and because you the provider are ultimately responsible for all things related to confidentiality (regardless of what your client is comfortable with), as well as the security of your patient's health information, it's important to fully understand the technology you're using.
Create safety nets
Safety is also a concern when you're providing services remotely. For example, what if a client in another region says she's suicidal? What if another one faints or appears to have a heart attack while speaking with you via video? Who's responsible for helping them if they're on the other side of the state?
"If the client is in crisis, we have to ask ourselves, what's the ethical and legal way to respond?" says Cindy Juntunen, PhD, who's developing a telepsychology seminar at the University of North Dakota. "We need to make sure there's a safety mechanism in place. Even if you're 300 miles away, your obligation doesn't end."
Establishing relationships with first responders in the client's location is an important initial step when beginning a relationship with a potential client remotely. Having the contact information of your client's family and friends at your fingertips is also important, Juntunen says.
Another option is arranging for your clients to receive telepsychology services out of a health-care facility in their area, such as a local clinic, instead of from their homes. "That gives you the extra safety cushion of having medical professionals right there if anything happens," Juntunen says. "There's also the added bonus of better ensured privacy for the client."
It's also important to determine whether telepractice is suitable for certain clients, says Juntunen. Like the Joint Telepsychology Task Force guidelines, she recommends that psychologists meet clients face to face before beginning remote counseling to get an overall picture of their mental state. Then you can decide whether a client would be better served with in-person sessions or telepsychology.
Some psychological problems and mental health disorders may be treated exceptionally well with telepsychology. Agoraphobia and generalized anxiety disorder are good examples, says Palomares, since telepsychology puts a little extra distance between the provider and the patient.
He adds that even after you determine that telepsychology is appropriate and sessions are underway, you'll need to constantly evaluate and re-evaluate whether the client is still benefiting from that type of service. After a while, it may be time to switch to in-person meetings. But in either case, the important point is to be continuously reappraising the best choice for your client.
Alice G. Walton, PhD, is a writer in New York City.
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