Practicing distance therapy, legally and ethically

Interested in practicing virtual reality therapy? If so, it's important to get up to speed on the latest legal and ethical developments so you'll be sure to serve your clients safely, legally and effectively.

For starters, know that there is little consistent guidance across states on how psychologists should use these and other forms of electronic communication such as email, Skype and various forms of videoconferencing, says Deborah Baker, JD, director for prescriptive authority and regulatory affairs in APA's Practice Directorate. (See more on APA's work to create telehealth guidelines in the June Monitor.)

"While technology is pushing ahead at a rapid pace, psychology licensing laws have not yet caught up," she says. That's true in other fields as well, she notes: All health and mental health-care professions are wrestling with many of the same issues.

That said, experts in the field are beginning to develop guidelines to help psychology practitioners stay within their legal and ethical limits.

Interstate practice

One of the biggest unresolved issues concerns telepsychology across state lines. Email, videoconferencing and avatar therapy all allow psychologists to reach patients anywhere, but state licensing laws generally do not permit out-of-state psychologists to provide telepsychology services to consumers, says Baker, who helped conduct a 50-state review of telehealth laws in 2010 (see Telehealth). For most states, that means you may need to be licensed both in your own state and in your clients' state in order to practice with these modalities, she says.

There are exceptions, though. For example, many states have guest licensure provisions that allow out-of-state-licensed psychologists to provide services for a short period of time—ranging from 10 to 30 days in a calendar year—under specified conditions. In addition, the Association of State and Provincial Psychology Boards has created a credential called the Interjurisdictional Practice Certificate that facilitates temporary practice in other jurisdictions.

Providing distance therapy within your own state is simpler, and can help you reach people who wouldn't otherwise have access to services—rural residents or people with certain disabilities, for instance—and clients who want to receive services from home. In this case, you can confidently provide services as long as you abide by all applicable licensing requirements and professional standards of care, including understanding the technology you're using (more on that below), Baker says. A few additional steps can ensure you have the latest information in this fast-moving area, Baker adds. Make sure that you:

• Periodically check your state legislature's website for the latest state telehealth laws and regulations. If there is no telehealth law in your state, look to see if there is a board policy statement that provides guidance on telepractice, she recommends.

• Check whether your state licensing board has issued any policies related to telepsychology. As of last summer, several states, including Florida, Massachusetts, North Carolina, Texas, Virginia and Wisconsin, had such policies in place. (To contact any state board, visit the ASPPB website.)

• Contact your malpractice insurance carrier to confirm that telehealth services—both in-state and across jurisdictional lines—are covered under your malpractice policy. They are likely to be covered for in-state practice but not necessarily for interjurisdictional practice, Baker says.

Three states—California, Vermont and Kentucky—have already passed laws specifying psychologists' legal obligations in online therapy. For instance, Kentucky states that at the outset, a psychologist using telehealth must obtain the patient's informed consent, which includes documenting whether the patient has the necessary knowledge and skills to benefit from telehealth. Similarly, California requires that providers obtain both written and verbal informed consent before providing telehealth services, including a description of the potential risks, consequences, and benefits of telemedicine. The state does not, however, appear to extend this requirement to consultations between providers where the patient is not directly involved, Baker says.

Ethical telepractice

The ethics of telepsychology are in a similar state of flux, though there is a lot of good information available, says Jeffrey Barnett, PsyD, professor of psychology at Loyola University Maryland, who regularly teaches and writes about ethical issues in psychology. Included are telepsychology guidelines developed by both the Canadian Psychological Association and the Ohio Psychological Association.

In general, all of the standards of the APA ethics code apply, says Barnett. That includes standards on informed consent, competence to practice, confidentiality, doing no harm, and on how terminations, interruption of service and payment arrangements are handled.

"In fact, practicing with distance therapies actually raises the bar, because you also need to be competent in the media you're using," he says. To this end, get training in using the hardware and software involved in the treatment you plan to provide, Barnett recommends. For example, to preserve confidentiality and therefore meet the requirements of the Health Insurance Portability and Accountability Act, learn how to use encryption software, and for maximum ease of communication between you and your client, how to set up your equipment to provide good sound and visual resolution. You also need training on how to deal with some of the limits of telepsychology. With avatar therapy, for instance, you can't read a patient's expressions or body language, though some of that is changing due to advances in technology (see A second life for practice?).

Fortunately, there are many continuing education workshops on these topics, says Barnett. If you're unsure how to proceed, contact your state, provincial or territorial psychological association's ethics committee, the APA Ethics Office, your state licensing board, or knowledgeable colleagues, he recommends.

In addition, when using these technologies, it's important to conduct an initial assessment of each client to determine his or her appropriateness for telepsychology, says Barnett. A client who is suicidal, for example, may require much more active and intensive services than telepsychology can provide. Other factors to consider include making sure you have provided adequate emergency contact information in case your distance client faces a crisis, and ensuring that your patient's privacy and confidentiality are adequately protected by encrypting electronic transmissions and records, he says.

Barnett has an article covering these and more topics in the June 2011 issue Psychotherapy.

A new APA Task Force on the Development of Telepsychology Guidelines for Psychologists should further clarify psychologists' rights and obligations soon. The 10-member group—which includes representatives from APA, ASPPB and the APA Insurance Trust—met in July to review the area and discuss results of a survey sent to all APA governance groups, state associations, state and provincial psychology boards, telepractice-related organizations and interested individuals.

The group has developed a working plan and will begin drafting guidelines in the next several months. In addition, the task force is creating a Web page that will provide information about the task force's work and calls for comments, and will publicize this information in other APA venues as well.

Putting the proper safeguards in place should help to ensure that telehealth technologies live up to their promise of improving care, Barnett adds.

"There are a lot of good data showing that you can form a good therapeutic alliance using telepsychology, and that these modalities can help people with all sorts of issues," Barnett says. "Now we just need to develop the formal guidelines, and hopefully the laws and regulations, to make this a successful and safe area of practice."

Tori DeAngelis is a writer in Syracuse, N.Y.