Eileen A. Kohutis
This article appears in the Summer 2020 issue of the Independent Practitioner, newsletter of Division 42, Independent Practice, of the American Psychological Association.
Prior to COVID-19 pandemic, most psychologists had little experience with telepsychology even though the American Psychological Association (APA) developed guidelines for its use in 2013, Guidelines for the Practice of Telepsychology (2013). In fact, research in telepsychology, or telemental health or telemedicine has been going on since the 1950s. The pandemic has catapulted most of us into the world of telepsychology and telepsychology is more than just talking to patients using a telephone or camera on the computer. The Guidelines defined telepsychology as the “provision of psychological services using telecommunication technologies” (p. 792). The services may supplement traditional face-to-face in-person therapy sessions or may be stand-alone services and these technologies include all manner of electronic communications, such as telephone, email, internet, text, and videoconferencing. In this brief essay, I will provide a summary of a telepsychology program sponsored by the APA, Telepsychology Best Practices: 101 https://apa.content.online/catalog/product.xhtml?eid=15132&eid=1921. Because of the amount of material presented in the webinar, I am only going to highlight certain aspects of the program. At the time of this issue, the program is free and, after passing the tests for each of the four tow-hour segments, the psychologist earns eight (8) Continuing Education (CE) credits. Because this is not like a face-to-face session, it is important that a psychologist receive training by attending webinars, taking live on-line courses, and reading to improve his or her level of comfort, efficacy, and competence with this method. In doing so, providers will feel better prepared for any unusual circumstance that may arise and will learn ways of engaging with their patients and maintaining the therapeutic relationship.
Telepsychology gives us the opportunity to provide services to both our pre-COVID-19, (current) patients and to maintain continuity of care, as well as to people (new patients) who might not be able to receive services due to geographic, financial, physical, or other barriers. To do so effectively, we need to assess each patient’s appropriateness for telepsychology and comfort level with the technology.
The use of telepsychology requires many changes in how we do the business of psychotherapy. Because we do not have the same type of environmental control when working remotely (compared to when working in our offices), we need to alter our policies and forms accordingly. For instance, informed consent, along with confidentiality and privacy issues, need to be modified. A comprehensive assessment of the prospective patient needs to ascertain whether telepsychology is appropriate and whether or not the patient and psychologist feel comfortable with telepsychology. We also need to develop backup and safety plans for any unusual events that may occur and to have a list of relevant resources available to us. For example, if someone appears inebriated in our office, we have a plan. But, what about if someone uses a computer for their session and appears inebriated? What plan is in place? What about a situation where a person has told you of intimate partner violence and in mid-session, there is banging on that person’s door? What would you do?
We also must monitor the therapeutic relationship because factors, such as the type of device on which the telepsychology is being conducted, band width, and camera, which are not present in a face-to-face in-person setting, can become obstacles. If a patient is speaking to the psychologist on a phone, that person’s experience will be different than someone who can visually see the clinician. Similarly, if band width is slow, the psychologist will not be able to readily notice subtle body movements and affect in the patient. These types of misattunements can result in a patient feeling frustrated and not understood in treatment.
Some patients may not feel comfortable with telepsychology and it is not appropriate for every person. For example, people with have a history of acting out or who are chemically dependent may not be suitable candidates for this type of intervention. The psychologist treating a patient who chronically acts out will need to establish and maintain firm boundaries which would include having backup resources and possibly a collaborator who can assist with the treatment plan and call 911 if necessary. A person who has chemical dependency issues may similarly need a collaborator to help facilitate the treatment but the psychologist will need to have strategies in place to deal with potential triggers for that patient. On the other hand, a person who has a hoarding disorder has the opportunity to literally show the psychologist what his or her living conditions are so that the psychologist can develop a suitable course of action. In face-to-face treatment, unless that patient brought in photographs of the conditions, the psychologist could only surmise what they were like.
With all of the above considerations and questions in mind, I interviewed Marlene Maheu, Ph. D., one of leaders in telepsychology and also the presenter in Telepsychology Best Practices: 101.
- Intimate Partner Violence.
I asked Dr. Maheu about handling a situation in which the client is a victim of intimate partner violence. She suggested that the psychologist have a list of protocols outlining what to do for such a circumstance in the “waiting room” of the software program through which telepsychology is offered and to review them with the person. To increase privacy, the client needs to wear ear buds so that other people cannot hear what is being asked. Dr. Maheu also suggested having a radio play in the background to act as a white noise machine. If the person was unable to speak privately or if something has happened to alter the privacy of the session, then the use of a codeword that was previously agreed upon by both the patient and the psychologist would be a signal to end the session. The psychologist could then call 911 to assist the patient and to ensure the safety of the patient.
- Child Abuse Evaluations.
I asked Dr. Maheu about conducting child sexual abuse evaluations in the context of a child custody evaluation. She said that prior to doing so the situation needs to be carefully thought out and that in some instances, such as with young children, such an evaluation may not be possible. For example, one consideration is for the parent to pan the room where the interview will occur with the camera so that the psychologist can make certain no one else is in the room. When assured that no one else is present, the parent leaves the room and closes the door so that the interview with the child can begin. In the case of interviewing a young child, multiple cameras need to be set up so that the clinician can see the child’s behavior because some children may not be able to sit still for long periods of time. When the interview is over, the psychologist calls the parent on the telephone to indicate that the session has ended.
III. Psychologist In-Session Presentation.
Working remotely means that we can work from home, but working from home does not absolve us from any of our professional responsibilities, including our style of dress. While it may be tempting to only look professional from head to waist, it is important that our clothing beneath the waist is also appropriate, as it is easy for other parts of our bodies or our home settings to come into view during any given session due to a shift in the position of our device or its camera. Likewise, the patient needs to be dressed appropriately for similar reasons. Because patients will be coming into our homes, our “office” needs to be set up appropriately. This includes having the proper lighting for both you and your patient so that it illuminates your face and your client’s face rather than either one of you being in shadows. The angle of the camera needs to be set so that you can have a face-to-face interaction with the patient rather than looking as if you are asleep or inattentive because the camera is not at the right level. Fixing the camera angle may be remedied by simply placing a few books under the camera. Ensuring privacy for you and your patient may require nothing more than a sign on the door saying “quiet please.” In other words, the psychologist needs to maintain the professional and environmental boundaries conducting a telepsychology session in the same way as in their own office.
- Practicing “Out of State.”
Although telepsychology enables us to provide services to people not in our immediate geographic proximity, we need to be aware of practicing across state lines. It is important to know the laws for the state in which the psychologist is practicing, as well as for the state where the patient is. For example, a patient could be a resident of Kentucky, but now “sheltered in” in Indiana. While we are in this pandemic, many states have relaxed their licensing laws and allow us to see people who live in another state. It is unknown whether the states will keep this policy in effect when the pandemic is over or how it will change.
- Use of Social Media.
Dr. Maheu said that most licensing board complaints are due to purported professional boundary violations. These violations can come from what the psychologist has posted personal information on various social media platforms, such as linking your personal Facebook page linked to your business Facebook page. Likewise, sending a text message to a patient with an emoticon in it could raise questions about if/how emoticons are good practice. These “cutesy text messages” with patients are typically considered professional boundary violations.
- HIPAA Compliance
Because telepsychology is technology-dependent, we need to be certain that the technology we use is HIPAA-compliant. Many of the pre-installed apps on our smart devices are not HIPAA-compliant and neither are most text messages. It is incumbent on the psychologist get a Business Associate Agreement (BAA) from each vendor because protected patient information could be shared between you and your patient. Some free email programs, such as Gmail, Outlook, and Yahoo are not secure but a paid version, such as GSuite and Office 365 may be if the psychologist gets a signed BAA. Encryption is required in transmitting patient information and vendors offering BAAs will explain the encryption method.
VII. The Business of Telepsychology.
Telepsychology is becoming a business venture. Companies such as Google, Amazon, Walgreens, and Facebook offer psychological services, but who is actually providing the clinical service? What is the level of education and training of the providers in those companies? While it may be tempting for a psychologist to consider signing up to be a provider for one of these businesses, the clinician must find out what is involved and to fully understand professional/clinical expectations, as well as what the professional liability is for the psychologist. Further, it is likely that each company’s agreement is different. Most importantly, the psychologist needs to check with their malpractice carrier before venturing into this endeavor and checking with your own state’s licensing board regulations to make certain that you are practicing within the law. Your state’s professional association may also have information about clinical, ethical, and legal responsibilities as well as risks for you to consider. For example, you may be licensed to practice in Kansas, but if you enter into an agreement with one of these companies and a caller is from England, are you covered for international practice? Checking these businesses needs to include your thoroughly vetting them.
Closing Remarks
COVID-19 is drastically and dramatically changing how most of us practice, in particular launching us into the world of telepsychology. Exciting as telepsychology may be as a viable option for clinical services during this time of COVID-19 (and otherwise), it is not without its own limitations. The prudent psychologist who wants to pursue telepsychology needs to weigh all the options to make an informed decision about its suitability for his or her own practice. I also strongly recommend the APA’s CE program on telepsychology as a starting point.
REFERENCES
American Psychological Association. (2013). Guidelines for the practice of telepsychology.
Retrieved May 23, 2020, from http://www.apa.org/practice/guidelines/telepsychology.aspx
Maheu, M. May 19, 2020. Personal communication.
ADDITIONAL RESOURCES
American Telemedicine Association. www.americantelmed.org.
Corey, D.M. & Ben-Porath, Y.S. (2020). Practical guidance on the use of the MMPI instruments
in remote psychological testing. Professional Psychology: Research & Practice (in press).
Dale, M. D. (2020). Making the case for videoconferencing and remote-child custody
evaluations: The evidentiary, ethical, and empirical arguments for accepting new technology.
Psychology, Public Policy, and Law (in press)
Gloff, N.E., Lenoue, S.R., Novins, D.K. & Myers, K. (2015). Telemental health for children &
adolescents. International Review of Psychiatry, 27(6), 513-524.
https://doi.org/10.3109/09540261.2015.1086322
Larson, S. Winter 2019. The nuts and bolts of business associate agreements. Good Practice.
21-22. https://www.apaservices.org/practice/good-practice/business-associate-agreements.pdf
Luxton, D.D., Nelson, E., Maheu, M. (2016). A practitioner’s guide to telemental health: How to
conduct legal, ethical, and evidence-based telepractice.(ebook) Washington, DC: American
Psychological Association. http://dx.doi.org/10/1037/14938-001
Myers, K. & Turvey, C. (Eds.) 2013. Telemental Health: Clinical, technical and administrative
foundations for evidence-based practice. NY: Elsevier.
Nelson, E-L., Cain, S. & Sharp, S. (2017). Considerations for conducting telemental health with
children & adolescents. Child and Adolescent Psychiatric Clinics of North America, 26, 77-
Telebehavioral Health Institute. www.Telehealth.org.
Eileen A. Kohutis, Ph. D. is a licensed psychologist in independent practice in Livingston, New Jersey. She conducts evaluations for child custody, personal injury, employment cases. She has written and presented about issues in child custody and somatic and factitious disorders including Munchausen by proxy (now called factitious disorder imposed on another), malingering, and psychological testing. She is also a rebuttal expert. She sees patients in individual and marital psychotherapy.