TeleMental Health Dictionary of Terms (A-Z)
Clinical Update February 2017
By Zur Institute
Telemental health is defined as the use of telecommunications technology to provide mental health services. It includes everything from telephones to texting to videoconferencing. In this age of constant connection through the Internet, it’s no surprise that telemental health is on the rise.
There’s no question that the future of therapy includes telemental health. Now is the time to get informed.
Access to care is the biggest reason that the US federal government, and many state and local governments, have been funding telemental health research. People living in rural and remote areas often have high-speed Internet connections, but they lack access to many forms of health care. Fortunately, the research looks very good for telemental health enthusiasts!
Bad Internet connections can make a video session go poorly. Sometimes clinicians will get the impression that the software they are using is causing the problem, when in fact it’s problems in the Internet connection used by the clinician, the client, or both.
Cross-State Practice: This issue has always been one of the most confusing aspects of telemental health. At this point, until further notice, the therapist needs to be licensed to practice in the jurisdiction where the client is physically located.
Data breaches are a growing concern for everyone in our society, and telemental health clinicians need to take care to ensure they protect clients against such breaches. HIPAA has its own data breach rules, which fortunately include some guidance on ways to avoid them and how to respond to them.
Encryption is the magic that makes confidential telemental health work possible. Encryption, properly used, can protect you and your practice from almost anything. It can even prevent the need to report certain security breaches to clients and the feds.
Free videoconferencing options that also provide what we need for HIPAA compliance are available. Telemental health is booming, so many technology companies are focusing their energies on serving our field. Advancements in software and in the Internet’s infrastructure also make it financially feasible to create free and secure ways for us to connect with clients by video.
Getting paid for telemental health services is getting easier as time goes on. Insurance companies are starting to reimburse, and some states require that they do so. For the most part, insurance reimbursement is only available for sessions done by secure videoconferencing. Phone sessions often are not reimbursed.
Historically, telemental health practices were mostly cash-based. Although the need to go that route is coming down as third-party reimbursement opportunities increase, there is still value in considering a cash-based practice. The overhead costs of practicing telemental health are usually lower than office-based practice. No-shows rates are also reduced as clients can attend even when the weather is bad or their cars break down.
Informed Consent requires some important additional elements for telemental health clients. E.g., you need to give information about the risks and benefits of the technology, and about the limits of your ability to remotely intervene during an emergency. Some state laws define items that must go into telemental health informed consent, as do some ethics codes and professional guidelines. The American Psychological Association Guidelines for the Practice of Telepsychology and the ACA Code of Ethics are noteworthy examples. The American Telemedicine Association also provides guidance.
Judgment regarding the client’s suitability for telemental health is an important part of the practice. Many therapists practice telemental health in an “office-to-home” setting, which means the client is generally in their own home. Without other professionals being physically close by to help in an emergency, this context might not be appropriate for clients with certain conditions.
Knowledge of the client’s area and the tech you use in your practice are both important components of telemental health competence. Technical competence helps improve therapy outcomes. Area knowledge helps you make sure you can support your client in a crisis and it may help you get referrals, if necessary.
Local Champions are people in your clients’ local regions who can support your practice “on the ground.” Local champions can be found in many professional arenas. Social work, law enforcement, employee assistance, and many other professional services are all potential places to find local champions for your practice. Don’t be shy about reaching out to find local champions, especially in rural areas or around underserved populations. There are thousands of people out there waiting to help you help the people they serve!
Making eye contact in telemental health is not as tricky as it seems at first. Eye contact over video, in a nutshell, is facilitated by placing the camera in the right spot just above the video image of your client. You can also make the client video image large enough and sit back far enough to make sure your “gaze angle” is such that the client perceives you as making eye contact, while still allowing you to focus your eyes on the client’s video window instead of on your own camera.
Nonsecure email and texting can have a place in professional practice when clients request it. For performing telemental health services, however, they should be avoided to the greatest extent feasible. When a client comes to your office, you go to lengths to ensure their privacy and confidentiality. For your online work, using secure tools is like closing the office door and putting a white noise machine in the hallway.
“Other people’s computers” is one way to think about “the cloud.” When we use online videoconferencing services, record-keeping services, and the like, we’re using the cloud. This means we are able to put the security and effectiveness of our tools into the hands of experts who know how to do it right. However, since we are putting all that sensitive information on their computers, we also need good assurances of confidentiality and general protectiveness from those same experts. That’s why HIPAA requires us to get Business Associate Agreements with them.
Person-Centered Tech is an extremely important resource for all therapists who need help and guidance in managing their therapy tech and with understanding HIPAA and digital ethics. The site contains a huge number of free resources, so use it liberally.
Quickly starting up a telemental health practice can work out well when adding it as an option for existing clients you’ve been working with in-person. Therapists looking to find new clients in the telemental health realm, however, are advised to take it slowly and ensure they have all their ducks in a row before hanging that telemental health shingle.
Record keeping in telemental health is usually assumed to be electronic. It’s good to keep our records somewhere we can reach them when we are working with our clients. If the therapist’s office changes locations, as it can when doing telemental health, then keeping records on the cloud is often indicated. If the telemental health office is in a fixed place, however, then paper records may remain a viable option (all other things being equal.)
Skype: Facetime, and other consumer-oriented videoconferencing services are not appropriate for telemental health anymore. In fact, it could be a HIPAA violation to use them. But fear not! Many healthcare-grade, free, and simple videoconferencing options are now available. And for therapists wishing to make a serious go at telemental health, many paid platforms exist at reasonable costs.
Texting is coming into its own as a telemental health medium, with research indicating the effectiveness of texting-based interventions in a number of contexts. It does require some training and practice to do properly, however. Also, the issue of texting security is still a difficult one at times.
Uninterrupted video therapy sessions are possible when both the therapist and the client prepare their computers and spaces properly before each session begins. It’s important to start norming this process with clients at the first session so that they and their therapist can both take ownership of keeping the session interruption-free.
Videoconferencing is the most popular and heavily-researched delivery medium for telemental health. This is likely due to the fact that it is the closest functional equivalent to meeting in-person. Videoconferencing-based therapy has some of the benefits and risks that come from the online disinhibition effect. Well-prepared therapists can leverage the particular strengths of videoconferencing to great effect while also reducing the impact of its weaknesses.
Web Sites are the most important way to promote your services. Your site can be used to host essential forms, link clients to your “client portal” (if you have one), and provide important information to help deal with crises. Many professional guidelines for telemental health include some recommendations for using your website to assist telemental health clients.
Xylophone players, as well as other people who possess interesting skills, can tell you that it takes time and practice to get good at anything worth doing. The time it takes to get good at telemental health practice depends on a lot of things: how tech-comfortable are you? Are you looking to hang an online shingle or just add video as an option for your existing clients? Starting small and expanding outward as you improve is an often-recommended strategy for those looking to get serious about telemental health work.
You have a number of opportunities to start doing telemental health work in 2017. Reimbursement improvements and public interest in remote therapy mean more room for telemental health in your private practice. A number of ethical and well-managed companies (including some insurance companies!) are providing employment or contracting opportunities for licensed clinicians ready to work through video and other media.
Zur Institute is one of the most prolific educational institutions for psychotherapists, counselors and mental health professionals. Along with 170 high quality Online CE Courses, the Institute offers a large library of free articles and resources.