Telehealth: Practicing Psychotherapy On The InternetRisk Management And Great Opportunity

By Marlene Maheu, Ph. D.

 

Posted by permission. Copyright by Marlene Maheu, Ph.D. Originally posted at http://www.telehealth.net/articles/njpa.html

Imagine a dot.com referral service that allows consumers toselect a psychotherapist in their state of residence. Youregister, and eagerly await referrals. Within a month, youreceive an email referral from someone at the far end of yourstate.

The email describes the details of how a prospectivepatient “had to punish” her elderly grandmother for not eatingand not bathing last night. The consumer is requesting yourprofessional services for managing her anger toward hergrandmother. The note describes the punishment in enough detailthat you have reason to report her for elder abuse. You have hername, street address and telephone number, as well as that of hergrandmother. The consumer awaits your response. You look at thewebsite documentation, and they suggest you “follow your stateprotocols” or “dial 911” for all emergencies. What do youdo?

The unwitting clinician in the above scenario is in adifficult position. Depending on state laws, reporting thepatient could be mandatory. However, such a report is fraughtwith complications, and risk of losing or alienating the patientis high. Duty-to-warn situations, such as the one above, canleave the untrained and uninformed practitioner at increase riskfor malpractice when operating in email with unknown, unscreened,unseen and unheard prospective patients.

Yet, the assimilation of technology is a requirement foralmost any industry seeking to maintain a viable position intoday’s global marketplace. Psychotherapy is no exception.Practicing psychotherapy online is inevitable. Technology willincreasingly enhance our ability to offer services to patientswho are unable or unwilling to use existing face-to-face servicesbecause of geography, disability, finances, work schedules, and avariety of other life circumstances. Yet, as we can see with theabove vignette, barriers to such practice are becoming moresalient.

While technology has leapt ahead of our ability to develop abody of research and clear legal, regulatory or ethicalguidelines for the remote practice of psychotherapy, many earnestclinicians are seeking guidance to expand their practices withoutincurring additional risk. Making sense of often-conflictinginformational sources is time consuming and anxiety provoking.Therefore, this article will give a brief outline of barriers tousing telecommunication technologies, and suggest arisk-management model that takes advantage of the telEhealthliterature to carve a path through those barriers.

Barriers to Using the Internet for Psychotherapy

Barriers to the immediate practice on the Internet include avariety of factors. Only those of direct relevance to thepractitioner are discussed in the following section.

Economic Drivers

The Internet continues to explode, with worldwide estimatesfrom the NUA tracking firm to currently be at 407 million users.Commerce.net predictions are that the number of users will beover 765 million by the year 2005. The majority of Internet userssearch for health information and services. Mental health is thetopic of many Internet searchers, with a recent Harris pollshowing that information about “depression” was the mostfrequently accessed health topic, and that 4 of the top 10accessed health topics had a primary or secondary behavioralcomponent. It is only reasonable to assume that this trend willcontinue, as people can easily find health-related informationwithout the embarrassment of speaking to a professional orreligious community leader to find the answers to their personalquestions. Telecommunications technologies are being transformedinto social networking technologies as people form communities tofind answers and support for the problems that plague theireveryday existence.

The online mental health delivery system, however, is sorelylagging in development. Service delivery models suggested by manydot.com mental health websites put the practitioner at risk. Manysuch websites are developed with more of an eye toward making aprofit than delivering services that would benefit both thepatient and practitioner. For example:

• Some web-based businesses require that a practitioner sign aservice agreement that not only holds the practitionerresponsible for any and all malpractice liability, but explicitlyindemnifies the dot.com.
• Some web-based businesses encourage practitioners to workwith anonymous patients.
• Some web-based businesses encourage practitioners to ask thepatient to dial “911” for all emergencies, including suicide orhomicide.
• Some web-based businesses offer consent agreements anddisclaimers, but the effectiveness of such agreements on webpages is questionable.
• Some web-based businesses verify the practitioner’scredentials and state of licensure, they do not verify theconsumer’s state of residence. The practitioner, then, does nothave evidence of a consumer’s location when delivering services.Yet, the professional may be responsible for practicing out ofstate, even if consumers misrepresent themselves.

While some companies are beginning to offer creative services to both practitioners and consumers, there is tremendous opportunity for those with creative and innovative minds. Examples of promising models include http://masteringstress.com/, http://www.egetgoing.com/, http://nicotinefreedom.com/ and a host of other services that offer self-help, self-directed interventions, to be augmented by the services of a professional in the real world.

Training

Most practitioners are not trained to use advancedtelecommunications equipment, and therefore do not fullyunderstand the legal, ethical or practical ramifications of usingsuch technologies. Text-based environments, such as email andchat rooms, are the only current types of communication supportedby web services offering any form of confidentiality. Mostpractitioners have not had graduate training regardingpsychotherapeutic contact in text-based environments (email orchat). Practitioners are generally taught to conduct assessmentand treatment using auditory (voice amplitude, rate of speech,stuttering or hesitation) and visual cues (eye contact, blushing,fidgeting), not textual cues. Practitioners are also nottypically aware of the numerous ways in which their own computerprivacy can be compromised by computer savvy patients.

Utility

Many technology developers have not yet developed helpfulproducts and services for psychotherapists. Existing technologiesoften require more time and energy than traditional servicedelivery.

Confidentiality

Computer and Internet security and confidentiality are easilycompromised. Breaches of privacy are rampant. For example, manypractitioners do not know how to completely remove patient filesfrom their own computer hard drive, how to secure emailtransmissions to protect patient confidentiality, or how easily apatient can install a “Trojan Horse” program into thepractitioner’s computer to download the contents of thepractitioner’s computer onto a remote computer.

Legal protections for patients and practitioners are still influx. While federal standards to protect the transmission andprivacy of medical information are currently being developed,compliance is not yet mandatory for many such standards. A numberof Internet businesses are using the current, relativelyunregulated interval to gain a foothold on “market share,” whiletesting various business models with naïvepractitioners.

Attentiveness, Distraction and Privacy

From the clinician’s perspective, it is more difficult todetermine if a person is fully attentive or distracted during thetherapeutic interaction when using technology. Practitionerstherefore need to be trained or otherwise experienced in thevarious possibilities for misinterpretation when working witheach specific technology before offering services to thepublic.

Duty to Warn Situations

While many practitioners are trained in crisis managementthrough the telephone, they not trained in crisis managementthrough email or chat rooms. Training with one technology doesnot automatically amount to training in another. Furthermore,conclusive research into the efficacy of any treatment mediatedby email or chat room has not yet been conducted. While the lureof existing technology may be strong, the duty to protectpatients must be stronger.

Many dot.com developers also conveniently encouragepractitioners to “follow state law” when dealing with duty towarn situations, but state laws are not yet developed in moststates. Moreover, some dot.coms encourage practitioners to “refersuicidal or homicidal patients to 911.” Many practitioners arenot comfortable with such arrangements because they know thatthese patients are typically reluctant to engage law enforcementofficials to stop them from their intended actions.

Linguistic and Cultural Competence

With worldwide connectivity brought by the Internet, consumersfrom remote areas of the planet can easily make contact with aclinician. The clinician’s familiarity with colloquialexpressions, idioms, and local variations of word usage can becrucial when working with mentally ill, suicidal or homicidalpatients.

Similarly, cultural norms, local traditions, and religiousrituals can all play important roles in the lives of clients andpatients. To offer behavioral and mental health care in theabsence of such information is questionable practice.

Local Events and Emergency Backup

A related issue is that of the clinician needing to haveawareness of local area events that might influence the emotionalstate of consumers of Internet services. Similarly, it is theresponsibility of the professional to have adequate emergencybackup systems in place before offering services to consumers,even if patients do not think such backup relevant orimportant.

Reliability of the Connection

Unfortunately, reliability of contact is lessenedsignificantly when delivering services through telecommunicationtechnologies as they currently exist. Backup must bedeveloped.

Research

By 1998, behavioral health care via videoconferencingaccounted for nearly one fifth of all telemedicine consultationsin the United States. Other studies of current telEhealthprograms nationwide show that nearly one half involve some typeof mental health service. This high utilization rate makesbehavioral telEhealth the fastest-growing area of telEhealth.Such studies have been reported in the behavioral healthcareliterature for approximately 40 years. Much of these findings arerelated to videoconferencing and/or computer mediatedself-directed programs that augment traditionalpsychotherapy.

Pilot programs investigating two-way, interactivevideoconferencing generally use a model based on local evaluationof a patient by a clinician, with consultation or referral to aremote specialist who is accessed through videoconferencing.These studies are most often conducted in controlled settingswith small and often relatively homogeneous patient subgroups(not global population, such as found on the Internet).

Computer medicated self-directed programs have also been shownremarkably effective for treating a variety of disorders.Successful programs tend to regularly involve the intervention ofa psychotherapist, rather than being exclusivelypatient-driven.

Of particular note is that only a few studies have examinedthe clinical utility of using email or chat rooms with patients.These reports typically are anecdotal and inconclusive.Furthermore, research has not shown the efficacy of anyassessment instrument to rule out serious mental illness in theworldwide population accessible through an Internet website.

Risk Management Suggestions

The dubious practice of offering psychotherapy to unknownconsumers worldwide without the proper research to establish theutility, efficacy and reliability of email and chat rooms withany clinical population is fraught with pitfalls. However, therisk management procedures outlined below may also be consideredpotential solutions for practitioners seeking to deliver servicesto remote patients using videoconferencing. These protocols havebeen used as the basis for delivering psychotherapeutic servicesvia videoconferencing technologies for several decades.Suggestions include:

Obtain Training

Before proceeding to deliver services through technology, besure to obtain training from recognized training organizations orspecialists in proper use of specific technologies to conductpsychotherapy with behavioral health patients.

Referrals

Be cautious about accepting referrals exclusively in email.Accept referrals and conduct early assessment with patients byusing the telephone. Verify state of residence of all remotepatients by asking for proof.

Initial Assessment & Consultation

It is wise to follow the precedent set in telEhealth andtelemedicine programs when seeking to deliver remote services.Require face-to-face contact for assessment and diagnosis beforeusing technology of any kind to deliver psychotherapy. Obtain afully detailed consent agreement. Use videophones or dedicatedvideoconferencing equipment. When using the Internet, only usetechnologies that are encrypted (encrypted video technology isnot yet developed for the Internet.)

If face-to-face assessment by a specialist is not possible,conduct full assessment with the assistance and presence of alocal, non-specialist practitioner during videoconferencedevaluation of the patient. Obtain agreement from the localpractitioner to act as backup in the case of emergency.

Email Exchange

If public Internet-based email is used, these suggestions maybe helpful for licensed psychotherapists:

• Have an existing professional relationship with the patient.
• Provide the patient with informed consent about the use of email. Have your consent form indicate that:
  • contact in email has not been proven to be a validated approach to conducting psychotherapy;
  • if you engage in communication with the patient in email, you may be acting outside the existing standard of care for your profession; and
  • confidentiality problems exist, and that acceptable cures for those problems involve encryption.
• If the patient does not want to use encryption or work through a website offering encryption, do not ask patients to sign away their basic rights of privacy and confidentiality.
• Specify the type of inquiry you will address in email, (i.e., setting or rescheduling appointments, giving titles of books or webpages, giving referrals to other professionals).
• Explain the ease with which email can be intercepted not only on the public Internet, but by family members and friends of the patient.
• Inform patients of whom else might be seeing their email communications to you, and who might be responding to their requests in your place (supervisor, office manager, office assistant).
• Let the patient know when you typically will respond to email, and what to do if they do not get the response they anticipate. Make backup plan for when email is not received as expected, i.e., have the patient telephone you if upset or worried.
• Print all copies of email sent to and received from a patient. Place these hard copies in the patient’s paper file.
• Choose patients wisely when experimenting with new procedures. Email may not be a particularly good medium for highly reactive and potential dangerous patients such as those with borderline personality disorder, paranoia or dissociative disorders.
• Because state licensing laws differ from state to state, do not assume that sending email to a patient in another state is acceptable under practice regulations for that state. Inform yourself of the legal requirements for each state involved when sending email to patients. If you choose to work in email with patients you have never met face-to-face, require them to verify their state of residence. Ask your attorney approve your verification procedure.
• Do not refer to colleagues who do not use your level of precaution when communicating with patients in email.

Economic Drivers

Do not assume that a well-funded dot.com company or webmaster has your best interest in mind. Given recentmarket pressures, economic survival is questionable for most ofthese companies, and your protection is not necessarily theirhighest priority. It therefore is suggested that you thoroughlyexamine the service agreements offered by behavioral and mentalhealth care dot.coms. If you plan to develop your own website. Besure to get a written contract with your website developerregarding security and confidentiality of the files that will bekept.

Manage Your Risk

Regardless of the vendors you hire to mediate contact throughtechnology with your patients, describe your intended treatmentprotocols and their rationale in writing. Send copies of allagreements, disclaimers, consent forms, and treatment protocolsto your attorney. Seek the advice of your peers, and send a copyof these documents to your local, state and national ethicsboards, malpractice carriers and licensing boards. Ask them allto respond to you in writing about the legitimacy of theprofessional services you intend to deliver to the public. Whileyou may not obtain direct approval for the services you plan todeliver, you will have documented that you sought the advice ofyour peers in developing your innovative services.

A series of lawsuits will undoubtedly clarify legal andethical matters for our professions. Be prepared. The aboveactivities will take you a few hours, and can prevent years oflitigation.

Conclusion

There are innumerable growth opportunities for psychologicalpractice through telecommunication technologies. However, emailand chat rooms remove the diagnostic and clinical (auditory andvisual) cues relied upon by traditional practice. They have notbeen shown effective by well-designed research, and areaccessible by people from around the globe, with widely differingcultural and linguistic characteristics. Practitioners have notbeen trained to use these technologies to serve such a variedpopulation. Until these services are adapted to meet the legaland ethical requirements of mental health professionals in theseunprecedented circumstances, it is imprudent to use email andchat rooms to establish or maintain psychotherapeuticrelationships with unscreened, undiagnosed, unseen, unheard andunknown consumers through the Internet.

However, it is not only reasonable but also exciting toconsider the possibilities for psychotherapy afforded bytechnology. A successful model has been developed for the remotedelivery of mental and behavioral services in healthcare usingtwo-way, interactive videoconferencing. Numerous pilot projectsin behavioral telEhealth have set a precedent that requires aninitial face-to-face assessment, diagnosis, backup procedures,and a patient consent agreement in conjunction withvideoconferencing to conduct a wide range of traditionalpsychotherapeutic functions with patients, their families, andtheir other healthcare practitioners. Research has also shown theefficacy of computerized, self-directed programs when used inconjunction with traditional clinical care. Thesetechnology-based interventions The use of these technologies havebeen documented and shown effective in numerous situations withvarious types of patients.

Yet, the need for continued research is obvious. We needbetter international screening tools for determining who willbenefit from remote treatment, especially on the Internet. Weneed to identify which clinicians will be best-suited and mostcomfortable delivering services through these technologies. Weneed legislation to support our work and protect practitioners aswell as patients. We need clear practice and treatment guidelinesfor use with various technologies and patient populations.

At the individual level, and as with all other new areas ofpractice, it is wise to seek consultation, obtain specializedtraining, and familiarize ourselves with the literature. It isreasonable to follow a behavioral telEhealth model that has beenshown effective through credible research. It is prudent todocument that we have sought the advice of our peers.

The most important risk is that if we do not become active inshaping and developing new technology for our professions, otherswill. Propelling us to quicken our step rather wait, ourcompetition in the healthcare arena poses yet another and perhapsmore daunting threat. Rather than leaving our fate to bedetermined by business minds or inexperienced clinicians, thefuture of our professional rests upon the traditional, seasonedpsychotherapist/researcher who can lead the march of identifyingthe salient aspects of the therapeutic relationship for mediationthrough technology. Where are our leaders? When will they appear?We need them now. The challenge is great, and so it theopportunity.