The internet has greatly changed how we live our lives and how we communicate. Living in the modern world we are dependent on the internet. Now, instead of using your home phone or “landline” you probably are using your cell phone to make calls to friends and family (you may be reading this on your cellphone at this very moment). Cell phones are now widely used and in the last five years FaceTime and Skype have become easier to use and more widely available. With this increased availability to communicate via video TeleMedicine has exploded into a billion dollar industry. As TeleMedicine comes to be more prominent so will fear of it. With change comes fear. We fear what we don’t understand. We at first feared electricity, locomotives, telephones, automobiles, robots and most recently the internet. Once exposure increased, we became more familiar with the ways these modern inventions could help improve our lives. Fear of all of these inventions was due them being new, different and scary. Change is scary. But what if we are wrong? What if TeleMedicine isn’t scary? What if it could be done ethically, with trained practitioners and provide healing to those who may desperately need it?
In TeleMedicine there is fear of the unknown and still unexplored facets of delivering health care services through a virtual medium. In TeleTherapy specifically, fears of the effectiveness seem to be primary concerns to consumers, while the concerns of providers center around liability and the mechanics of providing services (Hertlein, Blumer, & Mihaloliakos, 2015). You may be asking yourself how does TeleMedicine affect me? Are people really doing relational and systemic therapy on their phones and computers? Should I care? The answers are: It is, Yes and Yes. In this article we hope to educate and go a little deeper than other blog posts/articles in educating you on TeleMedicine, and more specifically TeleTherapy.
There is no doubt that confidentiality is a major concern for any therapist. How will information be documented? Where will it be stored? Who will have access to it? These are all questions that patients should be aware of and therapist should be explaining in depth upon initiating treatment. In TeleTherapy it appears that an even greater focus is being placed on confidentiality and how information is tracked and stored. Having specific information about how the personal data of the patient will be stored, and being able to clearly explain this to the patient is imperative to creating a therapeutic relationship that feels secure. With the recent move to electronic health record systems most, if not all, systemic therapists are already using this type of record keeping. For the TeleTherapist, the difference will be knowing how to accurately and therapeutically share this protection with their patients.
In using a virtual delivery for therapy the responsibility of confidentiality not only falls on the therapist, the patient will also be responsible for safeguarding their own privacy. Finding safe and private space for sessions, keeping it clear of anything they do not want in camera, keeping other people out: all these things are the responsibility of the patient (Drum & Littleton, 2014). The therapist needs to make this clear upon intake that the patient should be aware of this privacy issues. If the therapist does not feel privacy and confidentiality are in place they need to openly discuss new measures moving forward, and be open to rescheduling the session if needed. Providers practicing TeleTherapy also need to recognize when a client is unable to create a safe and private space for themselves and not hesitate to end the online relationship and recommend in person treatment.
The actual system of delivery is the primary aspect of virtual therapy that providers need to be mindful of as they initiate services. Google “is Skype HIPAA compliant” or “is FaceTime HIPAA compliant” many articles will come up confirming that these means of teleconferencing are not currently compliant with HIPAA guidelines. Having HIPAA provide guidelines for how TeleTherapy should be practiced online is important. It protects the patient and creates structure for how the TeleTherapist should be using teleconferencing technology.
The structure is there now, we just need to create a space for TeleTherapy to be more accessible and less feared. The fact that so many people have Googled HIPAA compliance shows that people are interested in using this technology. Now we just need to stop fearing the change and come together to figure out how to do it in an ethical manner that protects the patient and meets them where the are!
Training and Education
Competency. How does one become competent? Practicing competency is an important part of both our ethical and state guidelines. To create ethical, competent systemic therapists an increase research and a wider practice of TeleTherapy is needed. Since there is not a wide range of available trainings individuals are practicing a type of therapy that they are not competent to do. Supporting individuals who have experience and/or interest in TeleTherapy and opening up discussions and space to ask questions can help create trainings for long term competency.
TeleTherapy is more than learning how to best use interventions through a computer screen. It should be pointed out that therapists that choose to practice TeleTherapy will need to learn how to use their technology in the most effective way and to stay up to date with technology and security protocols.
There are many aspects of TeleTherapy that would need to be covered by future trainings. Some obvious: How to best use interventions through a screen? How to properly use your technology? Some less intuitive: How to alter an informed consent agreement to apply to TeleTherapy? How to set office hours and keep professional boundaries? and How to manage self-care as a TeleTherapist? Not only do trainings need to be created to address these issues at the outset of TeleTherapy, they need to evolve as quickly as the technology that makes it possible through trainings on the newest changes to TeleTherapy and its evolving standards. As a new and developing model for treatment all of the questions, from basic to complex should be covered in a training to produce “competent” TeleTherapists.
Unfortunately there is not much more to say about the current state of TeleTherapy trainings. The available trainings at this time feel more like they exist just for CEU’s and to prove some degree of competency. Looking at technology from a non judgemental stance would help us in accepting it for what it is, a way connect with our patients in ways therapists in the past could never have imagined. Innovation in systemic therapy has always been progressive. Creating progressive, up to date trainings will educate and protect both the patients we treat and also the therapists that chose to heal with technology.
Impact on Therapeutic Relationship
TeleTherapy is no doubt difficult to provide with multiple people on the computer screen. We believe that one-to-one therapy with a systemic therapist who practices from a systemic/relationational scope can be just as effective online, as it is in person. For many clients and TeleTherapists it could produce a relationship that would not exist otherwise.
Many situations exist where individuals or families simply cannot access quality therapeutic services. Rural or under-resourced areas of the country do not always have any or enough providers to serve the community. If these low populous areas do have an accessible provider there is no guarantee of that provider being competent in the specific area for which a client is seeking assistance (Goodstein, 2012). A middle-aged, male therapist may be the only in-person therapist available for a young girl struggling with obsessive compulsive disorder. In this pairing there is no guarantee of the therapist being competent in treating OCD or of the young girl feeling that she can connect with a much older male therapist. TeleTherapy could be a solution to the problem of rural accessibility. By offering services online providers can reach clients who may otherwise have never pursued therapy out of inconvenience, and clients can have the opportunity to select from a wider array of therapists and select one that best fits their needs.
Expanding access to therapeutic care is a major advantage of TeleTherapy when looking at the relationship between therapist and client. In these cases there would be no relationship at all without the use of online modalities! This is not to say that teletherapy does not come with disadvantages when trying to join with a client. An oft cited challenge to providing therapy over video communication is the loss of nonverbal communication and, in turn, miscommunication (Prabhaker, 2013; Drum & Littleton, 2014; Hertlin, Blumer, & Mihaloliakos, 2015). A therapist missing out on a subtle movement, eye roll, blink, or teardrop could lead to hurt thoughts, ideas or feelings within the patient that could greatly affect the therapeutic relationship. But, without TeleTherapy the patient would have no therapeutic relationship. There is also a missed opportunity for physical connection. An act as simple as handing a client a box of tissues can create a kind of meaning and connection that is impossible to build in a virtual office.
Nothing can replace being in a space and feeling understood and validated by another person. The intensity of connection that comes from sitting in a room, one-on-one with someone cannot be replicated through the 13 inch screen of a Mac. Although TeleTherapy may not be an identical substitute for face to face therapy it does provide people who are feeling significant pain an opportunity they might not have thought existed or even possible, an opportunity to heal.
Licensing and liability issues
One of the greatest barriers to teletherapy is not one inherent to the delivery method, but to the lagging guidance and regulation from licensing boards: the practice of therapy across state lines. An example situation: A TeleTherapist begins seeing a client, both in Minnesota, and they form a long term, therapeutic relationship. That client takes an extended vacation to Hawaii. After this vacation the client decides to permanently move to Hawaii. Can a TeleTherapist bill for phone or video sessions while the client is on vacation? What about after they move permanently? Currently regulation between states is unclear at best. Each state has its own individual requirements for therapeutic licensure and regulation for the transfer of licence if a therapist is moving to a new state. These are all fine and well for therapists in a physical office but they leave the door closed to the virtual world. The vague regulations on state borders not only leave therapists confused, they also leave clients confused and uncertain about what teletherapy means for their own mobility and consistency in care. Fear of practicing outside of one’s designated borders is a hinderance to the developing world of TeleTherapy, and a fear that could be resolved with more clear guidance in the MFT community.
There are other concerns related to TeleTherapy that urgently require regulations to be enacted. From Goodstein, 2012, “Currently there are no constraints on who is offering what kind of services through the Internet. Individuals without the rigorous, supervised training of psychologists can simply label themselves “counselors,” “life coaches,” “therapists,” or whatever to offer their services through an Internet connection, a situation which poses a significant risk to consumers.” What Goodstein is saying is that anyone can make a profile online, say they are a “professional life coach” and begin practicing what amounts to therapy over the internet with no need to adhere to the legal and ethical expectations of a governing body. The purpose of governing boards is to ensure that clients are kept safe from unethically practicing professionals. Those calling themselves “life counselors” do not have an obligation to follow any set of rules, and thus pose a dangerous threat to unaware clients. By being clear about what teletherapy IS we can more easily identify what it ISN’T and protect not just clients but also the good standing of licensed professionals.
The extent of our current ethical guidelines on electronic therapy is as follows:
5300.0350 CODE OF ETHICS – Minnesota Board of Marriage and Family Therapists
P. Prior to commencing therapy through electronic means including, but not limited to, telephone and Internet, a therapist must:
(1) ensure compliance with all relevant laws for the delivery of the services;
(2) determine that technologically assisted therapy is appropriate for the client, taking into account the client’s physical, emotional, and intellectual needs;
(3) inform the client of the potential risks and benefits associated with technologically assisted therapy including, but not limited to, issues of confidentiality, clinical limitations, transmission difficulties, and ability to respond to emergencies;
(4) ensure the security of the communication medium; and
(5) only commence technologically assisted therapy after appropriate education, training, or supervised experience using the relevant technology.
This small addition to our ethical code was a needed step in forward progress. It is also short and unclear, especially when considering the vast possibilities that are encompassed in teletherapy. Practicing teletherapy, for the most part, comes down to practicing common sense and having a good therapeutic intuition. The remainder comes down to being a responsible therapist by knowing and following the laws and ethics set forth by the governing board. Statutes and regulations not only protect clients from unqualified therapists but they also protect therapists from a slew of issues. Right now therapists are unguarded by a lack of guidelines around technologically based services as well as a lack of training opportunities to best understand the few regulations that do exist. With this gap in available knowledge it’s no wonder teletherapy is seen with a sense fear.
No matter how you feel about about TeleMedicine and more specifically TeleTherapy, it is important that we open a dialogue about these concerns. In these dialogues we need to not just consider the barriers to overcome in a new area of practice but we need to keep our eyes open to the possibilities that TeleTherapy could, and will someday create in assisting those in need. Because no matter how we feel about technology it is the “wave of the future” and our patients use it as much as we do, or possibly more.
If we do not work on how systemic therapy fits in the new and ever expanding world of technology we will be left behind as other professional groups begin to develop their own expectations around online modalities. The communities we serve will lack the quality, ethical care we could provide to them if not for our fear of expanding our idea of “therapy”. Instead of waiting for the fear of TeleTherapy to die down we should embrace it. We should use it as motivation to explore the possibilities, develop the competency, and craft the technology to pursue a new way to give people the chance to heal and hope.
There are many wonderful therapists practicing systemic relational therapy in Minnesota and across the country. But what if someone has no access to one of these therapists because of geography, disability, money, time and or availability. What if they could connect with a therapist online in an ethical and therapeutically beneficial manner? That would be awesome! Everyone deserves access to quality systemic therapy. And if that therapy is TeleTherapy… then so be it.
Drum, K.B., & Littleton, H.L. (2014). Therapeutic boundaries in telepsychology: Unique issues and best practice recommendations. Professional Psychology: Research and Practice, 45(5), 309-315. doi: 10.1037/a0036127
Goodstein, L.D. (2012). The interstate delivery of psychological services: Opportunities and obstacles. Psychological Services, 9(3), 231-239. doi: 10.1037/a0027821
Hertlein, K.M., Blumer, M.L.C., Mihaloliakos, J.H. (2015). Marriage and family counselors’ perceived ethical issues related to online therapy. The Family Journal: Counseling and Therapy for Couples and Families, 23(1), 5-12). doi: 10.11771/1066480714547184
Prabhakar, E. (2013). E-therapy: ethical considerations of a changing healthcare communication environment. Pastoral Psychology, 62(2), 211-218.
Patrick Parker, MA LMFT