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Telehealth Foundation - Counselors
- 1. I want us to ask ourselves every day, how are we using technology to make a real difference in people’s lives?
- 2. Summarily rejecting technology advances seems as equally inappropriate as an enthusiastic and uncritical embrace of all technology, given its potential to better serve those in need and the efficiency with which it can deliver such services. Van Allen & Scott, 2011
- 3. Internet could serve as a proverbial “foot in the door” for clients who are uneasy about seeking mental health treatment Rummel & Joyce, 2010
- 4. “Clinicians will increasingly face expectations by their clients to provide services in the context of their preferred modes of communication.” Koocher, 2007
- 5. Freud corresponded with patients through letters, and some commentators note the historical link between correspondence therapy and modern-day e-therapy ( Recupero & Rainey, 2005; Pergament, 1998)
- 6. Online Self-Help Groups Appeared in 1982 and were the first form of e-help Kannani & Regehr, 2003
- 7. It is estimated that hundreds of e-therapy sites are active at any point in time (Maheu & Gordon, 2000) • E-therapy sites • Clinics • In 2001 300 independent e- therapy sites and 3 online clinics with 500 therapists Ainsworth, 2004
- 8. Examples of Online Counseling Sites • National Directory of Online Counselors http://www.etherapyweb.com/index.html • Luminet Solutions http://www.luminentsolutions.com/ls/Counseling • USC Telehealth http://usctelehealth.com/ • Ask The Internet Therapist http://www.asktheinternettherapist.com/ • My Therapy http://mytherapynet.com/
- 9. Can a meaningful clinical relationship be developed if a client and counselor do not share the same physical space? (Chester & Glass, 2006)
- 10. “People meet and fall in love on the Internet….SO why would a therapeutic relationship not also be possible?” (Alleman 2002 p. 201)
- 11. Research has shown that a meaningful therapeutic alliance can be formed over the Internet, even in the absence of nonverbal cues (Cook, 2001; Prado & Meyer, 2006). MIGHT SURPRISE SOME……..
- 12. Outline for Counselor Track Ethics Ethical Codes-Telehealth Competence Practice Guidelines for Telehealth Technologies Guidelines Informed Consent Therapeutic Alliance Building Videoconferencing Telephone Messaging Email Chat Cultural Issues
- 14. Ethics Use of technology by counselors •is increasing •presents unique ethical dilemmas (NBCC Policy, 2013)
- 15. Regulatory, ethical, and legal standards in psychology are not advancing at the same rate Van Allen & Roberts, 2011
- 16. Ethics Need to be re-written to address telehealth technologies
- 17. Development of Telehealth Ethical Codes • The National Board of Certified Counselors (NBCC) was the first one to adopt standards for online counseling in September 1997 • The American Counseling Association (ACA; 1999) speaks directly to the issue of computer technology and online counseling • The International Society for Mental Health Online (ISHMO) is a group established by professionals providing online services. Rummel & Joyce, 2011
- 18. • NAADAC (Association for Addiction Professionals) • National Board of Certified Counselors (NBCC) • American Counseling Association (ACA) • American Mental Health Counselor Association (AMHCA) • American Association of Marriage and Family Therapy (AAMFT) • National Association of Social Workers (NASW) Ethical Codes Related to the use of Technology in Counseling/Therapy/Treatment
- 19. Ethical Codes American Psychological Association (APA) •recognizes the need for development of guidelines •in 2011 approved a joint task force to develop telehealth guidelines for psychologists •telehealth technologies are not currently included in the APA Code of Ethics
- 20. International Certification & Reciprocity Consortium (IC&RC) •does not create or maintain a Code of Ethics •IC&RC member boards deal with matter individually and recommends contacting member boards directly •contact information for all member boards can be found at www.internationalcredentialing.org/findboard Ethical Codes
- 21. TELEHEALTH greater risk for miscommunications or misunderstandings that may be experienced negatively by the patient. Baker & Bufka, 2011 Client may feel like they are abandoned or neglected
- 22. Not only are psychologists ethically obligated to attain and maintain competency in specific practice areas and/or in working with specific populations, psychologists who use telehealth technology must also be competent in using the technology. Baker & Bufka, 2011
- 24. As in face-to-face therapy, competence is essential, and there must be no assumption that general therapeutic competence automatically translates to e therapy competence Midkaff & Wyatt, 2008
- 25. Verbal skill in face-to-face therapy does not necessarily translate into skill in written communication, especially interactive text-based communication that involves a series of interpersonal interpretations within each exchange (Childress, 2000)
- 26. Proficiency • Typing Skills- Speed Competency • Computer technology • email programs • Email functions • Chat boxes • Chat rooms • Avatars • Emoticons Rummel & Joyce, 2010; Midkaff & Wyatt, 2008
- 27. The American Psychological Association Insurance Trust will include online services falling within the psychologist’s license and state guidelines…. however, the insurance would likely be voided if a counseling psychologist were providing services outside their scope…. Malle, Vogel, & Rochlen, 2005 OUTSIDE SCOPE COULD MEAN PRACTICING OUTSIDE THE STATE THEY ARE LICENSED IN….
- 28. “Technology will continue to evolve, but the ethical principles remain constant” Koocher and Keith- Speigel (2008) (p. 212).
- 29. Synchronous Communications Telephone Chat (instant messaging) Video-conferencing Asynchronous Communications Email
- 30. American Telemedicine Association, 2013
- 31. Practice Guidelines for all Types of Telehealth Technologies • Verification of Location • Verification of Patient/Professional • Patient Appropriateness • Informed Consent • Patient Safety/Emergency Management
- 33. Clinical Guidelines: Verification of Location •Compliance with relevant licensing laws •Emergency management protocol is dependent upon where the patient receives services •Mandatory reporting and related ethical requirements •Provider payment amounts are tied to location Who do you report to?
- 34. Clinical Guidelines: Professional/Patient • Contact Information Verification for Professional/Patient • Online psychotherapists who do not provide services to minors should also consider including a direct statement that they do not provide services to minors, and require clients to provide their date of birth in order to verify the client’s age.
- 35. Patient Appropriateness for Telehealth https://www.ismho.org/therapy_suitability_assessment.asp International Society for Mental Health Online Person’s Suitability for Online Counseling ATA Practice Guidelines for Video-Based Online Mental Health Services, May 2013
- 36. Clinical Guidelines: Patient Appropriateness To date, no studies have identified any patient subgroup that does not benefit from, or is harmed by, mental healthcare provided through remote videoconferencing. ( (Day, 2002; O’Reilly et al., 2007 & Ruskin et al., 2004; Germain, Marchand, Bouchard, Guay, & Drouin, 2010; Hyler, Gangure, & Batchelder, 2005; Kroenke et al., 2009)) HOWEVER… Actively Psychotic?
- 37. Clinical Guidelines: Patient Appropriateness Considerations where professional staff are not immediately available •Patient expectations & level of comfort •Patient takes an active & cooperative role •Patient’s organizational & cognitive capacities MOST IMPORTANT
- 38. Clinical Guidelines: Patient Appropriateness Other considerations: •Patient’s Abilities with Technology…. responsible for equipment set-up, maintenance of computer settings, and privacy at his or her site along with technology competency •Geographic distance to nearest emergency medical facility, patient’s support system and medical status What is their comfort level?
- 39. Informed Consent ‘meeting of the minds’
- 40. Informed consent…..process by which clients are informed of their rights regarding treatment including the benefits and risks of treatment and alternatives to treatment. Walker, et al., 2005; Berg, Appelbaum, Lidz, & Parker, 2001; Faden & Beauchamp, 1986
- 41. The online therapeutic provider should develop a comprehensive informed consent process and documentation Midkeff & Wyatt, 2008 NO DIFFERENT THAN F2F EXCEPT……
- 42. Informed Consent • Check with your state as some specify that informed consent must be provided verbally and in writing to the patient • Include notice of the patient’s right to withhold or withdraw consent at any time without affecting the patient’s right to future care, treatment, or program benefit • description of the potential risks and consequences of using telehealth Baker & Bufka, 2011
- 43. Informed Consent • Applicability of existing patient confidentiality/ patient access protections • Assurances that patient-identifiable images or information from the telehealth encounter would not be disseminated to researchers or others without patient consent • Providers must include the signed consent in the patient’s record (Arizona’s Telemedicine Statute, 2004; Telemedicine Development Act of 1996, Oklahoma Telemedicine Act, 1997). Baker & Bufka, 2011
- 44. Clinical Guidelines: Informed Consent • Confidentiality • Technical failure • Emergency Plan • Risks & Benefits • Contact between sessions • Testimonials & Solicitation • Websites • Referrals
- 45. Confidentiality
- 46. Challenge and Response Process Rummel & Joyce, 2010 for messaging & telephone
- 47. Confidentiality Notification of HIPAA/42 CFR Part 2 Privacy/Security Issues with Telehealth Appropriate releases HIPAA 42 CFR Part 2 Use of HIPAA Compliant Devices Duty to Warn about SMS Texting/Email Storage of Messages Mandatory Reporting Requirements
- 48. Risks with Messaging • Unlike progress notes written by the therapist, e-mails contain an exact transcript. Like stored audiotapes, documents may remain available on computers even after a file has been deleted. • Providers may forewarn patients of content-specific risks so that patients may choose carefully what information may be discussed through e-therapy and what is better suited for a face-to-face session. Recupero & Rainey, 2005
- 49. Policies if Technology is Interrupted Rummel & Joyce, 2010
- 50. TELEHEALTH greater risk for miscommunications or misunderstandings that may be experienced negatively by the patient. Baker & Bufka, 2011 Client may feel like they are abandoned or neglected
- 51. Immediate Actions • Will the therapist initiate the contact • What will be the time frame • What if the client doesn’t respond , what actions will be taken • Prevent misunderstanding or accidental breach of confidentiality Rummel & Joyce, 2010
- 52. • Who will be responsible for getting back in contact? • Within what time frame should this contact be made, and by what means? GOAL Prevent misunderstandings or an accidental breach of client confidentiality Rummel & Joyce, 2010 DETEMINE……
- 53. • Providers’ websites should offer instruction (whom to call, phone numbers, etc.) in the event of a power outage in the client’s local area or in a time of emergency that occurs when the website is unavailable. • Since power will not be available, these instructions should be kept in hard copy by the client and therapist. Web-Based Instructions Midkiff & Wyatt, 2008
- 54. Abandonment While therapists ethically avoid abandoning their clients….. technological difficulties (e.g., broken internet connection) may isolate a client for extended periods or even force the termination of treatment altogether (e.g., dead computer). Baker & Ray 2011
- 56. Behaviors Necessitating Emergency Actions Rummel & Joyce, 2010 • Client abruptly terminating the session • Client not responding to counselors’ contact attempts • Threats of violence towards self or others • Disclosure of current physical/sexual abuse • Disclosure of consumption of dangerours levels of alcohol/drugs (llicit/illicit) • Disclosure of stopping medication
- 57. Clinical Guidelines: Emergency Management 1. Patient Safety in a Setting without Immediately Available Professionals 2. Patient Support & Uncooperative Patients 3. Transportation
- 58. Take Clients’ Statements Seriously Rummel & Joyce, 2010
- 60. Benefits of Online Counseling- Messaging • being able to send and receive messages at any time of day or night • never having to leave messages with intermediaries • avoidance of voice mail and ‘‘telephone tag’’ • being able to take virtually unlimited time to compose one’s message and to reflect on the therapist’s messages ( Midkaff & Wyatt, 2008; Benderly, 2005; Barnett & Scheetz, 2003; Childress, 2000; Grohol, 1999)
- 61. Benefits of Online Counseling- Messaging • Automatic maintenance of a record of communications • cost savings, in some cases, as compared to face-to- face therapy • feeling less inhibited about self-disclosure • convenient scheduling • Enjoyment of the comfort of one’s own private space ( Midkaff & Wyatt, 2008; Benderly, 2005; Barnett & Scheetz, 2003; Childress, 2000; Grohol, 1999)
- 62. Risks Associated with Online Counseling- Messaging • messages may be lost in cyberspace or otherwise may not be received • breach of confidentiality by hackers or at the level of the Internet service provider • e-mails may not be received if they are sent to the wrong address (which might also breach confidentiality) • confidentiality could be breached at either end by others with access to the e-mail account/computer (Manhaul-Baugus, 2001; Rosik & Brown,2001; Frankel, 2000; Hunt v. Disciplinary Board, 1980; Midkaff & Wyatt, 2008)
- 64. Verification of Expectations Regarding Contact Between Sessions • Will clients have ability to contact the counselor 24/7 • Expectations of counselor to respond • Response time between email exchanges • Clients who use videoconferencing can email or message the counselor in between sessions
- 66. Client Testimonials • Many ethical codes do not allow client testimonials • Client Confidentiality Issues • Easy to place testimonials on Website ADVISE AGAINST Midkiff & Wyatt, 2008
- 67. Sending an e-mail may have the feel of a virtual knock on the door…. the therapist would tend to be protected against complaints of solicitation if no overture is ever initiated by the therapist Midkiff & Wyatt, 2008
- 68. A rule of thumb: no first contact by the therapist Midkaff & Wyatt, 2008
- 69. Making Referrals
- 70. Referral Policy • Create a policy for making a referral for a current client due to disorder getting worse or a new problem that cannot be treated by the counselor (outside of scope) • Inform client of the need for the referral and provide information regarding contacting the new practitioner/provider • Inform practitioner/provider of referral with release from client (42 CFR Part 2) • Document referral in patient chart
- 72. Consumers’ Recommendations for Websites Palmiter &Renjilian (2003) • Specifically, consumers wanted to see – professional’s degree/licensure information – hours of availability – list of problems treated/list of therapies offered – years of experience/Educational background – insurances accepted/fee scale – emergency procedures – description of policies – therapy information/links to self-help information – resumé /picture of the clinician
- 73. Therapeutic Alliance Building Using Telehealth Technologies
- 74. Building Rapport • Active listening • Verbal engagement • Emotional engagement • Empathy • Self-disclosure (Evans 2009)
- 75. How to do….. this using Telehealth Technologies
- 77. Clinical Guidelines: Physical Environment • Aim to provide comparable professional specifications of a standard services room
- 78. Ensure Privacy
- 79. Distractions
- 80. Announce Presence of Other People
- 81. Seating, Lighting, Camera Positioning Videocounseling Vignette
- 82. Telephone
- 84. Absence of face-to-face cues Skills/Attitudes when working via telephone: •Welcoming manner •Voice tone/style •Interactive nature •Structure-checking in •Summarization (Center for Credentialing & Education, 2011)
- 85. “It takes practice for a counselor to learn to trust their “inner ear” and rely only on what they are hearing.” Rosenfield, 2003
- 86. Silence
- 88. Distractions For the Client For the Counselor
- 89. Messaging- Chat & Email
- 90. Comfort with Internet Modalities and Software (Center for Credentialing & Education, 2011)
- 91. Not This……
- 92. Expressive Writing Skills (Center for Credentialing & Education, 2011)
- 93. People who hate to write, or are poor typists probably will not be drawn to text-based therapy. Self- selection is at work….. Suler, 2004
- 94. “Disinhibition Effect” (Suler, 2004, p. 321) This effect could decrease client defensiveness and self-consciousness, therefore increasing client self-disclosure (Alleman, 2002; Chester & Glass, 2006
- 95. Online Disinhibition Effect (Suler, 2004, p. 321)
- 96. Ways that mimic face-to-face cues • Colors • ALL CAPS • Smiley ;-) faces • rrrrepeated llletters • fonts, sizes, typefaces • difrunt spellin • ?????? punctuation!!!!!!!! • spacing between l e t t e r s, betweenwords, and between lines
- 97. Keyboarding Strategies Suler, 2004 • Emoticons like the smiley, winky, and frown, which are seemingly simple character sets that nevertheless capture very subtle nuances of meaning and emotion. • -- Parenthetical expressions that convey body language or "subvocal" thoughts and feelings (sigh, feeling unsure here). • -- Voice accentuation via the use of caps, asterisks, and other keyboard characters in order to place vocal *EMPHASIS* on a particular word or phrase.
- 98. Keyboarding Strategies • Trailers to indicate a pause in thinking.... or a transition in one’s stream of thought. • -- LOL, the acronym for “laughing out loud” which serves a handy tool for responding to something funny • -- Exclamation Points which tend to lighten up the mood of otherwise bland or serious sounding text. • -- Expressive acronyms like imo (in my opinion) and jk (just kidding) used as shorthand expressions. Suler, 2004
- 100. Zone for Reflection • In online therapy clinicians can experiment with creative ways of encouraging clients take advantage of the opportunity to self-reflect before responding to the clinician’s message • In other cases the clinician may suggest that clients NOT delay their response in order to encourage a more spontaneous, uncensored reply • For the therapist, the zone for reflection allows interventions to be more carefully planned and countertransference reactions managed more effectively Suler, 2004
- 101. Development of Therapeutic Alliance using Telehealth Technologies Skills/Attitudes when working via e-mail: •Warmth & Caring •Conversational •Contextualizing •Descriptive Immediacy •Similes, metaphors and stories •Writing style (font, capitials, colors) •Empathic mirroring (Suler 2004)
- 102. “I HAVE A VISUAL IMAGE OF YOU TRYING TO JUGGLE YOUR RECOVERY, COMMITMENTS TO FAMILY AND SEARCH FOR A NEW JOB.” WARMTH and CARING (Suler 2004)
- 103. “I CAN SEE YOU SITTING AT YOUR MEETING, JOHN, TRYING TO BE PRESENT BUT DISTRACTED AND WORRYING ABOUT COMPLETING YOUR JOB APPLICATION AND GOING TO YOUR SON’S BASEBALL GAME.” DESCRIPTIVE IMMEDIACY (Suler 2004)
- 104. WRITING STYLE SHOULD BE CONVERSATIONAL AND LESS FORMAL AND CONTAIN FREQUENT USE OF THE CLIENT’S NAME. CONVERSATIONAL (Suler 2004)
- 105. ATTENTION SHOULD BE PAID TO THE WRITING STYLE OF THE CLIENT AS WELL AS AN INDICATOR OR CUE TO THE CLIENT’S ISSUES. WRITING STYLE
- 106. Similes, Metaphors and Stories “Similes, metaphors and stories can appeal to some clients on various levels. May help the client feel more comfortable in expressing difficult feelings indirectly. If they see you are open to these techniques they may model your behavior if it is appropriate to their style and preferences. It might help the client to become more aware of internal dynamics and sharing them.” In ReadyMinds Distance Credentialed Counselor, 2011 From John Suler (2004), The Psychology of Text Relationships
- 107. Empathic Mirroring • Emphathic mirroring refers to using the client’s own words in your reply. • Using a reflective strategy can make the client feel heard and may strengthen the therapeutic alliance thus allowing the client to move into more difficult areas. In ReadyMinds Distance Credentialed Counselor, 2011 From John Suler (2004), The Psychology of Text Relationships
- 108. CONTEXTUALIZING • An example of contextualization is the difference between reading the newspaper and reading a novel that might make you cry: try to make things relevant in context” In ReadyMinds Distance Credentialed Counselor, 2011 From John Suler (2004), The Psychology of Text Relationships
- 110. Fast or Touch Typing (Center for Credentialing & Education, 2011)
- 111. Comfort to Respond Quickly When Necessary (Center for Credentialing & Education, 2011)
- 112. Chat • Synchronous communication provides the opportunity to schedule sessions defined by a specific, limited period of time - the culturally familiar “appointment.” • It can create a point-by-point connectedness that enhances feelings of intimacy, presence, interpersonal impact, and "arriving together" at ideas. • People may be more spontaneous, revealing, uncensored in their self disclosures. • Pauses in the conversation, coming late to a session, and no-shows are not lost as temporal cues that reveal important psychological meanings. Suler, 2004
- 113. Cultural Differences/ Counselor/Client Suitability • Less verbal individuals or those with accents or hearing difficulties may not feel comfortable working over the telephone • Clients who prefer chat usually want a more intimate real-time connection without “lag time” between their communications. • clients considering online counseling must have a basic grasp of written language and be able to express themselves in writing. These clients may also want time to edit and reflect on their communications with the counselor. Rosenfield, 2003
Editor's Notes
- Talking to a psychotherapist over the Internet could serve as a proverbial “foot in thedoor” for clients who are uneasy about seeking mental health treatment, and once they get comfortablewith this idea, face-to-face counseling could be the next step. Also, research has postulatedthat for some men, online psychotherapy is more comfortable than coming in for faceto-face sessions (Rochlen, Land, & Wong, 2004 ) Rummel & Joyce, 2010)
- It may be surprising to some, but preliminary research has shown that a meaningful therapeutic alliance can be formed over the Internet, even in the absence of nonverbal cues (Cook, 2001; Prado & Meyer, 2006). For example, Cook (2001) studied the working alliance (as measured by the Working Alliance Inventory) in Internet therapy via both asynchronous and synchronous communication methods. Scores on the Working Alliance Inventory were compared for a sample of clients who had received Internet psychotherapy and a sample of clients from previous literature who had received face-to-face psychotherapy. Results indicated no significant differences between the two groups. Cook found that a working alliance was strongly established between clients and providers of synchronous and asynchronous e-therapy. Cook and Doyle (2002) found similar results after only one online session. However, Leibert, Archer, Munson, and York (2006) found that clients receiving face-to-face counseling had stronger perceived working alliances than those in e-therapy, but the e-therapy users still had high satisfaction ratings of their experience. In a review of the literature, Mallen, Vogel, Rochlen, and Day (2005) noted that collectively, findings indicate that clients are just as satisfied with online psychotherapy as they are with face to face psychotherapy. Rummel & Joyce, 2010
- There are all sorts of ethical issues associated with telehealth.
- More counselors are using technology (email, smart phones, tablets, etc.) to conduct their business and as such this brings new and unique ethical dilemmas. In fact in some cases, technology use has become so ubiquitous that counselors may forget about Privacy, Security, and Confidentiality issues which puts them at risk for ethical violations. Source National Board of Certified Counselors (NBCC). (2013). NBCC Adopts Revisions to Ethical Standards. The National Certified Counselor, 29(1), 1-23.
- Professional Associations and states need to revise/rewrite a portion of their ethical codes to address the use of various telehealth technologies. Source Telemental Health Institute. (2013). Retrieved from telehealth.org.
- Listed here are the addiction counseling accrediting bodies that currently all have some specific ethical codes related to the use of telehealth technologies when providing treatment services: Source NAADAC. (2013). NAADAC Code of Ethics Principles. Retrieved from http://www.naadac.org/membership/code-of-ethics. National Board for Certified Counselors (NBCC). (2012). National Board for Certified Counselors Code of Ethics. Retrieved from http://www.nbcc.org/assets/ethics/nbcc-codeofethics.pdf. American Counseling Association (ACA). (2005). ACA Code of Ethics. Retrieved from http://www.counseling.org/Resources/aca-code-of-ethics.pdf. American Mental Health Counselor Association (AMHCA). (2010). Principles for AMHCA Code of Ethics. Retrieved from http://www.amhca.org/assets/news/AMHCA_Code_of_Ethics_2010_w_pagination_cxd_51110.pdf. American Association of Marriage and Family Therapy (AAMFT). (2012). Code of Ethics. Retrieved from http://www.aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx. National Association of Social Workers (NASW). (2008). Code of Ethics. Retrieved from http://www.socialworkers.org/pubs/code/default.asp. National Council of State Boards of Nursing (NCSBN). (2011). NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules. Retrieved from https://www.ncsbn.org/Model_Nursing_Practice_Act_March2011.pdf.
- The American Psychological Association put together a joint task force to develop telehealth guidelines for psychologists and their recommendations should be released soon. Source American Psychological Association (APA). (2010). Ethical Principles of Psychologists and Code of Conduct. Retrieved from http://www.apa.org/ethics/code/index.aspx.
- The International Certification and Reciprocity Consortium, or IC&RC , puts this responsibility on individual states. They do not have a national Code of Ethics. So if you are looking for telehealth technology-related ethical codes and you are an IC&RC state, you will need to go to your local board. Source IC&RC. Find a Board. Retrieved from www.internationalcredentialing.org/findboard.
- Informed consentis especially important when providing telemental health servicesas there is a greater risk for miscommunications or misunderstandingsthat may be experienced negatively by the patientand potentially construed as abandonment or negligence
- For example, the American Psychological AssociationInsurance Trust will include online services falling within the psychologist’slicense and state guidelines; however, the insurancewould likely be voided ifa counseling psychologist were providing services outside the scope of his orher license. Therefore, if a counseling psychologist provided services to a clientfrom another state or territory, malpractice insurance companies may notbe obligated to cover any legal expenses or damages were the client to pursuea malpractice claim.
- Begin with a review of definitions: Telephone-based refers to the synchronous distance interaction in which information is received only through audio means. Chat-based refers to the synchronous distance interaction in which information is received through written messages. E-mail-based refers to the asynchronous distance interaction in which information is received through written text messages or e-mail. Synchronous communication such as telephone and chat are coordinated in what is often referred to as “real time” or “live” communication. Remember from the stump speech, the telephone was created in 1876 and in 1879, an article from the Lancet Journal talked about using the telephone to reduce unnecessary doctor office visits. Chat refers to instant messaging (IM) or Internet Relay Chat (IRC) - a completed text message can be viewed almost as soon as it is sent on a computer (Lancet Journal is an independent general medical journal.) Asynchronous communications such as e-mail allows two users to communicate with one another without being simultaneously connected.
- Published May 2013This practice guidelines document focuses on telemental health services delivered in real-time using internet based videoconferencing technologies through personal computers and mobile devices. These guidelines serve as a companion document to ATA’s Practice Guidelines for Videoconferencing-based Telemental Health, a document adopted in 2009 that focuses on real-time videoconferencing-based telemental health services delivered using technologies other than the Internet.
- Contact info for both provider and patient should be verified. Reasonable expectations about contact between sessions should be discussed and verified with the patient. The provider should provide a specific time frame for expected response between session contacts. This should also include a discussion of emergency management between sessions.
- Professionals should consider the patients’ expectations and level of comfort with home-based care to determine the appropriateness of using videoconferencing in this setting. An unsupervised setting requires that the patient take a more active and cooperative role in the treatment process than an in-person setting. Determining whether a patient can handle such demands may be more dependent on the patient’s organizational and cognitive capacities, than on diagnosis. Luxton DD, O'Brien K, McCann RA, Mishkind MC. Home-based telemental healthcare safety planning: what you need to know. Telemed J E Health. 2012;18(8):629-33. Luxton DD, Sirotin AP, Mishkind MC. Safety of telemental healthcare delivered to clinically unsupervised settings: a systematic review. Telemed J E Health. 2010;16(6):705-11.)
- the first session, the therapist and client come up with a challengeand response to initiate each subsequent session—in other words, a specified question the therapistasks and an answer that the client must give. If the client does not give the decided-upon answer,the therapist can then be alerted to a possible confidentiality breach
- that should the synchronous chat conversation be disconnected, the psychotherapist will wait 5 min and then call the client on his or her phone, and leave a voice mail psychotherapist will wait 5 min and then call the client on his or her phone, and leave a voice mail message if the client does not respond. The importance of discussing this procedure with clients Rummel & Joyce, 2010
- Informed consentis especially important when providing telemental health servicesas there is a greater risk for miscommunications or misunderstandingsthat may be experienced negatively by the patientand potentially construed as abandonment or negligence
- It is also good practice for an online psychotherapist to, in the first session, set up an agreed-upon procedure with each client in the event of technology failure. For example, will the therapist be responsible for getting back in contact with the client, or vice versa? Within what time frame should this contact be made, and by what means? For example, a psychotherapist and client might set up an agreement that should the synchronous chat conversation be disconnected, the psychotherapist will wait 5 min and then call the client on his or her phone, and leave a voice mail message if the client does not respond. The importance of discussing this procedure with clients cannot be underscored enough in order to prevent misunderstandings or an accidental breach of client confidentiality Rummel & Joyce, 2010
- Therefore, the client should be aware what behaviors will be construed by the clinician as an emergency (e.g., the client abruptly terminating the chat session, allusions to suicide, or direct threats) and what action will then be taken in the event that any of these behaviors occur. Similarly, clinicians should collect identifying client information, as well as the client’s location and contact information, so that they are able to alert an emergency management team or Child Protective Services, if necessary, and direct them to the right place. One could make this a mandatory requirement for engaging in online psychotherapy, just as consent to videotaping is a requirement for clients seeing student-therapists in some training agencies. In an online realm, because the clinician will never physically be there to prevent a client from engaging in a harmful action during the psychotherapy session itself, it is all the more imperative that psychotherapists take client statements seriously. Online psychotherapists who do not provide services to minors should also consider including a direct statement that they do not provide services to minors, and require clients to provide their date of birth in order to verify the client’s age. Rummel & Joyce, 2010
- 4. Patient Safety when providing Services in a Setting without Immediately Available Professional Staff For treatment occurring where the patient is in a setting without clinical staff, the professional may request the contact information of a family or community member who could be called upon for support in the case of an emergency. This person will be called “the Patient Support Person” an individual selected by the patient. 5. Patient Support Person and Uncooperative Patients It is possible that a patient will not cooperate in his or her own emergency management, which underlies the practice of involuntary hospitalization in mental healthcare. Professionals should be prepared for this as well as the possibility that Patient Support Persons also may not cooperate if the patients themselves are adamant that they do not want to seek emergency care. Therefore, any emergency plan shall include local emergency personnel and knowledge of available resources in case of involuntary hospitalization. 6. Transportation The professional should know any limitations the patient has in terms of self-transporting and/or access to transportation. Strategies to overcome these limitations in light of an emergency shall be developed prior to starting treatment for patients in settings without staff immediately available. In the event of a behavioral and/or medical emergency, the patient’s Patient Support Person should discuss with emergency personnel whether they should transport the patient. 7. Local Emergency Personnel In providing care to patients in settings without professional staff immediately available, determining distance between local emergency personnel in the patient’s community and the patient’s location can shape the professional’s decision process in determining appropriate actions. Acquire telephone numbers for local resources in the patient’s community and have that contact information readily available at the beginning of each session. Prior to each session, the provider should also determine the patient’s location and whether there have been any changes to the patient’s personal support system or the emergency management protocol.
- As discussed earlier… Operation PAR, Inc., is a leading Substance Abuse Mental health Treatment Provider in the State of Florida. It was established in 1970 from a grassroots movement and now operates as a treatment provider offering a full continuum of services from prevention to long term residential as well as medication assisted treatment services. Operation PAR serves all ages and embraces technology to reach more individuals and their family members with mental health and SUDs. Online services are provided through a HIPAA complaint web-base portal and services include: education for client, families and loved ones, family sessions, discharge session with new providers, training for clinical staff, clinical supervision, EBP training and certification, contingency management (client incentives), involvement of family, and support system for clients. OperationPAR uses a HIPAA compliant portal that allows clients to log-in and enter into a safe and secure portal in order to: attend group therapy using videoconferencing email chat with their counselors receive other counseling services This is just one example of a treatment program that uses telehealth technologies.
- This is not an exhaustive list of issues to consider when connecting with clients through TH technologies but will provide a starting point for a discussion on several areas of importance in developing client engagement. Keep in mind it is the professional’s responsibility to seek appropriate education, training, or supervised experience using the relevant technology to deliver services.
- Building rapport is how the counselor/client develop a therapeutic relationship. Ask the audience to think about the various ways in which they build rapport with their clients in face-to-face settings. Use the list above as a guide. Active listening: paying close attention to the words, pauses or no pauses, emotions Verbal engagement: open ended questions Emotional engagement: getting the client out of their head and in touch with emotions Showing empathy about the client’s situation and feelings rather than providing a professional interpretation Self-disclosure: in an office setting, the client will see décor, certificates/degrees and other items that reflect professional credentials and personal tastes, hobbies, etc. In online counseling the use of an avatar such as a photograph or a webpage with a background or biographical sketch would provide the client with more information about who the counselor is and what they are about. In telephone counseling, the counselor could share professional and personal information as relevant to the counseling relationship. In Alemi, et al., 2007, it is suggested that when using email to deliver services, the client and counselor establish contact with an introductory email. It is suggested the counselor email contain: Description of the clinician’s background Statement regarding confidentiality, privacy & security of email exchanges Ask the client to introduce themselves and include age, who they are, what they do, etc.
- Both the professional and the patient’s room/environment should aim to provide comparable professional specifications of a standard services room. The physical environment guidelines pertain to both the patient’s and the professional’s room or environment where the videoconferencing is taking place. Ensure privacy so clinical discussion cannot be overheard by others outside of the room where the service is provided. If other people are in either the patient or the professional’s room, both the professional and patient should be made aware of the other person and agree to their presence. Seating and lighting should be tailored to allow maximum comfort to the participants. Both professional and patient should maximize clarity and visibility of the person at the other end of the video services. Reduce backlighting from windows or light fixtures. Both provider and patient cameras should be on a secure, stable platform to avoid wobbling and shaking during the videoconferencing session. To the extent possible, the patient and provider cameras should be placed at the same elevation as the eyes with the face clearly visible to the other person.
- In regard to telephone counseling, Rosenfield (2003) says it takes practice for a counselor to learn to trust their “inner ear” and rely only on what they are hearing. Changes in inflection and silences for prolonged periods can represent a communication. The counselor needs to be more interactive and the response style recommended is quick, brief and frequent. Very intensive form of counseling Telephone silences may seem longer than in person and Rosenfield (1997) suggests the counselor break silences that last longer than a minute on the telephone. Just as in face-to-face sessions, it would be important to take into account what was said prior to the silence and counselors may need to provide more reflections, paraphrasing and summary on the telephone. Be ready for unintended distractions or intrusions such as emergency vehicle noise, lawn mowers or other phones/fax machines. Important to reassure the client that no one else is listening-in or can over hear the conversation.
- The smiley often is used to clarify a friendly feeling when otherwise the tone of your sentence might be ambiguous. It also can reflect benign assertiveness, an attempt to undo hostility, subtle denial or sarcasm, self-consciousness, and apologetic anxiety. The winky is like elbowing your e-mail partner, implying that you both know something that doesn't need to be said out loud. It often is used to express sarcasm. It's an intentional effort to convey some underlying mood or state of mind, almost implicitly saying, "Hey, if there is something hidden or unconscious going on inside me, this is probably it!"
- Trailers Combined with such vocal expressions as.... uh.... um.... trailers can mimic the cadence of in-person speech, perhaps simulating hesitation or confusion. can mimic the cadence of in-person speech, perhaps simulating hesitation or confusion LOL without having to actually say "Oh, that's funny!" It's feels more natural and spontaneous - more like the way you would respond in a face-to-face situation. !!!!! Text peppered lightly with exclamations, at just the right spots, provides a varying texture of energy that highlights mood and enthusiasm. Too many exclamation points may result in text that seems contrived, shallow, or even uncomfortably manic.
- An example of warmth & caring might be conveyed to client by using visual imagery such as “I have a visual image of you trying to juggle your recovery, commitments to family and search for a new job.” This is also seen in descriptive immediacy but is an immediate visual reflection and often used in the beginning or end of the e-mail message, e.g., “I can see you sitting at your meeting, John, trying to be present but distracted and worrying about completing your job application and going to your son’s baseball game.” Writing style should be conversational and less formal and contain frequent use of the client’s name. Attention should be paid to the writing style of the client as well as an indicator or cue to the client’s issues. Suler, J.R. (2004). The psychology of text relationships. In Online Counseling: a manual for mental health professionals (R. Kraus, J. Zack & G. Striker, Eds). London: Elsevier Academic Press. (Lesson 11 DCC Final)
- “Text construction reflects an important personality trait - text empathy. Is there just the right measure of organization so the reader understands, along with the right measure of spontaneity so the reader appreciates the writer’s genuineness? Does the sender pay attention to and anticipate the needs of the recipient? Empathic people specifically respond to what their text partners have said. They ask their partners questions about themselves and their lives. They also construct their messages anticipating what it will be like for the recipient to read it. They write in a style that is both engaging and readily understood. With appropriate use of spacing, paragraph breaks, and various keyboard characters (....///**) to serve as highlights and dividers, they visually construct the message so that it is easy and pleasing to read. They estimate just how long is too long. Essentially, they are good writers who pay attention to the needs of their reader. This is quite unlike people with narcissistic tendencies who have difficulty putting themselves into the shoes of the recipient. They may produce lengthy blocks of unbroken text, expecting that their partner will sustain an interest in scrolling, and reading for seemingly endless screens of long-winded descriptions of what the sender thinks and feels. Paradoxically, the narcissistic person's need to be heard and admired may result in the recipient hitting the delete key out of frustration or boredom. Text empathy includes an intuitive feeling for what the others might be feeling and thinking. Curiously, people report that even in the stripped down sensory world of text relationships - even in the bare bones of chat communication - others sometimes sense what’s on your mind, even when you didn't say anything to that effect. Did they detect your state of mind from subtle clues in what or how you typed? Are they picking up on some seemingly minor change in how you typically express yourself? Or does their empathy reach beyond your words appearing on the screen? Obviously, this intuitive insight into the message body is a skill crucial to the success of an online clinician. It’s a skill that may be different than intuition in face-to-face communication.” John Suler The Psychology of Text Relationships This article originally appeared as Suler, J.R. (2004). The psychology of text relationships. In Online Counseling: a manual for mental health professionals (R. Kraus, J. Zack & G. Striker, Eds). London: Elsevier Academic Press
- This section will discuss how professionals using telehealth (TH) technologies connect differently with clients than in a face-to-face setting. The TH technologies to be covered in this section include telephone, e-mail and chat. The stump speech has provided a great deal of information around using TH technologies to deliver counseling services in regard to the type of computer and software requirements, confidentiality, privacy, portability, reimbursement and ethics yet there is another important aspect and that has to do with client engagement. What skills are needed to build rapport and conduct counseling with clients when utilizing TH technologies such as telephone, chat and email? How do we adapt our basic counseling skills for use in an electronic environment?
- Fast or touch-typing: e-mail and especially chat TH technologies may be frustrating for the “hunt and peck” typist Internet modalities and software include instant messaging (IM), chat, email, downloading the latest software program when necessary. Tolerance for technical problems Previous online relationships: Ask the audience to consider their own online relationships, e.g., texting, chatting or e-mailing with friends, family, co-workers and how those experiences have impacted the relationships and increased skill sets in electronic communications. Lessons learned about tone, ALL CAPS, reply all, emoticons are part of the personal skill set that both professionals and clients bring to a therapeutic relationship developed through telehealth technology delivery.