Guidelines and Ethical Decision-Making Regarding TeleMental Health

 
Introduction

• TeleMental Health or e-therapy activities may include:
  • Providing clinical services by phone, text, email, video chat, virtual reality (VR) or other digital means, to an individual in a different geographical area.
  • Using the telephone for crisis intervention or other contacts between in-person sessions.
  • Conducting telephone sessions with patients who are not able to attend in-person sessions for a period of time.
  • Using e-mail, chats, video-conferencing and other digital means for in between in-person session contacts with clients.
  • Using e-mail, video-conferencing, virtual reality or other digital means to provide online counseling services with no in-person contact.

 
Getting Started

• Make a reasonable attempt to verify the client’s identity. This can include obtaining or viewing a copy of a driver’s license or State ID, or other means that are appropriate to the client and the situation.
• Obtain reasonably necessary and relevant information about your client.
• Therapists must pay attention to whether the client is a minor, and to related issues of consent to treatment.
• Take into consideration that for some clients, the appeal of telehealth is to remain somewhat anonymous.
• Have a crisis intervention plan in place, including emergency contacts and ways to reach local emergency services and make referrals to local psychotherapists, psychiatrists and psychiatric hospitals in the client’s geographic vicinity.
• Screen clients before engaging in telehealth: Not all clients are suited for this mode of therapy, for clinical, technical, or other reasons.

 
Informed Consent

• Provide online services after obtaining an informed consent that highlights essential information that clients should know prior to entering into a professional relationship.
• Informed consent is a process where clients have access to information, based on which they can make informed decision.
• To the extent that it is possible, verify that each client has the legal authority to consent to treatment (online or otherwise).
• Ensure that informed consent addresses issues such as the nature of the services to be provided, options and alternatives available, relative risks and benefits of each, confidentiality and its limits, fees and financial arrangements, vulnerability of digital communication, emergency contact information, and the like.
• Take measures to ensure that recipients understand the nature of the online services to be provided. Clarify limits and expectations in advance, such as how often clients may contact you and how quickly you may be able or chose to respond.
• Informed consent is an ongoing process. Re-visit this as your and your clients’ situations evolve.
• Make clear the specific limits to confidentiality that exist in online communication.
• Inform clients of the possibilities of interruption of service due to dropped calls.
• Inform clients of the potential limitations of telehealth when it comes to crisis interventions and dealing with dangerous situations.

 
Finances

• Have a clear agreement in regard to what is being charged, how it is being charged, the rates and accepted methods of payment.
• Clarify financial issues in advance, including relevant insurance issues. Many insurance companies do reimburse for telehealth services, but this is not guaranteed.
• If you bill for a video or telephone session, you need to disclose it to the insurance company. Verify with insurer whether they cover therapy via e-mail, text, video-conferencing, etc.
• Some state laws consider telephone sessions exempt from telemedicine reimbursement. California is one such state, where therapy via the phone is not considered telehealth. Be informed.

 
Security

• Be astute and thorough with regard to online security and backups.
• Use appropriate safeguards, such as virus and firewall protection, as well as passwords and encryption to help preserve confidentiality.
• When doing assessments via the Internet, be especially cautious about test security issues, the absence of behavioral observations, and possibly not knowing who actually competes the materials and if they are completed independently.

 
Relevant Laws And Regulations

• Comply with HIPAA regulations. (See our online course on HIPAA or the HIPAA kit for up-to-date information.)
• Follow relevant and applicable state laws, licensing board rules and therapists’ state and national professional association guidelines and code of ethics.
• Giving special, serious consideration to issues of practicing across state lines. Generally, the laws of the state or country where the client lives have jurisdiction over treatment.
• The issue of residency on the part of the client is relevant to whether a therapist can treat a client. If a client lives in the same state as the therapist, and simply travels to other states, the therapist can usually treat the client, so long as the client’s trips are finite and the residency status has not changed.
• Be familiar with relevant laws in each client’s jurisdiction and the relevant law in the state you are licensed, such as mandatory reporting requirements. Comply with the relevant legal requirements.

 
Standard Of Care

• Practice within the standard of care.
• Provide clinical services only within your areas of clinical competence and scope of practice.
• Provide telehealth services only within your scope of technological competence.
• Research local and online resources so that appropriate referrals can be made if a client’s treatment needs require them.
• Obtain any needed training in advance to ensure the smooth use of online technologies and provide clients with needed training prior to providing actual clinical services online.
• Document online services (simply because the services are provided online does not exempt the need for good record keeping). Follow applicable laws for record retention and disposal.

 
Conclusion

• TeleMental Health is one of the fastest growing fields in mental health. Regularly update yourself on the latest research and changes in laws, regulations and codes of ethics. Concerns of privacy, security, HIPAA compliance, practicing across state lines, scope of practice, competence, and interruption of service are some of the most important issues to pay attention to.
• Always remember that your profession’s ethics code and your licensure law apply to the provision of online services. Be knowledgeable of these ethics and legal standards.
• When faced by a dilemma or challenging situation, consult with an experienced colleague and document the consultation.
• Be sensitive to the potential loss of cues in text communication.

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