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Psychology and Technology:
What Happens When They Collide?
Mudita Bahadur, Ph.D.
Carol Falender, Ph.D.
Recently a client inquired about therapy for herself and her husband. Because her husband resides in a foreign country, she was hoping he could be "Skyped-in” to the sessions. The client insisted that "lots of therapists do this now.” Aside from the 12-hour time difference that would make such an arrangement logistically difficult, her request raised a range of ethical issues related to "telehealth.”
A second client is moving to another state to begin college and wants to have sessions several times a week. There will be a three-hour time difference, and he wants sessions at 7:00 a.m. EST.
Telehealth uses electronic information and telecommunications technologies to support long-distance clinical health care; patient and professional health-related education; public health; and health administration (HRSA, 2009). "Telepsychology” provides non-face-to-face psychological services using distance communication technology such as telephone, email, chat, and videoconferencing (Ohio Psychological Association, 2008). Telehealth and telepsychology practices are growing and show no signs of slowing down (Fitzgerald et al., 2010).
According to California Business and Professions Code § 2290.5, telehealth or "telemedicine” means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, or data communications. Neither a telephone conversation nor an electronic mail message between a health care practitioner and patient constitutes "telemedicine” for purposes of this section (http://law.onecle.com/california/business/2290.5.html).
Psychologists must review the circumstances of each case and use appropriate ethical standards to determine if telehealth or Internet-based therapy is right for their practices. Psychologists must also be alert to changes in regulatory and ethical standards for telehealth and telepsychology.
The APA Code of Ethics (APA, 2002) indirectly refers to telehealth issues in the Introduction and Applicability section, where it states, "This Ethics Code applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists. Areas covered include but are not limited to the clinical, counseling, and school practice of psychology; research; teaching; supervision of trainees; public service; policy development; social intervention; development of assessment instruments; conducting assessments; educational counseling; organizational consulting; forensic activities; program design and evaluation; and administration. This Ethics Code applies to these activities across a variety of contexts, such as in-person, postal, telephone, Internet, and other electronic transmissions. These activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code.”
Within the state of California, the Telemedicine Development Act of 1996 (CTEC, 2006) established laws governing the delivery of health care services through telemedicine and requirements for the payment for telemedicine. One of the requirements established by this legislation limits California-licensed practitioners to practicing telemedicine within California. The California Board of Psychology reiterates this necessity, cautioning California consumers seeking psychological services over the Internet to "verify that the practitioner has a current and valid license in the State of California” (http://www.psychboard.ca.gov/consumers/internet-thrpy.shtml).
Teleheath raises ethical concerns in many areas outlined in the APA Ethics Code. Section 2.01, Boundaries of Competence, raises the need to determine if the psychologist is competent and licensed to provide service in the area where the client is residing. Section 4.01, Maintaining Confidentiality, speaks to issues of privacy and security which are of paramount importance when using Internet-based communication technology. Section 10.01, Informal Consent to Therapy, specifies that psychologists, when obtaining informed consent, need to instruct clients about the limits of confidentiality and the nature of the therapeutic relationship. In the case of telehealth, other ethical considerations may arise, such as the need to provide clients with emergency plans as well as methods of communication other than the Internet.
Telehealth practice is expanding because of the advantages it offers, such as the convenience of an office with just a laptop, possible lower fees, greater accessibility to services that lower overhead costs, and greater access to services for patients living in rural or underserved areas (Koocher, 2009).
Psychologists must proceed with caution and care when entering into relationships with clients based on telehealth, telepsychology, and other technologies to deliver services.
Some considerations in deciding to proceed are:
Psychologists should know where their clients reside. Licenses are valid where they are issued, but not necessarily in other states where clients may permanently reside. Psychologists are responsible for looking into the laws in the states or jurisdictions where their clients reside regarding licensures for psychologists providing services.
Psychologists are responsible for ensuring the accurate identifications of their clients and for completing standard intakes with emergency contact information. Psychologists are also responsible for confirming that persons seeking their services are 18-years-old or older.
Psychologists are responsible for electronic confidentiality. This is especially important for communication encryption, firewalls, and other means for blocking unauthorized computer access.
Psychologists are responsible for making their clients aware of the limitations of telepsychology and for assessing whether their clients’ presentations are appropriate for this modality.
Psychologists are responsible for clarifying emergency procedures and for providing clients with contact information other than email addresses, given that psychologists may not check their email messages regularly.
Psychologists are responsible for understanding their clients’ contextual circumstances, such as cultural and diversity influences that may impact the therapy.
Psychologists should be aware that telehealth triggers thetion encryption to protect against security breaches that would compromise their clients’ privacy and confidentiality. ?
Mudita Bahadur, Ph.D., is a licensed psychologist in Santa Monica and a member of the LACPA Ethics Committee. Dr. Bahadur has worked at the Saint John’s Child and Family Development Center specializing in therapy and assessments with young children for the past 14 years and has been in private practice for 10 years.
Carol Falender, Ph.D., is Chair of the Los Angeles County Psychological Association Ethics Committee. She is co-author of Clinical Supervision: A Competency-based Approach and co-editor of Casebook for Clinical Supervision: A Competency-based Approach, both published by the American Psychological Association, and has lectured extensively on ethics and clinical supervision.
American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57(12), 1060-1073.
Fitzgerald, T.D., Hunter, P.V., Hadjistravropoulos, T., & Koocher, G.P. (2010). Ethical and legal considerations for internet-based psychotherapy. Cognitive Behaviour Therapy, 39 (3), 173-187.
Koocher, G.P. (2009) Any minute now but far far away: Electronically mediated mental health. Clinical Psychology, 16 (3), 339-342.
Maheu, M. Ehealth, Telehealth, & Telemedicine Blog. elehealth.net/blog/tag/maheu/
Ohio Psychological Association. (2008). Telepsychology Guidelines. http://www.ohpsych.org/TelepsychologyGuidelinesApproved041208.pdf
Zur, O. Ethical decision making & codes of ethics on telehealth.