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ETHICAL CHALLENGES, RISK MANAGEMENT, AND THE EMERGING TECHNOLOGY OF TELEHEALTH FOR MENTAL HEALTH

by Jackson Rainer, Ph.D, ABPP.


3 Credit Hours - $69
Last revised: 03/30/2015

Course content © Copyright 2013 - 2017 by Jackson Rainer, Ph.D, ABPP. All rights reserved.



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COURSE OUTLINE

 

About the Author

Learning Objectives

Common Definitions, terms, and language

Telemental health

Telecommunications

Client

In-person

Remote

Jurisdiction

Preparing for the technological world

Does telemental health alter the treatment experience?

Research on efficacy

Media and social networks

Two case studies

Ethics, meta-ethics, and overarching principles of conduct

Five meta-ethical principles

General standards of care in the delivery of telemental health services

Informed consent, confidentiality of data and information

Intrajurisdictional practice

Issues of clinical risk management

Definitions, terms, and a common language

Therapeutic errors and primary risk factors associated with mental disorders

Non-clinical risks that may intrude on the therapeutic process

Reimbursement for telemental health

The ethical challenges of practice including technology

Assets and barriers

Recommended reading and resources

Codes of ethics on telehealth and e-therapy

American Counseling Association Code of Ethics

American Medical Association

American Mental Health Counselors Association

American Psychological Association

American Psychiatric Association

American Telemedicine Association

National Board of Certified Counselors

Others

Telehealth 50-state review

References

 

About the Author

 

Rainer photo 110Dr. Jackson Rainer is a board certified clinical psychologist.  He is nationally known and respected as a psychotherapist, teacher, and supervisor.  In urban and rural settings, he has directed community mental health institutions and agencies, practiced psychotherapy with children, adults, couples and families, and taught in universities and professional settings for a practice life than spans more than 25 years.  Dr. Rainer is currently the Department Head of Psychology and Counseling at Valdosta State University, Valdosta, Georgia.    He is the former chair of the Publication Board for Division 29, Psychotherapy, of the American Psychological Association, is on the editorial and publication boards of seven psychology journals, and serves as a Media Representative for the APA.  More information about Dr. Rainer can be found here.  

 

LEARNING OBJECTIVES

Define four terms and processes related to technology and mental health

Critique the research about the efficacy of technology assisted mental health service provision

Explain the ethical concerns of telemental health

Discuss the provisions and laws related to telemental health in your state

 

AN INTRODUCTION, COURSE OVERVIEW, AND A BIT OF HISTORY

 

The world of technology has richly enhanced the speed, efficiency, and quality of how people interact with each other.  Individuals communicate through smart phones and personal digital assistants (PDAs), social networking sites, internet-based videoconferencing, and other forms of electronic communication.  Over the last five decades, technology has positively influenced the fields of psychiatry, psychology, and other mental health disciplines, and has radically changed how evaluations, therapy, and psychosocial interventions can be delivered to underserved populations, e.g., rural, prison, and veterans’ services.  In the 1950s, the field of psychiatry became the pioneer in the distal delivery of mental health consultation, training, education, and research (Wittson & Benschoter, 1972).  Terms such as “telemedicine,” “telehealth,” “e-health,” and “m-health” became broadly used in the health field to include conventional applications such as telephone consultation, internet and email exchange, chat room conversations, and videoconferencing.  These technologies have been used as primary or supplementary means of providing mental health treatment.  Specific terms used in behavioral mental health include “telemental heath,” “e-mental health,” telepsychology,” and “telepsychiatry”, and apply to the expansion of technology and its value in therapeutic processes (Baker & Bufka, 2011).

 

The first known telehealth program gave birth to “Eliza”, a computer program using natural language to simulate counseling dialogue in a therapeutic interview (Wiezenbaum, 1966). Following Eliza, telehealth primarily consisted of telephone-based treatments in the form of teleconferencing.  Technology-based mental health services more fully emerged in the late 1960s when the Nebraska Psychiatric Institute received a grant from the National Institute of Mental Health which linked the institute with Norfolk State Hospital, over 100 miles away, by closed-circuit television.   Late that same decade, the institute was linked to the Omaha Veterans Administration Hospital and other VA hospitals in the state and region, all of whom recognized the potential benefits of implementing telemental health services to soldiers returning from the battlefield (Godleski, Vadnal, & Tasman, 2001).  Other telehealth programs germinated and grew throughout the 1970s, mostly providing services to rural and remote populations, providing access to specialists in towns with only general medical practitioners (Brown, 1995). 

 

In this contemporary day and age, individuals and groups have benefited by telehealth systems that would otherwise not have had adequate access to health care.   Today, the VA is the largest consumer of telemental health services in the world, with over 45,000 videoconferencing and 5000 home telemental health encounters annually (Godleski, Nieves, Darkins, & Lehmann, 2008). Technology has enabled distance education and the rapid, effective sharing of information for the client and between providers who are separated either geographically or within institutions.

 

In contemporary time, technology is used as a generic term to describe new tools employed for old problems. Telehealth delivers many benefits, though concerns linger regarding the mechanics, therapeutic efficacy, reimbursement, and ethics related to the utilization of telemental health.  Technology development continues to make quantum leaps; advances have brought tremendous improvements and convenience to members of today’s society.  However, with the technology, a degree of depersonalization has been discovered with a favoring of science over art.  This is the primary argument surrounding the increased use of technology and is found in the discussion of the healing encounter, defined as containing a balanced integration of knowledge, clinical skill, and effective communication.  Clinicians continue speak to the need for intimacy and a trust in the shared personal interaction required for meaningful change to occur.

 

This continuing education paper seeks to examine the continuing emergence of telehealth in mental health service delivery, the ethical challenges of new technology, and the risk management concerns raised in a technology-based environment.

 

A COMMON UNDERSTANDING OF TERMINOLOGY

 

Telemental health is defined, for the purposes of this discussion, as the provision of mental health services using telecommunication technologies.  The practice of telemental health involves consideration of legal requirements, ethical standards, telecommunication technologies, intra- and interagency policies, other external constraints, and any additional demands of the particular professional context.  Telecommunications is the preparation, transmission, communication, or related processing of information by electrical, electromagnetic, electromechanical, electro-optical, or electronic means (Committee on National Security Systems, 2010).  Telecommunication technologies include but are not limited to telephone, mobile devices, interactive videoconferencing, email, chat, text, and internet (e.g., self-help websites, blogs, and social media).  The information that is transmitted may be in writing, and can include images, sounds, or other data.  These communications can be synchronous with multiple parties in real time, such as interactive videoconferencing or telephone, or asynchronous, such as email, online bulletin boards, or storing/forwarding information.

 

The American Psychological Association’s Telehealth Practice Organization Task Force provides operational definitions that are relevant to this discussion.  The Guidelines for the practice of telepsychology (draft released for public comment on July 27, 2012) state the following:

 

“The term ‘client/patient’ refers to the recipient of psychological services, whether psychological services are delivered in the context of healthcare, corporate, supervision, and/or consulting services.  The term ‘in-person,’ which is used in combination with the provision of services, refers to interactions in which the psychologist and the client/patient are in the same physical space and does not include interactions that may occur through the use of technologies.  The term ‘remote’ which is also used in combination with the provision of services utilizing telecommunication technologies, refers to the delivery of a service that is provided at a different access point from where the psychologist is physically located.  The term ‘remote’ includes no consideration related to distance, and may refer to an access point in a location that is in the office next door to the psychologist or thousands of miles away from the psychologist.  The terms ‘jurisdictions’ or ‘jurisdictional’ are used when referring to the governing bodies at states, territories, and provincial governments.”

(p.4)

 

PREPARING FOR THE TELEMENTAL HEALTH WORLD

 

With the new technology, health care providers are able to connect easily and virtually with clients without the requirement of face-to-face encounters.  Whether the communications are limited to scheduling appointments or involve the provision of counseling and psychotherapy interventions remotely, using this technology for delivery of health care services raises unique issues related to how these services are coordinated.  While using technology to provide virtual services can enhance and increase access to care, such as for rural populations or linguistic minorities, the technology itself creates new challenges and potential risks that practitioners must carefully consider.  Providers are obligated to attain and maintain competency in specific practice areas and in work with specific populations; those who use telemental health must also be competent to use the technology.  At this point in time, there is a lack of uniformity and clear guidance on legal, regulatory, and ethical requirements regarding reimbursement policies, privacy and security issues, and best practice guidelines for using advanced technology in service provision.

 

The Efficacy Research Results to Date:  Does telemental health alter the treatment experience?

 

Sound research is available that speaks to the efficacy of telemental health.  Randomized clinical trials using telephone-delivered cognitive-behavioral therapy (CBT) for participants with depression, anxiety, and obsessive-compulsive disorder have yielded positive findings (Ekberg, et al., 2011; Gold, Coulson, & Howard, 2012; Lovell et al., 2006; Mohr et al., 2005).  Telephone delivered intervention for CBT is primarily studied as a result of its veracity as a validated therapeutic model.  CBT telephone delivered treatment has high patient satisfaction (Bee et al., 2008).  While qualitative and quantitative successes continue to be reported for CBT telephone psychotherapy, there are challenges to be discussed.  First, there is a lack of control over the client’s environment, e.g., privacy during phone call and interruptions during calls.  Second, mobile phones are not secure lines of communication.  Third, there are challenges developing a therapeutic alliance over the telephone, e.g., a lack of access to anon-auditory cues.  Finally, there are some situations that may not be best suited for telephone delivered treatment, e.g., suicidal or homicidal intent, and the best practice notion that practitioner must have a risk assessment plan securely in place when lethality is an issue (Brenes, Ingram, & Danhaur, 2011).

 

The growth of telemental health has expanded to include computer-assisted therapy, virtual reality programming, i.e., high tech 3D virtual worlds using avatar-based interaction and videoconferencing to treat depression, anxiety, childhood disorders, posttraumatic stress disorder, smoking cessation, and substance abuse disorders (Gorini, Gaggioli, Vigna, & Riva,2008; Riper, et al, 2010).  Technology has aided in the assessment of mental disorders and routed individuals for necessary mental health care.  For example, Hollandare, Andersson, and Engstrom (2010) compared online versions of the Beck Depression Inventory (BDI-II) and the Montgomery Asberg Depression Rating Scale – Self Rated, to paper versions of the tests and concluded that both tests administered online retained their psychometric properties (r = .89 and .84, respectively).  The authors reported that online test advantages included easy administration, dissemination, and data analysis that could serve to improve clinical outcomes (Hollandare, et al., 2010).  Clients, families, and staff have rated technology highly in terms of its reliability, convenience, easy-to-use features, and comparability to face-to-face treatment (Bee, et al., 2008; Grady & Singleton, 2011; Khasanshina, Wolfe, Emerson, & Stachura, 2008; Mohr, Hart, & Marmar, 2006).

 

The most researched aspects of telemental health have been computer assisted therapy (CAT) in the form of cognitive behavior therapy (CBT).  CAT can be delivered on various computing devices such as personal computer, PDAs, interactive voice response systems, gaming machines, CD-ROMS, DVDs, cell phones, and virtual reality devices (Marks, Cavagh, & Gega, 2007) and is primarily used as an adjunct to standard in-person treatment.  CAT has been primarily delivered through CBT to treatment depression and anxiety (Craske et al., 2009; Foroushani, Schneider, & Assareh, 2011).  CAT can be accessed virtually anywhere by patients and it extends the range of mental health service to help clients improve at their own pace.  Added benefits for CAT users includes immediacy and no travel time, avoidance of inconvenient appointments, and a reduced risk of mental health stigma (Marks, et al., 2007).  Carroll and Rounsaville (2010) report additional strengths of CAT as providing in-home accessibility, reducing the disparity gap due to the shortage of clinicians to deliver empirically validated therapies, and maintenance of the anonymity of individuals who may feel more comfortable providing sensitive information to a computer than to a clinician.

 

Internationally, CAT has been widely utilized and adopted as a standard treatment for certain mental disorders.  For example, the National Institute for Clinical Excellence in the United Kingdom has adopted two computer-assisted CBT treatments:  Beating the Blues for mild and moderate depression and FearFighter for phobia, panic, and anxiety as first-line treatments (Marks, et al., 2007).  The use of technology in mental health has been revolutionary in its approach to addressing environmental barriers, e.g. transportation, childcare, perceived stigma, and restrictive work schedules to in-person psychotherapy (Bee, Lovell, Lidbetter, Easton, & Gask, 2010).  Specific examples and case studies will help with the understanding of the technology.

 

Anxiety. Klein et al., (2011) examined post-treatment effectiveness using five fully automated self-help cognitive behavior e-therapy programs for generalized anxiety disorder (GAD), panic disorder with or without agoraphobia (PD/A), obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and social anxiety disorder (SAD).  The e-therapy programs were offered free of charge to the international public via Anxiety OnLine, an open access virtual psychology clinic for anxiety disorders.  A sample of 225 individuals self-selected one of the five e-therapy programs and completed a 12-week post treatment assessment.  The authors noted significant reductions in all five anxiety disorder severity ratings, including increased confidence in managing one’s own mental health care, decreases in the total number of clinical diagnoses (except for PD/A), improvements in quality of life, general psychological distress levels, and treatment satisfaction (Klein, et al., 2011).  Successful results were also found in a web-based self-help randomized controlled study for individuals with anxiety, depression, and stress (van Straten, Cujpers, & Smits, 2008).  A sample of 213 individuals was randomized to a four-week online intervention or wait listed.  The online intervention was found to be effective in reducing symptoms of depression, anxiety, and enhancing quality of life; it was helpful in reducing work-related stress, but not statistically significant.

 

Individuals with Psychosis.  Steinwachs et al., (2011) evaluated a web-based tool to help patients with schizophrenia communicate with their physicians about their health care.  Twenty-four patients were assigned to a web-based intervention that consisted of online videos of actors simulating a patient discussing treatment concerns, while the control group was shown an educational video about schizophrenia treatment.  Both groups were observed during routine visits with their physician.  The authors reported that the intervention group patients compared to the control group had longer visits with their physicians, experience less verbal dominance by physicians, asked more questions about treatment, disclosed more lifestyle information, and better understood the information exchanged.  Another pilot study in Australia is exploring the use of internet enabled mobile devices and social networking technologies to promote exercise as an intervention for young first episode psychotic patients.  Participants would be asked to participate in a nine-week running program, then asked to post messages about their running experiences on line.  Finally, they would be asked to attend three in-person interviews (Killackey et al., 2011).

 

Childhood Disorders.  Siemer, Fogel, and Voorhees (2011) performed a review of the literature to identify ways in which telemental health and web applications have been used with children and adolescents.  They identified 20 unique populations, and found technology-based interventions included treatment for depression (e.g., MoodGym, Project CATCH-IT), anxiety (e.g., BRAVE Program, ClimateSchools, and Spence), eating disorders (e.g., My Body, My Life), substance abuse (e.g., ClimateSchools), and health promotion (e.g., Kindertelefoon, YooMagaine, Ciao, and ReachOut).  While there was not enough evidence to determine the effectiveness of all the studies the authors identified, it is promising to see that researchers are working to develop technologies that would most likely appeal to this age group.

 

Posttraumatic Stress Disorder (PTSD).  Most of the technology-based interventions for PTSD have been through the Veteran’s Administration (VA) to treat soldiers returning from the battlefield.  Morland, et al., (2010) conducted a randomized controlled noninferiority trial of 125 male veterans with PTSD who suffered from anger difficulties.  Participants were randomly assigned to a CBT anger management in-person group therapy and a CBT anger management group via videoconferencing.  The researchers found that both groups showed meaningful reductions in anger symptoms with post treatment (three and six months) and that videoconferencing provide a feasible option to treat veterans residing in rural or remote areas.

 

Inmates.  Morgan, Patrick, and Magaletta (2008) conducted a study with 186 inmates who sought mental health services.  Inmates were assigned to either in-person psychiatric services or telemental health services and both groups were reported to have similar outcomes such as satisfaction with services and improved symptomatology.

 

Phobia.  Botella et al., (2010) conducted a study in Spain with 127 participants who suffered from a fear of public speaking.  Participants were randomized to three experimental groups:  CBT internet-based self-administered program, the same program applied by a therapist, and a waiting-list control group.  Both the in-person and internet-based intervention were equally efficacious and treatment gains were maintained at a one-year follow-up.

 

SOCIAL NETWORKS AND TELEMENTAL HEALTH

 

There is a well-known body of research that relates social support to the maintenance of physical and mental health.  Social support has been proven to buffer individuals from the debilitating effects of stress, marginalization, and disability.  “Individuals with minimal social support have statistically higher realities of cardiovascular disease, inflammation, cortisol levels, and impaired immune systems.  They are at a much higher risk for debilitating depression.  They even have an increased mortality rate” (Rossmeisl, et al., 2013, p. 32).  The evidence supports the notion that social support reduces heightened tension and hyperarousal, which enables an individual to increase adaptive problem-solving and lower catastrophic thinking.

 

Early research on social networks and internet usage focused on the potential hazards of social networking rather than face-to-face interactions.  A study by Karus et al., (1998) confirmed this fear when it was found that correlations between internet use and depression resulted in social isolation.  The study demonstrated that increased internet use was associated with more affective distress and social isolation.  The phenomenon was labeled “the internet paradox,” since a tool intended to enhance social support actually appeared to lead to a decrease in social engagement.  Other researchers found consequences of internet use, including poor familial relations (Nie, 2001), fewer face-to-face interactions (Nie, Hillygus, & Erbring, 2002), and decreased companionship of existing family and friends.

 

Currently, studies on internet use and social support continue to yield inconsistent findings.  What is particularly interesting is the research on self-help groups.  The data conclusively confirms the value of social support online in the form of mutual aid groups, Internet news groups, and electronic bulletin boards.  In general, research suggests that electronically-mediated support groups provide many of the same benefits as offered by face-to-face mental health groups, including mutual problem solving, sharing of information, expression of feeling, mutual support, empathy, and catharsis.  Those who favor online self-help groups speaks to the advantages that eliminate the barriers of time and distance, allow for worldwide participation, which contributes to richer information and perspectives from the group (Finn, 1999).  Others speak to peer equality, online anonymity, two-way learning, accessibility of professional medicine, and the ability for individuals with rare disorders to find others struggling with a similar condition to be among the benefits and conveniences generated from online self-help groups (Madara, 1997).  Similar studies have found that online groups are not only beneficial for individuals suffering from mental distress, but provide a means of support for family and friends (Perron, 2002).  Summarily, online social support groups are demonstrating value.  They serve as a resource for social support, providing empathy, encouragement, information, advice, hope, and a sense of community.  Their online availability makes them convenient and accessible, while the anonymity enhances a feeling of safety, reduces stigmatization and discrimination, and promotes self-disclosure, mutual support, and problem solving (Hsiung, 2000).

 

There is a $64,000 question yet to be answered in this discussion of social networking and mental health:  What about Facebook?  The answer is complex, since there are paradoxical findings.  Internet self-efficacy, the need to belong, and collective self-esteem have a positive influence on attitudes toward Facebook (Gangadharbatla, 2007).  For those who feel more confident in their ability to use the internet and who anticipated fewer technological problems, the use of Facebook is associated with increased social support and decreased depression.  Fewer benefits resulted from Facebook when individuals perceived the experience as frustrating and anxiety provoking.  For those individuals who use the internet solely for information, longer internet usage is associated with greater social isolation and depression.  However, those who use the internet for connecting with others, time spent online is associated with increased social support and decreased depression (Selfhout, Branje, Delsing, ter Bogt, & Meeus, 2009).

 

Two Case Studies

 

Case Study 1.

 

This first case study illustrates the complexities that unfold with telemental health services.   Two university professors, a social worker and an educator, offered a regionally grant-funded virtual classroom for gifted children aged nine to twelve.  Students and their parents applied to a regional university center in a Midwestern state, submitting formal testing results, school grades, and a detailed demographic questionnaire.  Accepted students were provided a nine week course of study that included enrichment reading activities, math strategies, and a counseling group purported to offer members support for the challenges of giftedness.  The virtual classroom was capped at twenty-five students, with all activities lead by the educator, a graduate assistant, and the social worker.  Students came from four states, were identified by first names, and given access to the classroom on a learning platform similar to one used by the university.  The group met using chatroom and discussion boards embedded in the platform.  Parents were given full access to the classroom activities, but were asked not to participate, other than observers.

 

At the six-week point, the social worker initiated a values clarification discussion regarding self-esteem and what was termed “striving for excellence.”  As the conversation in the chat room unfolded, one child disclosed information about his parent that that sounded abusive.  The boy’s peers asked questions that continued to point to potentially troublesome behavior from parent to child.  Several parents emailed the social worker, stating their concern for the child’s safety.  The social worker, who knew the child and family to be residents of an adjacent state, did not have guidelines for intervention, nor was it known whether such an e-conversation warranted a report to Child Protective Services, either locally or in the child’s residential jurisdiction.  The social worker reported, “We did not expect this type of disclosure.  The group was psychoeducational, and I didn’t see it as a therapy group of any type.  I don’t know whether I did anything correctly, and felt like I was out on a limb, not knowing how to proceed.”

 

As a practitioner, what would you do?  In this and similar cases, telemental health creates obvious difficulty when considering the scope of therapeutic practice.  Variability in client parameters, e.g., age, choice of assessment and treatment, frequency/duration/intensity of intervention, and the treatment environment are all factors that should be considered regarding service delivery.  The group leaders realized that their informed consent parameters were insufficient to deal with the child’s disclosures, leaving them without a preferred therapeutic response to utilize.

 

Case Study 2.

 

The second case study revolves around a Facebook dilemma.  A young psychologist enjoyed an active social networking life with Facebook.  He had multiple friends, posted online regularly, and felt he had set good boundaries by refusing to friend or be friended by clients or former clients.  His Facebook messages were entirely personal and related to his life away from practice.  While infrequent, it was not unusual for friends to solicit advice about mental health, e.g., the value of biofeedback, resources for parenting children with ADHD, and smoking cessation practices.  One evening as the fellow checked his Facebook posting, he received a private message from a friend who he recognized as a high school peer who he had not seen since their graduation some fifteen years before.  The friend, whose family lived in another state, wrote a long and detailed account about her son who had been diagnosed several years prior with a thought disorder, and who was re-entering a psychotic episode.  She asked for advice, via Facebook, about “what to do.”

 

The psychologist responded to his friend’s email with advice about how to seek emergency services, where the closest mental health facility was to their family’s home, and the need to move with urgency.  Over the following week, there were several more emails from the mother, disclosing escalating chaos in her family’s home and that “[he] just won’t go for help.”  She told the psychologist that her family held a strong Evangelical Christian faith, and that she had contacted their minister, who had been to the home and prayed with them.  The minister referred the now psychotic young man to a local pastoral counselor.  An out-patient appointment was arranged for the following week.  The mother asked her friend, via Facebook, how they should “take care of things” until the appointment.  Again, the psychologist-friend responded via a private message on Facebook with his former suggestions for an emergency evaluation at an in-patient psychiatric facility.  He also wondered, in his message, about the potential for any danger, and spoke about the escalation of the problem and the urgent need to provide help.  He gave the friend his home telephone number and offered to talk with her about the situation with her son.  In the meantime, the friend was disclosing multiple “family problems” on her Facebook news feed without details about the distress in the family’s home.

 

The next message caused the psychologist-friend a great deal of alarm.  “I’m going to pay you for your time because I feel like you are my therapist already.  I’ve given my son your telephone number to call and maybe you can talk him into seeing the counselor next week.  Now he doesn’t even want to do that.  I really believe that the Lord works in mysterious ways and you must’ve come back into my life to help with my son.”  The breach of personal boundaries and misunderstanding of the lack of a professional relationship created a great deal of anxiety for the psychologist-friend.  He responded via Facebook message and spoke to the limits of his help and care, that he would not be able to accept the son or his family as a long-distance client, and that emergency services should be provided.  There was no further contact from the friend and the psychologist screened his calls during the weekend.  Two rambling, incoherent message were left on voice mail, presumably from the psychotic young man.

 

In a subsequent post, the psychologist read on his high school friend’s updated status that her son had found a gun in his father’s closet and “accidentally shot himself in the leg.  He is in the hospital and we’re not sure what caused him to do this.  Keep us in your prayers.”  Shaken, the young psychologist was unsure how to respond to the post, and did not hear any more from his friend.  He took the episode to supervision for help dealing with his distress and to discuss the ethical breach he felt.

 

In this second case, the boundaries of social networking and the illusion of a stronger or different relationship become apparent.  What seemed to the young psychologist as a more traditional social relationship that was voluntary and influenced by historical feelings of friendship, affection, and loyalty was limited when a real emergency unfolded.  The relationship quickly became fraught with risk, full of misunderstandings of what could be held in the context of the interaction and relationship.

 

ETHICS, META-ETHICS, AND OVERARCHING PRINCIPLES OF CONDUCT

 

In a routine practice life, providing clinical services brings a variety of complicated issues and decisions into play, all associated with legal and cultural contexts that must be taken into account.  An ethics code provides standards and principles that guide conduct within professions when there is no clear correct action or answer to follow. The development and observance of an ethics code are critical, as they are seen as indicators of a profession’s achievement of a level of maturity, including the ability to self-govern and maintain minimal standards of behavior and care in service to individuals.  Not only are members of the profession guided by their particular code, the next generation of professionals are educated and trained by using their ethics code in preparation for future professional activities.  Finally, a code of ethics serves to inform the public on what may be expected regarding appropriate behavior from members of the organization guided by the code.

 

Ethicists are grounded in theories and systems developed from moral philosophy and principles.  Contemporary theories of ethics are based on five meta-ethical principles – autonomy, beneficence, nonmaleficence, justice, and fidelity, which will be discussed in more depth.  It should be noted, though, that all of the theories, systems, and principles under consideration have been derived from the dominant European American tradition, and may be viewed quite differently by those from different cultural groups within the society. 

 

Contemporary ethics theories are drawn from several schools of thought who exist in a state of dynamic tension with each other.  The first approach comes from John Rawls who, in his book A Theory of Justice (1971), emphasized principles of right action.  Arguing that ‘the right’ comes before  ‘the good’, he maintained that a moral person must be guided by justice, with moral feelings noted as normal and necessary for the development of rules.  Although he advocated for consideration of the welfare of the disadvantaged and disenfranchised as well as that of the majority, he wrote that justice can only be achieved through some kind of contractual agreement on how basic societal institutions are to be structured.  His focus on distributive justice framed the discussion of social and political problems since the 1970s.  In his rubric, the greater good is considered over personal autonomy.  It is a top-down theory, known as a deductive model, which starts with an ethical principle which is applied it to a particular case.  Absolute principles are given priority over the complexities of the individual concern.  This approach takes the position that there can be only one correct account of the ethics of the situation; it is based on the principles that have been applied. This model of deontological ethics is figural based on rule-governed behavior, i.e., the overarching obligation to perform the 'right' action, regardless of actual consequences.  The philosophy harkens back to the writings of Immanuel Kant’s notion of the Categorical Imperative which speaks to duty as guiding this rubric and its corresponding principles.

 

Utilitarian theory concerns the practical consequences of various policies.  Utilitarian ethics are evaluated on the assumption that the right policy will be the one which results in the greatest happiness. Primary theorists of this school are Jeremy Bentham and John Stuart Mill, both of who distinguished between an act and a rule-governed moral decision. Later iterations of the theory included the ideas of motive or intent in morality and the impact of preference on moral decision making.  This inductive model is more “bottom up.”  Ethical reasoning moves from particular cases to general statements or positions.  The rubric de-emphasizes reasoning from principles, because principles are seen as derivatives of actual case experiences.  Tangentially, utilitarian theory relies on virtue ethics, derived from Aristotle and Confucius' notions asserting that the right action will be that chosen by a suitably 'virtuous' agent. This school of thought is one that emphasizes moral character in contrast to the approach which emphasizes duties or rules (deontology).   The Golden Rule, “Do unto others as you have them do unto you,” is a congruent example of virtue ethics, since helping another person in need is seen as charitable or benevolent.

 

In the early 1990s, there was an emergence of what became known as care ethics.  Articulated by the ethicists Beauchamp and Childress (1994), care ethics points to the emphasis of care as traits valued in intimate personal relationships, subsuming sympathy, compassion, fidelity, discernment, and love.  Caring refers to “care for, emotional commitment to, and willingness to act on behalf of persons with whom one has a significant relationship” (p. 85), and that “care ethics provides a needed corrective to two centuries of system-building in ethical theory and to the tendency to neglect such themes as sympathy, the moral emotions, and women’s experiences” (p. 92).  Care ethics, rather than being rule governed, is more context driven and “how actions are performed, which motives underlie them, and whether positive relationships are promoted or thwarted” (p. 86).

 

The integration of these multiple philosophical stances has been incorporated under the rubric of applied ethics (Callan & Callan,2008), which accounts for how moral and ethical schools of thought view right and wrong.  “Where absolutists, for examples, view behaviors generally seen as bad or negative (e.g., lying, stealing, and killing) as never justifiable, relativists point to the meaning of a behavior, emphasizing the intention behind it.  Generally, ethics have been viewed by people as ways of behaving in accord with acceptable standards.  As ethics thinking developed, these ways of behaving and the standards that underlie them have become incorporated as basic principles into ethics theories” (p. 134).  The integrated model states “that principles need to be made specific for cases, and case analysis needs illumination from general principles” (Beauchamp & Childress, 2001, p. 397).  In effect, “the model suggests an assimilation and accommodation process in which clinicians are guided by principles but open to adjustment based on particular cases and circumstances” (Kleespies, 2003, p. 29).

 

 In the philosophical examination of applied ethics, particular issues in private and public life are examined as matters of moral judgment. Applied ethics attempts to combine multiple philosophies and methods to identify the morally correct course of action in various fields of human life.  An emerging typology for applied ethics (Porter, 2006) uses seven domains to help improve organizations and social issues at the national and global level:

 

Typology for applied ethics

Decision ethics, or ethical theories and ethical decision processes

Professional ethics, or ethics to improve professionalism

Clinical ethics, or ethics to improve our basic health needs

Business ethics, or individual based morals to improve ethics in an organization

Organizational ethics, or ethics among organizations

Social ethics, or ethics among nations and as one global unit

Sexual ethics, or ethics based around sexual acts

 

Contemporary ethical thought attempts to overcome the divide particularly noted between deontology and utilitarianism - caused by the polarities between absolutist and relativist moral views - with case-based reasoning and contextual thinking, also known as casuistry. Casuistry starts with the immediate facts of a real and concrete case rather than beginning with theory. While casuistry makes use of the breadth of ethical theories, it does not view theory as the most important feature of moral reasoning.  Unlike legal and cultural aspects, which are essentially unalterable, applied ethical considerations are more contextual, meaning that decisions may be variable.  This is the essential operational definition of a dilemma, i.e., a cause, situation, or course of action between equal, but conflicting alternatives.  A dilemma is caused by a problem that seems incapable of a “best” solution.  Two different clinicians, working with the same problem, following the same laws and taking the same cultural characteristics into account, may arrive at very different, though equally acceptable, solutions.

 

Meta-ethical Principles

 

As noted above, an ethical dilemma occurs when a person is faced with two or more apparently equal or reasonable alternatives, though pursuance of either alternative leads to a divergent solution away from the other.  The decision of which option to choose is based on considerations determined by outside forces, such as agency policy, or state and federal law, and some may be quite idiosyncratic, such as the clinician’s personal values or the given facts of the situation.  Codes of ethics seek to provide a decision making paradigm, and rely on meta-ethical principles since, by definition, they transcend the context and individuals involved.  Their application in particular situations may change, vary in weight, or be applied with variability among individuals.  The five over-arching meta-ethics are autonomy, beneficence, nonmaleficence, justice, and fidelity.

 

Autonomy.  Autonomy, or self-determination, especially in the dominant western-European culture of the United States, is highly valued, and has been promoted as a fundamental social and political “right.”  The principle has been stated as:

 

One ought to respect a competent person’s choices, where one can do so without undue cost to oneself, where to do so will not violate other moral obligations, and where these choices do not threaten harm to other persons or parties (Battin, 1994, p. 107).

 

Self-determination is a foundation for the notions of informed consent and assessing decision-making competence.  Autonomy fully supports the idea of respect for the person.  European Americans, especially men living in the American patriarchy, tend to hold autonomy as the highest ideal, and believe it is respectful to increase a person’s autonomy or control.  This perspective is not necessarily shared by members of non-dominant cultural groups or by European American women.  The ongoing argument ensuing  over this notion contrasts autonomy with paternalism.  On one hand, autonomy is defined as self-governance, while paternalism is seen a state in which another person interferes with or controls another’s choices in the interest of what they perceive as that person’s own good or welfare.  In the truest form of autonomy, individual choice is respected to the extent that individual is acting on personal values, rather than attempting to impose values on another “because we’re doing this for your own good.”

 

Beneficence.  Beneficence is action intended to benefit others.  In general, most people do not have a legal responsibility to help others.  They may believe they have a moral responsibility, but the duty to “do good” is more internally than externally based in most situations.  That being said, mental health practitioners have an obligation to attempt to “do good” once a professional relationship has been established with an individual.   The obligation of beneficent treatment is derived from the fiduciary relationship between the client and the treatment provider.  When a clinician enters into an explicit or implicit contract to provide services to another, a commitment and subsequent obligation are made in an attempt to meet the needs of the individual and to promote well-being. This is not always easy, since what is perceived as “good” or “more good” if often dependent on one’s perspective and background.  Remember the old joke of the Boy Scout walking an elder, kicking and screaming, across the street.  Once the scout had wrestled the older person up the curb, he asked, “What is the problem?  I just wanted to help.”  The elder replied, “I didn’t want to cross the street.  I was going the other way, down the street.”

 

Nonmaleficence. The principle of nonmaleficence has its roots in the medical directive primum non nocere, or first, do no harm. This is an admirable notion in an ideal world, but in actual practice, the principle is more accurately defined as minimizing harm to as many interested parties as possible.  The issue is not necessarily about minimizing harm, but more pointedly, speaks to harm intentionally inflicted by the provider.  This is also more of an ideal, since whenever a clinician does or does not act, any harm that results may not be intended, although it could be foreseen.  Further complicating the issue of nonmaleficence is that the likelihood of perceived harm may be increased if the possibility is ignored that different values, such as those based on religion, spiritual beliefs, or cultural backgrounds, will affect interpretations of the issues at hand.  Regrettably, the relativity of harm sets forth no clear rules.  While nonmaleficence can be considered a bottom-line virtue, minimizing harm is often difficult and contextually dependent.  Clinicians are advised to keep the goal of minimizing harm clearly in mind, while realizing that personal views of what is and is not harmful may be inconsistent with the perspectives of other involved parties, especially if cultural differences exist.

 

Justice.  According to Beauchamp and Childress (2001), the meta-ethical principle of justice refers to “fair, equitable, and appropriate treatment in light of what is due or owed to persons” (p. 226).  It is the essence of fairness regarding treatment of others and how goods and services are distributed.  Issues of justice should be at the forefront of mental health providers’ minds, given the significant issues associated with the cost of care, the numbers of individuals who are uninsured or underinsured, and discrimination in service provision.  Essentially, someone who has a just claim has a right to, or is owed, something.  Someone who has suffered an injustice has been denied something that rightly belongs to that person, or, the individual has been given some unfair burden.  Because of the capitalistic nature of the United State society, it can be difficult to balance concerns for justice with concerns for remaining fiscally solvent.  The issue of justice, in the structure of American society, is complicated because of the lack of fair distribution of services and resources.  As Kleespies (2003) states, “Should health care be given according to equal share, need, some system of merit, the ability to pay, the potential benefit, and so forth?  These are questions that have not been answered” (p. 32).  In terms of telemental health, another level of distributive justice in the healthcare system comes to light.  When particular services and resources are scarce, there is increased competition for them.  Such issues of justice and discrimination are not only implicated in paying for services, but in other aspects of service provision.  Residents of rural areas are at a significant disadvantage with access to care.  Therefore, the value of telehealth begins to have increasing relevance.  To this end, the principle of justice suggests that providers actually have the responsibility to work proactively to reduce the impact of barriers to care.  In doing so, the professional also maximizes the principles of beneficence, nonmaleficence, and autonomy.

 

Fidelity.  Fidelity speaks to the importance of trust and loyalty in professional relationships. The principle of fidelity broadly requires that clinicians act in ways that are loyal. This includes keeping promises, behaving in expected ways, and performing duties in a trustworthy manner. Fidelity implies respect, competence and capability in the performance of expected interventions, and that agreements between provider and client are to be respected and maintained.  Because mental health professionals enter into fiduciary relationship with clients, they are expected to give precedence to clients over people with whom they do not have such relationships.  The meta-ethic of fidelity implies that this responsibility will take precedence over responsibilities to others and society.  Certainly, there are exceptions and some balancing needs to take place, but usually the principle of fidelity means the professional must act to maintain and enhance the trust of the client.  The primary ways this is achieved is through truth-telling and the maintenance of confidentiality.

 

The philosophical meta-ethical principles have significant implications for practice using telehealth and technology driven services.  These meta-ethics supplement and compliment professional ethics codes, agency policies and procedures, and state and federal laws.  They are influenced by the provider’s own values and cultural background and must be interpreted and implemented in light of the values and cultures of the client.  Because of the variability inherent in how the principles can be applied in a given situation, clinicians are advised to consider following a specific decision-making model, incorporate supervision and consultation, and document throughout the decision making process, all risk management concepts that will be discussed later in greater depth.

 

ETHICAL DILEMMAS AND TELEMENTAL HEALTH

 

Telemental health is responsible for the delivery of mental health services that would not otherwise be available.  The advent and development of technological resources are a “sign of the times.”  There are ethical concerns, despite its successes, regarding its use.  Fortunately, there is currently a good deal of interest in developing standards for ethical, legal, clinical, technological, and practice considerations regarding telemental health.  Over the past decade, the lack of uniformity in legal, regulatory, and ethical requirements regarding reimbursement policies, privacy and security issues, and best practices for using technology has raised considerable concern for practitioners across the variety of mental health disciplines. 

 

Different professional associations, e.g., American Psychological Association, Canadian Psychological Association, and the American Counseling Association of America, have been criticized by their members for their inability to keep up with the rapid development of technology.  Practitioners have been forced to operate without guidance and knowledge of the inherent risks to clients.  Ethical issues continue to arise and frustrate regarding how and when clinicians should inform their clients about ways in which technology, e.g., electronic communication, online applications, electronic client records, social networking media, and use of videoconferencing and teleconferencing platforms, will be employed and how such usage might compromise confidentiality.  Many concerns lie with the technologies themselves.  In particular, Kaslow, Patterson, & Gottlieb (2011) raise concerns about ethical dilemmas concerning information-gathering about clients, students, or employees on the internet, particularly on social networking sites such as Facebook.

 

Case Study

 

It seems relevant to examine a case study at this point.  A young client came to see a psychotherapist for symptoms of mild depression resulting from job dissatisfaction.  During the fourth session, the client tells her therapist, “I thought about something you said last week that really made sense to me.  I wanted to tweet you on it, but didn’t have your phone number.  Would you give it to me?  I also sent you a friend request on Facebook.  I hope that’s OK.  I get more of my email through Facebook than I do with my gmail account.” 

 

The therapist, a middle-aged male, was caught off guard.  He stumbled with a response, saying, “I don’t understand twittering, and while I have a Facebook account, I only use it to can see pictures of my grandchildren, who live in another state.  Frankly, until you just told me, I didn’t even know that it has an email feature.”  The client responded, saying, “You really would like twitter and Facebook as a better way to communicate.  It is faster and we can communicate in real time.  I can teach you how to use all of this, if you would like.  It wouldn’t take but a few minutes.”  The therapist said, “This doesn’t feel like it would maintain those relational boundaries to allow me to help you in the best way that I know how.”  The client laughed and said, “The privacy thing?  That just isn’t a big deal anymore, at least not to the folks I know.” The therapist deferred and refused his client’s request, but felt exposed and alarmed with the exchange.

 

In this circumstance, the client proposed that she and the therapist become members of the same online social networks and establish means of communication outside of traditional face-to-face sessions.  How would you respond?  Clients, or potential clients who are in the same social networks, could post personal information online, and perhaps that private information might become more public than originally thought.  If the therapist’s information can be readily retrieved (and it can), blurry boundaries then become the norm rather than the exception to the rule.

 

As a matter of course, while acknowledging that there are no consistently clear guidelines regarding this type of occurrence, there are general guidelines that may be applied to technology dilemmas.  The American Psychological Association suggests that a therapist should refrain from a deliberate search for information about a client to avoid breaching confidentiality and privacy.  Further, therapists should add to their informed consent about any boundaries related to the nature of the relationship.  If the therapist learns information about a client from another source, it is imperative to continue to work in the best interest of the client.  Finally, is seems important and relevant to separate personal and professional life, even if a client, like the young woman in the case study, initiates an online friend request.  This change in relationship may inadvertently lead to a breach in confidentiality.

 

Informed Consent

 

The above example illustrates how quickly the parameters of therapy can be violated.  It is essential that clients understand and agree to the procedures and the processes of therapy at its onset, including the use of any technology resources.  The process of informed consent with clients does imply certain absolutes, and it also acknowledges that there has been a thoughtful assessment of what will be shared with clients, i.e., in terms of the general course of therapy, which is to be discussed and agreed upon by the therapist and client.  As varying determinations are made during the course of treatment that suggests a redirection of therapy, the process of informed consent is to be repeated.

 

The primary philosophical issue underlying the obligation of informed consent involves the meta-ethical principle of autonomy.  Any procedure performed on or on behalf of a client without consent diminishes that person’s capacity to act in a free and self-determining manner.  Based on the definition and intent of the principle, all opportunities for choice emphasize and underline autonomy.  In fact, much of mental health treatment is directed toward increasing an individual’s autonomy.  Because of this, informed consent is a precondition for an effective therapeutic encounter.

 

In a seminal paper, Haas (1991) outlined several categories of information that, if revealed and discussed with the client, would constitute necessary and sufficient informed consent.  The pragmatics of the necessary and sufficient elements of informed consent are well defined and described, and can be summarized as follows (p. 183-185):

 

Elements of Informed Consent (Haas, 1991)

The risks and benefits of treatment

The logistics of treatment

The qualifications of the provider

The risks and benefits of alternatives to treatment

Clarity regarding technique

Emergency procedures

Confidentiality and its limits

 

The inclusion of technology into therapy colors the clinician’s approach to all seven elements noted above.  As Haas notes, “The informed consent procedure can be considered as a specific example of a person-environment interaction…Informed consent increases the likelihood that clients can challenge what their therapists offer them, and this in turn makes it important to be comfortable with what one does” (p.186).

 

To date, only a few states have enacted laws regulating how mental health clinicians (specifically, licensed psychologists) may use telemental health in providing services to residents (APAPO, 2010).  In those states, telehealth is specifically defined in either statute or regulation, spelling out what kinds of technological communication are regulated.  Those state laws also outline what information ought to be disclosed in informed consent procedures before providing telehealth as a means of therapeutic communication.  Although these state requirements vary, the underlying purpose for all such disclosure is intended to protect the client from any risks inherent in furnishing services via telemental health.  In addition, a number of licensing boards have issued opinion and policy statements on the use of technology in the delivery of mental health services.  While such opinions do not hold the same weight as a statute or regulation, they do provide some guidance for appropriate practice and for how state ethics boards may respond to complaints about a clinician’s provision of telemental health services.

 

The American Psychological Association has issued a professional statement to help its members prepare for the telehealth world.  Written by Deborah Baker and Lynn Bufka (2011, p. 407).), they state (See Table):

 

preparING for the telehealth world

“Some…states have broader requirements of what constitutes a valid telehealth informed consent.  Those states specify that the informed consent must be provided verbally and in writing to the patient.  The informed consent for telehealth must include notice of the patient’s right to 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; applicability of existing patient confidentiality and patient access protections; and assurances that patient-identifiable images or information from the telehealth encounter would not be disseminated to researchers or others without patient consent.

 

Informed consent for telehealth is not required for telehealth consultations where the patient is not directly involved (e.g., consultation between providers), or in emergency situations where patient consent cannot be obtained easily or in a timely manner.  Other informed consent requirements may include notification to the patient about how electronic patient communications are stored, description of who may access these communications, discussion of when the [clinician] would respond to routine electronic messages and under what circumstances the [clinician] would use alternative (nonelectronic) communications for emergency purposes, and a description outlining reporting mandates by state law”

 

There is no doubt that in the next decade, clinicians will find increasing consistency in state laws and board policies regarding mandatory or recommended disclosures that should be provided to clients before providing telemental health services.  It is seen as especially important since telemental health, which by definition is always provided at a distance, makes for greater risks of miscommunications and misunderstandings that may be experienced and negatively construed as abandonment or negligence.

 

Privacy and Security

 

The Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA), PL.104-19, sets the federal privacy and security standards that will ultimately apply to the provision of telemental services.  The rules state that clinicians must use reasonable safeguards to protect their client’s personal information from unauthorized and unintended disclosure or uses.  Currently, all rules under HIPAA are technologically neutral, i.e., they do not require the use of any specific technologies, nor do they guide therapeutic interventions using telemental health.  Instead, the rules protect information and direct that the provider use common security mechanisms such as passwords, digital signatures, firewalls, data encryption, encryption over public networks, backup systems, and disaster recovery plans (Kumekawa, 2001).  Privacy and security are the covered entities in the HIPAA directives, and clinicians may communicate with their clients electronically as long as reasonable safeguards are used when doing so.  Again, the focus is on “reasonableness.”  There is no prohibition on the use of email in communicating, nor is there any need for specific encryption to be used.

 

HIPAA guidelines for the use of web-based videoconferencing for telemental health “….are what potential risks to confidential patient information might using telehealth technology pose and how those risks can be appropriately minimized” (Baker & Bufka, 2011, p. 408).  Concerns arise about difficulties:

 

in verifying an individual’s identity when emailing, texting, or tweeting;

ensuring privacy at both the clinician’s and patient’s location , (unless this has been specifically waived by the patient);

possible disruption of service, e.g., “dropped” calls;

storage and maintenance of information created or collected during a telemental health encounter, such as recording a conversation; and

assessing the risks for unintended or unauthorized disclosure when using unsecured communication.

 

Regardless of the specific technology resources that clinicians might use in the provision of telemental health, the primary focus remains to ensure against unauthorized or unintended disclosures of confidential client information.  How that is done and what kinds of technology should be used to become a part of the risk management and assessment process and remain in the subjective purview of the clinician.

 

A Case Example

 

A non-traditional college student (male, mid-40s) began to exhibit strange behavior in his undergraduate psychology classes.  His behavior was erratic and he came to two professors, complaining that their courses (neuroscience and experimental psychology) were “going against Christian principles” and that “regardless of how much I love you, I’m going to have to drop the courses.”  He stopped coming to both classes, but was seen on a frequent basis in the psychology building over a two week period of time.  He continued to email the professors using his university account, and ultimately disclosed his history with a bipolar disorder to one of the professors, who also served as his advisor.  The faculty member responded to his email by referring him to the counseling center and suggesting that he pursue a medical withdrawal for the semester.  Subsequent emails came from a yahoo account, rather than the university email address.  The advisor and second professor conferred and decided not to go against university policy by corresponding on the yahoo account.  Ultimately, the student was hospitalized and his medications were stabilized.  On his return, he told his advisor that his wife and adult daughter were “answering my email” during the bipolar episode, and they all “wondered why” there was limited contact with the professors.

 

RISK MANAGEMENT ISSUES

 

It is assumed that clinicians are concerned with delivering ‘best-practice’ care to their clientele; best practice is represented by effective, integrated, and efficient service.  While evidence on patient safety and clinical risk management in physical health care has increased, there is limited research in these areas concerning mental health care, and even less when telemental health is considered.  Risk management speaks to safety for client and clinician.  Contemporary definitions move away from sole focus on adverse effects and “litigaphobia” and more toward a multi-dimensional approach evaluating both the gains and hazards of risk-taking.  From this perspective, managing risk not only focuses on eliminating risk, but on examining any potential benefits while reducing the potential for harm resulting from taking the risk.

 

Clinicians are reminded that autonomy and self-determination are benchmarks in the definition of mental health.  Therefore, the pursuit of wellness and life satisfaction is a collaborative process between client and clinician, characterized by a partnership between negotiating all aspects of care, including potential risks.  Such a collegial stance establishes a context for treatment, and allows both understanding and taking shared responsibility for possible consequences for certain treatment decisions, including all benefits and risks.

 

Risk management, as a general principle, speaks to the need for quality and safety at all levels of service provision.  Over the course of time, this has been defined by an unambiguous focus on quality assurance, with a sustained commitment to continuous improvement.  In 2004, the Australian/New Zealand Risk Management Standard was adopted, which describes a process for risk management that is easily understood and readily implemented.  The seven step process is seen as dynamic and interactive and is instructive for the purposes of this discussion.  Step one asks for an establishment of context for the risk-occurrence.  Then, three steps are engaged to assess the risk:  the identification of the risk, followed by analysis of each risk factor, then evaluation and weighting of the varied risk factors and the impact of options for treatment.  The fifth and sixth steps of the process direct the clinician to monitor, review, communicate, and consult with all relevant parties.  Finally, a treatment plan for mitigating the risk is chosen, constructed, and implemented (HSE, 2004). 

 

In the United States, a comprehensive literature review highlights the inconsistency of basic patient safety concepts in mental health, e.g. defining and calculating adverse events, and a scarcity of high quality patient safety research in mental health (Callaly, Arya, & Minas, 2005).  Due to the lack of patient safety principles specific to mental health care, concepts and strategies from medical healthcare settings are frequently adopted.  This may be appropriate for some aspects of risk management, but mental health care differs from medical patient care in patient populations and illnesses, as well as from institutional and historical contexts.  There are unique safety issues in mental health care that require particular consideration regarding clinical risks.  While medication related risks are common to both populations, there are specific risks, such as suicidality, violence, and self-harm that must be considered.

 

In general, four areas of risk are relevant for consideration when dealing with mental health issues.  The utilization of telemental health strategies should be considered as an overlay to these general concerns. 

 

The first is client vulnerability.  Clients may be at risk for exposure, damage, or harm due to personal or external factors, including cultural differences, poverty, lack of community resource, developmental delays or disabilities, or lack of insight or ability for proper self-care.   Closely tied to the notion of vulnerability is the clinical risk of treatment errors.  The clinician is obligated to maintain standard procedures for consultation and supervision, which includes any special training related to general risks particularly sensitive or relevant to the clientele served.

 

The second area of general risk is the consideration of self-harm or suicide potential.  Clinicians are obligated to assess and take special precautions when a client demonstrates risk from self-harm, intentional injury, and actions/behaviors destructive to personal safety or health. 

 

The third area of focus centers on mental instability.  When a client’s general reality functioning and ability to adequately perform activities of daily living are assessed to be impaired, particularly in relation to psychotic processes, the clinician is obligated to assess and intervene.   This area of focus also includes substance use and abuse.

 

Finally, risk to others must be assessed.  When a client places another at risk for harm or danger, or encourages others in the causing of harm or injury to others, an intervention is warranted.  The literature suggests that clinicians are particularly alarmed with this risk of violence/aggression, which includes physical violence, such as assault, and verbal/psychological violence, such as threat, against others.  Other risks mentioned in the literature speak to environmental violence, access and use of weapons, and physical or verbal abuse common in domestic violence.

 

Risk assessment and management involves a professional duty to care on the clinician’s part, and is directed toward the client.  Health needs must be balanced with issues of personal and public safety.  It is worth restating that this includes the promotion of the client’s autonomy and decision making while balancing the demands of personal, professional, and public accountability.  As stated earlier, managing risk should not just focus on eliminating risk, but of providing a process for ensuring that potential benefits are increased and the likelihood of harm occurring as a result of taking risks are reduced.

 

There is little in the literature that speaks to risk management and the utilization of technology.  Therefore, it is prudent for the clinician to extrapolate from existing standards in the application of risk assessment principles and management when utilizing telemental health strategies.  In everyday practice, the clinician takes reasonable care to protect personal safety and the health, welfare, and safety of others under care.  People with mental illness, whatever the nature, are to be treated in the same way as people with any other illness or medical condition.  Care and treatment needs are to be properly assessed, and whenever possible, provided in full agreement and with input from the client and significant others.  Utilizing technology and telemental health services becomes a relevant factor when assessing an individual’s capacity for self-care.

 

REIMBURSEMENT FOR TELEMENTAL HEALTH

 

Despite the promise to harness telehealth technology to promote more efficient health care delivery and improve access to mental health care services, the growth of telemental health programs has not been as robust as anticipated in the last two decades.  One reason, often cited, for the underutilization of telemental health services is the absence of consistent, comprehensive reimbursement policies.  The lack of an overall telemedicine reimbursement policy stems from “the multiplicity of payment sources and policies within the current United States health care system where the cast majority of health care costs are pay by private insurers, Medicare, and Medicaid” (Office for the Advancement of Telehealth, 2003, p.2).

 

Reimbursement varies by insurer and state.  At the writing of this document (2013), thirteen states require private sector insurance companies to pay for telehealth services.  Maryland, California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas, and Virginia have now mandated that private payers cover telehealth services that are considered medically necessary and would otherwise be covered when provided face-to-face.  This means that health insurers and managed care organizations provide coverage for health care services using appropriate telehealth technology, and that coverage cannot be denied because services were provided through telehealth rather than in person.  Insurers are not required to cover telehealth services if the health services would not be a covered benefit even if provided in person, or the provider is out-of-network (Monitor on Psychology, 2012).

 

Not all states require reimbursement rates on par with rates for face-to-face services, and there is still no universal definition of what constitutes telehealth services.  Reimbursement rates also differ widely among Medicare, Medicaid, and private payers across states, causing continued confusion in the health provider community.  In general, the Balanced Budget Act of 1997 is the federal act mandating Medicare reimbursement for certain telemedicine services (it is important to note that Medicare uses the term telemedicine rather than telehealth).  In 2000, Congress sought to address some of the limitations on Medicare reimbursement for telemedicine services in the Benefits Improvement and Protection Act, which was incorporated into the 2001 Consolidated Appropriations Act.  It effected several changes to telemedicine reimbursement but still continues to limit coverage to only patients living in certain regions of the country and receiving services at approved sites via lie audio-video communications (Fleischer & Dechene, 2010).  Medicaid programs are administered by each state, though federal law has established certain minimum requirements for all states to follow in order to qualify for federal Medicaid funding.  Because federal law is silent as to whether Medicaid reimbursement for telehealth is mandatory, states have the option to offer Medicaid reimbursement.  As many as 35 states now allow for at least some reimbursement for behavioral telehealth (Office for the Advancement of Telehealth, 2010).

 

Telehealth Gone Wrong: A Case Example

 

There are no federal laws regulating telehealth.  Consequently, states have been forced to develop their own standards for care and for reimbursement.  The need for standardization is clear, and made clearer by an example of telemental health “gone wrong.”  A group known as Second Life (Gorini, et al., 2008), described how a British organization created a 3-D online virtual world for abused children to learn life skills.  The program was available internationally and was widely advertised as a therapeutic intervention in the United States.  In 2007, the British Broadcasting Company (BBC) published an expose about allegations of child abuse taking place in Second Life.  Essentially, some members were using Second Life to trade child abuse images.  The “safe” virtual community in Second Life for children was also the choice site for pedophiles.  While different communities could be established within Second Life, there was no clear means of protecting under-aged individuals from child predators.

 

What Is Happening In Your State?

 

In March, 2010, the American Psychological Association’s Practice Directorate Office, Legal and Regulatory Affairs, conducted a comprehensive review of the current state of affairs in telehealth.  While it is oriented to psychologists, the document contains valuable information for all disciplines and includes:  state law provisions, additional notable activities related to technology, availability for temporary/guest license, and penalties for violation.  The document is designed as a guide, rather than as legal advice.  The reader is referred to the document for information, understanding that the law and related information are changing.  Therefore, the completeness, currency, and accuracy of the document make it definitely a work in progress.  The APA Telehealth 50-State Review document (APA, 2010) can be found here or here.

 

SUMMARY AND CONCLUSIONS

 

The world of technology is moving forward, though growth in telemental health has been uneven.  As an invention, telemental health has provided tremendous access to underserved groups of people who would not have had access to mental health care.  Over three decades of research has shown the effectiveness of telemental health in diagnosing and providing treatment for all age groups, racial/ethnic backgrounds, and geographic locations.   However, technological change outpaces researchers’ abilities to conceptualize the field, much less assess and document organizations’ abilities to respond. There is a pronounced difficulty of tracking diffuse and unevenly documented telemental health activity in applied practice.  In terms of research study, this presents a strong problem of identifying samples for examination with dispersed populations, e.g., rural areas.  Currently, many of these technology-based interventions are on par with in-person mental health treatment, and more technological breakthroughs are underway.  In the future, telemental health is expected to be regarded as a first-line treatment for individuals suffering from certain mental disorders and for those living in mental health shortage areas, though it is clear that growth in this area is highly dependent on funding and reimbursement of practitioners.  Consequently, there needs to be clear legal and ethical guidelines to help clinicians navigate the intricacies of cyberspace and other forms of electronic communication.  This will protect the rights, privacy, and confidentiality of clients under care.  In the meantime, it appears to be inevitable that clinicians will be confronted with situations where they may need to use technology with some of their clients, and ethical dilemmas will quickly arise.

 

SUMMARY AND KEY POINTS

The definition of telemental health is the provision of mental health services in a technology-assisted environment, including telephone, internet media (written, voice, and digital pictures), and video conferencing

Telemental health consists of counseling and psychotherapy, psychological assessment and testing, diagnostics, and consultation

Telemental health employs the mediums of teleconferencing, video conferencing, virtual reality programs, internet, social networking, and mobile applications for smart phones

Empirical research supports the use of telemental health interventions and finds them to be comparable to face-to-face treatments

The benefits of telemental health include convenience, cost efficiency, east-to-use features, creative use of existing technologies, high acceptability, diverse applications, service provision to underserved groups who would not otherwise have access to care

Telemental health is becoming a more easily reimbursable form of treatment delivery

The ethical concerns with telemental health include a lack of national standards and guidelines, a lack of encryption which compromises confidentiality, uncertainty about ethical practices (e.g., the use of social networking sites), issues of privacy, appropriateness of services, conflicting legal and regulatory requirements, challenges with informed consent and disclosure, record keeping, and fees

 

SELECTED READINGS AND RESOURCES

 

American Psychological Association Practice Organization (2012).    Social media:  what’s your policy?  Good Practice, Spring/Summer, 10-18.

American Psychological Association (2012).  Guidelines for the Practice of Telepsychology (Draft).  Washington, DC:  APA.

American Psychological Association Practice Directorate, Legal & Regulatory Affairs. (2010, March).    Telehealth 50-State Review.  Washington, DC:  Author.

American Psychological Association Practice Organization (2010).  Telehealth:  Legal basics for psychologists.  Good Practice, 41, 2-7.

US Department of Health and Human Services, Health Resources and Services Administration. (2010). Special Report to the Senate Appropriations Committee:  Telehealth Licensure Report.  Washington, DC:  Author.

Zur, O. (2011).  Professional association codes of ethics and guidelines on telehealth or e-therapy. 

 

REFERENCES

 

American Psychological Association (2012).  Guidelines for the practice of telepsychology:  Report of the Telepsychology Task Force:  Draft released for public comment on July 27, 2012.  Washington, DC:  Author.

American Psychological Association Practice Organization. (2010).  Teleheath:  Legal basics for psychologists.  Good Practice, 41, 2-7.

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