“As technology becomes smaller, more accessible, and more affordable, we as mental health practitioners have to decide at what point (and to what extent) we will adopt the trend of implementing technology as a mechanism for service delivery” (Hertlein & Cohn, 2018).
Recently, the AAMFT devoted an entire issue of their magazine to the use of technology in mental health service delivery.
Like it or not, technology is changing our profession.
These days, in addition to working for themselves, therapists have the option to work for telemental health companies, and many are offering technology-centered services, such as email therapy, in their private practices. While our associations and state boards have been slow to adopt standards and laws regarding the provision of tech-centered therapy, many of us tech-savvy (or tech-interested) therapists have been figuring it out on our own.
And, perhaps, we’ve made mistakes, such as not using HIPAA-compliant software (e.g., Skype), or inadvertently practicing outside our jurisdiction.
Thankfully, our governing bodies are coming around and beginning to guide discussions about the requirements and benefits of providing online therapy. In this post, I’ll highlight some of the most important questions asked by authors featured in Family Therapy Magazine, as well as additional information I have found through my own research.
Tech-centered therapy is delivered via technological methods, including text messaging, email, phone, and live video. The use of technology in service delivery offers both synchronous and asynchronous methods. Phone and live video are synchronous, meaning feedback is immediate for participants. Text and email are asynchronous, meaning feedback is not immediately observable, offered, or received.
Each method must be considered thoroughly in regard to potential risks for clients, the treatment method and setting, therapist-client boundaries, and other factors that will define the process of therapy.
Top Concerns of Using Technology to Provide Therapy
For most therapists, concerns about using technology to deliver therapeutic services often represent three categories: a) relational, b) legal, and c) technological.
Relational Client Factors in Online Therapy
Does the therapeutic relationship suffer when therapist and client interact, exclusively, online?
Well, there’s no clear answer to this question. Part of our role as therapists is beneficence; that is, to do what is best for clients. Sometimes, online therapy is best for our clients, which means that at the very least, most of us should be competent in delivering tech-centered services.
Will I be able to effectively join and establish a strong therapeutic relationship with my clients?
The therapeutic relationship begins upon initial contact, no matter the setting in which therapy will take place. Joining with clients happens largely through habits, skills, and patterns that are global to service delivery, such as phone conversations, orienting a client to therapy, providing a thorough informed consent, and of course, showing care and concern for clients.
Ethics, Laws, and Liability in Online Therapy
During face-to-face therapy, we therapists have the benefit of observing a wide range of interactions. Should we encounter environmental interruptions or confidentiality challenges during therapy, they are likely related to our physical location.
Of course, when moving therapy to an online setting, potential challenges to confidentiality increase exponentially, and our observation of nonverbal communication as well as interpersonal dynamics may be impaired.
Online, or tech-centered therapy, is not a second-class service, but it is a different service than face-to-face therapy. Because it is a distinct service, it requires that we adhere not only to our state laws and rules and ethical codes, but that we add the highest possible standards for tech-centered therapy.
For example, securing informed consent and orienting clients to online therapy includes a list of tasks that are irrelevant for face-to-face therapy, including tech-related HIPAA and confidentiality compliance, what to do when there are tech problems, access to software and communication portals for clients, and so forth.
In order to comply with the highest possible standards:
Familiarize yourself with your state’s laws, rules, and regulations, including state tele-health laws.
Understand your nation’s guidelines and regulations, as well as the regulations for the nation in which your client is sitting at the time of a session.
Follow your association’s ethical standards.
Complete tele-mental health training and/or certification.
Start with privacy
What are the security limitations of your platforms? Plan to protect against security breaches, to the extent in your control.
Tech in Online Therapy: What/Where Is the Treatment Setting?
Video and Phone
Where does treatment occur?
Where are you providing services?
Is the environment appropriate for providing therapy?
How do you define a “session?”
What are your, and the client’s, expectations in terms of the setting, attire, possible distractions, and so forth?
With online service, it is more challenging for therapists to “control the flow of information and coordinate treatment” (Hartlein & Cohn, 2018). For example, clients may have access to recording options via your video or audio software.
What is your policy for clients recording sessions, and why?
What are the potential risks and benefits to clients and to you, if they keep a record of your conversation?
Text and Email
How long of an interaction can be expected?
How soon will you respond?
How are exchanges billed?
Asynchronous service delivery requires that you think through your definition of a therapeutic encounter, including how treatment, referrals, and termination processes are assessed and completed.
Sometimes, we stumble upon a new service delivery area or method, or we jump into a new opportunity, without considering the nuances that are relevant for us and our clients. While most of the time, this results in no harm to either party, it is our duty as therapists to not only be well-informed, but to also be ethical leaders for our clients, colleagues, and professional discipline.
Disclaimer: In this post, I introduce ideas relevant to tech-centered therapy, but in no way is this summary an exhaustive list of important legal, ethical, or practice requirements related to integrating technology and therapy.
Tele-mental health trainings and certifications
Ethical Standards for Technology Practice, by Association
AAMFT Code of Ethics, see Standard 6.1
Standards fo Technology in Social Work Practice (NASW, ASWB, CSWE, + CSWA)
ACA Code of Ethics, see Section H
DOWNLOAD THE CHECKLIST + CHEAT SHEET
For a checklist of what to consider before offering online therapy, as well as a list of resources on the subject, access the online therapy cheat sheet, in the free resource library. Register below, and check your inbox for login details.
Let me know, in the comments below:
What question do you have about online, or tech-delivered therapy?