“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-Therapy Terminology

Clarifying Terms

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.

Summary

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.

Resources

Tele-mental health trainings and certifications

Person-Centered Tech

Zur Institute

Ethical Standards for Technology Practice, by Association

The AAMFT’s Best Practices in the Online Practice of Couple and Family Therapy

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’s Chat!

Let me know, in the comments below:

What question do you have about online, or tech-delivered therapy?

10 Therapist (and Child)-Approved Activities to Support Kids with Anxiety

If you’re a mental health professional working with children, you will probably agree that many of the calls you receive from parents have something to do with anxiety or stress. Child therapists have the amazingly important yet challenging task of educating and supporting kids in a therapeutic setting that is both productive and fun. When working with children as young as preschool age, it can be a very daunting task to keep things fresh and exciting week after week! So, how do we help children develop the coping skills they need while keeping them engaged (and not glancing at their watch)? Here are ten therapist (and child!)-approved, fun activities that address anxiety-based disorders and promote relaxation and stress reduction in children:

The Art and Science of Therapy as Craft, Part 2: Crafting Questions

For this week's video chat, Dr. AnnaLynn Schooley returns to discuss therapy questions as an intentional craft, and she covers four basic question types: single answer, open, closed, relational, and circular.

Therapist Self-Disclosure Simplified

Self-disclosure is a touchy subject among therapists. Some therapists never self-disclose, while others feel stifled by having a rigid boundary around self-disclosure. As I consider self-disclosure in therapy, I ask myself, “When is self-disclosure appropriate?” “How does self-disclosure deepen the therapist-client connection?"

Solution Focused Brief Couples Therapy Tips, with Elliott Connie

Elliott Connie is a Solution Focused Brief Therapy (SFBT) practitioner, author, and speaker. He developed an approach to couples work that distills the essence of SFBT into guiding principles for working with couples.

As a therapist who loves working with couples, I am always interested in ways to enhance my couples therapy skills. For this reason, I invited Elliott to explain the reasons why SFBT is his choice for working with clients, as well as how it creates a contrasting experience for couples that have a history in therapy.

Family of Origin Exploration for the Therapist: How to Create Your Genogram

In article three of the Family of Origin for the Therapist series, you learned 3 simple steps for how to begin family of origin (FOO) exploration: 1) read Bowen’s chapter, 2) observe your FOO experience, and 3) reflect on what you learned. Hopefully, your curiosity has led to significant understanding.

Understanding is the foundation of Bowen Family Systems Theory (BFST). Bowen (1985) believed that if clients could understand themselves as members of their FOOs and as created by their histories, they could begin and continue significant change.

In today’s post, I offer the next step in developing understanding: Creating your genogram. I explain how to create a basic genogram that you can expand as you continue your exploration.

5 Tips for Keeping Up with Therapy Paperwork

In my interaction with therapists as a mentor and supervisor, I’ve learned that one of the main struggles therapists face is having too much work and not enough time. Many therapists find themselves overwhelmed by documentation responsibilities, in particular; this includes completing client notes, referrals, billing, treatment plans, etc.

In today’s post, I offer several strategies for keeping up with paperwork, so that you can stay on track and avoid the stress of falling behind.

Solution-Focused Brief Therapy Client Types, and Their Relevance To Every Session

In her 1989 article, Of Visitors, Complainants, and Customers, Insoo Kim Berg details three types of “client-therapist relationships” (p. 21). Her wording is significant, because she is not labeling clients; she is describing them in terms of their relationship to the therapist, the process of therapy, and the problem. These three relationships have undergirded Solution-Focused Brief Therapy theory and interventions over the years, although they are not consistently discussed in newer works. The client relationship types are widely applicable to therapy, regardless of theoretical orientation, making them one of the most useful concepts in marriage and family therapy.

In this post, I present a review of these client types, and I explain their relevance to and usefulness for all therapeutic sessions.

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One of the most common professional goals for my clients is expanding their private practice to include life coaching services. As professionals with a depth of knowledge in personal development and goal achievement strategies, therapists are ideal candidates for the coaching profession. Despite this near perfect fit, there are some important ethical consideration for therapists when offering coaching services alongside therapy, or when choosing to become professional coaches. In this post, I focus on offering solutions for these complications, in an effort to help you ethically practice coaching.

5 Step Plan for De-escalating an In-Session couple Argument

Most of us, therapists, have been there: A simple disagreement turns into an all-out screaming match in the middle of a therapy session. This is, thankfully, not a common scenario for most therapists, but it’s also not rare--especially for therapists who specialize in couple therapy.

In this post, I cover steps for disrupting an argument occurring in a couple therapy session. Intervention on the part of the therapist is necessary during some conflicts, because the arguments can cause further damage in the couple relationship. And, if therapists allow arguments to continue for too long, they can affect the couple’s sense of safety when in therapy.

The main goals of intervention in this case are to: