Module 3: Teletherapy Processing
Module Created by Caroline Wied, M.Ed., Kelly Lee, Ph.D., Morgan Kunde, and Krystal Simmons, Ph.D.
Teletherapy and Ethical Considerations
The American Psychological Association (APA, 2013) defines “telepsychology’ as “the provision of psychological services using telecommunication technologies” (p. 3). Telepsychology includes several methods of therapeutic services. Such as videoconferencing, instant messaging, and online chat (McCord et al., 2020). Guidelines for practicing teletherapy include competency of the technology and therapeutic services to ensure that ethical and professional standards of care are met (APA, 2013). It is important to obtain informed consent that specifically addresses concerns with telepsychology services. Also, it is important to ensure confidentiality and privacy with the increased risks inherent to the use of telecommunication technologies.
How to Set up the Session
It is essential to ensure proper setup for teletherapy sessions. This section will go over considerations of what to do before, during, and after the session. The following considerations are adapted from APA (2013) and Galpin et al., (2021).
- Office set up
- Ensure your virtual and physical space is professional, confidential, and free from distractions.
- Counselors can position themselves on a wall so that there is no potential for people viewing the session.
- Counselors should consider having minimal personal items and distracting patterns in the background.
- Make sure the room is well lit and the camera angle is appropriate to ensure the client can see you.
- Technology set up
- Ensure proper knowledge and training for the approved telehealth software used for service delivery, documentation, and communication.
- Make sure that the internet connectivity is secure and adequate.
- Check the picture and audio quality to ensure that the client can clearly see and hear the counselor.
- Session set up
- Confirm the client’s location beforehand and look up emergency resources such as the nearest hospital or emergency number, in case any medical or mental health emergency arises.
- Ensure the client is in a state in which you are able to provide services. If they are not, teletherapy may not be appropriate.
- Provide resources to clients
- Provide the client with information on how to log in and use the technology needed for telehealth services.
- Be able to explain to clients what makes the platform secure, and how users can inadvertently limit privacy and confidentiality.
- Having a case management session with the client before the start of any clinical service is helpful.
- Case management sessions can be 10-20 minutes to check that the client’s internet connection is sufficient, explain the informed consent and policies of the clinic, and describe issues of privacy and confidentiality as related to telehealth.
- Verify the client’s identity, if needed
- Confirm the client’s location and a phone number where the client can be reached
- Obtain emergency contact information from the client if an emergency arises.
- For example, contact information from another person in the house or nearby in case there is a medical or mental health emergency. This can be another responsible adult, a neighbor, significant other, or close family member. File this information in the electronic medical record system for safekeeping.
- Use the client’s personal environment to inform service decisions.
- For example, if someone is using a shared family computer in the living room, they need to be aware of their lack of privacy and potential interference from others in the space.
- Clearly describe the purpose and objectives of telehealth service
- Example
- Purpose: To continue therapy services even with traveling barriers
- Objectives: Anxiety management
- Example
- Explain relevant risks, benefits, and use between in-person or telehealth services
- Risks
- Ex) Confidentiality concerns
- Benefits
- Ex) Does not require travel or flexible scheduling
- Use
- Ex) An online software system rather than sitting face to face in person
- Risks
- Clinicians should communicate with their supervisor about the case using approved technology and ensure that documents are appropriately uploaded. This could include session notes, assessments, consent forms, and release of information forms.
- To maintain security, make sure electronic items are encrypted and/or password-protected, and physical items are double-locked and stored in a secure location.
Telehealth Microskills
Clinical microskills are fundamental in providing therapeutic services. However, it is even more imperative in providing teletherapy. When providing teletherapy some skills may need to be modified to ensure they are not being lost in translation or misinterpreted. The following is from Galpin et al. (2021), McCord et al. (2020), and Myers & Turvey (2013).
Body Language and Voice
In face-to-face clinical work, clinicians attempt to convey empathy and connection through use of eye contact, body positioning, and facial expressions. These may become lost and not translate well through an online platform. Here are some tips to alter them and convey that same warmth you want:
Eye Contact
Make sure that you are looking at the camera of your computer to convey eye contact. Sometimes it is helpful to put a sticker or eyes by the camera to remind yourself to look there. Another tip can be to sit slightly further away from your camera than normal so that there is more “room” for your gaze to move without it appearing as breaking eye contact.
Body Positioning
Make sure you take up the majority of space in your video box, and show the upper part of your body. You may need to adjust the camera so that it cuts off the very top of your hairline or head so that clients can see your torso. This can also help with modeling for the clients how you would like them to set up their own camera and video themselves.
Facial expressions
Seem interested in what they are saying and try to mirror their reactions. Because you will see yourself as well, consider covering that box up if it is distracting to you. You should adjust the lighting in the room to avoid unsightly shadows or backlighting on your face. Appropriate lighting of your face will allow for your facial expressions to be clearly seen.
Tone
Make sure to have a warm tone of voice similar to what you may use in an in-person session. It is easy for us to sometimes speak louder when on tele-platforms, so be sure to modulate your voice. Check the quality of your microphone. If the microphone causes your voice to come across as muffled or unclear, the tone of your voice will not be heard.
Flexibility and Establishing Rapport
- Technology issues can arise at any time, so be sure that there are multiple options for communication, in case one fails.
- For example, if video calling is not possible, do you have the capabilities to switch to a phone call?
- Establishing rapport includes reassuring that teletherapy is a valid and reliable service delivery model. Reiterating the purpose of telehealth delivery can help ease the client’s concerns.
- Clinicians can also establish rapport by responding to any changes to the client’s body language and emotions, and offering them choices when appropriate.
Managing Technological Issues
Having a reliable technological system for providing teletherapy services is of great importance. However, technical issues may arise and it is critical to be prepared for them. The following points are from McCord et al. (2020):
Preparing for a technological issue:
- At the onset of services, it is important to communicate plans if there are outages or downtime in the telepsychology services.
- For example, if the videoconferencing system is unstable a plan can be set for the clinician to contact the client by phone. Once contacted by phone the clinician and client can discuss options on how to continue. If possible, offer to continue services over the phone.
- It is important to explain to the client that technological issues are infrequent but an aspect of teletherapy.
- Maintaining clear and consistent communication is important through technical difficulties so the client does not feel unsure and abandoned.
Documentation
Documentation includes all records and forms necessary in therapeutic services. It is important to check with your training clinic and supervisors on the documentation protocols and procedures for teletherapy services. These considerations are adapted from McCord et al. (2020).
Record Keeping
- It is important to maintain notes of all contacts with the client.
- It is important to distinguish the type of service modality that has been used.
- For example, was the modality of services in-person, videoconferencing, or telephone.
- It is important to note the duration of the phone contact or teletherapy session.
- For example, the phone contact lasted 5 mins, the therapy session was a total of 52 minutes (42 minutes with the adolescent and 10 minutes with the father).
- It is important to note the location of the client in the documentation when providing telepsychological services.
- For example, the counselor can ask at the beginning of the session for the address of their location.
- It is important to keep all notes and forms private and secure when conducting telepsychological services.
- For example, make sure you are maintaining documentation on the secure platform as directed by the training clinic. Do not maintain or keep documentation on your personal platforms.
Progress in a Training Clinic
For supervisors or other psychologists in a training setting, additional considerations may be appropriate for guiding trainees in teletherapy.
- Ethically consider if trainees are competent in telehealth technology and therapeutic services.
- Make sure trainees are well versed in talking about the benefits and limits of teletherapy. Providing talking points or scripts may be helpful.
- Trainees should be familiar with the protocols of the clinic regarding teletherapy procedures.
- Supervisors may consider “testing” or having students “check out” their abilities in utilizing and conducting telehealth technology.
- Supervisors should incorporate discussions of culture and diversity considerations to encourage critical thinking of the teletherapy process.
Diversity Considerations
Diversity and multicultural components should always be recognized when providing therapeutic and teletherapy services. teletherapy possesses multicultural considerations that are built upon foundational multicultural counseling considerations. All diversity and multicultural components of teletherapy need to be acknowledged and addressed. These considerations are adapted from APA (2013), APA (2017), Galpin et al. (2021), and McCord et al. (2020).
Considerations include:
Socio-economic barriers
- Socio-economic gaps in access to technology may impair clients’ technology literacy. For example, clients who do not have access to a personal computer may feel uncomfortable receiving teletherapy. Also, older clients who are not experienced in using technology may not feel comfortable with teletherapy.
- The client’s socioeconomic status may prohibit access to services. For example, If the client does not have access to a computer, stable form of internet, and a secure and private location they may not be able to receive teletherapy services.
- Socio-economic status is also often intertwined with race and ethnicity, so in addition to SES, clinicians can also consider how these accessibility issues relate to race and ethnicity.
Nonverbal barriers
- Nonverbal cultural data is unavailable. Full-body language and gestures are not seen on telehealth platforms. For example, depending on the client’s culture their eye contact can vary. On telehealth platforms, it may be very difficult to identify this.
Clinician evaluation
- It is important for a clinician to evaluate and address personal biases.
- It is important for a clinician to develop cultural awareness. The clinician’s cultural awareness should include how clinicians view culture in the context of the client conceptualization, diagnosis, treatment plan, and interventions.
- It is important for a clinician to be open to talking about culture throughout the therapeutic process. This models to the client that these conversations are welcomed and warranted in the assessment.
Video
The following video depicts a therapy session and determining fit for telepsychology. The purpose of this video is to observe and reflect on the interactions between the therapist and client along with how the therapist managed a challenging situation. The second video explores case studies for further discussion and training considerations when engaging in teletherapy.
Resources
- Theravue-Online counseling training platform: theravue.com
- Deliberate Practice-Online counseling training platform: dpfortherapists.com
References
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). Retrieved from https://www.apa.org/ethics/code/.
American Psychological Association. (2017). Ethnic and Racial Minorities & Socioeconomic Status. Retrieved from https://www.apa.org/pi/ses/resources/publications/minorities.
Galpin, K., Sikka, N., King, S. L., Horvath, K. A., Shipman, S. A., & AAMC Telehealth Advisory Committee (2021). Expert Consensus: Telehealth Skills for Health Care Professionals. Telemedicine Journal and e-Health: The Official Journal of the American Telemedicine Association, 27(7), 820–824.
McCord, C., Bernard, P., Walsh, M., Rosner, C., & Console, K. (2020). A consolidated model for telepsychology practice. Journal of Clinical Psychology, 76(6), 1060-1082. doi: 10.1002/jclp.22954
Myers, K., & Turvey, C. L. (Eds.). (2013). Telemental health: Clinical, technical, and administrative foundations for evidence-based practice. Elsevier.