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It's More Than Just a Call: Ethical Issues in Providing Behavioral Telehealth
by Gerald P. Koocher, Ph.D., ABPP and Patricia Keith‑Spiegel, Ph.D.

3 CE Hours - $74

Last revised: 11/08/2023

Course content © copyright 2023 by Gerald P. Koocher, Ph.D. and Patricia Keith-Spiegel, Ph.D. All rights reserved.

   

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Learning Objectives

This is an intermediate-level course. Upon completing this course, mental health professionals will be able to:

The information in this course is based on the most accurate information available to the authors at the time of writing. Telehealth practice and associated technologies have evolved rapidly in the context of the COVID-19 pandemic and post-COVID preferences of clients and practitioners. New information and regulations that supersedes these course materials will continue to emerge. Readers should track regulatory changes in jurisdictions where they hold licenses and in jurisdictions they enter via telehealth to offer professional services. Throughout the course we have attempted to identify areas of caution that readers should apply in their own practices. This course will provide mental health clinicians with a fundamental understanding of ethical concerns in telehealth practice, and provide ethical guidance. At the end of the course, we provide a summary table that can serve as a checklist of issues that clinicians should consider regarding their telehealth practices. We have identified areas of ethical risk in providing mental health care via telehealth, and hope that the content will enable readers to reduce or minimize risk to their practice and their clients while participating in such care.

Outline

Introduction

The COVID-19 pandemic accelerated the already burgeoning use of telehealth to deliver behavioral health services. As we progress into the post-COVID era many clinicians and clients have some preference for continued or increased use of telehealth based on convenience factors. At the same time, we must remain mindful of ethical best practices to assure the welfare of people we treat and adherence to professional and licensing standards. We must also recognize that regulations put in place to facilitate and ease practice across borders during the COVID emergency have expired. Regulatory policies and best-practices will continue to evolve rapidly. This course aims to provide clear guidance to clinicians in the context of standards set by the major mental health professional organizations, using case examples and links to useful resources. Although many different terms have appeared across professions, we will use the term “telehealth” for all of these services to remain inclusive of assessment, preventative, and remedial services provided by mental health professionals whether directed to people affected by physical or mental illness.

For the sake of consistency and without intending offense, we will consistently use the word “client” when referring to the recipient of our services, understanding that some readers would prefer “patient.” Similarly, we will refer to evaluation of clients as “assessment” and treatment services as “therapy,” with full understanding that some professions typically use “psychotherapy” or “counseling” to describe such services aimed at generally improving the human condition.

In discussing best practices, we shall focus on the American Psychological Association’s (APA) Ethical Principles of Psychologist and Code of Conduct (2017), the American Association of Marriage for Family Therapy’s (AAMFT) Code of Ethics (2015), the American Counseling Association’s (ACA) Code of Ethics (2014), the National Association of Social Workers’(NASW) Code of Ethics (2021), and the International Union of Psychological Science’s (IUPS) Universal Declaration of Ethical Principles and Code of Conduct (2008). New guidelines released by the Canadian Psychological Association (2023) generally track the same concerns as those promulgated by professional groups in the United States. It will come as no surprise that broad agreement exists across professions about what constitutes good ethical practice. Because of differences in the evolution of each profession, the range of client populations each serves, and current levels of practice-licensing, the focus and specificity of detail varies. Many changes have occurred in professional ethics codes to reflect the inclusion of references to electronic and telehealth services. In some cases, these adaptations seem minor (e.g., stating the application of principles in electronic as well as paper records). In other cases, professional standards have broadened scope to cover access to telehealth and disruption of such services, and even to the extent of specifying the concept of sexual intimacies with clients using telehealth! (NASW: 1.09(a)) We have documented such changes in Table 1.

We have arrayed the primary topical principles and specific rules of each of these professional organizations as they apply to telehealth-based behavioral health services in Table 1 and will cite these elements as we discuss cases by citing the abbreviation of the organization and code element. For example, informed consent in telehealth-based services would be addressed by the APA code as (APA 3.10) listed under Human Relations, however the ACA code might involve possible citation of (ACA A2, E3, and H2) depending on the case circumstances under Client Welfare, Assessment, or Distance Counseling respectively. In addition to providing citations for work we refer to, we also provide a list of other useful articles and websites offering more resources. We encourage readers to browse the full list.

The broad cross-cutting ethical principles that we must remain mindful of in providing services remotely include: regulatory authority, practitioner competence, respect for the rights of clients, confidentiality/privacy issues, record keeping and fees, and advertising or public statements. Some special issues come up in the context of assessment and therapy. We will address each of these in major sub-headings.

A special note for psychologists: The APA will circulate a draft revision of its Ethical Standards of Psychologists and Code of Conduct for public comment in late 2023 and hopes to hold a vote on a final version in late 2024 with an effective date in 2025. We do not expect fundamental changes in the content discussed in this course, although the new code will likely codify many of the cautions and recommendations included in this course. We encourage you to review the new code as soon as drafts become available.

Regulatory Authority

All professional associations and licensing boards expect clinicians to obey the law in general terms. The ACA’s ethics code addresses this point specifically by obligating members to have knowledge about legal considerations in telehealth (ACA, H.1-1.b). The AAMFT also addresses the issue by cautioning therapists to, “follow all applicable laws regarding location of practice and services, and do not use technologically assisted means for practicing outside of their allowed jurisdictions.” (AAMFT, 6.5). The APA addresses this issue only in the introduction to its ethics code, noting that "psychologists must consider this Ethics Code in addition to applicable laws and psychology board regulations.” The NASW makes clear that adherence to law and regulatory standards is expected and added language in its 2021 ethics code revision by editing in many references to electronic and telehealth issues. Interestingly, the IUPS (which has no enforcement authority) does not explicitly address the issue in its ethical declaration.

Interjurisdictional Practice

Interjurisdictional practice presents one of the most significant ethical challenges to telehealth practice because of the ability to easily reach populations across state lines. Telehealth offers a significant potential benefit to consumers by giving greater access to services and providing continuity of services to existing clients who relocate. State regulatory bodies typically address how one can provide telepsychology within the state; however, clinicians must remain aware that each state has its own set of laws and regulations about how it permits clinicians from other jurisdiction to treat its residents. Some states make provisions to allow clinicians similarly credentialed in other jurisdictions to provide services for a limited period without formal notification to licensing boards, others require permission or notification prior to initiating services, and still others allow clinicians residing out of state to treat its residents only if also licensed in the state where the client is located at the time-of-service delivery.

The COVID-19 pandemic caused many states to declare emergencies that allowed broad latitude in telehealth practice, including mandates that insurers pay foy telehealth services and allowing access to interstate practice. Those authorizations ended by mid-2023, however many clients and practitioners found telehealth services practical, convenient, and effective. One result has included advocacy at the state level for legislative changes to make some changes initiated during the pandemic permanent. Practitioners are cautioned to carefully monitor the regulations imposed by their own state licensing authorities and those jurisdictions where the receiving client may reside.

Case 1:

An overly enthusiastic psychologist, licensed in California, plunged into the telehealth practice world at the height of the COVID-19 pandemic without paying much attention to clients’ home states. One of the clients they treated for “intense situational anxiety” ultimately developed unforeseen florid psychotic symptoms. The client, a Florida resident, filed a licensing board complaint there complaining that the psychologist “Has stolen my mind and targeted me for abduction by space aliens.” Many states, including Florida, issued emergency waivers during the start of COVID-19 allowing clinicians comparably licensed in other states to deliver telehealth-based services, but rescinded that authorization as the acuity of the crisis waned. The Florida board found no evidence of the psychologist having conspired with space aliens or mind-stealing but cited him for practicing without a Florida license after the declared emergency had ended.

As noted above, clinicians have an obligation to remain aware of the relevant requirements for the jurisdiction in which they seek to practice, including changes and updates. Medicine and nursing have developed interstate compacts that assist in making interstate practice more fluid and a similar compact for psychology (PSYPACT) has been adopted by more than 40 states. The relaxed rules during the COVID-19 pandemic may have accelerated cross-jurisdictional practice going forward, however each clinician remains ethically responsible for clarifying their responsibilities under cross-jurisdictional practice.

Case 2:

A licensed psychologist in New Hampshire signed up for PSYPACT and the interjurisdictional practice certificate associated with it. They have continued to treat one of their New Hampshire clients who relocated to Texas for college. The client just called for an emergency Zoom appointment. It seems that they are five weeks pregnant and do not want to carry the pregnancy to term. They want to discuss their options. The psychologist faces a significant regulatory issue but may not fully grasp the situation.

The Supreme Court’s decision to overturn Roe v. Wade put the regulation of abortion in the hands of states. New Hampshire has not placed new restrictions on reproductive health issues, but many states have done some, Including Texas. The case above illustrates an important point: interstate telehealth practice requires practitioners to understand the laws that apply in both the sending and receiving states. If a clinician practices in a state where abortion is illegal or heavily restricted, they may face prohibitions if they provide clients with specific information about how to obtain an abortion in another state. Doing so might lead to the of allegation assisting, aiding, or abetting in termination of a pregnancy.

Psychologists who serve clients via telehealth across state lines under PSYPACT auspices or temporary practice provisions must remain aware of the law where the client is sitting. The PSYPACT Commission has provided guidance indicating that the receiving state (where the client sits) could impose its requirements regarding public health, safety, and welfare on the practicing out-of-state psychologist. These could include requirements regarding mandatory abuse reporting, controlled substances, duty to warn/protect, and informed consent.

In this context, providing information or guidance from New Hampshire to their client in Texas may put the psychologist at some risk. Texas has implemented a “bounty hunter” statute that offers a $10,000 incentive for people to bring lawsuits against anyone who aids or abets an abortion that would be illegal in Texas. Mental health providers are not the primary targets of such laws, and some states where abortion is legal have enacted laws stating that they will not collaborate in enforcement of such statutes. Nonetheless, a possibility exists that this psychologist might potentially run afoul of such situations when her client gets advice while sitting in such a state.

Many professional associations including the APA, AAMFT, and NASW have stepped forward to urge their colleagues to focus only on the best interests of their clients. (See for example: https://www.apa.org/news/press/releases/2023/02/reproductive-health-decisions-confidential ; and https://onlinesocialwork.vcu.edu/blog/what-is-reproductive-justice/#:~:text=In%20addition%2C%20the%20NASW%20says,abortion%2C%20contraception%20and%20family%20planning.)

Practitioner Competence

In 2012, the APA created a task force to develop a set of guidelines for telehealth practice (Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013) to educate and inform. Since that time, the published literature in this arena has grown exponentially. (See, for example: APA, 2020; APASI, 2023; Barnett, Serafim, & Sharara, 2023.) The resulting practices have focused on aspects of telehealth services that differ from the in-person delivery. The resulting key issues involve: Competence, Standards of Care, Informed Consent, Confidentiality, Security/Transmission of Data, Disposal of Data, Testing and Assessment, and Interjurisdictional Practice. These describe a range of factors that require attention under the general heading of Competence to Practice Remotely.

The general Competence section of the APA’s ethics code focuses on practicing within the boundaries of one’s competence (APA, 2.01), maintaining competence (APA, 2.03), having sound scientific and professional judgment (APA, 2.04), and understanding how exceptions might be permitted in emergency contexts (APA, 2.02). The APA’s current ethics code (2017) does not address services via telehealth per se, but rather, expects clinicians to do some interpolation. In essence, psychologists are expected to adapt existing standards to fit the telehealth environment. The IUPS addresses these issues as “taking care to do no harm” and “developing and maintaining competence.” The AAMFT addresses professional competence and integrity together in six standards: Maintenance of Competence (3.1), Knowledge of Regulatory Standards (3.2), Development of New Skills (3.6), Exploitation (3.8), Scope of Competence (3.10, and Public Statements (3.11), plus an entire section on services via telehealth (AAMFT, 6.0-6.6). The ACA addresses similar issues under the headings Boundaries of Competence (C.2.a), New Specialty Areas of Practice (C.2.b), Assessment - Limits of Competence (E.2a), and Distance Counseling (H.1 Knowledge and Legal Considerations and H.1.b Laws and Statutes).

Unifying Concepts

Unifying concepts across all of the professional groups include adequate skill development in delivering services remotely (including clinical proficiency and technical aptitude), accuracy in presenting one’s credentials, avoiding harm to or exploitation of clients in the new mode of service delivery, and responsibly adhering to legal and regulatory standards. One can reasonably assume that in the course of becoming licensed as a mental health professional you had exposure to the fundamentals of assessment, treatment, and ethical conduct in coursework and supervised practice. Even so, new research, new techniques, new technologies, and the evolution of our work in society continues to change.

Do you know the half-life of knowledge in your field? This concept refers to the number of years it takes post-degree for half of the knowledge you acquired in in your education/training to become outdated or obsolete based on progress in your field. Various sources have posited that the half-life of knowledge acquired in a psychology doctoral program is seven to eight years. However, specialty practices can have significant differences. For example, the half-life in practicing psychoanalytic therapies has been estimated at 15.6 years, while psychopharmacology practice weighs in at 4.8 years (i.e., due to new drug development and medical research) and forensic psychology would have a 6.6 year half-life (i.e., due in part to changes in law and case decisions). (See concept.paloaltou.edu/do-you-know-what-the-half-life-of-knowledge-in-forensic-psychology-is.) This phenomenon is one reason that most states require their licensed mental health practitioners to complete some number of continuing professional education hours between licensing intervals. In addition, many states are now mandating completion of continuing education related to telehealth and related technologies.

In considering telehealth-based practice, we must similarly understand the degree to which our particular approaches and techniques translate to that mode of communication. Fortunately, our fields have developed a growing body of research to aid us in determining the effectiveness of remote service delivery. The COVID-19 pandemic also provided an illustration of how an existing clinical relationship can assist in a migration to remote service delivery. Many psychotherapists have had the experience of offering professional help by telephone to existing clients to accommodate travel needs, relocations, and emergencies. The fact that a therapeutic relationship established in an office-based context already existed created a smooth transition for many clients who sought to continue treatment while in social isolation. However, conducting an intake evaluation and establishing a therapeutic relationship with a new client via telehealth requires some new adjustments. We must now give ethical consideration to the issue of half-life in telehealth-based services. Using the radioactive decay model and considering both the rapid evolution in online services, associated technologies, and regulatory changes, the analogy will be closer to the 4.8 years (or less) associated with psychopharmacology than to the 15.6 years for psychoanalysis.

Case 3:

A client reached out to a psychologist seeking psychotherapy. They explained that although they lived more than 2,000 miles from the psychologist, “As soon as I saw your photo on LinkedIn, I felt an instant spiritual connection.”

When the psychologist explained that they lacked the credentials to offer teletherapy in the client’s state the potential client replied, “Okay, well then I’ll move to your state next week, as soon as I get discharged. Every once in a while I end up getting committed when I go off my meds. The drugs stifle my creative juices and block my ability to time-travel.” The psychologist gently declined to take on the client and re-directed them to the discharge planning team at the hospital where they were receiving treatment for schizoaffective disorder with paranoid features.,

Case 4:

An anxious client felt hesitant about beginning treatment with a psychologist. They had long experienced social anxiety and felt increasingly isolated when they began to work from home because of the COVID-19 pandemic and their history of asthma. The psychologist’s telepractice turned out quite well for him. They did not need to increase their exposure risk to the virus by taking public transportation and could talk from surroundings that they could control and felt comfortable with.

These two cases offer a distinct contrast in types of clients and adjustment to telehealth services. The client in case 3 clearly seems subject to impulsivity, mood lability, poor judgment, and delusional thinking. Such a client, residing a substantial distance away, would most likely pose significant clinical management problems and have a high risk for further decompensation. The client in Case 4 found a safe way to engage in treatment for their anxiety while avoiding unnecessary infection risks and remaining in a comfortable familiar setting. Their circumstances presented the psychologist with an eminently more treatable client.

At the start of a professional relationship, clinicians should begin conducting a comprehensive evaluation of the client’s treatment requirements. It is also imperative for clinicians to confirm that their skill set and expertise aligns with the specific treatment needs of the client. This advice might appear self-evident, but it is essential to emphasize that the expected standard of care for online services is no less rigorous than that for in-person services. This standard encompasses the delivery of professional services even in emergencies and situations where immediate services are not readily accessible, as stipulated in the ethical codes of professional associations.

When a therapist feels uncertainty regarding their clinical competence to effectively address the unique needs of a particular client, it is highly advisable not to make these determinations in isolation. Instead, clinicians should seek consultation and collaboration with expert colleagues to enrich their decision-making process and enhance their assessment of their own competence. This collaborative approach ensures that clients receive the highest quality of care and that their diverse and dynamic treatment needs are met effectively, even in challenging or uncertain situations. In addition, the consultation with colleagues can help clarify expected standards of care in one’s community.

Technological Competence

The transition to offering professional services online poses a significant challenge for many practitioners. To ensure the competent and effective delivery of professional services, it is imperative to have a solid grasp of the hardware and software tools essential for this mode of delivery. This aspect of care is deemed so crucial that some have highlighted it as a fundamental mandatory competency that all practitioners should possess (Weisenmuller & Luzier, 2023).

Venturing into the realm of online professional services requires practitioners to adapt to new technological landscapes. No longer is it sufficient to rely solely on traditional skills used for in-person methods. Practitioners need to master the operation of various hardware components, such as computers, webcams, microphones, headphones, and the use of specific software designed for telehealth or secure online communication.

Technological competence presents a challenge for both clinicians and clients. Clinicians have the ethical responsibility to assure that they can offer services via telehealth competently from a technological standpoint, aside from their clinical skills. The AAMFT (Standard 6) and the ACA (Standard H) address such necessities directly, although the APA does so through indirect references such as assuring general competence, client welfare, and controlling interruption of services (APA, Standards 2, 3.12, 10.09; NASW, Standard 1). Before undertaking to offer services via telehealth, clinicians need to assure that they have adequate working equipment that meets regulatory compliance obligations (e.g., HIPAA), stable high-quality Internet access, and sufficient familiarity with their system and communication platform/software to manage effectively. Similarly, the client will need to have adequate equipment, robust Internet access, and sufficient understanding to make the necessary connection effectively and safely.

Case 5:

A naive social worker felt a particularly urgent need for ramping up a telehealth practice, when COVID-19 precautions prevented their existing clients from continuing in office-based treatment. Unfortunately, they lacked the sophistication to pull together the components necessary to mount an adequate delivery system. Amid much demand and social isolation, they could not arrange expert help to create a secure robust system. They had no landline at home, relying on a cell phone, despite poor service in that geographic area. They were unable to put a video-based communication system in place and attempts to treat their clients via cell phone resulted in frequent dropped calls frustrating them and their clients.

The COVID-19 pandemic quickly taught many health and mental health clinicians and hospital systems about their telehealth platform flaws, as demand ramped up swiftly. Many clinicians found themselves climbing a steep learning curve figuring out how to use a telehealth service, and then spending a significant amount of time providing technical support to help clients get on board. Many clients lacked a good Internet connection or proper equipment. Given the nature of the health crisis and social isolation context, many technical errors could reasonably be excused. However, going forward into a more normalized telehealth-based service arena, pre-screening of user skills and technology adequacy will prove essential.

The importance of this technological competency extends beyond mere proficiency. It has evolved into a core skill set that professionals must possess in the modern era. In summary, mastering the tools and technologies required for online professional services is a non-negotiable requirement in today's evolving healthcare landscape. Part of effectively using one’s equipment also involves details that have a unique connection to psychotherapy. For example, consider the nature of eye contact in online therapy. Making direct eye contact involves looking straight into the camera lens, whereas the normal reaction when using a computer screen would involve looking directly at the screen. Thus, watching the facial response of the client in real time involves appearing to gaze away from the camera. Similarly, using a laptop computer and relying on the built-in microphone and speaker may yield a less than adequate sound transmission, contrasted with a use of a headphone and microphone apparatus. Practitioners may want to undertake a technology audit and consider upgrading equipment and Internet access as a required investment.

Our social work colleague has learned from their challenging experience during the pandemic. They have now had the chance to upgrade their Internet connection, computer, microphone, headset, and other equipment. They want to offer telehealth services to all of their clients as a matter of convenience. They will still need to consider whether the people they want to serve have access to similarly adequate systems. They will also need to consider potential back-up plans should technology fail on either side of the therapeutic connection.

The question of client access raises social justice and equity issues in the sense that the ability to gain access to proper equipment depends on economic capacity. Some temptation may exist to refer clients to public Internet connection points such as public libraries or community centers with connected public use computers. The use of public computers should be avoided because of the significant lack of privacy for participants. For clients without good private Internet access, a shift to telephone-based communication may prove more viable and confidential.

Respect for the Rights of Clients

The fundamental duties of care owed to our clients, apart from offering competent service, involves avoiding harm (APA, 3.04; AAMFT, 1.9; ACA, A.4), avoiding interruption of services or abandonment (APA, 3,12 and 10.09-10; AAMFT, 1.11; ACA, A.11-12; NASW, 1.15); and assuring them that we will hold their rights paramount (APA, 3.11; AAMFT, 1.13; ACA, A.1). At the beginning of any professional relationship, and whenever a change occurs, clinicians have an obligation to review and update consent with each client. Such discussions involve a process of consent rather than a single event. For example, when a client used to receiving care in the clinician’s office transitions to telehealth-based services, many of the conditions of service will change. Such changes will require a full understanding and advance approval by all parties.

Informed Consent

Informed consent requires reaching an agreement on all the factors that might reasonably influence the client’s decision about working with the clinician from the start of the professional relationship (APA, 2020; APA, 3.20; AAMFT, 1.2; ACA, A.2; NASW, 1.03). Practice via telehealth requires new approaches to reaching this informed decision. What boundaries apply? How are fees handled if a technology failure truncates a session? How can we preserve confidentiality when using Internet-based services?

Fundamental steps include:

Key aspects of the discussion should also include describing the security precautions the practitioner uses and how these may impact each client’s privacy. For example, does the client understand the relative risks and benefits associated with the use of each type of technology (e.g., phone, video conferencing, texting, email)? Are there particular laws in the client’s jurisdiction that must be followed that may impact confidentiality (e.g., mandatory reporting laws)? What emergency contacts does the client wish to provide? How does the practitioner wish to be contacted regarding client mental health emergencies (e.g., do not use text or e-mail, if unable to reach by phone go to the nearest emergency room)? What availability does the clinician have for client contact between sessions, and how will technology or connection difficulties be addressed? Will the client need to download and use certain secure software for treatment sessions and other communications?

Electronic Communications Policies

Practitioners should consider creating an electronic communications policy that not only addresses the communication issues mentioned above, but also addresses the practitioner’s policy on how various technologies may apply to communication between practitioner and client. For example, some clinicians may prefer a policy of only providing clinical services via videoconferencing and telephone, but limits the use of email and text messaging to administrative purposes only (e.g., for scheduling and other nonclinical issues). The practitioner’s policy about participating or not participating in social media with clients should also be specifically addressed.

Mental health professionals should approach participation in social media with considerable caution and careful forethought. While all practitioners certainly have the right to participate in social media as part of their personal lives, all should consider the potential consequences of including clients in these communications. The level of self-disclosure can easily lead to sharing of personal information far beyond what a therapist would typically consider appropriate with clients.

Practitioners may want to include a statement about not conducting online searches for client information without the client’s permission. Intentionally searching for client information online without their knowledge or permission qualifies as a type of soft boundary crossing that may violate the client’s trust and thereby negatively impact the treatment relationship. Practitioners who want to retain the ability to conduct such searches should consider explaining the reasons for doing so, such as having the ability to verify information shared by the client, and obtain their informed consent prior to taking such actions. A sample Informed Consent to Telepsychology and a sample Electronic Communications Policy can be found at https://parma.trustinsurance.com/Resource-Center/Document-Library-Quick-Guides. Other examples can easily be found by conducting an online search. Additionally, the APA provides a checklist to guide practitioners in developing their own informed consent to telepsychology document (APA, 2020). Note that while APA, ACA, and AAMFT do not cite patient-targeted searches, the 2021 NASW ethics code specifically calls out these steps as required.

Case 6:

A psychologist has begun working with a new patient around issues of performance anxiety. The patient is very bright, funny, articulate, and likable while interacting with the psychologist and in other one-on-one and small group situations but sought treatment because they feel nervous when speaking to large groups, a requirement of a new job. They were somewhat vague when asked about their employer, describing it as a public interest advocacy group. After the third session the psychologist became curious and looked up the patient on Google. They discovered that their new job is a highly visible national leadership role with a white supremacist neo-Nazi organization. The psychologist’s great grandparents died in Germany during the Holocaust.

The psychologist must now consider how this information may trigger countertransference feelings about the client and how to proceed. At the same time, the client does not know that their therapist has become aware of publicly available information he chose not to disclose in therapy. Can the psychologist continue to effectively treat this client? If the psychologist believes that they should discontinue treatment, how do they proceed and what do they reveal? Does the psychologist have a right or obligation to reveal what they has learned about the client and how they feels about it, given that the issues have nothing to do with the client’s reason for seeking treatment?

Some of the important new considerations introduced with the use of telehealth include challenges in getting clients’ attention, assuring they understand key issues, and documenting their agreement to proceed. Digital consumers have become cavalier with respect to the terms and conditions (T&C) presented for approval in smartphone applications, software, and web sites. Just think of how often you have actually opened and read the T&C materials, as opposed to simply checking off the box as you tried to install or use such programs and sites. Our ethical duty requires us to reasonably assure that clients understand any incremental risks associated with obtaining services via telehealth.

Clinicians may want to establish distinct secure email and phone numbers for use solely by their clients. In doing so, clinicians must clarify mutual expectations for communication and response. Consider the following case examples.

Case 7:

A prolific user of electronic communication tools has taken to sending their therapist frequent uninvited updates on the insights they experience between sessions using text and e-mail messages, almost daily, ever since using a telehealth platform for their appointments. Most recently, they sent a late night text to the therapist reading: “I now recognize that my relationship with my partner is a replay of my pathological connection to my father! I’m going to break up with them tonight.”

A few hours later, the partner sent their (different) therapist a text message at 3:00 a.m. reading, “ I just got dumped because I remind them too much of their father. I’m shattered. My life is over.”

The client’s messages have potentially substantial clinical content and their therapist will likely begin to feel tempted to respond or overwhelmed by the time involved in tracking the substance between sessions. Either therapist could well be asleep and not see the potentially suicidal affect in their text message for many hours.

Clients need to know (and get occasional reminders) about agreed communication methods and response times for normal and emergency communications. A clinician may agree to accept non-emergency asynchronous e-mail (e.g., sending a message without expecting an immediate response) or text messages, but should take care to specify a reasonable response timeframe on evenings and weekends. We also recommend limiting the use of asynchronous communications for non-emergency appointment-setting or logistics, but avoiding any substantive content. Similarly, reminders against using asynchronous communications in emergencies will warrant frequent repetition.

Technology disruptions and technical errors can complicate, interfere with, or terminate communication without warning. Clinicians should develop response plans for such situations, and share these plans with clients. Clients should agree to the proposed procedures and understand what to do. In assessing client suitability for services via telehealth clinicians must consider clients’ psychological status and technical competence. Clients need to understand how to avoid accidental transmission of messages to others and how to exercise vigilance in their means of responding. Social media sites should be avoided, as these have high vulnerability to accidental misdirection and confidentiality compromise. Similarly, clinicians should decline to engage clients in ways that might promote distracted driving or create emotional distress for clients sitting in public settings.

Case 8:

A client’s Internet connection failed, so they decided to connect to their court ordered anger management therapy session from a local Starbucks coffee shop. Unsatisfied by the client’s assurance that they were alone in a back corner of the shop, the therapist expressed concern about the lack of privacy. The client was frustrated by their home Internet problems and eager to finish the required number of therapy hours in their court-ordered anger management program. When the therapist declined to continue unless the client could find a private area, a fit of verbal rage ensued. Not knowing what triggered the meltdown taking place in the rear of the shop, an employee dialed 911.

Billing for services via telehealth can also become a source of misunderstanding. Services may involve sessions that vary in duration on a planned or disrupted basis. Practitioners’ charges may vary for texting, telephone, e-mail, and videoconferencing. All such charges and variations require discussion and agreement in advance of service delivery as part of the consent process. All elements of the consent process should be provided to clients in writing and discussed orally. Documentation can occur via electronic or postal mail. Clinicians should maintain a copy of the information provided in the client’s clinical record, along with notes in the client’s records specifying the date the information was provided and some confirmation by the client that they received, understood, and agreed to the conditions.

Standards of Care

Understanding how to translate usual standards of care to a telehealth-mediated format first requires a presumption of practitioner competence and client consent, as discussed earlier in this course. The next consideration requires an understanding of the factors that might lead to avoiding harm (APA, 3.04; AAMFT, 1.9; ACA, A.1 and A.4), minimizing disruption (APA, 3.12, 10.09-.10; AMFT, 1.11, ACA, A.11-.12, NASW, 1.15, 1.17) and considering public emergencies or other urgent circumstances APA, 2.02; NASW, 6.03). Attending to these issues will require clinicians to weigh client variables and the nature of our techniques in the context of client needs and any emergency contexts.

Client Variables such as psychological instability, symptoms associated with severe pathology (e.g., unstable paranoid delusions, psychotic decompensation, or repeated suicide attempts) may mitigate against remote treatment, since emergency local interventions may become necessary. In some situations, such as when the clinician has a well-established therapeutic alliance and good back-up resources located near the client, remote treatment of unstable clients may become a viable alternative. In certain underserved areas or at times when public safety emergencies limit travel, remote treatment may become the only option available for such clients. Other clients dealing with relationship issues or less severe psychological symptoms, and intake assessments aimed at evaluating feasibility for telehealth-based treatments, present lower risk levels.

Treatment Techniques may also add a variable dimension to consider. For example, can or should a clinician attempt high-intensity exposure therapies for remote delivery? How well will multiple client therapies such as complex family therapy issues with a wide age-span work via telehealth? Which psychological assessment techniques lend themselves to remote use and how should we interpret such results as contrasted with face-to-face assessments? Over time, we will likely have research evidence to better answer such questions, but at present we must rely on thoughtful clinicians to assess the wisdom of deploying specialized or complex interventions remotely.

Use of Apps and AI as Treatment Aids

Many clients who seek out telepsychology may also have also begun independently using mental health or mindfulness smartphone applications (apps). Others may have tried an emerging wave of AI (artificial intelligence) driven “psychological support” computer programs (see for example: https://elomia.com/demo/). Examples of self-help smartphone apps include Headspace, iBreathe, Quit That!, Hapify, Calm, and I Am Sober. Still, other apps and AI-assisted programs are available for practitioners as ROM (routine outcome monitoring) tools. ROM has also been referred to as progress monitoring, measurement-based care, and feedback-informed treatment. These products can gather symptom reports from clients remotely between session and feed the data back to therapists. For example, Novopsych makes 80 psychological measurements such as the PHQ-9, GAD-7, PCL-5, and DASS-21 available for remote administration.

While some practitioners may find certain apps effective and useful on an anecdotal basis or as an adjunct to ongoing treatment, a cautious approach is warranted. Apps vary widely in quality and sophistication and some may pose privacy risks or even prove clinically harmful to clients. Many “mental health and wellness” apps were not created, monitored, or evaluated by mental health professionals and only a small percentage have been studied for safety and effectiveness. Few have published valid data to support their safety and efficacy. For example, Lau et al. (2020) reported that only 2.08% of 1,009 publicly available mobile apps described as providing psychosocial wellness and stress management aid had published peer-reviewed evidence in support of their use. Similarly, Kim et al. (2018) reviewed 695 apps targeting autistic spectrum disorders and found that only 4.9% documented any evidence to support their effectiveness.

Other research has found that approximately 70% of apps do not disclose their privacy policies to users. Many share users’ personal information without their permission or knowledge (Sunyaev et al., 2015). This lack of disclosure may mean little to some clients since a 2017 study by Deloitte found that 91% of consumers accept the terms and conditions without reading them (Cakebread, 2017). ProPrivacy.com claims that number is higher, with only 1% of subjects in a social experiment actually reading the terms of conditions (Sandle, 2020). Clients might feel differently about the sharing of mental health data as opposed to data gleaned by shopping apps or gaming apps. The personal information gleaned from such apps is sold chiefly to marketing companies (Marshall, et al., 2020). All new clients should be asked about their use of mental health and wellness apps as part of an intake evaluation or clinical history. Therapists should consider cautioning clients about such data sharing.

Apps that are developed or supported by mental health practitioners and provide valid mHealth (mobile health) data can be useful by gathering and providing clinical symptom data in real time. Such data can, for example, track depression, anxiety, pain, or distress levels over time and in so doing provide routine monitoring of treatment outcomes. Just as with the apps of unproven effectiveness, it will be important to assure privacy and understand how data-sharing beyond the client may occur. Even when individual client-level data is not shared, some mHealth apps aggregate data for other commercial purposes or research.

Practitioners will want to explore clients’ experiences with apps and consider whether the app may be contraindicated or ineffective. It will also be helpful for practitioners to download these apps to use them personally and determine if they are likely to be helpful to clients and consistent with the goals of treatment. It may also be helpful to consult with experienced colleagues to find out which apps they have used and which ones their clients have used successfully, along with reading reviews of available apps. App recommendations to clients should be based on the potential for clinical effectiveness and security of client information and data.

Preparing for Client Emergencies

When treating clients who reside in the practitioner’s home community, the clinician will likely have good knowledge regarding available community resources should a crisis arise during the course of treatment. However, when treating telehealth clients from distant locations, practitioners will typically lack familiarity with emergency resources in the client’s local community (e.g., facilities offering assistance for situations involving threats of harm to self or others). For this reason, psychotherapists should investigate the availability of such resources at the start of treatment rather than waiting until a crisis develops. When treating clients for depression, anger issues, domestic violence, or similar potential indicia of harm to self or others, sharing local resource information at the start of the professional relationship may prove helpful. Such information might include crisis hotline telephone numbers and other resources relevant to client needs (e.g., referrals for medication, domestic violence shelters, or substance-abuse treatment programs).

Sharing of these resources can flow as part of the usual caveats that the therapist cannot be available 24/7/365, and that in a crisis the client should not delay in seeking help.

Practitioners can also provide information on national resources such as the National Suicide Prevention Lifeline: 988, Suicide and Crisis Lifeline (https://988lifeline.org/), the National Suicide Hotline: 800-273-TALK (8255), the Crisis Text Line: Text HOME to 741741 (https://www.crisistextline.org/), and The Trevor Project (for the LGBTQ+ Community): Text START to 678678, call 866-488-7386, or chat on trevorproject.org.

Practitioners should include documentation in clients’ files that such emergency instructions and resources have been provided.

Office Configurations

When providing telehealth treatment from one’s professional office, privacy precautions in the therapist’s physical space would most likely already be addressed. When considering use of a space in one’s home not already configured as a private office, give consideration to soundproofing and other measures to avoid interruptions or breaches from family members, pets, or people making deliveries. For videoconferencing, check the lighting you plan to use. Avoid backlighting and overhead spot lighting. Consider ways to illuminate the face of the therapist for client viewing, purchase of a headset with a microphone, or an external microphone to reduce extraneous noise and enhance auditory acuity for both client and therapist.

Place your camera directly in front of your face at the top of the monitor so that the client views the psychotherapist looking directly at them during the session. When using a laptop computer, place it in an elevated position for the same reason. Take steps to minimize background distractions and make it easier for the client to focus on the therapist. Check sound and video quality before each session. Practitioners should also make use of password-protected WiFi, just as in a personal office. Secure storage and preservation via backup is also a necessity for all client records.

Case 9:

A licensed mental health counselor enjoyed their role as a stay-at-home parent and telehealth psychotherapist, while their spouse worked outside the home as a physician’s assistant. No one expected a snow day that would leave their 5 and 7 year olds at home. Their usual plan of conducting sessions from the dining room table was not going to work with the kids at play. They considered closing themself in the bedroom with a blurred out Zoom background but realized that there would likely be interruptions by the otherwise unsupervised kids.

The counselor had a plan that worked well 95% of the time when they were home alone. One can argue that an occasional brief interruption by one of the kids might not truly compromise a therapy session. However, this would not be fair to their clients and could risk excessive self-disclosure or distraction as their children wander into view. They need plans for back-up childcare including plans for privacy even when the children are under supervision in the home during sessions.

Client’s Setting

Just as practitioners take steps to assure a smooth professional interaction, clients should be helped to secure their end of the communication process and understand what is expected of them from the start of the telehealth relationship. For example, clients may not be aware of the security risks associated with connecting to some WiFi networks (e.g., free public WiFi) and should be cautioned against using such connections for therapy. Public or open WiFi networks are inherently more vulnerable due to lack of encryption (McCoy, 2022). Practitioners should also avoid vulnerable WiFi networks. When no safe public WiFi is available a 4G or 5G cell phone may have the capacity to initiate a portable hotspot for smartphone-based telehealth applications.

Clients may not give much thought to the implications of where they locate themselves when participating in treatment sessions. The role of a private location where others will not be present and where interruptions will not likely occur should be explained to clients (APA, 2015). It may even be helpful to have each client hold up their camera and scan the room they are in so the psychotherapist will be aware of their setting and so any limitations and challenges can then be addressed. Of course, some clients may be quite limited in their options and need to participate in treatment sessions from their home where others may hear the content of online sessions. In these cases, privacy risk mitigation measures can be implemented and may include the use of white noise machines, having the client situate themselves away from shared walls or open windows, the use of headphones, and either coordinating or adapting session times to coincide with periods when the client most likely expects to have privacy in their home. Psychotherapists will need to use their best judgment in these situations and explore available options with these clients.

Confidentiality and Privacy

Normally, in-person service clinical notes or session content would come to light only through court orders, but online content is often publicly discoverable. We must advise our clients that we cannot assure total confidentiality when using telehealth platforms, but we can deploy security measures, privacy settings, and other safeguards. Providing such information should typically occur at the outset of services as part of the consent process. Additional information on standard confidentiality limitations (e.g., mandated reporting of child or vulnerable person abuse and other state-specific requirements) and cautions about broadcast conversations should be part of the consent process. Other threats to confidentiality could include misdirection of material in texts or email, use of social media, or viewing of messages by others who have access to the client’s or therapist’s devices and space.

Case 10:

A social worker practiced psychotherapy from their home office while also managing another business – the East Oshkosh Cat Fancier Society. They often worked on updating the society’s web site during breaks between clients. One busy afternoon they accidentally posted therapy notes to Society’s on-line bulletin board and did not notice their error and remove the files until the next morning.

Case 11:

A licensed marriage and family therapist had their home office scanner set to forward copies of insurance information containing client’s names, diagnoses, and services to their billing assistant via preprogrammed email. At the end of a busy workday they entered an incorrect scanner code and sent the scanned copies to members of their church choir.

Even when we rely on secure technology systems to manage confidential information, we must remain mindful of the potential for human error. This includes following basic security protocols to ensure that we never place sensitive client data at unnecessary risk. Using strong passwords (i.e., using combinations of more than eight upper and lower case letters, numbers, and symbols) to protect our electronic devices, securing the devices when not in use, and limiting use of such devices to professional activities, serve as good practice (Smucker Barnwell & Adams Larsen, 2018). Similarly, because no e-mail message or web posting is truly and irrevocably deleted, we should exercise caution before hitting the “send” button. Modifying the carpenter’s maxim of “measure twice, cut once,” we should check purpose, content, and addresses twice, transmit once.

National Security

National security claims have historically provided justification for breaching therapy clients’ privacy dating back at least to the Nixon administration’s attempt to get records from the psychiatrist who treated Daniel Ellsberg, leaker of the so called Pentagon Papers (Koocher & Keith-Spiegel, 2016). Clients who express concerns about government monitoring of their telehealth-assisted mental health services may not be paranoid. National security issues formed the basis of at least one significant instance of eavesdropping on psychotherapy more than two decades ago as illustrated in this case using real names in the public record:

Case 12:

Theresa Marie Squillacote (also known as Tina, Mary Teresa Miller, The Swan, Margaret, Margit, Theresa Stand, and Lisa Martin) and her husband, Kurt Stand, were convicted of espionage. Squillacote had earned a law degree and worked for the Department of Defense in a position requiring security clearance. In 1996, the FBI obtained a warrant to conduct clandestine electronic surveillance, including the monitoring of all conversations in Squillacote’s home, calls made to and from the home, and Squillacote’s office. Based on the monitored conversations, including Squillacote’s conversations with her psychotherapists, a Behavioral Analysis Program (BAP) team at the FBI prepared a report of her personality for use in furthering the investigation and ultimately entrapping her. The BAP report noted that she suffered from depression, took antidepressant medications, and had “a cluster of personality characteristics often loosely referred to as ‘emotional and dramatic.’” The BAP team recommended taking advantage of Squillacote’s “emotional vulnerability” by describing the type of person with whom she might develop a relationship and pass on classified materials. Ultimately, she did transmit national defense secrets to a government officer who posed as a foreign agent and used strategies provided by the BAP team (Koocher & Keith-Spiegel, 2016; United States v. Squillacote, 2000). In 1999, she was sentenced to Federal prison for treason, and was ultimately released in October, 2015.

Citing Edward Snowden’s 2013 disclosures of National Security Agency data, some practitioners have raised increased concerns about the confidentiality of clinicians’ record storage, cloud communications, and telehealth therapy with respect to governmental surveillance (Lustgarten, 2015; Lustgarten and Colbow, 2017). In the context of the Squillacote case and current technology, it seems likely that under similar circumstances any online therapy could become a ripe target for government monitoring. According to Snowden, the same holds true for anyone who sits in a therapy office with cell phone in their pocket, even if the phone is “powered off” (Greenberg, 2014). A 2018 Supreme Court decision has limited warrantless access to law enforcement agencies (Carpenter v. United States), but that decision does not apply to national security agencies. Absent access to a SCIF (Sensitive Compartmented Information Facility), pronounced "skiff" in United States military and national security/national defense and intelligence parlance (i.e., an enclosed area within a building used to process sensitive classified information) clients and therapists should recognize that interested intelligence agencies can probably listen in on any telehealth-based services.

Social Media

Social media afford access to a wealth of personal information. Even clinicians who use social media solely for personal and not for professional purposes still face some confidentiality hazards. Many people do not carefully read terms and conditions when signing up for social media sites, and not all users have the sophistication to carefully log out or locate and deploy privacy settings for different platforms. Anyone with access to the clinician’s social media platform may pass along photos and content to someone else in the thread of viewers that may include a client. A considerable amount of personal data including addresses, birthdates, licensing information, provider identifiers, and other public record data are easily obtainable.

Similarly, clinicians can use search engines to acquire public record information about clients, or even view clients’ social media postings without prior explanation to or consent from the client. Before undertaking such a search, clinicians should ask themselves why they want to do this and how they will handle any information with the potential to complicate their professional work with the client.

Case 13:

A psychologist and devout Catholic has been treating a client for anxiety and depression over the past few months. Out of curiosity, they search the client’s on the web and discovers that the client is a defrocked Catholic priest who relocated to the psychologist’s area from a distant state where they had been accused of child molestation and embezzlement of church funds. The psychologist also learns that authorities in the client’s home state have an interest in finding their current whereabouts.

What does the psychologist do with adverse information about the client that they do not know the psychologist has? The psychologist will certainly have altered personal feelings about the client, as well as owing them a duty of confidentiality. The results of the psychologist’s search cannot help but alter their ability to view and treat the client in the same way going forward.

Clinicians who work with adolescents and young adults may encounter requests or expectations by clients to communicate via evolving social media platforms. Although new mhealth apps (i.e., mobile or cell phone health applications) are increasingly available and potentially useful in therapeutic monitoring (e.g., to check in daily for anxiety, depression, safe-sex practices, or substance use issues) security remains an issue. Clinicians should carefully consider all risks and benefits including confidentiality, client vulnerability, record keeping, and contractual agreements with service providers and carriers. Before initiating use of any new modes of communication, clients should provide, and clinicians should carefully document their process for obtaining, informed consent.

Incidental Informalities

When delivering services directly to clients at home, whether by personal home visits or telehealth systems, many opportunities for incidental events and observations may occur, even when clients are coached to find a private area of the home from which to communicate. In some cases, space constraints may pose privacy challenges. In other situations, a child may intrude or another family member may overhear content best kept private. In some cases, unanticipated screen exposures may provide a degree of embarrassing entertainment.

Case 14:

A client located the quietest corner of their apartment and donned headphones for their teletherapy session. In fact, they were so quiet and unobtrusive that their partner did not realize what was happening and crossed behind them nude to and from the bathroom in full view of the laptop computer camera and the client’s therapist. When the therapist mentioned this, the client excused themself for a moment, and got up to alert their partner. In so doing, it became instantly clear that the client had forgotten that they were also under-dressed from the waist down.

Extra care should be taken to assist clients in having the safest and most secure sessions possible, and this may require coaching them to consider a level of privacy that they may not have considered. Clinicians should also consider how to respond if they encounter incidental observations that might trigger a mandated reporting situation, as described earlier. A recent news story reported on the case of a teacher in Chicago who, along with some students in their live-streaming first-grade class, witnessed an 18-year-old engage in a sex act with a 7-year-old during a break from class (see: news.yahoo.com/log-off-log-off-teacher-202700392.html). As mandated reporters of suspected abuse, mental health clinicians could find themselves inadvertently witnessing reportable events. If such events take place out of the clinician’s home jurisdiction, the report must go to the proper agency at the victim’s location. Because reporting rules and definitions of protected classes of individuals differ across states (Koocher & Keith-Spiegel, 2016), clinicians need to become aware of the rules for the jurisdictions in which their clients sit.

Current Security Guidance

Clinicians should recognize that numerous threats to client privacy exist, and we ought to do our best to minimize these with our telehealth clients.

Professional guidelines coach clinicians to “take reasonable steps to ensure that security measures are in place to protect data and information related to their clients/patients from unintended access or disclosure” (APA, 2015, Guideline 5). The question of what constitutes “reasonable steps” depends on the eyes of the beholder, and many psychotherapists practicing today are not “digital natives” (i.e., people brought up during the age of digital technology and therefore thoroughly familiar with computers and Internet operations from an early age).

Router Security

A starting point for establishing basic router security includes configuring one’s WiFi router to operate in compliance with industry best practices. Practitioners are encouraged to select a very secure data encryption option when choosing and setting up their router. WiFi Protected Access 3 (WPA3) provides the strongest encryption currently available to the public and is highly recommended. WPA2 can also be used, and though it is more secure than original WPA, both are significantly more vulnerable to hacking than WPA3.

Practitioners should also protect their router’s Service Set Identifier (SSID), which often comes out of the box with a default name that matches the router’s manufacturer such as “Netgear” or “Linksys” by changing the default SSID to a unique identifier. Practitioners should also select routers that have been manufactured recently enough to include more modern data security protocols. For example, inclusion of the WPA3 protocol became mandatory in new routers beginning in July 2020 (WiFi Alliance,2020). Most routers from established manufacturers produced after this date will include adequate security protocols. In addition, it is wise to regularly update their router’s firmware (built-in operating software) to ensure protection against the latest security vulnerabilities.

Use of Secure Passwords

Common wisdom for the creation of effective passwords to minimize security risks to privacy involves creating a password of 8-12 characters using at least one upper case letter, one lower case letter, one numeral, and one symbol, such as “P@$$wORD” (Fulmer, et al., 2019). However, this guidance has been found quite vulnerable to hacking and such password can now be hacked in approximately three days (McMillan, 2017). The National Institute of Standards and Technology (NIST) has revised its guidance on the creation of passwords to now include longer phrases of unrelated words all in lower case such as “correct horse battery staple” (typed without any spaces as one word). Pass phrases are better when they are three or more unrelated words. "Canoeworkredfloated” is a better choice than "I-floated.to.work.in.a.red.canoe.” Avoid using personal information – such as your name or username, a child or pet's name, an important date, a favorite ice cream, etc. – in any part of your password or phrase.

NIST estimated that such passwords would take approximately 550 years to hack using currently available technology (McMillan, 2017). Additional guidance can be found in the NIST’s Special Publication 800-63-3 (NIST, 2017) which also recommends that passwords never include personally identifiable words or phrases, that a single password not be used for all devices and accounts, and that passwords only need to be changed when compromised. However, when changing passwords, significant changes should be made, rather than minor changes such as a single letter or number. Because secure passwords are complex, practitioners should consider using a password manager, which can be used to securely generate and store passwords (National Cyber Security Centre, 2018). Biometric authentication (i.e., FaceID or Windows Hello) can also supplement the use of traditional passwords and add a layer of security to personal devices.

NIST’s revised password guidance includes the following recommendations:

Multifactor Authentication (MFA)

Beyond the use of secure passwords, NIST (2017) recommends the use of MFA. This adds an additional layer of security to verify the identity of a user before granting access to an account, and avoids the problem of guessable or duplicative password use. MFA does not rely on user-generated passwords.

Use of MFA does significantly improve data security, but it does not make an account totally immune to compromise. Some MFA protocols are more secure than others. SMS-/voice-based MFA is considered less secure than app-based MFA (i.e., smartphone applications create push notifications or one-time passwords). The most secure form of MFA includes the use of physical tokens such as hardware keys that use the Fast Identity Online (FIDO) protocol, a standardized authentication scheme significantly more secure than traditional passwords (CISA, n.d.). Consider weighing the potential benefits of enhanced MFA protocols against the practicality of deploying them in your own workflow. Practitioners should also consider any unique factors that may make their clinical data more of a target (i.e., working with clients in high-profile or sensitive roles) and should adopt the most secure MFA protocol(s) that they expect to be reliably able to maintain for record transmission and storage.

Use of Other Security Measures

In addition to deploying secure passwords, store them securely! Do not write them on a note that is taped to your monitor! Do not share them with others. Deploy a good quality firewall program and keep it up to date. Do the same for antivirus and malware protection (APA, 2015). Keep your computer operating system up to date because system updates often include anti-virus security patches that target emerging system vulnerabilities. For similar reasons, regularly update your web browsers and any software used for telehealth purposes (Burnett, Searfim, and Sharara, 2023). Ideally, practitioners should proactively check for software updates rather than simply relying on automated alerts. Most operating systems do have mechanisms for alerting users to the presence of security updates, but many users ignore, overlook, or unintentionally disable these updates. When alerted of a security update’s availability, act promptly.

Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH) Act

Aside from any state and jurisdictional requirements regarding licensing, clinicians must comply with federal privacy and data transmission requirements. HIPAA and the HITECH Act’s privacy requirements extend to all client data. These rules govern what client health information may be disclosed and provide policies governing electronic client health information-secure transmission, transmission quality, audit trails, and breach notification policies. Clinicians must have business associate agreements with any third parties that may have access to clients’ data (e.g., accounting and billing services, practice management data, answering services, and cloud storage).

During the early stages of the COVID-19 pandemic, the Department of Health and Human Services (HHS) issued an emergency waiver of some HIPAA privacy requirements (see: hhs.gov/sites/default/files/hipaa-and-covid-19-limited-hipaa-waiver-bulletin-508.pdf), authorizing enforcement discretion in telehealth remoter communications (hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html). Clinicians who wanted to use audio or video communication technology to provide telehealth to clients during the COVID-19 nationwide public health emergency were authorized to use any non-public-facing remote communication product available to communicate with their clients. Covered health care providers were authorized to use popular private-facing applications allowing for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype, to provide telehealth services without risk of penalties for noncompliance with the HIPAA rules for the good-faith provision of mental health services via telehealth during the COVID-19 nationwide public health emergency. Clinicians were still expected to notify clients that these third-party applications potentially introduce privacy risks. Clinicians were also expected to enable all available encryption and privacy modes when using such applications. However, Facebook Live, Twitch, TikTok, and similar video communication applications of a public-facing nature were specifically not permitted for use in providing covered health care services.

A key consideration involves the potential for outside parties (e.g., individuals in the participant’s/client’s home or hackers) to gain access to telehealth sessions or stored information. Clinicians’ use of platforms not fully compatible with the HIPAA, although currently permissible as per emergency regulations, still require careful discussion as part of the consent process. When emergency state and federal declarations regarding COVID-19 are lifted, clinicians should expect a resumption of secure communication standards.

Record Keeping and Fees

Ethical attention to record keeping and fees remain essentially the same whether the service delivery occurs in one’s office or via telehealth (APA, 6.01, 6.04, 6.06; AAMFT, 6.4, 8.2 and 8.4; ACA, A.10 & H.5; NASW, 1.13, 3.04, & 3.05). The key nuances involve earning fees across jurisdictions and accuracy in billing. As noted earlier, practitioners must clarify for clients what fees will be charged and whether those fees are allowed under any third party coverage that the clinician is willing to accept. For example, does the third-party payor cover telehealth sessions? Is the time spent on replying to email or text messages charged by the clinician? Will a client’s coverage extend to a provider in a state other than the one in which the insurance is purchased? The clinician should be as specific as possible in discussing fees for virtual services and should work with the client to understand any third-party issues.

National HIPAA standards in the United States govern consent processes and control of records, but some states afford greater protections to clients’ privacy. Given the emergency waivers granted by HSS (as cited earlier), some exceptions in disclosure of information and means of transmission were relaxed for the period of the Federal emergency declaration for COVID-19.

State exemptions may vary, and clinicians are responsible for knowing their state’s policy. Record retention duration requirements were not affected by the COVID-19 declaration, but these also vary across state lines. Thus, clinicians should plan to retain records for the length of time required in the most conservative jurisdiction where their clients may sit during a telehealth-based session. For example, many states require keeping a full clinical record for five years following the last clinical session, or one year past the date when the client attains age 18, whichever is longer. Other states use seven years. Retention of financial records can also become important if the clinician or client become subject to a regulatory audit following the termination of services. We recommend retaining a complete clinical and billing record for at least seven years.

Documentation Associated with Telehealth

Telehealth services require adhering to the same documentation and record-keeping requirements as for in-person care (APA, 2015; Barnett, Serafim, & Sharara, 2023). This includes documenting all interactions with and about clients including online sessions, telephone communications, emails, and text messages. Emails and text messages may be copied and printed for inclusion in a physical record or preserved electronically and uploaded into an electronic record. Alternatively, one could put summary notes of the communications in the record, but exact copies provide the most accuracy.

Relevant professional ethics codes and the practitioner’s state licensing or health records laws should be the guide regardless of the technology medium or platform used. The APA Record Keeping Guidelines (APA, 2016) provide good, detailed guidance. Just as with paper records, practitioners should ensure that all are stored securely whether in physical records or as electronic health records (EHRs) to minimize risks of unauthorized access. Examples include HIPAA-compliant cloud storage, the use of encrypted external hard drives, or both.

Practitioners need to understand and adhere to applicable laws for the retention and disposal of records. Disposing of electronic records, including equipment such as photocopiers, scanners, and hard drives, may require special technology or destruction techniques to ensure preservation of confidentiality.

Advertising and Public Statements

Maintaining an up-to-date and effective professional social media presence has become critical as both an advertising strategy and as a way clients will find you. Do expect that prospective and actual clients will search for information about you on the Internet (Cox, Simmonds, & Moulton-Perkins, 2021; Wu & Sonne, 2021). This is especially likely when providing telehealth services. Carefully consider what you choose to disclose by way of personal information in social media. Develop a clear policy that you can share with clients to explain that you will not accept “friend requests,” and that you maintain good privacy controls.

Those who plan an expansive telehealth presence may want to set up a secure professional website, optimized for search engines. This gives you the opportunity to control and present your professional identity and skills to the public. By using search engine optimization (SEO), the site will often be among the top search results and thereby one of the first sources of data available about you to potential clients.

Obligations to remain accurate in one’s advertising and public statements remain essentially the same whether the service delivery occurs in one’s office or via telehealth. Accuracy is expected and misrepresentative, false, or deceptive statements must be eschewed (APA, 5.01; AAMFT, 3.11 & 9.1; ACA, C.3.b, C.4.a; NASW, 4.06). In addition, clinicians have an ethical obligation to honor advertised pricing, if any. This may pose problems to the extent that web-posted materials may remain discoverable for a very long time. Practitioners who wish to make pricing offers available online might want to consider including expiration dates with any such offers.

Another hazard of web-based advertising is the potential to trigger negative reviews or other public responses critical of one’s work or advertising. This risk applies to any practitioner to some extent. However, when working in an on-line environment, web-savvy clients who become angry or unhappy may have the interest and ability to use social media or online ratings as a way to express their feelings toward their online clinician.

Case 15:

As a skilled web site builder, a licensed mental health counselor planned to attract new clients by offering a free online assessment offer. The offer stated that the counselor will offer “a free 30-minute consultation to assess your needs and discuss a treatment plan.” One individual who took them up on their offer did not feel at all satisfied following the consultation session and posted angry public comments stating that the counselor “is an overblown clown and totally incompetent.”

Recognizing that they owed this individual a duty of confidentiality and that engaging in an argument over social media would not help attract clients, the counselor framed a different approach. They posted a simple response stating: “As a skilled, licensed professional, my ethics preclude discussing any client, or even acknowledging a person’s status as a current for former client.” In so doing, they demonstrated considerable professionalism, self-restraint, and ethical conduct that probably would assure some potential clients. They neither confirmed nor denied that the individual was their client, but simply made a professionalism-affirming statement without contesting any prior postings.

Special Issues Regarding Assessment

Both the APA and ACA address assessment ethics without specific reference to telehealth for test administration or data collection (APA, 9.01-03 & 9.10; ACA, E, 3 & E 7.c), although APA has proposed specifics in the new draft of their Ethical Principles of Psychologists and Code of Conduct that they began circulating for public comment in late 2023. The key issues involve addressing behavioral science integrity (i.e., assuring that the reliability and validity of the instruments is addressed in reporting) and maintaining test security. Some instruments such as inventories seeking objective answers (i.e., letters or numbers of answer choices) lend themselves easily to adaptation for remote administration. Test instruments that require manipulation of materials present practical problems that may be impossible to overcome via telehealth, although test publishers do have some products in development that may lend themselves to remote administration using touchscreen technology. Other individually administered tests may present special issues if the stimulus materials cannot be rendered in a manner equivalent to an in vivo setting (e.g., remote rendering of Rorschach inkblots) and behavioral observations cannot be assessed as one might do in person.

Where clear norms or published evidence do not support the comparability of in vivo versus telehealth-collected test data, the ethical obligation to explain and defend the rationales or bases for interpretation falls to the clinician (Chenneville & Schwartz-Mette, 2020). Reports using data obtained via telehealth should specify this method of collection, along with any applicable caveats or limitations. Record-keeping fundamentals that apply when conducting assessment via telehealth appear in Table 2. Some test publishers make certain instruments available for proctored remote administration and scoring. In such instances, the clinician has responsibility for understanding the procedures and interpretive algorithms used by the testing service. Regardless of the mode of administration used, the clinician has the ethical responsibility of providing informed consent and feedback unless the nature of the evaluation precludes feedback as described in the consent process.

Special Issues Regarding Psychotherapy

In an analysis of the ethical issues telehealth-based psychotherapy raises under the Universal Declaration of Ethical Principles for Psychologists (International Union of Psychological Science, 2006) Fitzgerald and her colleagues (2010) compiled a list of issues from the international code pertinent to what they termed Internet-based psychotherapy. The list appears as Table 3.

These fundamentals align at an overarching conceptual level with the APA, ACA, AAMFT, and NASW codes of ethics. Some of the particular issues that apply at a practical level involve points already covered in this course. Some special nuances come into play when serving international populations because many countries handle Internet access and monitoring differently and less privately than in the United States. Clinicians’ lack of knowledge regarding local resources and sensitivity to cultural and linguistic issues may raise bias, competence, and harm-avoidance issues.

What Should I Do?

Several commentators (e.g., Barnett, Serafim, & Sharara, 2023; Martin, Millan, & Campbell, 2020; https://parma.trustinsurance.com/Resource-Center/Telepsychology-Resources) have recommended strategic steps to consider with attention focused on both ethics and risk management when deciding whether and how to implement telehealth-based behavioral health services for specific clients. The best suggestions from all sources are synthesized in Table 4. In addition, by taking this course you have already tackled the most important step: becoming aware of the many issues to consider as you undertake providing telehealth services. The next set of steps involve assessing any legal and regulatory issues that you may need to address. You will want to assure that both you and any clients you agree to serve in this way have adequate equipment, resources, and ability to proceed. As with office-based services, you will need to collect necessary background and business information, while also discussing information necessary for a well-informed consent decision by your client. You will need to create and preserve all the relevant clinical and business records that apply to your services, and accurately indicate the mode of service delivery in any such records or third-party billing. Conduct a practice check with each client using the equipment and software to ensure their comfort and capability to engage in telehealth-based services. You will also need to stay abreast of evolving technology and regulatory changes that may occur, particularly in the post-COVID emergency era when regulatory authorities may seek to impose more limitations on telehealth-based practice. Finally, you will want to maintain a network of colleagues and other professionals to assist with consultation and support as needed.

Appendix

Table 1. Summary of Professional Ethical Codes Relevant to telehealth-Based Practice

American Psychological Association Code of Conduct (2017)

Topical Principle

Specific Rule(s)

Competence

2.01 Boundaries of Competence

2.02 Providing Services in Emergencies

2.03 Maintaining Competence

2.04 Bases for Scientific and Professional Judgments

Human Relations

3.04 Avoiding Harm

3.10 Informed Consent

3.11 Psychological Services Delivered to or Through Organizations

3.12 Interruption of Psychological Services

Privacy and Confidentiality

4.01 Maintaining Confidentiality

4.02 Discussing the Limits of Confidentiality

4.03 Recording

4.04 Minimizing Intrusions on Privacy

4.05 Disclosures

4.06 Consultations

Advertising and Other Public Statements

5.01 Avoidance of False or Deceptive Statements

Record Keeping and Fees

6.01 Documentation of Professional and Scientific Work

6.04 Fees and Financial Arrangements

6.06 Accuracy in Reports to Payers and Funding Sources

Assessment

9.01 Bases for Assessment

9.02 Use of Assessments

9.03 Informed Consent in Assessments

9.10 Explaining Assessment Results

Therapy

10.01 Informed Consent to Therapy

10.09 Interruption of Therapy

10.10 Termination of Therapy

International Union of Psychological Science’s Universal Declaration of Ethical Principles and Code of Conduct

Topical Principle

Specific Rule(s)

Respect for the dignity of persons and peoples

Consent

Privacy

Confidentiality

Fairness and justice

Competent Caring for the wellbeing of Persons and peoples

Taking care to do no harm

Developing and Maintaining Competence

Integrity

Avoiding incomplete disclosure

Maximizing impartiality and minimizing biases

Not exploiting for personal or professional gain

Professional and Scientific Responsibilities to Society

Responsibility to increase scientific and professional knowledge

Responsibility to protect such knowledge from abuse

Responsibility to train its members

Responsibility to develop ethical awareness

American Association for Marriage and Family Therapy (AAMFT) (2015)

Topical Principle

Specific Rule(s)

Responsibility to Clients

1.2 Informed Consent

1.9 Relationship Beneficial to Client

1.11 Non-Abandonment

1.12 Consent to Record

1.13 Relationship with Third Parties

Confidentiality

2.1 Disclosing Limits of Confidentiality

Professional Competence and Integrity

3.1 Maintenance of Competence

3.2 Knowledge of Regulatory Standards

3.6 Development of New Skills

3.8 Exploitation

3.10 Scope of Competence

3.11 Public Statements

Technology-Assisted Professional Services

6.1 Technology-Assisted Services

6.2 Consent to Treat or Supervise

6.3 Confidentiality and Professional Relationships

6.4 Technology and Documentation

6.5 Location of Services and Practice

6.6 Training and Use of Current Technology

Financial Arrangements

8.2 Disclosure of Financial Policies

8.4 Truthful Representation of Services

Advertising

9.1 Accurate Professional Representation

American Counseling Association (2014)

Topical Principle

Specific Rule(s)

Client Welfare

A.1 Client Welfare

A.2 Informed Consent

A.4 Avoiding Harm

A.10 Fees and Business Practices

A.11 Termination and Referral

A.12 Client Abandonment and Neglect

Privacy and Confidentiality

B.1.d Explanation of Limitations

B.3.e Transmitting Confidential Information

B.6c Permission to Record

B.7 Case Consultation

Knowledge and Compliance with Standards

C.2.a Boundaries of Competence

C.2.b New Specialty Areas of Practice

C.3.b Accurate Advertising

C.4.a Accurate Representation

C.6.b Reports to Third Parties

C.6.d Exploitation of Others

C.7.B Development and Innovation

Assessment

E.2a Limits of Competence

E.2.b Appropriate Use

E.3 Informed Consent in Assessment

E.7 Administration Conditions

E.7.c Technological Administration

Distance Counseling, Technology, and Social Media

H.1 Knowledge and Legal Considerations

H.1.b Laws and Statutes

H2 Informed Consent and Security

H.3 Client Verification

H.4 Distance Relationship

H.5 Records and Web Maintenance

National Association of Social Workers (NASW) (2021)
(Note: Bold areas are new (2021) additions to the NASW code pertaining to electronic/telehealth issues.)

Topical Principle

Specific Rule(s)

Ethical Responsibility to Clients

1.03 Informed Consent

(e) Social workers should discuss with clients the social workers’ policies concerning the use of technology in the provision of professional services.

1.04 Competence

1.05 Cultural Awareness and Social Diversity

(d) Social workers who provide electronic social work services should be aware of cultural and socioeconomic differences among clients and how they may use electronic technology. Social workers should assess cultural, environmental, economic, mental or physical ability, linguistic, and other issues that may affect the delivery or use of these services.

1.06 Conflicts of Interest

(e) Social workers should avoid communication with clients using technology (such as social networking sites, online chat, e-mail, text messages, telephone, and video) for personal or non-work-related purposes

1.07 Privacy and Confidentiality

(f) When social workers provide counseling services to families, couples, or groups, social workers should seek agreement among the parties involved concerning each individual's right to confidentiality and obligation to preserve the confidentiality of information shared by others. This agreement should include consideration of whether confidential information may be exchanged in person or electronically, among clients or with others outside of formal counseling sessions. Social workers should inform participants in family, couples, or group counseling that social workers cannot guarantee that all participants will honor such agreements.

(i) Social workers should not discuss confidential information, electronically or in person, in any setting unless privacy can be ensured. Social workers should not discuss confidential information in public or semipublic areas such as hallways, waiting rooms, elevators, and restaurants.

(m) Social workers should take reasonable steps to protect the confidentiality of electronic communications, including information provided to clients or third parties. Social workers should use applicable safeguards (such as encryption, firewalls, and passwords) when using electronic communications such as e-mail, online posts, online chat sessions, mobile communication, and text messages.

(n) Social workers should develop and disclose policies and procedures for notifying clients of any breach of confidential information in a timely manner.

(o) In the event of unauthorized access to client records or information, including any unauthorized access to the social worker’s electronic communication or storage systems, social workers should inform clients of such disclosures, consistent with applicable laws and professional standards.

(p) Social workers should develop and inform clients about their policies, consistent with prevailing social work ethical standards, on the use of electronic technology, including Internet-based search engines, to gather information about clients.

(q) Social workers should avoid searching or gathering client information electronically unless there are compelling professional reasons, and when appropriate, with the client’s informed consent.

(r) Social workers should avoid posting any identifying or confidential information about clients on professional websites or other forms of social media.

1.08 Access to records

(b) Social workers should develop and inform clients about their policies, consistent with prevailing social work ethical standards, on the use of technology to provide clients with access to their records.

1.09 Sexual Relationships

(a) Social workers should under no circumstances engage in sexual activities, inappropriate sexual communications through the use of technology or in person, or sexual contact with current clients, whether such contact is consensual or forced.

1.13 Payment for Services

1.15 Interruption of Services - Social workers should make reasonable efforts to ensure continuity of services in the event that services are interrupted by factors such as unavailability, disruptions in electronic communication, relocation, illness, mental or physical ability, or death.

1.17 Termination of Services

Ethical Responsibilities to Colleagues

2.05 Consultation

2.06 Sexual Relationships

(a) Social workers who function as supervisors or educators should not engage in sexual activities or contact (including verbal, written, electronic, or physical contact) with supervisees, students, trainees, or other colleagues over whom they exercise professional authority.

2.09 Incompetence of Colleagues

2.10 Unethical Conduct of Colleagues

(a) Social workers should take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues, including unethical conduct using technology.

Ethical Responsibilities in Practice Settings

3.01 Supervision and Consultation

(a) Social workers who provide supervision or consultation (whether in-person or remotely) should have the necessary knowledge and skill to supervise or consult appropriately and should do so only within their areas of knowledge and competence.

(c) Social workers should not engage in any dual or multiple relationships with supervisees in which there is a risk of exploitation of or potential harm to the supervisee, including dual relationships that may arise while using social networking sites or other electronic media.

3.02 Education and Training

(d) Social workers who function as educators or field instructors for students should not engage in any dual or multiple relationships with students in which there is a risk of exploitation or potential harm to the student, including dual relationships that may arise while using social networking sites or other electronic media. Social work educators and field instructors are responsible for setting clear, appropriate, and culturally sensitive boundaries.

3.04 Client Records – including electronic

3.05 Billing

Ethical Responsibilities as Professionals

4.01 Competence

4.04 Dishonesty, Fraud, and Deception

4.06 Misrepresentation
Research and Evaluation

5.02 Evaluation and Research

(f) When using electronic technology to facilitate evaluation or research, social workers should ensure that participants provide informed consent for the use of such technology. Social workers should assess whether participants are able to use the technology and, when appropriate, offer reasonable alternatives to participate in the evaluation or research.

Ethical Responsibilities to Broader Society

6.03 Public Emergencies

 

Table 2. Record Keeping When Using Remote Test Administration
  • Confirm the identity of the client, ideally by capturing an image of their government-issued photo ID.
  • Assure that the client has access to a sufficiently robust Internet connection and equipment to complete test assessment and test the system before beginning data collection.
  • Follow all normal informed consent procedures, including any special limitations applying to the telehealth context.
  • Assure appropriate proctoring, if necessary, to assure examinees will complete the inventory or other test items on their own.
  • Assure the testing environment is and remains conducive to obtaining optimal and valid responses (e.g., private, quiet, comfortable).
  • Assure test security is maintained and that any efforts to record test administration are properly authorized.
  • Record or note any unusual events that may occur during testing and cite these as appropriate in the interpretation of the test results.
  • Record or document taking all of these steps.

 

Table 3. Internet-Based Psychotherapy (IBP) and the Universal Declaration of Ethical Principles for Psychologists

Principle

Issues pertinent to IBP
I. Respect for the dignity of persons/peoples

Consent, Privacy, Confidentiality, Fairness, and Justice
II. Competent caring for persons/peoples Taking care to do no harm and Maintaining competence
III. Integrity Avoiding incomplete disclosures, maximizing impartiality/minimizing biases, non-exploitation

IV. Responsibilities to society

 Increase professional/scientific knowledge, protect against misuse, provide adequate training, and develop ethical awareness

 

Table 4. Preliminary Steps When Preparing to Deliver Psychotherapy via telehealth
  • Determine whether services you plan to deliver via telehealth can provide results at least as effectively as face-to-face service, drawing on evidence-based findings regarding client attributes and the planned techniques or approaches.
  • Make sure you have the technological competence to deliver effective services.
  • Review any available literature supporting the use of telehealth-delivered services with each client’s specific diagnosis.
  • Identify all new clients well. Ask to see and take a screenshot of a government-issued photo ID and determine both their home community and any other locations where they may be located when you provide services.
  • Assess each prospective client to determine whether telehealth treatment is optimal for their unique treatment or assessment needs and document this determination and your rationale in the client’s case file.
  • Review current laws (state and federal) as well as regulations (i.e., licensing board) to assure full compliance for the services you plan to offer.
  • Remain mindful that, when you enter another state from the state where you are licensed and sitting via telehealth, you have an obligation to uphold the laws of the receiving state where the client sits. This may include mandatory reporting or other obligations that do not apply in your home state.
  • Prepare in advance for crises and emergencies from the start of the professional relationship. This include researching emergency resources in the client’s home community.
  • Contact your professional liability insurance company to be sure that your coverage extends to the services you plan to offer.
  • Assess whether your technology equipment, platform, and Internet access will prove appropriate for each client you agree to serve.
  • Assess what each client will need in terms of equipment, Internet access, and skills to make use of your services.
  • During the consent process, discuss your plans and policies regarding telehealth use with each client and confirm their agreement at the outset of the telehealth relationship, even if you have already done so in person.
  • Discuss and resolve any issues of confidentiality and security that might arise with the use of telehealth, including the privacy of your own workspace and the clients’ access to a quiet private area during the sessions. If needed, take a few minutes at the start of a professional relationship to update clients on how to protect their privacy.
  • Take care to minimize any threats to clients’ privacy by using secure passwords and multilevel authentication, encryption, secure WiFi, an up-to-date firewall, virus, and malware protection. Also assure that all services you use for interaction with clients align consistently with HIPAA’s privacy and security rule. In some cases this may require special platform adjustments and documentation (e.g., upgrading a Zoom account to Zoom for Healthcare and obtaining business associate documentation from the platform vendor.
  • Exercise great caution about engaging with clients on social media platforms with close attention to boundary issues and avoiding excessive self disclosure.
  • Assure agreement on whether either party plans to record the session and if so, how and what security and retention/disposition arrangements will apply.
  • Document doing all of this in your records.
  • Conduct a practice check with each client using the equipment and software to ensure their comfort and capability to engage in telehealth-based services.
  • Conduct routine monitoring or symptom check-ins with each client to ensure that telehealth-based services continue to meet their intended therapeutic purpose.
  • Keep up to date professionally on the latest developments related to telehealth-based practice.
  • Maintain a network of mental health colleagues and other professionals (e.g., attorney and technology services/equipment specialists) for on-going consultation and support as needed.

Recommended Web-based Resources

American Psychiatric Association (APA) and American Telemedicine Association (ATA). (2018). Best Practices in Videoconferencing-Based Telemental Health. APA-ATA-Best-Practices-in-Videoconferencing-Based-Telemental-Health%20(2).pdf

American Psychological Association (APA). Telepsychology Guidelines: apa.org/pubs/journals/features/amp-a0035001.pdf

American Psychological Association (APA). (2020, March). Informed consent checklist for telepsychological services. apa.org/practice/programs/dmhi/research-information/informed-consent-checklist

Assortment of Guidelines references and links assembled by Dr. Kenneth Pope: kspope.com/telepsychology.php

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