Telepsychology: same ethics, new room

Transcript

RyanIt's two minutes to five on a Thursday. A psychologist opens her video session, and her client's face pops up. Behind him there's a steering wheel, and through the window, trucks rolling past.

SoheeHe's at a highway rest stop. He's on a road trip a few states away, and he didn't want to miss his session.

RyanAnd you can feel the questions stacking up. Is this private? Is it safe? Is she even allowed to treat him right now, where he's sitting?

SoheeWelcome to EPPP Prep, the podcast. I'm Sohee.

RyanAnd I'm Ryan. Today it's telepsychology. The exam tends to treat it less as new ethics and more as the same ethics, applied in a new room.

SoheeLet's define it. The American Psychological Association's 2013 telepsychology guidelines define telepsychology as the provision of psychological services using telecommunication technologies.

RyanAnd that covers a lot: telephones, mobile devices, videoconferencing, email, chat, text messages, and the internet.

SoheeThere's a useful distinction here. Email, text and discussion boards are asynchronous, meaning there's a time lapse between sending and receiving. Videoconferencing, instant messaging and online chat are synchronous. They happen in real time.

RyanAnd the evidence base is encouraging. One review that the telepsychology model cites found videoconferencing psychotherapy feasible, with good user satisfaction and clinical outcomes similar to in-person therapy.

SoheeFirst big idea. The Ethics Code itself already reaches these services. Its Introduction says it applies across contexts: in person, postal, telephone, Internet, and other electronic transmissions.

RyanAnd it's written into specific standards. Standard 3.10, on informed consent, applies whether psychologists provide services in person, or via electronic transmission or other forms of communication, and it calls for language the person can reasonably understand.

SoheeThen Standard 4.02, part c. Psychologists who offer services, products or information via electronic transmission inform clients of the risks to privacy and the limits of confidentiality. Episode one covered the rest of confidentiality, so we'll keep moving.

RyanSo when an answer choice says telepsychology falls outside the Ethics Code, or needs its own separate code, cross it out. It's the same Code.

SoheeNow the guidelines. Who wrote them, and how binding are they?

RyanThey came from a joint task force with members from the APA, the APA Insurance Trust, and the Association of State and Provincial Psychology Boards. APA adopted them in 2013, and they're divided into eight parts.

SoheeAnd here's the exam-relevant part. They're aspirational, not prescriptive. One review of telepsychology guidelines called that a weakness, but also noted it allows flexibility as practice evolves.

RyanSo keep the hierarchy straight. The Ethics Code's Standards are the enforceable rules. The telepsychology guidelines are recommendations that help you practice well.

SoheeLet's start where trouble usually starts: competence. Standard 2.01 says psychologists planning services involving techniques or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.

RyanThe reviews add two layers. First, you must be competent in the treatment itself, regardless of the mode of communication. Second, you need to know the technology: hardware, software like firewalls and encryption, and the internet, including bandwidth.

SoheeAnd the APA guidelines go a step further. They recommend training in clinical skills specific to telehealth, like getting familiar with the telehealth literature and seeking help from an experienced colleague.

RyanNext question: is telepsychology right for this client at all? The consolidated model calls this client appropriateness.

SoheeAnd it explains why crisis risk can be higher at a distance. A less controlled setting, like being at home with access to means for self-harm. No visual cues on the telephone. Trouble confirming identity by text or email. And often, no way to confirm the person's location.

RyanThen consent. The special addition for telepractice is telling clients the possible risks, benefits and alternatives to telepsychology services, in language a lay audience can easily understand.

SoheeAnd it's the moment to set expectations. Attendance policies, communication policies, and other boundaries, including clearly documenting when and how the psychologist is available, especially during emergencies.

RyanNow, back to our rest stop. Identity and location.

SoheeThe model says psychologists should be able to verify the client's identity, and also make it possible for clients to verify the psychologist's identity and credentials. Pre-established security questions are one suggestion.

RyanAnd location, every single time. The rehabilitation psychology review says providers should routinely confirm the patient's location at each visit, so emergency services can be reached quickly in a crisis.

SoheeWhich leads straight to licensure. The model is direct. Services are only provided within legal geographic borders where you're fully licensed, so the client's location must be verified, even if they're out of state or out of the country.

RyanAnd a comparison of the guidelines puts it this way. When provider and client are in different jurisdictions, it's the provider's responsibility to research and comply with the regulations and laws in both jurisdictions.

SoheeThis is where a newer policy solution comes in. PSYPACT, the Psychology Interjurisdictional Compact.

RyanIt was formed in February 2015 by the Association of State and Provincial Psychology Boards, to facilitate interstate telepsychology and temporary in-person psychology services. It works through legislation that states enact.

SoheeSo if a question asks about the policy response to practicing telepsychology across state lines, think of the compact. But because it runs through state legislation, the psychologist still checks the rules where she is and where the client is.

RyanPause and think. Back to the client in his car. He's in a state where his psychologist isn't licensed, he's beside a busy highway, and he seems fine. What does good practice look like?

SoheeShe already knows where he is, because she confirms location every session. She weighs the room: is it quiet, private, out of earshot, at an identifiable location in case of an emergency? And because the model says services are provided only within borders where she's fully licensed, she checks what the law allows where he's sitting, complying with both jurisdictions, rather than carrying on as if he were at home.

RyanLet's talk privacy and security. The model says to set policies on encryption, transmission, storage and disposal, and to follow federal rules like HIPAA, the Health Insurance Portability and Accountability Act, and the HITECH Act, the Health Information Technology for Economic and Clinical Health Act.

SoheeAnd when necessary, to consult and contract with technology experts. Then tell clients how their information is protected. For email therapy, that might mean coaching the client on a strong password, encryption, and reading messages somewhere private.

RyanThe APA guidelines also name risks that are easy to forget. Search engines. Social networking sites. Breaches of security methods. Other people gaining access to phone or email. And therapist-client boundary issues.

SoheeThen outages. Video freezes. The model says to plan for it and share the plan at the start: who contacts whom if the call drops, and maybe a telephone session as the backup.

RyanThe aim, in the model's words, is that clients are not made to feel abandoned or unsure of their treatment.

SoheeEmergencies are the big one. Before services start, the psychologist learns the local resources at the client's end: inpatient and outpatient facilities, crisis and emergency lines, and local protocols for mental health emergencies. And there's an emergency contact on file.

RyanThe rehabilitation review adds that high-acuity patients should have a patient-specific emergency plan.

SoheeAssessment is its own trap. Many traditional tests were designed for in-person administration. Some may not be appropriate online, and it can be hard to confirm who's responding, control the testing environment, and keep standardized procedures.

RyanSo a tempting wrong answer is: give the usual battery over video and interpret it normally. The Code's Standard 9.02 asks that tests be used in ways that are appropriate in light of the research and evidence on their proper application.

SoheeSupervision can happen at a distance too. The model calls it telesupervision, and says that if you do it, a contingency plan for outages is a must.

RyanSo how does the exam frame all this? Trap one: telepsychology has its own ethics. No. The same Code applies.

SoheeTrap two: the telepsychology guidelines are enforceable rules. No. They're aspirational. The Code's Standards are what's enforced.

RyanTrap three: only the psychologist's location matters. The guidelines put the burden on the psychologist to verify where the client is and to comply with the law in both jurisdictions.

SoheeTrap four: consent for video work needs nothing extra. Clients should hear the risks to privacy and limits of confidentiality of electronic services, plus the risks, benefits and alternatives of telepsychology.

RyanLet's recap. Telepsychology is psychological services delivered through telecommunication technologies, either synchronous or asynchronous.

SoheeThe Ethics Code applies across all of it, including consent obtained by electronic means and telling clients about the privacy risks of electronic services.

RyanThe 2013 APA guidelines came from a joint task force with the boards' association and the APA Insurance Trust, and they're aspirational. They stress competence in both treatment and technology, client appropriateness, consent, identity and location, privacy and security, outages, emergency plans, and careful online assessment.

SoheeVerify where the client is, every time, and know the law of both places. PSYPACT, formed in 2015, is the interstate compact built for this.

RyanIf technology makes you a little nervous, you're in good company. But notice how much of today was ethics you already know. Competence, consent, privacy, safety. Same principles, new room.

SoheeYou're doing the steady work that adds up. Keep going, one episode at a time. Thanks for listening to EPPP Prep.

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