Law and Ethics: Telehealth (6 hours)

Course Description

This very readable and thought-provoking course is the result of extensive research into expert opinion, government documentation, current studies, and current practices by practicing therapists on the cutting edge of telehealth. The rapid expansion and innovation telehealth in the mental health field reflects the pervasiveness of computer and telecommunications technology in our lives. This is creating important opportunities for improved services and access. At the same time, telehealth practices and technologies pose substantial legal and ethical challenges.

This course provides a solid understanding of current telehealth media. It also familiarizes the participant with media their clients may be using. The course covers all ethical and legal areas being affected by telehealth, including safely, privacy, working across state lines, government access to records, encryption, contraindications, benefits and motives for telehealth practices, and much more. The participant will have practical, defensible guidelines for ethical and legal telehealth practice. The participant will be linked to an extensive, categorized, annotated list of resources that is maintained by the author.

The course includes a sample form: Private Practice Policies for Tele-Mental Health in a generic fill-in-the-blank format plus suggestions for customizing it to your practice.

Learning Objectives

By the end of the course, participants will be able to:

Define telehealth, tele-mental health, and e-therapy.

Identify and describe the media used in telehealth.

Identify current legal issues in telehealth.

Seek consultation or other information services in order to be legally compliant when engaging in telehealth activities.

Interpret the ethical challenges in telehealth according to accepted ethical guidelines for telehealth activities, including new or novel circumstances that arise from factors such as technological innovation.

Identify the motives for using telehealth practices.

Identify the strengths and weaknesses of the technologies most used in telehealth practices.

Describe the contraindications for using telehealth practices.

Abide by ethical guidelines when engaging in telehealth activities, including:

- Maintain safety.

- Maintain privacy despite the challenges posed by electronic communication.

- Avoid using electronic media when sufficient privacy cannot be adequately ensured.

- Determine the level of privacy needed for the various telehealth activities

- Work with clients that can benefit from telehealth practices

- Identify contraindications to the use of specific telehealth practices

- Working within legal scope of practice, and scope of competency while adopting telehealth practices.

- Work with clients in geographical or government boundaries that are permitted and appropriate

- Gain informed consent for telehealth practices

- Have emergency policies that account for telehealth practices

- Maintain legal compliance with state and federal laws, including HIPAA.

- Make sure that websites and other online media and information published are legally compliant, such as maintaining a privacy policy as required.

- Acquire and manage all forms, agreements, and other clinical and administrative records appropriately.

- Maintain security of electronic data systems and the data itself.

- Monitor and manage the online reputation of the professional and the organization.

- Assist clients, within reason, in maintaining safety and well being online

- Operate within the requirements of existing malpractice coverage.

- Ensure that telehealth services are delivered with adequate cultural and linguistic competence for the populations designated to receive it.

Telehealth: Ethical and Legal Practice

BIO

Robert A. Yourell has experience with online education, psychotherapy, virtual communities, online presentations, and professional roles requiring corporate HIPAA compliance. He has provided clinical direct care and roles in the mental health field for over 30 years.

Disclaimer

The views, opinions, and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of the continuing education unit provider or the licensing board.

Copyright Notice

U.S. copyright. All rights reserved, Robert A. Yourell.

Foreword: Sources and Approach to this Course 

This program has been developed from diverse sources. Materials from national organizations specializing in telehealth have been consulted, as well as numerous articles from legal and clinical experts. This includes documentation from The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for  Substance Abuse Treatment (CSAT) that resulted from extensive consultation with experts in substance abuse, mental health, and telehealth. The document was intended for "building substance abuse  treatment capacity using E-therapy for hard-to-reach and traditionally underserved populations." The document is titled Considerations for the Provision of E-Therapy. (Taylor, Symonette, & Singleton, 2009)

As the author of this course, I have experience with online education, psychotherapy, virtual communities, online presentations, and professional roles requiring corporate HIPAA compliance. I have made every effort to produce a balanced course that recognizes that this is a relatively new area in which legislation, case law, and clinical efforts are under development and subject to change. - Robert A. Yourell

Introduction

The reader is by now well aware that diverse and widespread electronic communication is pervasive, affecting many areas of our lives. Media such as instant messaging (IM), email, and telecommunications ranging from hard line phones to the audio-video capacities of Skype have replaced face-to-face meetings and dramatically increased the type and volume of data that we can manage. We engage in personal and business communication for working from home, doing banking, shopping, and many other activities. And those are merely some of the more commonplace expressions of the new electronic world of communication.

Taken for granted: Electronic communication is so well embedded into our lives, that we may not always realize that it can be characterized as electronic communication, and that as such, it is pioneering in the sense that the rules for ethical and legal electronic activities are new and rapidly evolving. Media reports of controversies over privacy, government intrusion, and even the role of virtual communities and communication in crime, terrorism, and democratic revolution remind us of the unsettled nature of this domain.

This unsettled nature requires mental health professionals to develop policies and be aware of changes to the landscape in order to provide quality care and avoid unnecessary criminal or civil liability. Our increasing comfort or even nonchalance with electronic communication, including telehealth activities (to be defined later) can make us vulnerable to legal and ethical problems.

The need for caution: We may be tempted to compare the current state of electronic communication to the use of the telephone, saying that such media only amount to an added convenience. However, the issues covered in this course will show that there must be a systematic consideration of the issues. That mental health services are behind medicine in systematically implementing these new media makes this all the more of a concern.

There has already been a dramatic surge in the use of electronic communications by mental health professionals and organizations. There is ample reason to believe mental health services and administration will make increasing use of electronic communication methods in the coming years.

Incentives for adoption: There are many incentives for adoption of electronic communications in mental health. They range from business needs and public perceptions or expectations, to the need to reach populations that have been under-served and that can benefit from these new media.

There is also the matter of integration of electronic communications with additional electronic features that enhance services and management. These include the orchestration of media to enhance therapy, somewhat like what was referred to as "bibliotherapy" even before the advent of the personal computer. This refers to the therapist recommending helpful books to the client. More advanced versions of this are computer-assisted therapy modes. These include using virtual worlds for desensitization in PTSD and for behavior rehearsal in Aspberger's syndrome.

During this course, we will cover myriad modern manifestations of telehealth and e-therapy technology and the media that have come to be so pervasive.

Convergence: In time, it is likely that there will be a strong convergence of things that are now more or less separate. Not that we have not seen a great deal of melding of features--features that have become so familiar in these combinations that we may not think of them as convergence. We anticipate that the following technologies (which will be described throughout the course) will merge into mental health practices: Mobile devices, automation, media, interactivity, digital communication methods, and human delivery of mental health interventions.

What's now: This convergence will require much development of law, ethical guidelines, technological standards, research, and practical experience before there is anything resembling confident standards of care for a familiar set of practices and tools in the tele-mental health arena. Pending that, this course relies upon applying existing, accepted ethical guidelines and law to current and emerging scenarios of tele-mental health practice.

Is Telehealth Effective? Who is it For?

Yes: In a word, yes. But for whom, under what circumstances, with what policies and technologies, for what diagnoses, and with what kind of providers and systems? A great deal of research attention is being brought to bear on these questions. Although the jury is still out, it appears that telehealth will be found to benefit many populations in numerous ways. Some of these benefits were mentioned in the introduction where incentives for telehealth were discussed.

Confidence: Enough research and surveys have been conducted to give us confidence that telehealth, including e-therapy can provide high client satisfaction as well as good clinical outcomes. (Taylor, Symonette, & Singleton, 2009) It will be years before there is a well-fleshed-out list of conditions that are proven to respond well to therapy through electronic communications. The landscape will be further complicated by the amount of change in what constitutes therapy. This is because of the integration of interactive and automated media. There is already a dizzying array of iPad and computer applications for clients and therapists that range from basic self-help functions to complex treatment, diagnostic, and record-keeping aids.

Specific diagnoses and issues: The state of research on tele-mental health and the more typical e-therapy applications of video conferencing is promising, but mostly tells us that more research is needed. Reporting on a metastudy on tele-mental health (including telephone, video conferencing, and other Internet interventions), Hailey, Roine, and Ohinmaa (2008) state that they "identified 72 publications on telemental health (TMH) that reported clinical or administrative outcomes. Of these, 65 papers described clinical studies and 32 (49 percent) were judged to be of high or good quality." Research on video conferencing interventions suffered from less quality.

The authors reported promising results for specific problems: "There was evidence of success with TMH in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorder, substance abuse, eating disorders and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive-compulsive disorder were less convincing. The majority of the papers (82 percent) were judged to warrant further study indicating a continued need for good-quality studies on the use of TMH in routine care."

Similar results: Newer studies are continuing the trend of reporting similarities between outcomes between face-to-face and video conferencing interventions. This has even been shown in group therapy. Greene, Morland, Macdonald, Frueh, Grubbs, & Rosen (2010) report on a study of 112 veterans with PTSD and severe anger problems that were treated in video conference groups and face-to-face groups. "No significant differences" were found in outcomes or even process variables such as " therapeutic alliance, satisfaction, treatment credibility, attendance, homework completion and attrition." There was somewhat less experience of alliance with the group leader in the video conference groups. Those who had the strongest alliance achieved better anger control. This did not affect the aggregate outcomes, however.

Clinical common sense: For now, the best advice from an ethical perspective is to follow the soundest time-tested principles, but to adapt them to these new scenarios. We will attempt to model this by taking some fundamental ethical areas that are especially affected by telehealth issues, and use them to provide guidelines for ethical responding.

The greater the need for telehealth modalities, the greater the incentive to push the envelope by making it available to under-served populations. This means we must take care not to make guinea pigs out of people in a discriminatory manner. However, barring contraindications, we should use the technology to expand our reach while monitoring for any new lessons as to the limits and strengths of these efforts.

Contraindications and cautions: It is unlikely that we will regret using clinical common sense in determining what constitutes contraindications and any means of mitigating the risks or drawbacks of telehealth media. For example, persons with significant levels of emotional instability, cognitive impairment, danger risk, sociopathy, delusions, and hallucinations are much less likely to benefit from e-therapy without additional measures. That is, most will not do well without some form of real-world assistance and supervision. This includes diagnoses such as complex PTSD, borderline personality disorder, serious head trauma, developmental disability. It includes populations such as prison inmates, children, and persons that have not had much exposure to computers or Internet use.

Patterns of use: The ways people use the Internet tell us a lot about the future of telehealth and e-therapy. Fox (2011) reports on a 2010 survey of Americans by the Pew Memorial Trust. The author found that 80% of people that use the Internet have used it for researching health information. This equates to 59% of the public when we account for those that are not Internet users.

A large share use sites involving interactivity of some kind, ranging from social network sites such as Facebook, to mutual-support sites to which they can post material such as questions and answers. 62% of adult Internet users have used social networking sites. 27% have used health-oriented sites that involve tracking indicators or factors such as weight or exercise, according to the report. People are more likely to engage in this activity if they are caring for someone suffering from a chronic illness or disability, or if they have such a condition. Social network users are more likely to engage in these activities, as are cell phone users.

More nuanced patterns of use are emerging. Roughly 20% of Internet users use peer support regarding personal health matters. They are more likely to turn to non-professionals for ideas on coping with a health issue or getting quick relief, while they tend to look to professionals for more technical answers. Despite concerns about misinformation and scams on the Internet, people report a good level of satisfaction in their use for health concerns.

These statistics tell us that, whether we are ready or not, there is a vibrant and growing array of online activities and offerings that pertain to our well being, and there is every reason to believe that the public will be expecting mental health information and services to be available online in an integrated fashion. This is not just a business insight. It has important clinical implications.

While we're at it, consider how the expectations of professionals and the public are being shaped along with the innovations and events in this arena. The following are all in a dynamic interplay, influencing each other along the way: the public, competing providers, clinical insights, case law, legislation, new technologies, and ethical guidelines.

Defining Telehealth and E-Therapy 

Introduction

Perhaps the earliest exercise of mental telehealth services beyond the telephone took place at the Nebraska Psychiatric Institute in 1959. There, a closed-circuit television enabled psychiatric consultation. (Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2005) Since then, the myriad modern manifestations of mental-telehealth and general integration of computer and network technologies into health care and society in general have resulted in many new terms and concepts.

They roughly fall into 1) current technologies and media, 2) terms specific to telehealth and technology in health systems, and 3) terms pertaining to telecommunications and electronic technology in psychotherapy and mental health services and systems in general.

Terms used for e-therapy include e-counseling, cybercounseling, cybertherapy, teletherapy, telepsychotherapy, and psychotechnology. These terms have been popular among clinical professionals and mainstream media. Phrases used include "electronic forms of behavioral health service delivery" and "The provision of behavioral health services delivered interactively from a distance, in discussion."

There are also varying definitions for these terms, and varying reimbursement policies from organizations such as insurance companies and Medicare. In this section, we will establish core definitions for the purposes of this course, and review perspectives from additional sources.

Telehealth

The reader may also see terms such as e-health or telemedicine used synonymously with telehealth. E-health is most likely to refer to health services are delivered via the Internet.

Our definition, similar definitions: For the purposes of this course, we will use the following definition of telehealth, which is devised from the perspective of the mental health services provider, and made short by focusing on these essential characteristics:

Telehealth provides health services and administration through electronic communications media.

This definition is similar to one used by the Institute of Medicine (IOM): "Telemedicine [telehealth] is the use of telecommunications and information technologies to share and to maintain patient health information and to provide clinical care and health education to patients and professionals when distance separates the participants." (Field, 1996)

We are using a broad, flexible definition because this field is a flurry of innovation. In contrast, the American Psychiatric Association, as of this writing, is still limiting the definition to video conferencing. Further, it limits it ambiguously to "a specifically defined form" whatever that means, and further limits its use to populations in "remote locations or otherwise underserved areas." (American Psychiatric Association, Undated)

Bauer (2009) points out that the Greek prefix "tele" means the end, far off, or distance. Now, it is almost synonymous with electronic or digital when it appears in words such as telephone, telecommunications, or telehealth. This is why the definition used in this course is so simple. Bauer adds that the core elements of any definition must include 1) the use of "information and communication technology" (ICT), 2) "Geographic distance between the participants", and 3) "Health or medical uses."

Regulators and payers: According to material on reimbursement by the American Psychological Association (2011), "When used broadly by regulators and others, the term telehealth services may refer to all interactions between health care professionals and their patients that do not happen in person. By contrast, payers often use much narrower definitions of telehealth services." This definition does not address the involvement of electronic communications in administration of health data. Most of this activity does not involve interaction with patients. (Bauer, 2009)

Telehealth systems: From a systems perspective, Bauer (2009) states, "According to one view, a telehealth or telemedicine system can be defined as follows: A telemedicine system is an integrated, typically regional, health care network offering comprehensive health service to a defined population through the use of telecommunications and computer technology." This definition emphasizes larger systems over the more utility-driven use of specific media by individual providers or small groups that are not integrated into a telehealth system.

In legislation. an example from California: A somewhat restrictive definition for telemedicine was developed for California law (and it includes masters-level therapists as health care providers), as follows:

"...the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Neither a telephone conversation nor an electronic mail message between a health care practitioner and patient constitutes "telemedicine" for purposes of this section.

"(2) For purposes of this section, 'interactive' means an audio, video, or data communication involving a real time (synchronous) or near real time (asynchronous) two-way transfer of medical data and information." (California Business and Professions Code, 1996)

Tele-Mental Health

You will also see it in print, without the hyphen, as telemental health. This refers to telehealth practices that serve mental health needs and systems.

E-Therapy:

For this course, we will define e-therapy like so:

E-therapy is the provision of psychotherapy and counseling through telecommunications media.

Above,  "therapy" refers to mental health therapy provided by appropriately trained and licensed therapists, as opposed to other therapies such as physical therapy.) It is a subset of the tele-mental health domain. Note that assessment, as an integral part of therapy, is part of e-therapy. Various consultation and coaching services use the same media, so there are terms such as e-coaching.

Taylor, Symonette, and Singleton (2009) introduce e-therapy as, "The provision of behavioral health services delivered interactively from a distance, in discussion." Their work provides the following definition, saying that e-therapy "serves as the conceptual framework for the information provided in this document."

E-therapy is the use of electronic media and information technologies to provide services for participants in different locations. It is used by skilled and knowledgeable professionals (e.g., counselors, and therapists) to address a variety of individual, familial, and social issues. E-therapy can (1) include a range of services, including screening,  assessment, primary treatment, and after care; (2) provide more accessible modes of treatment than the traditional ones to those who actively use the recent development of  technology (i.e., adolescents and young adults); (3) help people access treatment services  who traditionally would not seek services because of barriers related to geography, shame and guilt, stigma, or other issues; and 4) be provided as a sole treatment modality, or in  combination with other treatment modalities, like traditional or existing treatments.

Telepsychology.net defines a related and overlapping term, telepsychology: "The term telepsychology will be used inclusively on this page to include providing psychotherapy and psychological assessment and testing using various electronic means such as videoconferencing, teleconferencing and telephone therapy, psychotherapy and counseling over the internet through various software packages with or without a video camera or webcam, counseling via email or internet chat, using social networking sites like myspace and facebook, etc." (TelePsychology.net, 2011) This is a more exclusive definition intended for practicing psychologists, hence, it goes beyond definitions of e-therapy to include psychological testing.

Electronic Communications Services and their Security Issues

Where we discuss security, we are focusing on weaknesses in the technology, but will discuss problems with the users themselves (such as being tricked) later. The following are the more commonly utilized services:

Telephone

The telephone is the oldest medium for telehealth. The hard line (typical phone line that was nearly universal for decades) is very secure so long as someone doesn't tap directly into the line or use some kind of technology in your location.

Cordless phones: If the phone is cordless there is a low risk of snooping, because modern wireless phones have security features such as encryption and channel hopping (randomly using different frequencies for broadcast) that eludes most attempts to snoop. Also, the broadcast covers only a short distance, unlike cell phones.

Cell phones have a greater risk because of the stronger broadcast and the channeling of the conversation through multiple points, but only if there is a sophisticated, dedicated spy. They must overcome the digital encryption used by most systems.

Smart phones: With the melding of cell phones and computers in today's smart phones, there are security concerns in addition to cellular technology. These are the same as those of online computer use involving the remaining services in this section.

Email

There are two main ways to see your email. The first way involves using an email program (referred to as a "client") such as Outlook. The second way is to view it through your browser while it is shown to you by a service such as Hotmail, Gmail, or Yahoo. This is called webmail.

Insecure? Email is usually considered an insecure means of communication, because the information flows through a number of connection points (computers called servers) where the data leaves a copy of itself. Staff at these facilities might gain access to the data. However, there are means of securing email communications.

This method is the same as that used for credit card transactions or other purchases on reputable websites. When you are making a purchase, you should see the beginning of the website address change from HTTP to HTTPS. This means that the website is using a form of secure technology that encrypts the data travelling between the website and your computer. The technology is called SSL (secure socket layer). The encryption is considered worthy of commercial transactions. If you are in a location with a public wireless connection, such as a cybercafe, this encryption protects you from anyone that taps into your connection there. That's because the information stays encrypted until it gets into your computer. If they're looking over your shoulder, that's another matter.

Once the message reaches your computer, it is decrypted (decoded), so you can understand it. This means that it is now only as secure as your other methods of protection. If someone guesses your password, they can see your email as well as you can.

Discussion Forum

There are countless forums on every imaginable subject. The same concerns you read about for social media (below) exist for discussion forums. Some professional forums require verified membership. In these forums, all members agree to honor confidentiality. However, clinical information is still limited and obscured, and names of clients are definitely not to be divulged.

Because the membership is limited to professionals that are required to maintain confidentiality, a member might be tempted to divulge information that could reveal the identity of the client. This would be a mistake. There are too many ways that the information could be public. Besides, unless the client has given permission, you are violating confidentiality simply by that fact. If the client gave permission, it would not be in their best interest, and still should not be done. The information must not indicate who the client is.

As for the public, forums are extremely popular for exchanging support around problems, health issues, and interests. There is a support forum for nearly (if not every) diagnosis.

Other terms for discussion forums include listserve (an older term that actually only applies to certain forums), discussion list, and email list. The latter terms derive from that fact that discussion lists began as email services that sent a copy of each message to every participant. These still exist, and most discussion forums offer the option of receiving email that contains the new messages. This allows the participant to be current and respond quickly to important messages.

Discussion forums don't fit the image of direct clinical mental health care, but they can be part of an offering of service. For example, there are discussion forums that provide professional moderation and responses for people with a mental health issue. This could be considered an augmentation of services. But, because a large membership is usually needed for adequate participation, it is more likely that a clinician would refer a client to an existing forum known to be of good quality. **example of offering by an org?

Chat, Text Message, or Instant Message

This is a real-time exchange of text messages. Some chat services offer security. Some are part of a secure conference set up. It suffers from an extreme lack of sensory input regarding the emotional state of the client, and is limited by the typing speed of the participant and their patience for doing something that would be much more effective over the phone.

Chat is, nonetheless, a major means of communicating in virtual worlds (below). It may be used for an initial contact because of the convenience of pushing a "chat now" button that does not require the more personal or vulnerable nature of a telephone contact. Clients may feel that this is a convenient way to test the water.

If they are in an environment in which they do not wish to be heard speaking to someone, text affords them covert silence. There are some distinctions between the various text messaging modes, and they may involve additional features or restrictions. Twitter is a very unique kind of text message service.

VoIP Telephony (Video Conference Calls)

VoIP calls with audio and, optionally, video (e.g. Skype -often referred to as "video conference calls," even when there are only two people involved), can make you feel like you're using a telephone. VoIP stands for voice over Internet protocol. This means that the sound of your voice is digitized and sent over the Internet.

Not exactly a phone call: Even when only using audio, there are some characteristics that distinguish VoIP from a normal phone call, though these differences are diminishing as technologies converge. If the power goes out, or there is a problem with the modem, computer, or other features necessary for the call, then a VoIP call will have problems or go dead altogether.

Secure encryption: VoIP services are very secure if they use encryption (as Skype does). However, the calls are more vulnerable to failure or poor quality than traditional phone lines.

Government intrusion: As with other communications, a court order can penetrate your privacy or that of your clients, despite the encryption, because the data is stored by the company.

There are additional encryption solutions such as ZPhone or In-Confidence, but they require cooperation by both parties. This encryption would serve to prevent staff at a VoIP service from accessing your conversations. It would also prevent government intrusion. However, while the additional encryption is legal, a judge can order you to decrypt a file if there is sufficient reason to trump the fifth amendment.

This happened in a case in which there was testimony by a border guard that an individual had child pornography on their encrypted laptop files. (McCullagh, 2009) At the minimum, make sure that your VoIP provider uses encryption to help prevent unauthorized access. And remember that encryption can only do its job if other protections (such as not using public wifi) are in place.

As of this writing, the U.S. government is attempting to make it illegal for companies to allow communications that they cannot decrypt. (McCullagh, D. 2010, 2)

As of this writing, the U.S. government is attempting to make it illegal for companies to allow communications that they cannot decrypt. (McCullagh, D. 2010, 2)

Videoconference

Multiple individuals in remote areas can meet through audio and video (and use additional media such as slides or a white board) during a teleconference. This may be called a teleconference, web conference or video conference. There are various secure services that provide this functionality. They usually rely on the VoIP technology discussed above, plus additional features. People with little technical knowledge can have simple web conferences (with video and even multiple participants at separate locations) on Skype.

As with VoIP, make sure than the transmission is encrypted if personal health information is discussed.

Social Community or Social Media Sites

These include sites such as Facebook, Twitter and LinkedIn. This is a rapidly evolving and multifaceted phenomenon bristling with threats and opportunities. The greatest threat these sites pose to personal health information is that a misguided clinician or staff person would be clueless enough to post it. Since it shouldn't be there in the first place, hackers shouldn't have anything to hack.

Outside of client information, though, there is the matter of the professional's or organization's reputation. These can be compromised by dissatisfied clients, or by a clinician or staffer using poor judgement. Friends of a clinician may thoughtlessly post a compromising photo or other embarrassing data. Enemies could do worse.

Clinicians and organizations should have ongoing notifications of any mentions of their names, at the minimum. This can be done with Google Alerts and other free or fee services. **Add resources

Social Virtual World

Sites such as Second Life are a world unto themselves in which the user interacts with others using avatars, the modern-day equivalent of puppets. Unless the therapist has a full-blown business plan for doing business there, a fully developed ethical and legal basis, and a very solid understanding of the virtual world, they should only venture there under a pseudonym, and preserve the security of their password as with any other account. This is a very specialized issue that falls outside the scope of this course.

Intranet

This is a network for data sharing and processing that is privately managed and not necessarily able to access the Internet, except through a controlled channel. Data can be kept within an organization or set of organizations, without being accessible through the Internet or only in a very controlled and limited manner. Most corporations have intranets. This has not prevented breaches. HIPAA has been expanded with mandatory reporting and tracking of breaches. In the first year of this tracking, beginning in 2009, 4.9 million patients are known to have suffered data breaches. It is not known how many additional breaches went undetected or unreported. (Miller, 2011)

Additional Risk Factors: Human and Automated

Bumbling and Lack of Encryption

Human error, it seems, knows no bounds. One of the greatest causes of privacy breaches is the lost laptop. This periodically makes the news, and in the period of one year beginning in 2009, affected 1.5 million patients' private data. (Miller, 2011)

How many therapists and other mental health workers keep records on their personal laptops. How many have already lost laptops containing private client information (or had them stolen)? Encryption would prevent anyone from getting access to the information. In the absence of encryption, secure passwords would prevent all but dedicated individuals from access. But if you keep passwords on your computer, then any number of accounts could be compromised, including your banking.

Cracked encryption is very rare compared to all other sources of data breaches. When encrypted data is breached, it is almost always because of access to key codes. Otherwise, it can be because an outdated and weak encryption was used. Current encryption methods are so strong, even knowing exactly how they work does not allow the encryption to be broken. **cite

Boundary Crossings at Work

When staff look at private health information without authorization, this is a data breach.

In many cases, no other harm is done, and no one is the wiser. The data may not make it out into the wild, but it has been breached, nonetheless.

Mischief at Work

Here we are referring to an employee who, for some reason, pulls an inside job, in effect, by gaining access to private information and doing something inappropriate with it. Whether it is to sell it to a tabloid because it concerns a celebrity, or post it as revenge for a broken heart, it is a serious breach. As of this writing, the only examples of major data breaches of this kind have been those of corporate, military, and government records released by whistleblowers to outfits such as Wikileaks. However, mental health organizations must do their best to prevent them.

Finding and Guessing

One of the most common sources of breaches is through stolen passwords. The codes that you use to log into online accounts and (we hope) your computer are supposed to be carefully-guarded secrets. But if they are not well-hidden enough, they may be found. If they are not tricky enough, they may be guessed.

Social Engineering

This refers to the art of getting people to compromise their own security. Phishing scams, phreaking, and other terms hint at the diverse, dark world of people dedicated to violating your privacy or that of your organization. Scams can be as simple as posing to be someone authorized to ask you for information. These fraudsters can be very nice. They've been known to bring cookies, or even to have ID cards. They may send very convincing email from a bank or online service, indicating that your privacy as been breached. The message provides a link you can click on so you can log in and change your password. However, the link is to the scammer's computer, and your input is playing into their deception. Many credit card numbers have been acquired from unsuspecting people this way.

Sophisticated Snooping

There are many ways to get access to computer input or online data. A keylogger installed on a computer will record everything you do and send it to the snooper. An IT staffer at work might do this in the course of servicing the computers, because he or she also leads a life of crime. An employer may do it simply to find out if employees are wasting time or doing other inappropriate things.

Hacking

Hacking is more sophisticated means of compromising computers. Unfortunately, the hacker community becomes more sophisticated and powerful as legitimate programmers race against them to preserve security. Many hackers are funded by organized crime. Organized cybercrime is surging.

Bots

Hackers and snoopers create digital robots called bots to do their bidding. They do things such as search the Internet for computers that don't have firewall protection. They turn these computers into "zombies" that send out spam or perform other tricks.

The Medium is the Immorality

Crowell, Narvaez, and Gomberg (2009) argue that electronic communication poses an elevated risk of unethical behavior, because "the usual social or moral constraints operative under normal (non-technology-mediated) circumstances (e. g., face-to-face communication) may be reduced, thereby facilitating the occurrence of unethical activities..." They cite factors such as psychological distance, disinhibition, and devaluing of intellectual property rights.

They take the position that this makes it all the more important that education engender "ethical sensitivity." They feel that ethics must be integrated into education, and they cite works that go into detail as to how to carry this out. They suggest using means such as having students work through moral dilemmas and discuss the ethical aspects of various scenarios.

Motivations for Data Theft and Other Intrusions

Stalking and Manipulation

Stalkers have gone techno, using various means to track and bother their victims. Hacking accounts (gaining unauthorized access) is a popular means. The GPS data continuously provided by many smart phones and cars is another vulnerability. Many people do not know how to turn it off, or even that they should.

Identity Theft and Transactions

By stealing enough information to pass as someone else, the thief can withdraw money from the ATM, make credit card transactions, or pass bad checks--at least the checks are bad if the thief has drained the account. A thief can get money or costly items just with your name, credit card, and address information.

Medical Identity Theft

This is a variation in which the person passes as someone else in order to get medical care. If the billing is not noticed by the victim, they may be surprised one day to find that they have used up the limit on their insurance policy, or that they have new pre-existing conditions.

The Ponemon Institute estimates that 0.2% of the population may engage in this practice in a given year, with much of it apparently facilitated by the "victim." In many cases, family members unmet medical needs drive the person to allow them to take advantage of their insurance or other benefits. (Mills, 2010)

Being Special, Very Special

Some hackers go about their craft for the thrill of achievement, and the ego-inflating bumps in status they can achieve before the hacker community. Their drive is to be a legend.

Protest, Revenge, and Corporate Spying

These are other agendas that may drive a conspirator to seek forbidden data. Groups such as The Yes Men and Anonymous have made social statements out of breaches. Corporate spies take many forms, gathering illicit corporate intelligence for substantial, secret financial rewards from competing firms.

Curiosity

Often committed by staff, unauthorized access is often driven by nothing more than curiosity. However, that curiosity might also have a profit motive if the image or other data is purchased by a publication.

Categories of Electronic Communications

Introduction

Various means of categorization have been provided in order to fulfill various purposes. The author has prepared the following categories based on the needs of clinicians. They reflect the most current manifestations of electronic media used in tele mental health. These media are rapidly evolving and merging in various ways. 

Note that we will also cover media that are not necessarily a part of telehealth activity. However, familiarity with it will at least help you understand your clients' activities online.

By Media Utilized

The most basic distinction between media is between audio, video, and text.

Text: Instant messaging involves real-time exchanges of text messages.

Audio and video: Internet telephone services involve audio and (optionally) video. Skype is a very popular Internet telephone service. Such services (Internet telephony) are called VoIP (voice over Internet protocol) because the sound is digitized for transmission across the Internet, which is a digital medium. The distinction between VoIP and regular telephones is becoming blurred as the technologies mature. Long distance services may use VoIP as part or all of a transmission in order to offer lower rates.

Synchronous vs. Asynchronous

This is an important distinction, because it refers to whether the interaction is immediate or delayed. A telephone conversation is synchronous, while an email exchange is asynchronous (not synchronized in time; not immediate). Clearly asynchronous communications such as email have serious disadvantages posed by the lack of immediacy. However, asynchronous communication also has advantages. Consider online discussion forums. These are opportunities for a discussion of topics, usually organized by theme. For example, people can discuss the challenges of raising children with ADD. An advantage is that the posts (submissions of text by participants) accumulate over time. This means that the discussion can serve as a source of helpful material at any time. Also, people can join the discussion after reading what has already been said. Regular participants can participate according to their schedule, without having to be there for a live discussion scheduled at a specific time. These advantages have made the discussion forum a very popular venue for diverse topics.

Consider email. The therapist can provide additional support to clients without the restrictions of additional meeting times or connecting by telephone. 

These categories may be combined in a virtual environment or social media site. One may participate in a real-time text chat and then receive follow up messages in one's virtual mailbox later.

By Level of Security

This category could easily fall into the "bad categories" because the security of various media changes regularly. Security measures are constantly researched, tested, and improved. Thus, the landscape is continuously changing. The addition of SSL security to webmail is a good example. Although it is not a very stable category, the level of security is a vital characteristic of electronic communications. Businesses, governments, and psychotherapy clients all want their privacy. Legislation such as HIPAA imposes legal demands regarding privacy.

One aspect of security is government intrusion. A court can impose an order that data be unencrypted for legal purposes. This happens in a number of countries, including the USA.

By Level of Virtual Reality

Virtual reality is an artificial environment represented through digital media and with which the user can interact. This category asks how fully the user's experience is enveloped by a virtual reality? The author divides the levels into:

1. Minimal: The telephone is a physical object that provides sound. A Skype (computer telephone) interface may be used similarly. Although both media have additional elements that lend complexity, they are minimal compared to other deployments of electronic media where virtual reality is concerned.

2. Supported Engagement: Such services use additional support features such as those that can be added to a teleconference. These may include showing slides or other additional media, and additional data management features such as providing a recording of the service or connecting to social media features such as those of Facebook. These services begin to resemble a world because of the kind of engagement they create and the degree to which they begin to envelop the user's identity and senses. Facebook is not a virtual reality platform, but it can be like a world unto itself.

3. Virtual Reality: These media are exceptionally artificial in the sense that the "reality" is what is represented to the user through the computer. The visual environment is on screen, or seen through video goggles that block out the rest of the world.

Social virtual worlds such as Second Life enable users to interact by controlling avatars (people, animals, or objects that represent them in the virtual world). Multiplayer interactive games such as World of Warcraft involve social virtual worlds, but in a very structured game environment.

Non-social virtual worlds are limited to the user, and are used for more control over what takes place. These virtual reality media are used for exposure therapy to achieve desensitization and skill practice. The user may not have an avatar, simply seeing the world as though he or she is there. This first-person view is more like real life and can be a more intense experience than watching your own avatar.

In science fiction, we see virtual realities in which the user has a completely embodied illusion. The film The Matrix is an excellent example. In time, neuroscience may yield a fourth category that covers such experiences. The developments in virtual reality and neuroscience pose fascinating philosophical questions as to the nature of humanity and consciousness.

By Format or Equipment Required

The requirements for the application and activity should not exceed the equipment and connection available to the user. The main concerns are:

Connection speed (bandwidth): A highly graphic intensive experience such as a virtual world may function poorly if the connection speed is inadequate. For the sake of being specific: Bandwidth is the amount of data that can flow through during a given amount of time. For example 4 Mbps means four megabytes per second. Speed is a little different, because it has to do with how long it takes for a given amount of data to arrive at its destination. Speed is affected by a number of things, such as the number places the data stops along the way.

Processing speed: Some tasks require more computing power than others.

Screen space: Email can work pretty well on nearly any screen size, including small cell phones. However, a virtual world or highly interactive website may be impossible to use on a small screen.

Peripherals or additional equipment: The user must have and understand how to use any required accessories. Headphones with a microphone (a headset) will be needed for computer telephone calls or other live verbal interaction. Some applications require a high level of bandwidth.

By Scenario

This is a very practical category for the practitioner or delivery system, and can readily be discussed in terms of legal and ethical implications. We will cover some of the most common examples.

Distant location: Here, most or all the service from the provider is via telecommunications of some kind. This is because of the distance involved (or difficulty of access). Generally, this takes place because there are not enough, if any, qualified providers in the area.

Too many locations: A variant on this is that the population is spread across such a large area that too much staff time would be occupied by travel. This makes telehealth a cost-effective choice.

Client unable to travel: Physical or psychiatric disability (e.g., agoraphobia) prevents the client from going to a therapist. It is not feasible to have a therapist provide house calls.

Specific client needs or preferences: In this scenario, it is not contraindicated to use telehealth media, and the client is attracted to it. Example: The client is pressed for time and does not feel that face to face sessions are necessary because of their relatively good level of functioning.

Superstar: An area that is still contentious is that of a therapist that has marketed so well that he or she is prized and preferred by distant clients (whether or not the therapist is actually better than the locally available talent). This is a legally and ethically risky proposition, because of issues discussed in this course.

Online impulse buy: People may search online for a therapist or simply be surfing, and decide to connect with a therapist online because of immediacy and convenience. Such surfers may have little idea of what a therapist really does, and they may have no inclination to fill out forms or learn about matters covered in informed consent. They may want to relate to the therapist like they would an online psychic or real-world bartender.

It's just coaching: There may be legitimate and legal ways that a therapist can relate to potential clients such as the online impulse buy, but professionals should not fall into this kind of service lightly. They may be able to conceptualize the initial contact as a consultation that serves to provide information and to complete an initial assessment for continued treatment, referral, or additional meetings that function as coaching.

This brings up numerous issues, such as the obligations of a therapist who doubles as a coach. Again, these are not patterns of service that a provider should fall into without due consideration, consultation, and policy development. For an example of the liability issues, consider the therapist that is seeing a client as a coach, and is accused of malpractice in some form.

Because of the therapist's marketing, training, and methods used, he or she might be found to have been practicing psychotherapy, but to have failed to have discharged certain duties to the client, such as informed consent, adequate assessment and diagnosis, or management of boundaries (matters typically handled much less formally in coaching). This can happen when a coaching client turns out to have more serious issues than initially anticipated. Clients initially can appear to be much higher functioning than they really are.

Special or integrated systems: This is a developing area. An example would be the use of virtual reality for exposure therapy where the virtual environment is controlled by the therapist, who is present. In this scenario, special technology is only available at the treatment office. The electronic medium is used along with the physical presence of the therapist. This is just one example of what, for now, is a catch-all category.

Bad Categories

Therapeutic Effectiveness: Not only is it too soon to draw sweeping conclusions about the relative merits of given systems or electronic media, the variations in deployment are far too diverse. Conclusions about therapeutic effectiveness are emerging and guiding further development in a reciprocal fashion. This landscape will not stabilize in the foreseeable future.

Danger: Every electronic service or medium poses certain risks. Their deployments are too varied to yield an overall danger rating. Online classified ads such as Craigslist have famously resulted in scams, opportunities for pedophiles, and even murders. 

Cost: A telehealth system can be deployed with any combination and number of components, and any level of scale. The investment to develop and maintain a telehealth system can vary wildly.

Addictiveness: Addiction associated with electronic media is a very important clinical and social concern. But people vary so much in their vulnerabilities to addiction, so it is questionable to attempt to rate a medium as to its level of addictiveness. Besides, the media themselves are deployed with quite variably. For example, a virtual community with gambling will be more addictive to some, while a virtual community for anonymous sex between avatars will be more addictive to others. Meanwhile, most people will not get hooked. As of this writing, telehealth practices in themselves have not been determined to be addictive. And it is not the medium that is likely to be addictive, so much as what content and interactivity is provided through the medium. 

Text or Non-Text Based: This distinction misses the point that media online are quite diverse. It is better to distinguish between the various media as specified above. Text-based communication comes more and more in connection with other media now, anyway.

Social virtual worlds often involve text chat as the primary mode of communication, but they take place in a graphic virtual environment with avatars. Text is being supplanted by live audio. 

The Applications of Tele-Mental Health

Clinical Functions

These divisions can blur, because functions and media overlap. For example, data from a clinical discussion may be converted into data for record keeping quite easily.

Outreach

Most persons with psychiatric problems do not receive adequate mental health care. There are many reasons for this, and telehealth practices may help to lower some of these obstacles. Broadly, key aspects are 1) the public perception of desirability, appropriateness, and potential value of getting help, and 2) the availability and accessibility of help.

Specific examples of these include: The diversity of offerings (including those that do not require direct human contact), potentially lower costs, time savings, added features, and the increased availability and persuasiveness of information that encourages people to get help.

A free initial consultation by phone is an early telehealth offering. Now there are diverse channels that may bring a person into contact with a therapist or other help source, and there are diverse means of communication along the way. Instant chat and therapist-monitored discussion forums are two examples. 

Assessment, diagnosis, and progress monitoring

Assessment tools range from informal checklists designed by amateurs to sophisticated systems of analysis and interpretation. They can serve various purposes, including deriving a diagnosis, charting progress (through repeated administration), educating clients through feedback on the results, and engaging potential clients by creating an interesting means of getting feedback or doing self-assessment.

The later function can be an aspect of marketing, and is used by legitimate clinical programs as well as questionable or cult programs. The Internet has allowed a great proliferation of diverse assessments. Screening tools may be online or loaded onto the client's computer as a software program.

If a provider provides clients with assessment tools, or directs them to online tools, the provider must make sure that the tools are legitimate and useful, since there are many amateur assessments for various problems, personality types, and so forth. Some tools provide feedback designed for clients to understand without interpretation by the clinician.

These tools can extend the value of therapy without incurring excessive additional costs. Many are free. They range from self-scored questionnaires for sophisticated systems of analysis and feedback.

Managed care systems, employee assistance programs, and the military are investing in assessment and media that can improve behavioral (and physical) health while reducing the load on clinicians to some degree. This may smack of replacing clinicians or misleading clients into thinking they don't need help that they actually need. However, such systems can reinforce the importance of therapy and clinician contact as well. This is an important design consideration with ethical and legal implications.

There are many variations on this aspect that can be considered. For example, certain results during an informal and free online assessment can trigger the system to provide a connection to an appropriate in-network provider and encourage the user to take advantage of the opportunity for a live call or other appropriate form of contact.

Internet self-assessment has been shown to be as helpful as those done with paper and pencil

 (Vallejo, Jordán, Diáz, Comeche, & Ortega,  2007). The practitioner should be careful not to allow software to substitute for a live assessment. Although it is too soon to say with assurance where to draw the line, many assessments require the clinician's capacity to assess the client through all senses, especially taking in clues such as body language and verbal inflection. (Fenichel, 2000)

Provider-client communications/direct treatment

We haven't heard of psychotherapy by telegraph, but long before there were computers, much communication, including therapeutic communication, took place by phone. Initial phone evaluation, appointment setting, and crisis calls have long been common place.

These activities have extended from telephones to cell phones, Skype, and to some degree texting. Potential clients also fill out online forms at therapists' sites and sites that market therapists. From there, they may have some email correspondence prior to initiation direct contact.

Psychosocial education

When therapist provide information that can aid clients, this is referred to as psychosocial education. This activity has historically involved direct communication by the therapist, having clients attend presentations, or recommending media such as books.

Therapists have used media to augment or extend psychotherapy services since before the personal computer. Computer media and interactive programs increased the availability and diversity of such offerings. The web has increased the diversity and richness of the offerings further, with added social or human interactive aspects and widespread availability.

Therapists have at least some responsibility to understand the current offerings well enough to be conversant and to keep track of especially relevant and high quality offerings for the problems in which they specialize. This includes websites that are rich with legitimate information or that have well-managed discussion forums.

Self-help

Clients often get information (and sometimes misconceptions or alarmist material) by visiting various sites or discussion forums. Some of the comments on psychosocial education are applicable here. Therapists have a responsibility to follow their ethical guidelines and legal obligations when preparing materials for the web, just as they do in writing articles or books. However, a new dimension in ethical standards must evolve to embrace the high level of interactivity, rich media, and automation that can now be delivered.

Group support

Online group support can take the form of chat rooms, discussion forums, conference calls, and meetings in virtual worlds. Discussion forums are a very popular means of group support for many diverse problems. Virtual worlds and chat rooms can have real time group support meetings. A chat room allows real time exchange of text messages for everyone that visits a chat room. A chat room, on its surface, appears on the screen as a window in which new messages pop up, one after the other, as they are input by the various people visiting that Internet address (URL).

Social support

People are building social support locally and globally. Interactivity is improving as the feature set of social platforms such as Facebook improve. Users have reported that they feel more supported and better able to deal with psychiatric or emotional challenges.

However, there are concerns that people who spend too little time involved in real-world social functioning may experience impaired social functioning in a use-it-or-lose-it fashion. The online world may provide an escape that is self-reinforcing in people that do not practice managing their moods and confronting situations in the real world.

There may be a good deal of individual variation in these matters. The best advice at this point in our understanding may be to make clients aware of the pros and cons and resulting needs (such as the need to develop a local support network of friends), and help them monitor themselves for red flags such as increasing isolation or anxiety in social situations.

Behavior practice and exposure therapy: Virtual worlds are being used for this.

Therapists and personal coaches have assisted people in navigating environments in which they have had trouble. This is been done in the real world as well as via imagination. Now virtual worlds are providing another venue. Even without the assistance of a therapist, some users of Second Life report that they have gained therapeutic value by exploring social situations and self concept in this medium. They say that these experiences have improved their performance in the real world through reduced anxiety and improved social expression. One theory is that the illusion of having a sexy, well-built avatar that mingles with glamorous people disrupts existing self-representations, allowing change to take place more easily. This has significant implications for therapy, in that therapists can use virtual social worlds as a cross between bibliotherapy and in vivo behavior practice.

Non-social virtual worlds can be used for a more controlled experience, and are typically thought of as a means of desensitization. The military is investing in such applications for veterans with PTSD. Of course, they are also being used as training aids for everything from flying aircraft to carrying out maneuvers on foot in tight urban warfare.

The boundary between virtual and real is blurring as our own navigation is increasingly supported by technology. Game controllers are connected to real weapons and robotic devices. Missiles allow a virtual piggyback ride and heads up display through a camera signal and telemetry. The pervasive exposure to virtual environments is increasingly taken for granted by a large portion of the population. This is paving the way for continued innovation and integration of telehealth as well as generating new ethical quandaries.

Manual or automated reminders

Various forms of reminders can be automated or carried out personally by therapists or paraprofessionals. Automated messages have helped people remember to take medication, to avoid situations that provoke relapse, and to use cognitive strategies that reduce anxiety or improve self-esteem. These can appear on cell phones as verbal or text messages.

Problem-solving or crisis contacts

The telephone has long been the primary means of fielding crisis contacts (crisis calls). EAPs and major group practices designate "on-call" staff to field such calls. With the addition of video, counselors have the ability to use another sense for assessment. Moderated discussion forums can be monitored for posts that indicate a crisis. With instant chat and online interfaces, staff or automated programs can guide callers to the appropriate resource while reducing the load on clinical professionals.

Aftercare

Aftercare means treatment following inpatient care for substance abuse or another psychiatric problem. Often, a structured outpatient program is required as the level of care. This can mean group therapy three times per week, individual counseling once per week, involvement in a self-help group such as Alcoholics Anonymous, use of media such as books, homework such as journaling, and lifestyle modifications that help to prevent relapse.

There is an online aftercare program that provides multi-modal services. It is eGetGoing.com. We will review this program's features because online substance abuse treatment programs have shown merit (Copeland and Martin, 2004), this program is in use on a full scale, and because it demonstrates the integration of multiple telehealth media and features.

According to their promotional material, the features are as follows:

›        Modeled after existing, traditional outpatient programs

›        Has support of an affiliate treatment organization that provides live treatment (CRC Health Corporation)

›        Staffed by certified addiction counselors

›        JCAHO and other program certifications

›        Coverage by most major insurers

›        Measures to protect anonymity

›        Less costly treatment through use of online platform

›        Two weekly online recovery group counseling meetings (real-time, fully interactive)

›        Individual counseling as needed (live audio and video)

›        Videos provided during each group meeting that show a simulated (with actors) group therapy process. Each video illustrates and inspires discussion of recovery issues such as managing emotions in the service of recovery.

›        Coordination and communication with other providers or referring organizations such as EAPs or Probation staff in the same manner as occurs with live programs.

The program offers additional tools, including:

›        A white board (an area of the screen that the counselor can use to show text or diagrams generated real time or from files)

›        An internal email system that allows private contact among group members with the counselor.

›        A personalized page for each client where they can access materials and receive messages left for them by the counselor such as personalized feedback.

›        A personalized page for professionals involved with the case, where tracking can take place as authorized by the client.

›        A measure to aid confidentiality is that the participants in group do not see each other's faces. It is quite possible to have a portion of the screen used to show each participant's face, so this is not a default condition, necessarily. One could ask why this is necessary, when clients of live programs are able to see each other's faces as well as take in their body language. This fact brings into question whether this measure is actually a technological convenience for the program.

Case management and provider collaboration

Various telehealth approaches to these issues are used, with more creative approaches yet to be developed. Consider the fact that you can easily create conference calls on Skype. You have the ability to copy an email response to multiple recipients (especially if you share encryption) to expedite coordination of information among clients and other professionals.

Avatar Therapy

Research is beginning to demonstrate what has been claimed by people involved in virtual worlds such as Second Life: That self image and behavior can change for the better, simply by participating with an avatar. (Blascovich, & Bailenson, 2010)

As you'll recall, the avatar is the "being" that represents you in a virtual world. If you're having trouble imagining this, you can find countless videos showing this by going to YouTube.com and searching on "Second Life." ("Avatar" searches will yield many hits on the movie called Avatar, and this could be very confusing.)

It may be that social acceptance and a highly fit and attractive avatar trigger the behavioral genetics of hierarchy that we observe in animals. This phenomenon may also be part of a class of observations concerning the use of optical illusions that alter they way we remember and process things about our own existence. Optical illusions have cured chronic pain with a mirror illusion or with an expanding hand illusion. Perhaps avatar illusions (if we can call unconscious identification with an avatar an illusion) are already curing low self-esteem.

This area will need a lot of study before it is adequately understood. Whatever we learn may result in new ways of purposely designing avatars, their environments, and their activities to produce desired change. Add to this our ability to match avatar movements precisely to our own body movements (through automation; no mouse or joystick) and we see yet another way that these illusions are becoming more influential, not just entertaining.

If avatar therapy becomes fully realized, it will provide an especially radical example of the convergence of technologies and new clinical practices. 

Clinician supervision and training

Electronic communication can facilitate supervision and training. (Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly, 2005) The methods used are similar to those discussed previously. They can include unobtrusive session monitoring (or post-session review) and feedback when the client permits it. Supervision resources can be extended by reducing travel time. Therapists and interns in remote areas can have access to supervision and training that otherwise would not have been possible. Some therapists are getting continuing education credits online. (But you knew that.)

Administrative Functions

We must also attend to the administrative uses of telehealth, because of 1) organizational needs, 2) intra-organizational needs, 3) legal and funding requirements, 4) ethical requirements, and 5) the potentially high level of challenge and investment that these systems can require (where poor execution can result in legal liability and ethical breaches, such as compromised privacy).

Fait Accompli: Indeed, this is not a problem looming on the horizon--electronic communications in the administrative domain are a fait accompli. Those providers that are less technologically engaged are getting more and more incentives for electronic communications in service of administrative functions. Few, if any, group practices that take insurance are without the technology and policies needed in this domain.

Safety and Privacy: Legal and ethical requirements in the administrative arena are primarily those of client safety and privacy of records. HIPAA (Health Insurance Portability and Accountability Act) legislation was developed largely because of 1) the needs of health corporations for a legal framework that allows for electronic transmission of records, and 2) the needs of citizens to have their privacy protected.

HIPAA: Now that electronic communication is so pervasive, even solo practitioners must understand relevant HIPAA rules. This is because they are 1) billing managed care companies using electronic communications such as FAX machines (devices that have been around so long they seem out of place in this discussion) and online interfaces, 2) communicating with clients by Skype and email, among other things, 3) discussing clinical issues on discussion forums, and 4) providing case management services such as making referrals with the aid of email, email attachments (documents sent as "attachments" via email), FAX, and Skype. We encourage you to take a continuing education course on HIPAA.

Mobile apps and automation: The high level of mobility of healthcare workers presents opportunities for tremendous cost savings, as well as reduction of sources of medical errors. Mobile applications that are able to comply with privacy and other telemedicine standards are being adopted by major organizations. Mental health systems will probably find variations on this, although the demands are not as intense. Even small groups and solo providers are beginning to do mobile telehealth, perhaps without thinking through the issues.

Mobile telehealth activities include the following when used for professional health purposes: Cell phones, laptop use of Skype, exchange of text messages by cell phone or other mobile device, and the river of new applications being developed for mobile devices. These applications automate various mental health relevant activities. These are as simple as automated reminders to clients regarding appointments, medication, or new habits that need reinforcement. They are becoming much more complex and interactive.

Ethical, Legal, and Regulatory Issues 

Introduction

As with most innovations, ethics codes and laws have lagged behind the opportunities and changes stemming from tele-mental health. (Alemi et al., 1994) For many issues, it has not been difficult to recognize how the ethical guidelines should shape our practices. However, the technologies can sometimes lead to uncertainty or neglect of ethical issues. It's one thing to say that privacy must be protected, and another to say how much risk or exposure should be tolerated where there is a wide divergence in levels of security available. If a client is perfectly comfortable risking their privacy in an insecure medium such as email, should the therapist insist that this is not acceptable and enforce other means of communication or require encryption? How much is too much to expect a group practice to invest when putting security measures in place? How long and obscure should a password be when a provider protects their computer files? How much should a therapist know about the threats to safety posed by each of the online service types such as Facebook in order to discuss with a client their online behavior in terms of the client's safety or addiction risks?

No legislation or ethical guidelines can achieve that level of detail, (Ragusea & VandeCreek, 2003) especially given the constantly changing nature of telehealth and the larger technological and social environment. New threats and new applications of technology appear regularly. Ethical guidelines cannot provide precise standards for managing each ethical issue posed by telehealth practices. They offer guidelines to be applied using professional judgement, sometimes in novel circumstances.

Professionals, including mental health clinicians, have run into trouble through their personal or professional use of social media such as Facebook or discussion forums. Therapists must do their best to maintain a separate professional and personal identity online. However, the details of one's personal identity can profoundly affect one's professional identity. This means that the professional must consider the consequences of online disclosures.

Clients, meanwhile, expose themselves to legal or other problems by posting personal information that can compromise them. Attorneys and law enforcement professionals now make it a routine matter to explore social media and other sites for helpful (read damaging) information about parties to lawsuits and suspects. There is the case of a woman whose long-term disability insurance was unexpectedly terminated because the company found an excuse: the woman had some pictures of herself smiling in happy environments. As of this writing, a lawsuit has been filed on the woman's behalf. To what degree should therapists and psychiatrists be accountable for guiding clients to avoid such threats?

Specific Issues: Applying Existing Ethical Guidelines 

In this section, we will review ethical topics that can be found in accepted ethics guidelines such as those of the APA and NASW. We will select ones that are especially germane to telehealth. The primary source of inspiration for this section is the California Board of Psychology (2011)

Competence: Professionals should not assume that their existing skills fully translate into electronic media, even the audiovisual environment of Skype. Nor should they assume that they have a complete skill set in such environs. They must understand any special skills they may need that stem from technical requirements, strengths, and limitations or risks associated with the media used.

Contraindications: The professional must consider the technical and personal capacities of the client, as well as any threats that the media may pose. For example, an unstable and suicidal client may not be able to tolerate the therapist suddenly vanishing because of a power outage.

Emergency policies and availability: Telehealth media pose additional requirements in this area. Distant clients should be aware of local emergency resources and back up communication access. A toll-free hard line is an alternative to Skype for clients with telephones. The therapist should know how he or she will initiate a welfare check should the client become unavailable or make comments that arouse concern.

Documentation and policies: The professional should make their documentation reflect the measures they have taken in all areas affected by telehealth media. Their policies should be reflected in forms such as their disclosure statement and statement of policies, including their emergency procedures.

Informed consent: Documented informed consent must incorporate telehealth issues. This includes making sure that the client understands the issues pertaining to any online services that may be used. The client must understand what should and should not be done with these media. For example, personal information should not be shared through insecure media such as email. The California Business & Professions Code (1996) requires the use of a specific, written informed consent when therapy is provided using audio, video, or data communications. (This may change to verbal consent, as of this writing.)

Privacy: Informed consent documentation should include the implications of telehealth technologies for privacy, because electronic media pose their own threats. This should include policies regarding the specific media used. For example, email is a relatively insecure medium. If the therapist is associated with an online forum or other means of sharing support publicly or in a closed group, the client should be informed of the fact that, once digitized, their information can be reproduced. This includes audio (anything they say into the microphone or telephone), and video (if a cam is used), not just text.

Additional Legal and Liability Issues

Billing and HIPAA: The professional should understand and comply with the HIPAA requirements pertaining to their practice. This includes required informed consent documentation and policies pertaining to the uses and privacy protections pertaining to the client's "protected health information" (PHI). This includes what information will be transmitted to insurers or other professionals or agencies and how it can be used. 

Geographic area served: This topic can be frustrating and disappointing for clinicians who which to acquire clients from anywhere in the world. State laws of many states preclude practitioners from treating people in states in which they are not licensed to practice. There are also liability and case law issues that are a moving target. For example. in a liability suit, questions may be raised as to why a therapist would see a client from a distance with electronic media, when there are therapists that are just a qualified that are available to see the client face to face. There is also the matter of liability insurance: will it cover the practitioner that treats someone in a state in which they are not licensed?

Licensing: As indicated in the geographic topic, the professional must be in compliance with the licensing laws in their own state, and consider the laws pertaining to the area potentially being served or be at risk for being outside scope of practice. (Taylor, Symonette, & Singleton, 2009) States are passing laws pertaining to this issue, and they can be very restrictive.

As of this writing, it is not clear whether those laws will stand as they are, or whether legislation allowing more freedom in this regard will be passed. There are efforts to make it easier for telehealth providers to function across state lines. The American Bar Association is recommending measures along these lines, such as easier reciprocity and a standardized application that can be used for multiple areas. (Demetriou, American Bar Association, 2008)

Liability coverage: The professional should consult with their malpractice provider as to the insurance and liability implications of any new media that the practitioner is considering. The practitioner could end up practicing naked without realizing it.

Privacy policies for websites: Every websites that accept user data should have a privacy statement pertaining to the functioning of the website. Federal law (and laws of many states) requires that the privacy policy contain certain elements. There are websites that automate this process. such as www.FreePrivacyPolicy.com.

Acquisition of forms and signatures: If the professional is not systematic, he or she may find that they have not made sure to get signed policy, disclosure, or release forms back from clients, when they are seeing clients at a distance. This leaves the therapist exposed, perhaps unwittingly. As of this writing, California requires written consent from the client before service delivery. Efforts are being made to allow verbal consent.

Restriction of settings: There has been a concern that, in the interest of profit, managed care firms might require patients to accept telehealth against their wishes. For example, as of this writing, California legislators have proposed to outlaw such a requirement. (Telehealth Advancement Act of 2011) **time sensitive

Specific Guidelines?

An oft-cited attempt at providing extensive practical and ethical guidelines for tele-mental health comes from the American Telemedicine Association (2010). The document, available online (see Resources) provides guidance in the ethics section. They parallel existing, accepted ethical guidelines. Much of the text would stand as a collection of general ethical guidelines for clinical practice if "telemental health" were substituted by "mental health practices" throughout.

Here are some examples:

Telemental health organizations and providers shall ensure that appropriate staff is available to meet patient and provider needs before, during, and after telemental health encounters of all types.

Telemental health organizations and practitioners shall determine processes for documentation, storage, and retrieval of telemental health records.

The document makes an incorrect legal assumption in at least one statement:

Although no special consents are needed to use telemental health to serve patients, additional layers of consent are required during the course of treatment of persons with mental health conditions.

In at least one state, California, special written consent is required. (This may change to verbal consent.) Also, it is important to gain informed consent, which involves discussion the special requirements of any telehealth medium to be used. The document omits this topic except where it denies the need for it. This gives the appearance of a pro-industry bias.

On the other hand, the document highlights specific areas of telehealth that require special attention. For example, it recognizes that telehealth has its own privacy vulnerabilities:

Special  attention shall be paid to the enhanced need for privacy and confidentiality and every attempt to preserve the patient’s right to privacy shall be employed.

In another example, it shows recognition that telehealth practices might be conducted where they do not comply with specific requirements. In one statement, it applies this to clinical supervision. In another, it recognizes that care must be taken to ensure that requirements pertaining to scope of practice are not skirted:

Supervising practitioners shall comply with state and federal requirements for in-person supervision for residents and other practitioners whose positions are federally or state funded.

Organizations and practitioners shall have agreements in place to assure licensing, credentialing, training, and authentication of patients and practitioners as appropriate and according to local, state, and national requirements.

Appendixes to this course show additional material along these lines.

Special Focus: Administrative Issues  

Diverse Responsibilities and Solutions 

Responsibilities: Where telehealth is concerned, policies, staff training, and technological investment must be brought to bear in order to meet the responsibilities inherent in electronic communications. These include: 1) prevention of security breaches by hackers (acquisition of information, hoaxes, and installation of viruses), 2) prevention of boundary crossing or ethical lapses by employees, and 3) prevention of criminal mischief by employees.

Threats: The outcomes that such efforts attempt to thwart include: 1) threats to the safety or well being of patients or staff, 2) unauthorized release of private health information such as psychotherapy notes or client identities, 3) posting of information that would reflect negatively on the organization, and 4) noncompliance with legal and regulatory requirements. 

Integration: Telehealth is, in part, such an intrinsic aspect of the electronic infrastructure of an office or organization, that all decisions regarding computer, communications, and data management must consider any effects that they may have on telehealth performance or policies, and vice versa.

It is outside the scope of this course to provide an adequate training on computer security and records management, but some details will be provided shortly. For now, note that the kinds of measures being used include:

Password protection

Shredding (or wiping) of electronic data (meaning complete erasure)

Secure storage of data including back up data

Off-site storage to prevent data loss

File encryption

Auditing and monitoring of employee activity

Monitoring and managing the company's (or professional's) online reputation

Effective integration requires that IT staff, marketing professionals, and other consultants be up-to-date, competent, and specialized.

Small-timers: Even solo practitioners need to use most of the above mentioned measures and technologies. This means that practitioners with less funding and infrastructure must go through a process of learning, self-assessment, setting objectives, selecting and acquiring tools, implementing the chosen solutions, and monitoring the results. They should lean heavily on the best sources of information and advice in order to avoid wasting time or making poor choices. National organizations have regular articles on these subjects intended for their members. **specifics needed

Policy Development

When employees are the problem: There are many examples of healthcare organization staff violating ethical boundaries. Sometimes this is well intentioned and accidental, as in the case of a physician that unintentionally provided too much information about a case when writing about healthcare experiences on Facebook. This made it possible to identify a patient. Clear policies and staff training can help to reduce such incidents.

Policies developing; the case of social media: A survey of organizations regarding their policies concerning use of social media indicates that companies are aware of a surge in social media use, and are recognizing that social media can play an important role in their marketing efforts. Part of this awareness is of the threats that social media use can pose to the organization, employees, and patients. However, as of 2011, the survey found that 45% of organizations did not have policies pertaining to social media. Only 31% had specific policies. (Health Care Compliance Association and Society of Corporate Compliance and Ethics, 2011) The report indicates that a minority of organizations has formal monitoring. Instead most default to reacting to incidents as they occur.

Private practice policies: In some areas there may be laws requiring informed consent to include written policies. In any case, they can be useful to prevent misunderstandings or even liability. See the sample form provided as an appendix to this course. It includes suggestions for customizing it to your practice.

Security Measures 

Introduction

In this section, we will cover some fundamental guidelines and concepts for security measures that can help the professional meet their responsibilities for compliance with laws, regulations, and ethics.

Password Protection

Passwords are a common means of guarding against unauthorized access to data and functions of computers and networks. When people log in to an online email site such as Hotmail or Google Mail, they must supply a user name and password in order to gain access. The professional must have a password that is sufficiently long and unpredictable that it can thwart unauthorized people from "hacking" their account. They must also keep whatever record they maintain of their passwords secure. At the same time, it is necessary to have someone authorized and able to access data in case of illness when that data is needed for professional reasons. There is a great deal of information available online as to current standards for passwords, password management, and other security measures.

Other things that can be password protected are the initial access to your computer after turning it on, re-accessing the computer after stepping away or allowing the screen saver to activate, access to specific programs, files, or directories, and online accounts.

How to Create and Store Secure Passwords

You should use the following guidelines in creating passwords:

Do not use the same password for multiple accounts, except perhaps for accounts which, if breached, would not produce much harm.

Use at least eight characters.

Use various types of characters: upper case, lower case, numbers, and symbol characters such as the ampersand.

Do not use full words, names, meaningful numbers such as birthdays, or patterns of numbers or letters such as 123456.

For your most sensitive accounts, change passwords periodically.

Do not allow your browser or other software to automate filling in your passwords except for less sensitive accounts or where you have a computer safe from theft. Even so, you must be prepared to change any such passwords if the computer is compromised or stolen.

Since you probably can't remember all your passwords, you must have a way to refer to them. Many people use a booklet or removable thumb drive. However, you must remember to hide the source away properly, and to have back up in case of loss. If lost, you will need to change the pass words, at least for sensitive accounts.

You can use software programs that encrypt your passwords. This allows you to use a single password for all accounts. You can remember a single password, so you will not need a booklet. However, this will not help you if you are using someone else's computer. You will also want to make sure that the encrypted data is backed up properly.

Firewalls  

Firewalls protect computers and networks from unauthorized access from persons using the Internet to hack computers. In other words, they keep persons or programs outside the network from getting in. Any competent IT (information technology) professional charged with maintaining a computer network. Computers and the devices that connect them to the Internet (routers or modems) have firewalls that must be configured properly.

Shredding 

When users delete files such as documents, these files actually remain on the hard drive until they are written over by other data. This may take a long time. Programs have been designed to wipe (or shred) files so that they cannot be retrieved.

Back Up

Loss of data can be costly and compromise clinical care. Individuals and organizations must have proper back up policies, practices, and equipment. This can be as simple as having a schedule for burning files to media such as disks or external hard drives that are kept in secure locations. Users must be sure than any storage of data onto other computers is HIPAA compliant. For example, there is "cloud" storage, which means that the data is uploaded via the Internet to an organization's computers intended for this purpose. These are not necessarily sufficiently secure. Encryption is a means of gaining added security for all these measures.

Encryption 

Encryption scrambles data so completely that it is nearly impossible to unscramble without a software "key" that unlocks the encryption. There are various encryption programs and strategies. There are free encryption programs, and a great deal of useful information about this online. Some programs actually keep the data that is used encrypted, not just the back up data.

Reputation Management

Professionals, organizations, and specialized services perform monitoring of the Internet to identify threats to the reputation of the professionals or organization. This can be done passively and with no financial investment by setting up alerts with Google. These can include variations on names such as the professional's name, the business' name, and even topics that the user wants to monitor.

This is a subject worthy of further research, because there are various strategies to choose from, and because it is a rapidly developing area. Example strategies include responding to negative articles or posts (submissions of comments or brief articles)  online, soliciting positive comments from people familiar with the professional or organization, and producing positive articles or posts. Where information is untrue and harmful, legal action may be the appropriate solution.

Where a client posts accusatory or negative information, the professional is bound by confidentiality not to reveal information about the client. Without verification, the post may not be coming from the person, but may be from an imposter.

In such situations, legal advice is needed to determine whether to respond, and what response is appropriate. Public accusations are not the same as a legal action in which the therapist is permitted to acknowledge the fact of the individual having been a client in order to mount a defense or pursue a debt.

Billing

Billing is likely to have electronic aspects, regardless of whether there is telehealth activity taking place outside of billing. HIPAA covers the matter of maintaining confidentiality of identifying information. Where credit card payments are concerned, the professional can arrange for the service be identified as something other than psychotherapy (such as "Consult"), and that the business name be something other than one that implies mental health services. This is because various bank and processor staff will see the data. It may even be that the individual would not want their spouse to know that the consultation is for.

The professional's policies should clearly indicate under what circumstances billable hours or sessions will accrue. Will the client be charged if they follow up via email with additional questions? What about a five minute emergency call between sessions? What about fifteen minutes? What if there are three of them? What accountability does the professional accept if the session is cut short by an outage?

The practitioner must be certain what media will be covered by payers such as insurance companies. Medicare began allowing online videoconferencing as of 2001 (Maheu, 2001).

Copy Machines: Surprise!

Copy machines may store thousands of documents on hard drives. This poses a tremendous security risk, especially when the machine is sold. The documentation may not adequately explain this. Organizations and practitioners must make sure that the machine is set up properly in order to prevent this. A copy machine that is not treated with the same security measures as files (in terms of being locked away) is a HIPAA violation if it is retaining images of personal health data such as client records.

Work station responsibility

Staff must not leave their computer work stations or laptops unattended without signing out, or someone else may use their identity to search client records without authorization or engage in other mischief. Staff are fired for unauthorized medical record access. There are many incidents of staff being unable to resist the temptation because of a personal connection or because of the notoriety of a patient.

IT Support 

Even solo practitioners can develop relationships with consultants or affordable support services. The time involved in troubleshooting technical problems can be far out of proportion to the cost of using a service. Organizations are likely to have full-time staff for such support.

Cultural and Linguistic Competence 

Issues in Culture and Ethnicity  

Incentives and obligations: Telehealth providers must be concerned with issues of culture, class, and language, because one of the incentives for telehealth being the need to reach persons with poor access to mental health services.

Reasons for poor access in this context may include poverty and rural living, and the areas needing access may be high in persons with limited English language and with significant differences in culture from those designing or providing telehealth services. Ethnic and racial minority populations are much less likely to have good access to quality mental health services. (Wells, Klap, Koike, and Sherbourne, 2001; Harris, Edlund, and Larson, 2005).

Systems thinking: From a systems perspective, one of the needs in this regard is to recognize the obstacles to receiving telehealth services that affect these populations. Systems and interventions must be designed with these realities in mind, and be customized to the specific populations and regions in question.

Cultural competency is an important part of our ethical standards, and refers to our need to understand those with whom we work. According to Castro, Proescholdbell, Abeita, and Rodriguez  (1999) cultural competence is “the capacity of a service provider or an organization to understand and work effectively in accordance with the cultural beliefs and practices of  persons from a given ethnic/racial group.”

Warning: Maheu  (2001) warns that clinical care that fails to incorporate such knowledge is likely to fall outside the standard of care because, in part, it can impair informed consent, assessment, communication and education with clients, and the relationship and collaboration needed for direct care.

Thus, according to Taylor, Symonette, and Singleton (2009), "it is important to be  aware of cultural beliefs and communication nuances among minority groups, as they are  important components for practitioners to incorporate during online counseling sessions." and "a  culturally engaged practitioner always considers a client’s cultural background and  experiences, which may influence the utilization of E-therapy as a relevant form of treatment  for substance abuse."

Infrastructure development: In some scenarios, an organization is responsible for providing the infrastructure necessary for telehealth services. For example, an employer may contract with a managed care firm to cover employees in an under-served area. Federal grantees have been tasked with developing large-scale projects in under-served areas with high minority populations. One example is a program that includes telepsychiatry in southeast Georgia. (Diamand, Ellis, Marcin, Mawis, Nagrampa, Nesbitt, 2004) Such development should be undertaken with a good understanding of the populations to be served. Measures should be taken to ensure cultural relevance. 

The appendix "HHS Material on Cultural Competence" provides background on the issues that must be managed in this area.

Appendix: Generic Private Practice Policies for Tele-Mental Health

Note: Can be incorporated into your existing policy statement or exist as a separate policy statement, signed separately.

Note: this policy is based on a review of recommendations and other literature. It has not been reviewed by an attorny or national organization. It does not constitute legal advice. It can only serve as a guide in preparing your own policies.

These are my policies regarding communication by phone and other electronic means. It incudes policies on our between-session contacts.

Telemedicine Policies (Electronic Communications)

Messages and Privacy

I check messages (**how often) on weekdays and (**how often) on weekends.

I usually respond within (**time period) but there are circumstances that may delay a response. If I do not respond, please try again in case there was a technical problem.

Preserve your privacy: Unless you take special measures, email and text messages have more risk to privacy than phone or VoIP (such as Skype). If you elect to use less secure methods, avoid revealing sensitive information. For email, use a provider with SSL (HTTPS).

Emergencies

In an immediate or life-threatening emergency such as suicidal feelings, go to an emergency room or dial 911. If you are safe enough to talk about it with me instead, (**state emergency contact policy).

(Note: This is for providers in California, adapt according to the law in your state and any changes in the law)

Services via Electronic Communication: 

Mental health services through electronic communication (such as telephone, Skype, FAX machine, and email) are telemedicine according to California law.

1. You will not lose the right to treatment or benefits if you decide not to accept telemedicine services.

2. Your confidentiality limits and protections (see Privacy Policy **Note: this directs the client to your existing privacy policy for your practice) are not to be changed as a result of using telemedicine. However, there are risks to privacy of electronic communication. Please discuss any concerns with me. I will do my best to inform you of the risks to privacy.

3. Your rights and ability to your records are the same, regardless as to whether they were generated through telemedicine. (See Policies on access to records **Note: this directs the client to your existing policy on records)

5. Telemedicine has benefits and risks or disadvantages. So long as I have your permission, I will work with you to use any telemedicine methods that can provide you with benefits such as saving time and travel. I will work with you to avoid disadvantages such as too much risk to your privacy or using electronic communication when a face-to-face visit appears to be necessary. Assessment and treatment may be improved through face-to-face interaction for some situations.

6. Note: Optionally, add any comments about specific media that you may rely on with some clients, such as video conference calls. Do you have any policies specifically on that? Specifically, do you do sessions by phone or VoIP? Do you have different rates for such contacts.

8. It is important to understand that at times, email communication or cell phone communication including text messages content between you and your therapist maybe misinterpreted due to lack of eye contact, vocal tone, and attending to facial expressions between client and therapist. If you are unsure about the intent or content of an email or the intent of the therapist via cell or phone conversations, you are encouraged to discuss concerns, questions and ask for clarification.

10. **Note: modify this according you your availability, and indicate your rates.

Between sessions, additional telephone contacts may be billed by the hour if they exceed five minutes. They should only be for exceptional situations such as a crisis. This does not apply to calls regarding scheduling.

11. Email contact can be used for scheduling only. (**Note: modify this if you use this or other media besides phone or Skype for therapeutic purposes. Includes rates.)

12. If you frequently contact your therapist via email or phone outside of your normal session, it is important to understand that your therapist will bill you for a portion of his or her time, based on his or her regular hourly rate as agreed upon.  As the therapist sees numerous clients per week, the therapist may receive numerous emails and calls each week from many clients.

**Note: Other topics to consider for this policy statement, if not covered in your existing policies, follow. Some of these topics may be part of your verbal interaction, depending on the kind of clients you see.

The possibility of an increased session frequency or level of care for clients that turn out to need more. Whether you can accommodate this. That you will provide referral or attempt to assist the client in locating a higher level of care. That a high level of between-session contacts may indicate a need for a higher level of care.

That it is not a good idea to share information such as recordings of calls or text from messages with others, because it compromises the client's privacy and could be regretted later because of the inability to control the materials once they are out of the client's control. It can also be taken out of context and damage the therapists reputation. It may be a cause to terminate treatment.

Your signature below indicates only that you understand the information and policies. Please discuss any questions or insights you have to your satisfaction before signing.

**Note: Many therapists also state that the signature indicates that the client agrees with the policies and will abide by them.

**Name and signature blanks go here in the same format as your other documents.

Appendix: HHS Material on Cultural Competence

Introduction

The following material is a well-cited explanation of cultural competence issues from HHS. (Taylor, Symonette, & Singleton, 2009) - RY

Keys to Cultural Competence

Beliefs and attitudes about particular groups of people usually dictate individuals’ behavior toward that group, regardless of the accuracy of the perception (HHS, 2001). Mistrust of the medical community has been documented repeatedly, according to the Epidemiologic Catchment Area study conducted in the early 1980s (HHS, 2001). In the study, nearly 50 percent of the African Americans surveyed reported a fear of receiving mental health treatment, compared with 20 percent of whites. Current-day discrimination and racism coupled with historical mistreatment are real barriers that may contribute to a lack of trust toward mental health treatment and the medical community (HHS, 2001).

In addition, a 1999 study funded by the Kaiser Family Foundation reported sim ilar findings within minority populations. Results indicated that 12 percent of African Americans and 15 percent of Latinos, vs. 1 percent of whites, believed t hat they had received substandard medical care because of their race (HHS, 2001) . Data from the Commonwealth Fund Minority Health Survey (1997) reported that 43 percent of African Americans and 28 percent of Latinos, compared with 5 percent of whites, perceived they were treated poorly by a health care professional bec ause of their race and cultural background (HHS, 2001). Likewise, immigrants and refugees are also leery of the U.S. health care system. Consequently, the deliv ery of mental health and substance use disorder treatment services for undocumented people is in jeopardy because this population fears deportation and mistreatment (HHS, 2001).  Few research studies examine the link between effective culturally competent substance abuse treatment services through electronic modalities for minority individuals. Sanchez-Page (2005) identifies and addresses four counseling inadequacies in delivering culturally appropriate mental health treatment online.  Lack of culturally suitable evaluation tools. Researchers and practitioners should design culturally suitable evaluation tools to measure the benefits of E-therapy compared with face-to-face counseling among minority populations and their white counterparts.  Lack of awareness about communication styles. Practitioners must understand the important impact of cultural communications styles among minority populations and how the absence of verbal and nonverbal cues associated with online counseling may negatively influence the relationship between the practitioner and client.  Limited access to technology in communities of color. Poverty and disproportionate access to technology within communities of color limit the use of E-therapy as a mainstream counseling option for minority groups. Consequently, further research is required to examine the usefulness of electronic therapy among minority populations. Lack of culturally appropriate online interventions. Develop culturally appropriate online interventions that address the cultural beliefs and practices of individuals from specific ethnic/racial groups (Castro, et al., 1999). By effectively addressing important cultural factors, clinicians may begin cultivating the opportunity to advance the integration of E-therapy among underrepresented and underserved populations (Sanchez-Page, 2005).

Stigma 

Members of minority communities often have critical views about mental illness (HHS, 2001).

In these communities, individuals who suffer from mental illness are often ostracized and subjected to shame and embarrassment by family members (HHS, 2001). Documenting the intensity of this stigma is difficult because minority groups are reluctant to address issues related to mental illness and substance abuse (HHS, 2001). Few cross-cultural studies have examined the relationship between race and mental illness. Zhang, Snowden, and Sue (1998) conducted a study comparing Asian Americans and whites living in Los Angeles. Data indicated that more than twice the number of whites (25 percent) would consider talking about their mental health challenges with a friend, compared with 12 percent of Asians. Study reports also showed that only 4 percent of Asian respondents would seek assistance from a mental health professional, compared with 26 percent of white respondents. Thirteen percent of white participants found it acceptable to discuss mental distress with a doctor, compared with only 3 percent of the Asian participants found it acceptable (HHS, 2001).

In the 1970s, the National Opinion Research Center began to evaluate societal views of mental illness. This extensive analysis initiated the 1996 General Social Survey (HHS, 2001), which gauged respondents’ personal opinions about mental illness when presented with various short stories depicting people diagnosed with mental illness. Study results indicated that respondents labeled people with mental illness as a menace and unfit to handle personal responsibilities. Intense criticism was aimed at individuals with substance abuse problems and schizophrenia. However, researchers observed that neither the race of neither the respondents nor of the individuals portrayed in the short stories factored into the stigma associated with mental illness (HHS, 2001).  On the other hand, a second study assessing public bias toward individuals with mental illness captured how different ethnic groups respond to people with mental illness (HHS, 2001). After interacting with individuals diagnosed with mental illness, Native Americans and whites reported a greater tolerance of people with mental illness, while African Americans, Latinos, and Asians reported less tolerance. The self-worth of family members and individuals diagnosed with mental illness is directly affected by the stigma of being labeled “crazy.” Often, the intense stigma attached to mental illness prevents people, particularly those within minority groups, from receiving treatment for mental illness. However, cultural sensitivity and acknowledgement of cultural stigma associated with receiving mental health and substance abuse treatment services is helpful when relating to minority clients (HHS, 2001).

Embracing Diversity 

Integrating fundamental parts of ethnic group culture, including styles of co mmunication, value systems, historical background, and religious and traditional beliefs, are believed to increase the use of mental health services among minor ity clients. Researchers recognize that by adapting mental health treatment serv ices to a client’s familiar culture, potentially significant treatment out comes may be realized (HHS, 2001). During the last decade, practitioners and oth er mental health care professionals began emphasizing the importance of deliveri ng culturally competent mental health services while encouraging buy-in from min ority consumers, families, and communities. For example, a noted culturally appr opriate 21mental health care service delivery model designed for children and adolescents with severe emotional disabilities concentrates on the strengths of ethnic groups’ culture for effective service delivery (Cross, Bazron, Dennis, and Isaacs, 1989). Principal components involved in adapting this mental health care service delivery model include policy, training, resources, practice, and research.  Linguistic competence is equally significant in developing culturally appropriate treatment services. The National Center for Cultural Competence at Georgetown University defines linguistic competence as the “capacity of an organization and its personnel to communicate effectively and convey information in a manner that is easily understood by diverse audiences, including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities. Linguistic competency requires organizational and provider capacity to respond effectively to the health literacy needs of populations served” (The National Center for Cultural Competence, 2006). For example, the bilingual website “Amigos” utilizes an electronic psychoeducational tool to help minorities access health-related resources (Guanipa, Nolte, and Lizarraga, 2002). Providing availability to computers, and educating the targeted community about mental health care and multiculturalism, was the objective of establishing “Amigos.” By implementing electronic modalities similar to the “Amigos” program, minority groups may cautiously utilize culturally and linguistically competent mental health and substance abuse treatment services. Continuing research by practitioners and further development of culturally appropriate online interventions may encourage the use of E-therapy by minority populations. 

Summary

- Developing and testing the effectiveness of culturally appropriate online substance abuse treatment interventions requires buy-in from minority consumers, families, communities, and mental health professionals.

- Therapists should recognize that the historical discrimination that minority groups have experienced in encounters with the medical community and the resulting feelings of mistrust from these encounters may influence the willingness of individuals to seek mental health and substance abuse treatment. 

- Poverty and limited access to technological resources may influence the utilization of E-therapy as a mainstream counseling option within some minority groups. In addition, consider that standard substance abuse curricula and general interventions may not necessarily provide the best treatment strategies for minority communities. 

- Practitioners must recognize and emphasize the importance of providing culturally competent treatment services and integrate fundamental components of ethnic group culture, including communication styles and religious and traditional beliefs.

Integrating these cultural components may increase the use of mental health services among minority clients. 

Appendix: California Board of Psychology: Information on Telepsychology

http://www.psychboard.ca.gov/consumers/telepsych.shtml

From time to time the board becomes aware of articles or information that would be educational and informative to licensed psychologists and the consumers of psychological services. In such cases, the board will attempt to bring this information to licensees and consumers, provided the necessary authorizations for publication can be obtained. In the posting of any information on its web site, the board will maintain sole discretion as to what information is posted.

The following information regarding telepsychology has been excerpted with the permission of the primary author from "Regulation of Telepsychology: A Survey of State Attorneys General" by Gerry Koocher & Elisabeth Morray. Professional Psychology: Research and Practice, October, 2000, vol. 31, issue #5, pages 503-508.

In light of the survey data obtained in this research, the authors offer the following regarding telepsychology:

1. Before engaging in the remote delivery of mental health services via electronic means, practitioners should carefully assess their competence to offer the particular services and consider the limitations of efficacy and effectiveness that may be a function of remote delivery.

2. Practitioners should consult with their professional liability insurance carrier to ascertain whether the planned services will be covered. Ideally, a written confirmation from a representative of the carrier should be obtained.

3. Practitioners are advised to seek consultation from colleagues and to provide all clients with clear written guidelines regarding planned emergency practices (e.g., suicide risk situations).

4. Because no uniform standards of practice exist at this time, thoughtful written plans that reflect careful consultation with colleagues may suffice to document thoughtful professionalism in the event of an adverse incident.

5. A careful statement on limitations of confidentiality should be developed and provided to clients at the start of the professional relationship. The statement should inform clients of the standard limitations (e.g., child abuse reporting mandates), any state-specific requirements, and cautions about privacy problems with broadcast conversations (e.g., overheard wireless phone conversations or captured Internet transmissions).

6. Clinicians should thoroughly inform clients of what they can expect in terms of services offered, unavailable services (e.g., emergency or psychopharmacology coverage), access to the practitioner, emergency coverage, and similar issues.

7. If third parties are billed for services offered via electronic means, practitioners must clearly indicate that fact on billing forms. If a third-party payer who is unsupportive of electronic service delivery is wrongly led to believe that the services took place in vivo as opposed to on-line, fraud charges may ultimately be filed.

Appendix: APA Statement on Services by Telephone, Teleconferencing, and Internet

NOTE: This has been superceded, but is a useful document in that it directly addresses ethics issues in terms of telehealth media. - RY

http://www.apa.org/ethics/education/telephone-statement.aspx

A statement by the Ethics Committee of the American Psychological Association

The American Psychological Association's Ethics Committee issued the following statement on November 5, 1997, based on its 1995 statement on the same topic.

The Ethics Committee can only address the relevance of and enforce the "Ethical Principles of Psychologists and Code of Conduct" and cannot say whether there may be other APA Guidelines that might provide guidance. The Ethics Code is not specific with regard to telephone therapy or teleconferencing or any electronically provided services as such and has no rules prohibiting such services. Complaints regarding such matters would be addressed on a case by case basis.

Delivery of services by such media as telephone, teleconferencing and internet is a rapidly evolving area. This will be the subject of APA task forces and will be considered in future revision of the Ethics Code. Until such time as a more definitive judgment is available, the Ethics Committee recommends that psychologists follow Standard 1.04c, Boundaries of Competence, which indicates that "In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect patients, clients, students, research participants, and others from harm." Other relevant standards include Assessment (Standards 2.01 -2.10), Therapy (4.01 - 4.09, especially 4.01 Structuring the Relationship and 4.02 Informed Consent to Therapy), and Confidentiality (5.01 - 5.11). Within the General Standards section, standards with particular relevance are 1.03, Professional and Scientific Relationship; 1.04 (a, b, and c), Boundaries of Competence; 1.06, Basis for Scientific and Professional Judgments; 1.07a, Describing the Nature and Results of Psychological Services; 1.14, Avoiding Harm; and 1.25, Fees and Financial Arrangements. Standards under Advertising, particularly 3.01 - 3.03 are also relevant.

Psychologists considering such services must review the characteristics of the services, the service delivery method, and the provisions for confidentiality. Psychologists must then consider the relevant ethical standards and other requirements, such as licensure board rules.

(This policy statement was issued under the 1992 Ethics Code. The 2003 Ethics Code supersedes the 1992 version of the Ethics Code. Therefore, this statement is considered inactive.)

Appendix: California Business and Professions Code Section 2290.5

Note: This is model legislation addressing telemedicine. It is especially of interest for California therapists and other healthcare providers. - RY

(a) (1) For the purposes of this section, "telemedicine" means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Neither a telephone conversation nor an electronic mail message between a health care practitioner and patient constitutes "telemedicine" for purposes of this section.

   (2) For purposes of this section, "interactive" means an audio, video, or data communication involving a real time (synchronous) or near real time (asynchronous) two-way transfer of medical data and information.

   (b) For the purposes of this section, "health care practitioner" has the same meaning as "licentiate" as defined in paragraph (2) of subdivision (a) of Section 805 and also includes a person licensed as an optometrist pursuant to Chapter 7 (commencing with Section 3000).

   (c) Prior to the delivery of health care via telemedicine, the health care practitioner who has ultimate authority over the care or primary diagnosis of the patient shall obtain verbal and written informed consent from the patient or the patient's legal representative. The informed consent procedure shall ensure that at least all of the following information is given to the patient or the patient's legal representative verbally and in writing:

   (1) The patient or the patient's legal representative retains the option to withhold or withdraw consent at any time without affecting the right to future care or treatment nor risking the loss or withdrawal of any program benefits to which the patient or the patient's legal representative would otherwise be entitled.

   (2) A description of the potential risks, consequences, and benefits of telemedicine.

   (3) All existing confidentiality protections apply.

   (4) All existing laws regarding patient access to medical information and copies of medical records apply.

   (5) Dissemination of any patient identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without the consent of the patient.

   (d) A patient or the patient's legal representative shall sign a written statement prior to the delivery of health care via telemedicine, indicating that the patient or the patient's legal representative understands the written information provided pursuant to subdivision (a), and that this information has been discussed with the health care practitioner, or his or her designee.

   (e) The written consent statement signed by the patient or the patient's legal representative shall become part of the patient's medical record.

   (f) The failure of a health care practitioner to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section.

(g) All existing laws regarding surrogate decision making shall apply. For purposes of this section, "surrogate decision making" means any decision made in the practice of medicine by a parent or legal representative for a minor or an incapacitated or incompetent individual.

   (h) Except as provided in paragraph (3) of subdivision (c), this section shall not apply when the patient is not directly involved in the telemedicine interaction, for example when one health care practitioner consults with another health care practitioner.

   (i) This section shall not apply in an emergency situation in which a patient is unable to give informed consent and the representative of that patient is not available in a timely manner.

   (j) This section shall not apply to a patient under the jurisdiction of the Department of Corrections or any other correctional facility.

   (k) This section shall not be construed to alter the scope of practice of any health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.

Resources

PsychIN Directory: Tele-Mental Health

http://www.psychinnovations.com/tele_mental_health_telehealth

Annotated directory of tools for research and reference now includes annotated, categorized tele-mental health resources including turnkey solutions.

Organizations (Some have publications and forums)

International Association of CyberPsychology, Training, and Rehabilitation

http://iactor.ning.com/

iACToR is the official voice and resource for the international community using advanced technologies in prevention, therapy, training, education, and rehabilitation. Our mission is to bring together top researchers, policy makers, funders, decision-makers and clinicians, pooling collective knowledge to improve the quality, affordability, and availability of existing healthcare.

Ultimately, through international collaboration with the most eminent experts in the field, we are working to overcome obstacles and increase access to top-quality healthcare for all citizens. By enhancing public awareness of the possibilities that technology offers, we move toward changing and improving healthcare as it currently exists.

TeleHealth.net

http://telehealth.net

American Telemedicine Association

http://www.americantelemed.org/

Telemental Health SIG

http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3326

The Telemental Health Special Interest Group includes administrators, clinicians, and information technology professionals. Its goal is to enhance and support the use of technology in the delivery of mental health services, and its mission is to promote dialogue between mental health practitioners, to improve the understanding and use of telehealth applications in the delivery of mental health services, and to provide guidance to the ATA Board of Directors regarding telemental health

ATA Wiki

http://wiki.americantelemed.org/

Online Therapy Institute

http://www.onlinetherapyinstitute.com

Has broad spectrum of resources and articles. Includes ethical frameworks and a social network that is free to join.

Offers training.

Verifies websites so that individuals and businesses can demonstrate to their audience that their website is ethical and in compliance with what OTI considers to be “best practice.”

Telehealth

http://www.selfhelpmagazine.com/ppc/telehealth.php

Telehealth issues and resources for professionals.

American Telemedicine Association

http://www.americantelemed.org/

"The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies. ATA and its diverse membership, works to fully integrate telemedicine into transformed healthcare systems to improve quality, equity and affordability of healthcare throughout the world. Established in 1993 as a non-profit organization and headquartered in Washington, DC, membership in the Association is open to individuals, healthcare institutions, companies and other organizations with an interest in promoting the deployment of telemedicine throughout the world. ATA is governed by a Board of Directors, which is elected by the association's membership."

The Center for Telehealth & E-Health Law

http://www.ctel.org/

Provides consultation, services, and online articles and resources.

"CTeL is the only organization that provides legal and regulatory expertise on emerging telehealth issues. CTeL’s Board of Directors is comprised of leading experts with years of experience in telehealth issues, such as: credentialing and privileging, e-prescribing, Federal Communications Commission (FCC) and telecommunication matters, physician and nurse licensure, and Medicare and Medicaid reimbursement."

APA Rural Health Resources

http://www.apa.org/practice/programs/rural/resources.aspx

Includes section on telehealth

ISMO

https://www.ismho.org/home.asp

We are an international community exploring and promoting Mental Health in the digital age. Our members include students, teachers, researchers, clinical practitioners, and others interested in using Internet technologies to sustain positive mental health. We meet online to discuss current issues and collaborate on projects to further our mission.

Ohio Psychological Association

Lot's of links to materials.

http://www.ohpsych.org/commtech.aspx

TelePsychology.net

http://www.telepsychology.net/

Telepsychology Guidelines, Ethics and Continuing Education

California Board of Psychology: Information on Telepsychology

http://www.psychboard.ca.gov/consumers/telepsych.shtml

"From time to time the board becomes aware of articles or information that would be educational and informative to licensed psychologists and the consumers of psychological services. In such cases, the board will attempt to bring this information to licensees and consumers, provided the necessary authorizations for publication can be obtained."

Citations

Laws, Legislation

California Business and Professions Code § 2290.5 (1996).

Telehealth Advancement Act of 2011 § 1374.13. (d) (2011).

Other Citations

Alemi, F., Stephens, R., Parran, T., Llorens, S., Bhatt, P., Ghadiri, A., et al. (1994). Automated monitoring of outcomes: Application to treatment of drug abuse. Medical Decision Making, 14, 180–187.

American Psychiatric Association. (Undated). Telepsychiatry. Accessed at: http://www.psych.org/Departments/HSF/UnderservedClearinghouse/Linkeddocuments/telepsychiatry.aspx

American Psychological Association. (2007). APA Resource Document On Telepsychiatry Via Videoconferencing. Accessed at: http://www.psych.org/psych_pract/tp_paper.cfm

American Psychological Association. (2007). APA Statement on Services by Telephone, Teleconferencing, and Internet. Accessed at http://www.apa.org/ethics/education/telephone-statement.aspx

American Psychological Association. (2011). Reimbursement for telehealth services. APA Practice Update, March, Accessed at: http://www.apapracticecentral.org/update/2011/03-31/reimbursement.aspx

American Telemedicine Association. 2009. Evidence-Based Practice for Telemental Health.

American Telemedicine Association. (2010). Practice guidelines for videoconferencing-based  telemental health. Telemental Health Standards and Guidelines Working Group. Accessed at: http://www.americantelemed.org/files/public/standards/PracticeGuidelinesforVideoconferencing-Based%20TelementalHealth.pdf

Bauer, K. (2009). Healthcare ethics in the information age, in Luppicini, R., and Adell, R. Handbook of Research on Technoethics. Hershey, New York: Information Science Reference, p. 170.

Blascovich, J. and Bailenson, J. (2010). Infinite reality: Avatars, eternal life, New Worlds and the Dawn of the Virtual Revolution. New York: Harper Collins Publishers.California Board of Psychology. (2011). Information on Telepsychology. Accessed at: http://www.psychboard.ca.gov/consumers/telepsych.shtml

Castro, F. G., Proescholdbell, R. J., Abeita, L., and Rodriguez, D. (1999). Ethnic and cultural minority groups. In B. S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook. New York: Oxford University Press.

Copeland, J. and Martin, G. (2004). Web-based interventions for substance use disorders: A qualitative review. Journal of Substance Abuse Treatment, 26, 109-116.

Crowell, C. R., Narvaez, D., and Gomberg, A. (2009). Moral Psychology and Information Ethics: Psychological Distance and the Components of Moral Behavior in a Digital World. In Handbook of Research on Technoethics. Hershey, New York: Information Science Reference, p. 700.

Diamand, R. J., Ellis, J., Marcin, J. P., Mawis, R., Nagrampa, E., Nesbitt, T. S. (2004). Using telemedicine to provide pediatric subspecialty care to children with special health care needs in an underserved rural community. Pediatrics, 113(1), 1-6.

Demetriou, A. J., American Bar Association, Health Law Section. (2008). Report to the house of delegates, August. Accessed at www.abanet.org/health/04_government_sub/media/116B_Tele_Final.pdf

Field, M. J. (1996). Telemedicine: A guide to assessing telecommunications in health care. Institute of Medicine, Committee on Evaluating Clinical Applications of Telemedicine.

Fenichel, M. (2000). Online therapy. Accessed at: http://www.fenichel.com/OnlineTherapy.shtml

Fox, F. (2011). The Social Life of Health Information. Pew Internet & American Life Project. Accessed at http://www.pewinternet.org/Data-Tools/Get-the-Latest-Statistics/Latest-Research.aspx

Hailey, D., Roine, R., and Ohinmaa, A. (2008). The effectiveness of telemental health applications: A review. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 53(11), 769-778.

Health Care Compliance Association and Society of Corporate Compliance and Ethics. (2011). Social Media and Compliance: A survey by the Health Care Compliance Association & the Society of Corporate Compliance and Ethics. Accessed at: http://www.hcca-info.org/staticcontent/2011SocialMediaSurvey_report.pdf

International Society for Mental Health Online. 2000. Suggested Principles for the Online Provision of Mental Health Services 2000. v 3.11. Accessed at https://www.ismho.org/suggestions.asp

Maheu, M. M., Pulier, M. L., Wilhelm, F. H., McMenamin, J., and Brown-Connolly, N. (2005). The mental health professional and the new technologies: A handbook for practice today. Mahwah, NJ: Erlbaum.

Maheu, M. M., Whitten, P., & Allen, A. (2001). E-health, telehealth, and telemedicine: A guide to start-up and success. San Francisco: Jossey-Bass Inc. 

McCullagh, D. (2010). Report: Feds to push for Net encryption backdoors. CNet News, 9/27. Accessed at: http://news.cnet.com/8301-31921_3-20017671-281.html#ixzz1MypW461V if

McCullagh, D. (2009). Judge orders defendant to decrypt PGP-protected laptop. CNet News, 2/26. Accessed at: http://news.cnet.com/8301-13578_3-10172866-38.html

Miller, S. R. (2011). Report details health care data theft. South Florida Business Journal, 2/23. Accessed at: http://www.bizjournals.com/southflorida/news/2011/02/23/report-details-health-care-reform-theft.html

Mills, E. (2010). Study: Medical identity theft is costly for victims. CNet News, 3/3. Accessed at http://news.cnet.com/8301-27080_3-10460902-245.html

National Association of Social Workers and Association of Social Work Boards. (2007). Standards for Technology and Social Work Practice. Accessed at http://www.socialworkers.org/practice/standards/NASWTechnologyStandards.pdf

Ohio Psychology Association. (2011). The Ethical Practice of Telepsychology Webinar, Accessed at: http://www.ohpsych.org/homestudies.aspx

Ragusea, A. S., and VandeCreek, L. (2003). Suggestions for the ethical practice of online psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 40, 94–102.

Taylor, E., Symonette, E., and Singleton, E. (2009). Considerations for the provision of e-therapy. Center for Substance Abuse Treatment. U.S. Department Of Health And Human Services, Substance Abuse and Mental Health Services Administration.

TelePsychology.net. (2011). Home Page. Accessed at: www.telepsychology.net

Vallejo, M. A., Jordán, C. M., Diáz, M. I., Comeche, M. I., and Ortega, J. (2007). Psychological assessment via the internet: A reliability and validity study of online (vs. paper-and pencil) versions of the General Health Questionnaire-28 (GHQ-28) and the Symptoms Check-List-90-Revised (SCL-90-R). Journal of Medical Internet Research, 9, 1–10.

Wells, K., Klap, R., Koike, A., and Sherbourne, C. (2001). Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. American Journal of Psychiatry, 158, 2027-2032.

End of text. Now take the course quiz.