Received: 22 February 2018
| Accepted: 23 February 2018
DOI: 10.1111/cpsp.12237
COMMENTARY
Do you see what we see? Psychology’s response to technology in
mental health
Linda F. Campbell1 | John C. Norcross2
1
University of Georgia, Athens, GA, USA
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
2
University of Scranton, Scranton, PA, USA
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Correspondence
Linda F. Campbell, University of Georgia, Athens, GA, USA.
Email: lcampbel@uga.edu
Keywords: cyberpsychology, ethics, guidelines, psychotherapy, technology, telehealth, telepsychology
The introduction of technology into psychological practice
creates wonderful opportunities but also uncertainties and
skepticism. In their “Technology use in mental health prac-
tice and research: Legal and ethical risks,” Lustgarten and
Elhai (2018) zero in on both sides of this new coin. We are
pleased to offer a few reflections on these accelerating tech-
nological developments and particularly on organized psy-
chology’s copious responses to them. We employ the term
telepsychology rather than the more generic technology or
telehealth as the American Psychological Association (2013)
has approved the former as a distinct term within the psycho-
logical community for technology-based tools.
Is it, in fact, a new coin? During a workshop several
months ago, one of us was asked, “I’ve been using the tele-
phone to talk with patients since 1967; am I practicing
telepsychology?” The answer was an unequivocal “yes.”
Any communication through electronic means has been rec-
ognized by all health organizations as telecommunication.
Advances in technology, new means of transmission,
the ubiquity of technology in society, and the level of inte-
gration into psychological practice and research have raised
the bar far beyond telephone use. Lustgarten and Elhai
(2018) capture the complexities of technology’s entry into
psychological practice and identify several elements of tra-
ditional practice that are most significantly influenced:
training, ethics, legal aspects, and technology.
1 | TRAINING
The lead article notes that formal training is not required
by the Standards of Accreditation for Health Service
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Psychology (APA, 2015) and is not informally taught in
psychology graduate programs. Lustgarten and Elhai
(2018) are unequivocally correct on the first point; we are
equivocal on their second point as virtually no research has
been conducted on informal training practices.
At the same time, telepsychology is defined as an
extension of traditional practice and research rather than a
specialty area. The discipline-specific knowledge, profes-
sion-wide competencies, and learning/curriculum elements
required by accreditation (e.g., ethics, assessment, interven-
tion, diversity, research) are those that are necessary to
minimally function as a licensed psychologist. Forensics,
neuropsychology, and consulting psychology, for example,
are variations from general practice that require training
beyond what is required to competently practice as a psy-
chologist. That is, telepsychology is not meant to apply to
a discrete category of psychologists differently than all
licensed psychologists. In fact, the major concerns of com-
petence, standards of care, confidentiality, storage and
transmission, boundaries, and welfare of others voiced by
Lustgarten and Elhai (2018) are key elements of the APA
Ethics Code (2017)for all professional activities. Telepsy-
chology is an extension of these existing standards rather
than a new area of practice and research. Interjurisdictional
practice is the sole exception.
What does this framing mean regarding clinical train-
ing? It is certainly reasonable that telepsychology be taught
in graduate programs, and Lustgarten and Elhai (2018)
assert that the subject should, in fact, be included in
doctoral-level ethics courses.
Psychologists can still practice without the ancillary use
of telepsychology with the exception of use of the
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| CAMPBELL
telephone. Use of telecommunications is still a choice and
not an integral part of practice, which largely explains the
absence of telepsychology in required training.
The internship training experience, however, typically
includes telecommunications. Psychology interns are rou-
tinely taught the types, complexities, and methods of
telepsychology. For example, the Veterans Administration
in Seattle, Washington deploys mobile videoconference
units to the northwestern part of the state in service to the
Native American populations. The VA psychologists and
interns located in Seattle remotely provide the psychologi-
cal services from their offices. The VA, the Department of
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Defense, and major medical centers are examples of train-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ing sites that include telepractice and in the process obvi-
ously train students on the job.
Licensed psychologists often expand their scope of
practice in their careers well after completion of formal
graduate training. Education in technology will take a simi-
lar path as those expanding their scope of practice into
working with children, conducting neuropsychological
assessments, or treating eating disorders. Most frequently,
these new competencies are gained through continuing edu-
cation, consultation, and/or supervision.
A psychologist developing a new competency would
typically undergo extensive continuing education (e.g.,
workshops, webinars) and acquire consultation or supervi-
sion for initial practice in the new competency. The consul-
tation or supervision for practice in telepsychology would
typically include ensuring clinical competence via telecom-
munication as different from in-person services and ensur-
ing competence in security for transmission and storage of
data.
Lustgarten and Elhai (2018) correctly note the absence
of formal education for telepsychology. The day may well
come when psychologists cannot practice without telepsy-
chology. At that time, their recommendation for required
training may be realized, but that day is not upon us yet.
2 | ETHICS
Lustgarten and Elhai (2018, pp. 19–20) assert that “the
American Psychological Association has not yet outlined
standards of care, competencies, or expectations for train-
ing. . ..” We sharply disagree; those authors do not see
what we see—literally. We believe that organized psychol-
ogy has proactively responded to technology in mental
health and that APA has indeed outlined those considera-
tions, in 2013.
In that year, APA adopted the Guidelines for the Prac-
tice of Telepsychology, which unfortunately are not refer-
enced in the lead article. Guidelines must be specific
enough to be useful, yet broad enough to apply to all
AND NORCROSS
psychologists practicing in the guideline area. The guideli-
nes, in keeping with the aim of telepsychology as an
extension of conventional practice, address (a) standards of
care, (b) competency, (c) informed consent, (d) confiden-
tiality, (e) security and transmission of data, (f) disposal of
data, (g) testing and assessment, and (h) interjurisdictional
practice. The first seven telepsychology guidelines have
corresponding ethical standards in the APA Ethics Code
(e.g., competence, confidentiality, informed consent). The
intention of this framework is to reinforce psychologists in
maintaining their core adherence to in-person standards of
care while being aware that telepractice might affect any of
these standards.
For example, how does telepractice effect informed con-
sent? One would retain the elements of an in-person
informed consent and add content addressing (a) remote
emergency services, (b) billing variations from in-person
service, (c) confidentiality limitations not applicable to in-
person services, and (d) means of storing and disposal of
e-mails, texts, and videoconferences. These and other ethi-
cal principles are addressed in APA’s A telepsychology
casebook: Using technology ethically and effectively in
your professional practice (Campbell, Millan, & Martin,
2018).
Guidelines are meant to assist psychologists in achiev-
ing best practices and standards of care, yet are not
enforceable. Increasingly, states are incorporating these
guidelines in whole or in part into their rules and regula-
tions, which are then enforceable.
APA has also been centrally involved in telepsychology
in other ways, such as alerting its members, publishing
books, and offering webinars. A major revision of the APA
Ethics Code is underway. Most assuredly, telepsychology
will have a more developed presence in the new code than
is currently the case.
Lustgarten and Elhai (2018) raise important aspects of
competence and how knowledge and skills are impacted by
the introduction of telepractice. We believe that compe-
tence expands in telepsychology into four variations:
1. Clinical competency: Diagnostic accuracy or treatment
selection may not prove as effective when practice is
conducted electronically. Psychologists cannot assume,
for example, that their DBT treatment will have the
same outcome as their in-person practice.
2. Technology competency: Psychologists are responsible
for acquiring competence in technology hardware, soft-
ware, and other devices of intended use.
3. Client/patient competency: Although psychologists are
not responsible for directly teaching clients about tech-
nology, psychologists must nonetheless be confident
that clients possess sufficient skills to participate in
telepractice given, for example, confidentiality
 CAMPBELL AND NORCROSS
requirements and security concerns (e.g., firewalls,
encryption, password protection).
4. Cultural competency: Psychologists must assess the
effect of language, family involvement, cultural prac-
tices, and contextual beliefs that can be altered when
not face to face.
We congratulate Lustgarten and Elhai (2018) for elo-
quently discussing standards of care within their section on
“Welfare.” When services are conducted remotely, psychol-
ogists no longer have control of the environment. External
factors are uncontrolled, yet psychologists are responsible
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for maintaining standards of care in these expanded envi-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
ronments. Following are three examples of Lustgarten and
Elhai’s (2018) observations:
1. Emergencies: Psychologists are familiar with emergency
services for their in-person practice; however, when the
client is in a remote location, psychologists remain
responsible for ensuring clients are familiar with their
local services.
2. Immediate environment: Are there other people in the
room? Are there distractions (e.g., pet and television
noise from outside the room)? Is the technology device
shared by others in the household? Could someone else
in the house be listening?
3. Best practices: Is telepractice the best choice for the
client? Psychologists assess whether a particular client
will benefit as much from treatment electronically as
in person. Client factors include diagnostic considera-
tions, interpersonal competences, willingness and abil-
ity to engage in the treatment plan, and technological
savvy.
We respectfully disagree with Lustgarten and Elhai
(2018) on a particular point regarding confidentiality. They
present confidentiality and privacy as companion factors
several times in their article. We assert that there is virtu-
ally no privacy in electronic communication and only lim-
ited confidentiality, which would need to be defined in the
informed consent. Further, confidentiality is a commitment
by psychologists not to reveal information received from
clients. Privacy is a term born of the Fourth Amendment to
the U.S. Constitution and refers to the right to be secure in
one’s person, house, papers, and effects against unreason-
able search by the government. Privacy certainly is relevant
to unwarranted wiretapping, hacking personal information,
and other intrusions; however, information introduced into
a public electronic forum (e.g., Facebook, Twitter) is not
secure.
We commend Lustgarten and Elhai (2018) for their
thorough discussion of the importance of choosing hard-
ware, software, and other technology-based tools that
| 3 of 5
comply with federal regulations. Moreover, we congratulate
them for alerting readers to the variable level of security
offered by the third-party providers (e.g., Apple, Google,
Microsoft) and advising them to use dedicated hardware
and software only for service sessions. These recommenda-
tions are among the most important considerations in
telepsychology.
3 | LEGAL ASPECTS
Lustgarten and Elhai (2018) identify federal policies and
regulations that impact psychological services, primarily
the Health Information Privacy and Accountability Act
(HIPAA), the Health Information and Technology for
Economic and Clinical Health (HITECH), and the Fam-
ily Educational Rights and Privacy Act (FERPA). The
purpose of these regulations is to safeguard the access,
maintenance, and transmission of Protected Health Infor-
mation (PHI). Protected Health Information includes
health status, provision of health care, payment for health
care or information collected by psychologists. Under-
standing of these requirements is essential in meeting the
standards of care. These regulations must also be met by
psychologists who are not engaging in telepractice but
who transmit client health information to insurance com-
panies electronically.
Psychologists are rightfully concerned about the legali-
ties of telepractice pertaining to jurisdictional boundaries
and the right to practice. Currently, all states but one allow
temporary practice if a psychologist or patient is in that
remote state (one in which the psychologist is not
licensed). Temporary practice typically is defined as
30 days. Although the American Medical Association has
determined that services take place in the location of the
patient, the location of practice or service delivery, as
determined by the Association of State and Provincial Psy-
chology Boards (ASPPB), is the location of the psycholo-
gist, not the client. Further, most states have either
reciprocity or an endorsement status in which psychologists
who are already licensed in good standing in another state
will receive expedited processing.
The ASPPB is developing an interstate agreement and
network titled Psychology Interjurisdictional Compact
(PSYPACT, www.asppb.net/page/PSYPACT). When
enacted by at least seven states, PSYPACT-participating
licensing boards will allow psychologists living in any the
participant jurisdictions to telepractice in any of the other
states with only a license in one of the states. In-person
practice would continue to require a license in the jurisdic-
tion where the client resides. These efforts by ASPPB, sup-
ported by the APA Practice Organization, are intended to
facilitate the practice of telepsychology.
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| CAMPBELL
4 | TECHNOLOGY
The incorporation of technology into practice is a signifi-
cant undertaking and involves complex, specific risk man-
agement practices over and above in-person practice.
Below we punctuate a few areas of technology considera-
tion.
4.1 | Security
Lustgarten and Elhai (2018) thoroughly describe the cen-
trality and means of securing data transmissions. Their arti-
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cle highlights the use of encrypted e-mail and other
This document is copyrighted by the American Psychological Association or one of its allied publishers.
methods of preventing access to data. Nonsecure networks
(such as those available in public locations) are vulnerable
as well as nonpassword-protected WiFi. Use of public
Internet cafes and smartphones in public locations substan-
tially increases access by third parties. The lead article pro-
vides a table of recommendations for use of technology in
practice and research that addresses each of these vulnera-
bilities.
4.2 | Telepsychology methods
Videoconferencing is far superior to other nonvisual means of
telepractice and will prove the probable goal for psychologists
planning to have a telepractice. The majority of psychologists
who use e-mail and texts espouse to only use these for infor-
mational purposes (e.g., appointments). A recent informal poll
of the Association of Psychology Training Clinics members
asked whether training clinics allowed the use of texting.
Approximately 25 clinical directors answered “absolutely
not” and three answered “yes with restrictions.”
We return to Lustgarten and Elhai’s (2018) sagacious
warning about losing control when the practice leaves the
office and enters the external environment. Information and
communication are now only a click away. Consider the
case of a psychologist with a written policy of only accept-
ing texts over the weekend if an appointment needs to be
changed. If that psychologist received, over the weekend, a
client text with a suicidal or homicidal threat, the fact that
the client went beyond the therapist’s parameters would
probably not be convincing in a negligence or malpractice
suit. Pandora’s (electronic) box has been opened.
4.3 | Social media
Social media is a blessing and a curse, but mostly a curse
from an ethics perspective. Those entering the profession
of psychology who have grown up with social media com-
munication are challenged to superimpose confidentiality,
secure communication, and multiple roles over the open
access to which they have become accustomed.
AND NORCROSS
We ask our graduate students to respond to this state-
ment, “Social media exists for the purpose of self-disclo-
sure.” Most students disagree initially and offer examples
of receiving news via apps, and it is true that many people
receive news from Facebook (even if initiated by Russian
operatives). After we note that receiving news is unidirec-
tional and not interactive, the student discussion soon turns
to the subject of self-disclosure. Psychologists who did not
grow up with social media typically superimpose electronic
communication over a sound foundation of ethical practice
and may struggle with the technology. By contrast, those
already steeped in technology typically struggle with pull-
ing in the reins on open access in their communication to
incorporate ethics and standards of care into their profes-
sional practices.
5 | CONCLUDING THOUGHTS
Love it, hate it, or terminally ambivalent about it, technol-
ogy is here to stay in mental health practice and research.
We commend Lustgarten and Elhai (2018) for comprehen-
sively explicating both the virtues and the risks of telepsy-
chology and sagely offering recommendations for
countering many vulnerabilities. Contrary to their state-
ments and implications, however, we are convinced that
organized psychology through APA has proactively
responded to telepsychology and will continue to do so. In
the end, the purposes of both the lead article and this com-
mentary are to inform clinical psychologists in their consid-
eration of telepsychology and to enhance their effective
care of patients.
CONFLICT OF INTERESTS
The authors have no conflict of interests to disclose.
ORCID
John C. Norcross http://orcid.org/0000-0002-4078-7333
REFERENCES
American Psychological Association (2013). Guidelines for the prac-
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American Psychological Association (2015). Standards of accredita-
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ed/accreditation/about/policies/standards-of-accreditation.pdf.
American Psychological Association (2017). Ethical principles of psy-
chologists and code of conduct. Retrieved from www.apa.org/
ethics/code/ethics-code-2017.pdf.
Campbell, L. F., Millan, F., & Martin, J. N. (2018). A telepsychology
casebook: Using technology ethically and effectively in your
 CAMPBELL AND NORCROSS | 5 of 5

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Association. https://doi.org/10.1037/0000046-000 How to cite this article: Campbell LF, Norcross JC.
Lustgarten, S. D., & Elhai, J. D. (2018). Technology use in Do you see what we see? Psychology’s response to
mental health practice and research: Legal and ethical risks. technology in mental health. Clin Psychol Sci Pract.
Clinical Psychology: Science and Practice. https://doi.org/10. 2018;25:e12237. https://doi.org/10.1111/cpsp.12237
1111/cpsp.12234
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.