Part Part Vii Manual 2day Certified Clinical Telemental Health Provider Training

Rehab Kids
2-Day Certified Clinical

Telemental Health
Provider Training
A Therapist Guide for Ethical,
Legal and Technology Concerns
when Using Teletherapy
Melissa Westendorf, Ph.D., J.D.
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2-Day Certified Clinical
Telemental Health
Provider Training
A Therapist Guide for Ethical,
Legal and Technology Concerns
when Using Teletherapy
Melissa Westendorf, Ph.D., J.D.
Rehab Kids
ZNM056740
7/20
Copyright © 2020
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192pp
7/20
Rehab Kids
MATERIALS PROVIDED BY
Melissa Westendorf, Ph.D., J.D., is a clinical and forensic

psychologist and founder of the Technology Wellness Center. As
a clinician, she has provided therapy to adults and adolescents
in the community and within the correctional setting. Dr.
Westendorf’s forensic practice is dedicated to assessing adults
and youth in either the criminal justice system or in civil matters.
As a technology wellness expert, she is dedicated to assisting
parents, children, adolescents, and adults on understanding the
complexities of technology use and the impact on our brains,
emotions, and interpersonal relationships. Dr. Westendorf’s
legal training coupled with her clinical background enables
her to work with individuals who are experiencing the legal
ramifications of technology use.
As a proactive psychologist and educator, Dr. Westendorf is a

keynote speaker at academic institutions, parent organizations,
businesses, and community groups, offering preventative tools
and resources that educate others on how to manage technology
use in a healthy manner. She is the co-author of Unplug! Raising
Kids in a Technology Addicted World. She has served on the
committee for legal issues for the American Psychological
Association and on the Psychology Examining Board for the
state of Wisconsin. Dr. Westendorf has been appointed as an
expert in high profile legal cases, featuring the psychological
ramifications of technology use. Her expertise has been relied
upon in a wide variety of articles, podcasts, radio segments,
and television programming. She has been featured on NPR
(National Public Radio), Wisconsin Public Radio, and ABC’s
20/20. She is a monthly contributor to The Morning Blend.
Speaker Disclosures:
Financial: Melissa Westendorf is a founder of the Technology Wellness Center. She is in private
practice. Dr. Westendorf receives a speaking honorarium from PESI, Inc.
Non-financial: Melissa Westendorf is a member of the American Psychological Association.
Materials that are included in this course may include interventions and modalities that are beyond the
authorized practice of mental health professionals. As a licensed professional, you are responsible for
reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of
practice in accordance with and in compliance with your professions standards.
Telebehavioral Health
2-day Certification Course
Melissa J Westendorf, J.D./Ph.D.

drmelissapesi@yahoo.com
 “Materials that are included in this course may include

interventions and modalities that are beyond the
authorized practice of mental health professionals. As
a licensed professional, you are responsible for
reviewing the scope of practice, including activities
that are defined in law as beyond the boundaries of
practice in accordance with and in compliance with
your professions standards.”
1
The struggle is real
Who am I?
 1992 – University of Iowa, B.S. in Psychology
 1995 – Licensed in Bartending in Pennsylvania
 1999 – Villanova School of Law (JD)
 1999 – Licensed in law in Wisconsin
 2002 – MCP-Hahnemann University (Ph.D.)
 2003 – Licensed in psychology in Wisconsin
2
Who am I really?
 Corrections psychologist
 Forensic psychologist
 Technology Wellness
3
Conflict of Interest
 I am not influenced, funded, employed, or affiliated
by any organization or entity presented.
 Publications mentioned in this program are for

reference and not designed to advertise or promote
sales of said publications.
 There is no financial connection to any

publications, programs, or apps mentioned.
 Most importantly (and disappointingly) I am not

sponsored by any lucrative industry
Questions During
Chat
Q&A
Raise hand
drmelissapesi@yahoo.com
4
Telemental health is
here to stay
 More people are seeking medical, including mental
health information online
 80% of Internet users, 93 million Americans, have
searched (Pew Internet & American Life Project 2019)
 Up from 62% in 2001
 Most Americans are 0pen to counseling

 42% have seen counselor at some point
 Millennials and Gen Xers have more interest than
Boomers and Elders
 https://www.barna.com/research/americans-
feel-good-counseling/
……… here to stay

 Up to 12% of people find therapist on the Internet
(2017)
 Affordability, Expertise, and Years of Experience are

three top considerations (46%, 42%, and 34%)
 Decreasing stigma (sort of) – 34% of millennials

report that mental illness brought them to therapy.
Lower for older generations
 Nearly half of those in therapy report a very

positive experience
https://www.barna.com/research/americans-feel-good-counseling/
5
It works
 2017 Meta-analysis indicated that telepsychology
or teletherapy can be just as effective as in-person
therapy.
 Improves patient satisfaction
 Reduces costs
 Related technologies are useful in diagnosing and
treating
 What do you think are the pros and cons of

telemental health?
Langarizadeh, M., Mohsen, S.T., Tavakol, K., et. al (2017)

www.ncbi.nlm.nih.gov/pmc/articles/PMC5723163/
Who Benefits?
 Rural patients
 Patients who move or Patients who travel a lot
 Busy professionals
 Young adults and Seniors
 Government and Privately insured
https://blog.sprucehealth.com/time-adopt-telemental-health-risk-losing-9-patients/
6
Benefits in therapy
 Forced to verbalize interpretation of nonverbals in
therapy
 More verbal explicitly with empathy

 Enhanced connection because part of their life in
the home
 Can meet significant family members

 Can foster connections
 Treatment completed in setting skills will be used
Benefits to therapy
 Direct data collection – such as view the bedroom if
sleep problems
 Can increase the dose more flexibly

 Access data not previously available
 Flexibility of location
 Increased sense of satisfaction
 More willing to share information if not eye-to-eye
(think Freud)
7
It Works in Application
 Clinical interviews
 Psychological testing
 Therapy
 Clinical supervision
 Case consultation
 CEU
 Research
It works, but………
 Skills
 Investment
 Subscribing to internet services, intermittent services
 Regular evaluation of services and delivery
 Reimbursement
 Unclear quality control
 Marginalizing patients who can not use tech
 Ethical concerns about privacy
8
Topics Covered
 Ethics Codes/HIPAA/Statutory Guidance

 Equipment Considerations for Telebehavioral Health
 Equipment/Policies
 Procedures/Platforms
 Clinical Considerations for Telebehavioral Health

 Client/Therapist Boundary issues
 Cultural Competence
 Administrative Issues related to Telebehavioral Health

 Social Media and Boundary Problems
 Record Keeping/Destruction
 Reimbursement
Terminology
 Asynchronous/Synchronous
 Electronic communication
 Encryption
 HIPAA compliant (Covered Entities and Business
Associates)/HITECH – Health Information Technology
for Economic and Clinical Health Act of 2009/PHI/ePHI
 Telehealth/telemental
health/telepsychology/teletherapy
 Originating Site (patient)
 Distance Site (provider)
9
Relevant Language
 Code of Ethics
 Statutory Language
 Federal
 State
Remember!
All existing laws (state and federal) and ethical

standards (per profession) apply to telebehavioral
practice – the only difference is the delivery
10
Relevant Associations
 American Psychological Association
 American Counseling Association
 National Association of Social Workers
 American Association of Marriage and Family
Therapists
 American Psychiatric Association

 American Telemedicine Association
Relevant Codes or Guidelines
 APA – Guidelines for the Practice of Telepsychology

 NASW – Technology in Social Work Practice
 ATA – Practice Guideline for Video-Based Online Mental
Health Services
 ACA – Code of Ethics, Section H – Distance Counseling,
Technology, and Social Media
 APA – Best Practices in Videoconferencing-Based
Telemental Health (April 2018) (Joint effort with ATA)
 AMFT -Teletherapy Guidelines.
11
APA Screenshot
https://www.apa.org/pubs/journals/features/amp-a0035001.pdf
Common Guidelines
 Competence
 Standards of Care in the Delivery
 Informed Consent
 Confidentiality of Data and Information
 Security and Transmission of Data and Information
 Disposal of Data and Information and Technologies
 Testing and Assessment
 Interjurisdictional Practice
APA Guidelines for the Practice of
Telepsychology 2013
12
NASW
https://www.socialworkers.org/includes/newIncludes/homepage/PRA-
BRO-33617.TechStandards_FINAL_POSTING.pdf
Common Guidelines
 Provision of Information to the Public

 Designing and Delivering Services
 Gathering, Managing, and Storing Information
 Social Work Education and Supervision
NASW, ASWB, CSWE, & CSWA Standards for Technology in Social Work
Practice, 2017
13
ATA
APA
ATA
14
AMFT
AMFT
15
Ethical Principles
 Beneficence and Nonmaleficence
 Fidelity and Responsibility
 Integrity
 Justice
 Respect for People’s Rights and Dignity
Ethical Principles of Psychologists and Code of Conduct

Copyright 2017 American Psychological Association
Beneficence and Nonmaleficence
 …strive to benefit those with whom they work and

take care to do no harm … When conflicts occur
among psychologists’ obligations or concerns, they
attempt to resolve these conflicts in a responsible
fashion that avoids or minimizes harm …
16
Fidelity and Responsibility
 …establish relationships of trust with those with
whom they work … uphold professional standards
of conduct, clarify their professional roles and
obligations, accept appropriate responsibility for
their behavior, and seek to manage conflicts of
interest that could lead to exploitation or harm …
strive to contribute a portion of their professional
time for little or no compensation or personal
advantage.
Integrity
 …seek to promote accuracy, honesty, and
truthfulness in the science, teaching, and practice
of psychology … do not steal, cheat or engage in
fraud, subterfuge, or intentional misrepresentation
of fact …have a serious obligation to consider the
need for, the possible consequences of, and their
responsibility to correct any resulting mistrust or
other harmful effects that arise from the use of
such techniques.
17
Justice
 …fairness and justice entitle all persons to access
to and benefit from the contributions of psychology
and to equal quality in the processes, procedures,
and services being conducted by psychologists …
exercise reasonable judgment and take precautions
to ensure that their potential biases, the
boundaries of their competence, and the
limitations of their expertise do not lead to or
condone unjust practices.
Respect for People’s

Rights and Dignity
 …respect the dignity and worth of all people, and
the rights of individuals to privacy, confidentiality,
and self-determination …are aware of and respect
cultural, individual, and role differences, including
those based on age, gender, gender identity, race,
ethnicity, culture, national origin, religion, sexual
orientation, disability, language and socioeconomic
status, and consider these factors when working
with members of such groups…
18
Application of Ethics
and Guidelines
*VA hospital
*traveling nurse, former military, service-connected
disability
*PTSD, anxiety
*married, no children
*interested in treatment
*resides in rural Idaho
*satellite VA center close to home
Ethics
 Beneficence/nonmaleficence – looking up the research
for using technology
 Fidelity and Responsibility – working within the VA
system, establishing a professional relationship
 Integrity – is there an evidence base for working with a
particular population – PTSD, PE, etc.
 Justice – rural – underserved population, travelers, won’t
go outside expertise with PTSD treatment
 Dignity and Rights – individual factors, including
cultural, SES, demographics, etc.
19
Evidence Based*
 Delivery of services (it works)
 Type of services (video, email, etc.)
 Methodology (CBT)
 Patient population (suicidal men)
 Patient diagnosis (PTSD)
Document document document
*sometimes anecdotal or case review
Tech appropriateness
 Literature review of treating PTSD with VT
 Type of therapy – prolonged exposure
 Patient interest
 Use best practice from appropriate guidelines
 Home or satellite clinic
 Traveling nurse (out of state/in state) state codes
 Individual factors (cultural, SES, communication)
 PTSD factors that are high risk
20
Competence
How To Build Competence

 Informal Training – CE – PESI 1-day seminar
 Formal Training – certificates through universities
or online education systems – e.g., this course
 Read Books – I have some referenced at the end

 Peer-Reviewed Literature
 Popular Media – such as reviews of
software/hardware/3rd party providers
 Clinical/Peer Supervision
21
Master Experts
Shifting Gears
Reminder
 Privacy – held by the client and it is their right to

keep their information private
 Confidentiality – what the client gives us and we are

duty bound to protect it
22
HIPAA - 1996
 Any company or individual that comes into contact
with PHI must enact and enforce appropriate
policies, procedures and safeguards to protect
data.
 HIPAA violations occur when there has been a

failure to enact and enforce appropriate policies,
procedures and safeguards, even when PHI has not
been disclosed to or accessed by unauthorized
individual
https://www.hipaaguide.net/hipaa-for-dummies/
Covered Entity
www.cms.gov
23
Flowchart
24
HIPAA - The Rules
 Privacy Rule - how, when, and circumstances PHI
can be used and disclosed
 Security Rule – sets minimum standards to
safeguard ePHI
 Breach Notification Rule – DHHS notified if breach
 Omnibus Rule – activated HIPAA-related changes
from HITECH Act (2013)
 Enforcement Rule – how investigations are carried
out
Privacy Rule
 PHI = “individually identifiable health information” held
or transmitted by a Covered Entity or it’s Business
Associates
 Permits flow of information for high quality health care

while protecting the public’s health and well-being
 Covered Entity = Providers who submit HIPAA

transactions, like claims, electronically are covered.
 Business Associates = If provider uses a third party to

help carry out health care functions then need BA
contract or agreement
https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
25
Security Rule
 Ensure confidentiality, integrity, and availability of
all ePHI they create, receive, maintain or transmit
 Identify and protect against reasonably anticipated

threats to the security or integrity of the
information
 Protect against reasonably anticipated,

impermissible uses, or disclosures
 Ensure compliance by their workforce
https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html
Security Rule
 Meant to be flexible due to small and large entities

covered
 The information that must be protected is

“individually identifiable health information,”
transmitted electronically, called ePHI
26
HITECH
 Signed by Obama in 2009 and provided for the
anticipated expansion of electronic records and
ePHI in the future. It expanded the scope of
privacy and security protections and increased the
potential legal liability for non-compliance with
more stringent enforcement.
 Looking for neglect and willful neglect

 Increased penalties and extended to BA
 Provided incentives for large orgs to transition EHR
HITECH – 2009
 Breach notification
 Electronic Health Record Access
 Business Associates and BA Agreements
 3rd party companies to help with HIPAA and
HITECH compliance.
27
HIPAA and Small Providers
OCR Summary of HIPAA Privacy Rule
FAQ
Sample Business Associate Contract Provisions
Am I a Covered Entity
Guidance on Significant Aspects of the Privacy Rule
Small providers HIPAA
https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/
small-providers-small-health-plans-small-businesses/index.html
Screen shot of the small providers

HIPAA
28
OCR and HITECH
 The HHS: Office of Civil Rights enforces HITECH
 Provides sample BAA clauses at HHS.gov
 Google OCR Sample BAA clauses
29
Personally Identifiable
 Emails are one of the 18 identifiers that HIPAA
defines as “without-a-doubt” personally identifying
 When coupled with health information, it becomes

“protected health information” and thereby
“confidential information”
 It does not violate HIPAA for a patient to send you

protected health information via unsecure tech (but
what about ethics?)
Other digitally –
related identifiers
 Device id or serial numbers

 Web url
 IP addresses
 Finger/voice prints - biometrics
 Photo images
 Anything else that could uniquely identify a patient
30
HIPAA Violations result from:
 Lack of risk analysis
 Lack of employee training
 Inadequate Business Associate Agreements
 Inappropriate disclosures of PHI
 Ignorance of the minimum necessary rule
 Failure to report breaches within the prescribed
timeframe
If you had any doubts…
31
Wall of Shame
 $1.5 million per violation/large orgs

 $10,000 - $20,000/the rest of us
 https://www.hipaaguide.net/hipaa-breaches/
32
Minimize Risk
 Only use the services you absolutely need to limit
risk
 Ensure you utilize HIPAA compliant products

 Do not shortcut a process just because it is
cumbersome
 Develop written policies!

 We do this to protect our client’s/patient’s privacy!
HIPAA Under Covid-19
33
34
Statutory/Regulatory Guidance
THE LOCATION OF THE CLIENT IS CONTROLLING
OTHERWISE:
 No cohesive system either between states or within states

(interjurisdictional or intrajurisdictional)
 Some statutes are silent, others are not
 Some statutes contradict other statutes within state
 Consult case law – good luck with that!
 International applicability?
35
States’ Interests
 Protect the consumer or state’s residents
 Keep out spoiled fruit
 Have standards of practice
 Good old turf wars
 Out of sync with this fast pace movement of
technology
 While you might be regulated for practice in your
state you also need to follow the laws of the state
of the client
Consumers’ Interests
36
Idaho
 Telehealth Act

37
Wisconsin
38
Arizona
39
40
Risk Management Guidance
 Does relationship derive from patient initiative or
from psychologist advertising across state lines?
 Rationale that telepsychology is at least equal or
superior to a referral for in-person in patient
jurisdiction?
 Take reasonable steps to ensure competence of
work and protect clients from harm (e.g.,
guidelines)?
 Conducted a conservative assessment that nothing
contraindicates telepsychology?
41
 DeMers, S.T., Harris, E.A., & Baker, D.C. (2018)
Interjurisdictional Practice, In Campbell, L.F.,
Millan, F., Martin, J.N. (Editors) A Telepsychology
Casebook: Using Technology Ethically and Effectively
in Your Professional Practice(pp.141-164).
Washington D.C.:APA.
Statutory reference
interjurisdictional practice
2013 APA 50 State Slides
https://www.apaservices.org/practice/advocacy/state
/telehealth-slides.pdf
42
50 State Slides
Iowa
43
Kentucky
Colorado
44
Attempts to Resolve
PSYPACT – ASPPB
 https://www.asppb.net/page/PSYPACT
 https://www.asppb.net/mpage/micrositehp
PSYPACT
Taskforce
Advisory Group
Drafting Team
PSYPACT Advisory Group
https://www.asppb.net/mpage/background
45
Documents
https://www.asppb.net/mpage/charters
E.Passport
 Quick Guide
 Promotes standardization in the criteria of

interstate telepsychology practice and facilitates
the process for licensed psychologists to provide
telepsychological services across state lines in
states that accept E.Passport
46
47
Successes/Failures/???
 STEP (2011)
 VETS Act of 2017 (2018)
 Medicare Telehealth Parity Act (2017)
 CONNECT for Health (2019)

 Permits waivers for telehealth restrictions during national and public health emergencies
 Includes home
 Mental and Behavior Health Connectivity Act
 Telehealth Addiction Services: TREAT Act
 Increased Broadband for Telehealth Reform
 BECOME AN ADVOCATE?
Checklist of Questions
 Check state law of location of client*
 Check in with that state’s Board (get in writing)
 Check your state law if you can practice out of
state without license
 Ask insurance carrier (get in writing)

 Follow procedure available in law (50 State Slide)
 Iowa example
*and for what services
48
Ask, ask, ask !!!
International Practice
 Some foreign soil has licensing regulations
 Call
 Licensing board of foreign soil
 Embassy
 Regulatory association
 Document all of above at least indicating you tried

to get the answer -- “reasonable professional”
49
Ethics Scenario
 You are providing therapy to a 17-year-old anxious
female. You have seen her for about 3 years and
have you have a great relationship. She is
productive in therapy and has made great strides in
reducing anxiety. In fact, she is now going to
college 1000 miles away (Colorado) and she wants
to continue to meet with you for therapy. You are
unsure, but she argues that she wants to continue
her progress and not “start all over again.” How do
you decide if you should pursue the option? If you
go ahead, then what?
Best Risk Management

 Stay within expertise
 Practice with evidence based procedures
 Remain HIPAA compliant
 Practice within malpractice insurance guidelines
 Statutory language or Board interpretation of language
 Run it by an informed telehealth attorney
Document document document
50
Equipment Recommendations
Telebehavioral Health
 Match technology to needs

 Tech must meet privacy standards (HIPAA/State)
 If good fit for client and therapist
 Supported for use with evidence-based
protocols/outcomes
 Show me the money
For Late Career Professionals
51
American Telemedicine
Association (ATA)
Practice Guidelines for Video-Based

Online Mental Health Services
Clinical Guidelines
Technical Guidelines
Administrative Guidelines
https://www.integration.samhsa.gov/operations-administration/practice-
Guidelines-for-video-based-online-mental-health-services_ATA_5_29_13.pdf
52
Clinical Guidelines
 Professional and Patient Identity and Location
 Patient Appropriateness
 Physical Environment
 Communication and Collaboration with the Txt
Team
 Emergency Management
 Medical Issues
2013 American Telemedicine Association
Provider and Patient

Identity and Location
 Identity : Provider – credentials or registration

with verifying info/or where to go; Client – photo
id, give full name
 Location: Confirm and document location of

client for reimbursement purposes, might also be
necessary to at least document provider for
billing purposes as well.
53
Why Identity and Location is important
 Provider and Patient Location Documentation

 Confirm where patient receiving services
 For licensing laws application – where services received
 For emergency services
 Mandatory reporting
 Provider payment
 Contact Information Verification

 Verification of Expectations – Contact Btw Sessions
Between Session Expectations

 Have to establish expectations
 What are response expectations
 24 hours
 Same day
 Within 2 days
 Phone or electronic
 Discussion of emergencies between sessions
54
Clinical – Patient Appropriateness
 Evidence base for using videotechnology
 Settings without staff
 Tech capability
 Cooperativeness and location for safety issues
 Ability to benefit from video teletherapy
 Risk factors
 Patient comfort
 Discussed in next section
Clinical - Physical Environment

 Want comparable professional specifications of a
standard services room
 Ensure privacy for both

 If someone present in either room, their presence
should be made known, code words if necessary
 How much is on screen – test out to see what can

be seen behind you and of the patient
55
Clinical - Physical Environment
 Stable platform for the device
 Lighting – no light behind the person, well-lit
 At eye level
 Where’s the door?
Technical Guidelines
 Videoconferencing Applications
 Device Characteristics
 Connectivity
 Privacy
56
General information
 Computer/Mobile/Tablet with integrated system
 High(er)-end equipment for camera, microphone,
television, or computer screen
 Use reputable vendors that provide BAA’s.

 Some cool features – virtual waiting room,
integrated calendars
 Take advantage of free offers and test it out
Device Characteristics
 Use high(er) grade equipment if possible, up-to-date

virus protection and personal firewall, security
patches as well
 Device security and oversight
 Backup plan if technology breaks down
 Ex., Will call you back after 1 minute
 If backup plan does not work then move to telephonic
communication or some other platform. Might involve
back up mental health care
 Cameras that permit movement and rotation
57
Other Considerations
 Large enough screen?
 Where is the camera?
 Do you have more than one screen?
 Can you hear adequately?
 Can you see enough of the person?
 Good resolution/Good lighting?
 Microphone
Other Considerations
 Do you want to view person and documents?
 Picture-in-Picture (PIP)?
 What’s your back-up?
 Noise cancelling products?
58
Administrative Guidelines
 Qualification and Training of Professionals

 Documentation and Record Keeping
 Payment and Billing
Qualification and Training

of Professionals
 Clinical, legal, and ethical training
 Proper conduct of videoconferencing
 Care consistent with jurisdictional licensing laws
and rules for their profession. Home and
Distance
 Contact licensing board to review practice

before starting the provision of any services.
Home and Distance
59
Connectivity
 Bandwidth – 384 Kbps or higher in each of the
downlink and uplink directions
 640X360 resolution at 30 frames per second

 Research preferred providers
 Pre-test the link before first session
 Use wired connections if possible
 Videoconference software should be able to adapt
to changing bandwidth
Telepractice
Procedural Recommendations
 In person (Best Practice)
 First session is the intake session
 Do everything just like you normally do
 Discuss the relevant forms for telebehavioral practice
 Some statutes require intake to be conducted in person
 Via videoconference
 First schedule a brief videoconference session
 Then send videoconference forms (securely) for patient to
review and sign, so you can do the first test run session
 Find program that does electronic signature or equivalent,
if no printer available – Docusign, SignNow, Hushmail
60
Via Videoconference –
The first session
 Discuss the videoconference consent forms
 Test out all the technical aspects
 Sight – how far away from device
 Sound – earphones
 Lighting – no light behind, well lit
 What they will see on the screen
 Help them troubleshoot
 This will help clarify if this is a good fit for the patient
 Remember some of this might not be billable, so check
with payer
Via Videoconference –
The first session
 Earphones – if someone on the other side of the door
only hear one side
 Take off notifications
 Dress professionally, yes with pants/skirt
 Put image on the top of the screen
 Eye level – prop with books
 No multitasking
 Limit surrounding noise
 Background noise (dog, street, mechanical equipment)
61
The first session
 Increase animation
 Backdrop
 No eating
 Camera enlarges hygiene issues
 Jewelry jingling, glare from glasses/bald head, loud
clothing
 Rocking in chair, twisting hair, other idiosyncrasies
Intake Requirements
 Standard Forms – No short cuts

 Informed Consents – one IC or IC plus
telebehavioral health addendums
(dynamic/evolving)
 Clinical Interview
 Future plan
62
Informed Consent
 Should be conducted in-person, in real-time.

 Need signatures
 All the same content as in-person informed consent
 Separate document or addendums
Ethics Code
 2013 Guidelines
…strive to obtain and document informed consent
that specifically addresses the unique concerns related
to the telepsychology services they provide. When doing
so, psychologist are cognizant of the applicable laws
and regulations, as well as organizational requirements
that govern informed consent in this area.
…reasonable efforts to use language that is reasonably

understandable to their clients/patients, in addition to,
…
63
Ethics Code
…those unique concerns that may be involved in

providing telepsychology services, psychologist may
include the manner in which they and their
clients/patients will use the particular
telecommunication technologies, the boundaries they
will establish and observe, and the procedures for
responding to electronic communications form
clients/patients.
IC: Key Topics
 Confidentiality and limits (next slide) in electronic

communication
 Agreed upon emergency plan

 Documentation process and storage
 Technical failure scenarios
2013 ATA Guidelines
64
IC: Key Topics
 Coordination of care with other professionals

 Between session contact protocol
 Termination conditions and when referral for in-
person
2013 ATA Guidelines
IC: Limitations
 Emerging field
 Miss some nonverbal cues (ex., telephone)
 Electronic communications might be missed
 Response time delayed
 Need for at least minimal technical specification
 Misdirected information
 Lack of privacy for client’s email on their end
65
Sample I.C.
Sample Telepsychology Informed Consent
Review your state’s informed consent requirements

and then add the telemental health components
66
67
Other IC considerations
 Must have a discussion about the IC
 This should be an ongoing assessment of the IC
 Patients will not reveal unless asked and then they
might not share
Emergency management
considerations
 Education and training

 Jurisdictional mental health involuntary
hospitalization laws
 Patient safety when providing services on-site

 Patient safety when providing services in-home
 Patient support person and uncooperative patients
68
considerations
 Transportation
 Local emergency personnel
 Referral Resources
 Know local referral sources
 Community and Cultural Competence
Communication and Collaboration

 Of course this is at the discretion of the patient
 However, have to consider emergency management
considerations, especially if client has history of
suicidal ideation
 If distance is NOT at a professional site, then

coordination with either primary care physician or
trusted friend of the patient
 If patient does not agree then this might be a deal

breaker. Depends on situation
69
Medical Issues
 Have to know about medication and prescriptions
in case of side effects or change in symptoms
 Dispensation availability
 If patient has medical issues then you will want to
know local medical providers with phone numbers
language in IC
70
Service Delivery
Recommendations
 Asynchronous and Synchronous

 All-in-one platforms
 Do it yourself
 Encryption
 Passwords
 VPN – Encryption
 Hardware/Software
Overview
 Asynchronous
 Store and forward
 Text
 Emails
 Videos
 Synchronous
 Real time
 Video
 telephone
71
All-in-One Asynchronous
 betterhelp
 ReGain
 TeenCounseling
 talkspace
 Breakthrough
 Amwell
 7 Cups
 Doctor on Demand
*look for accreditation by the American Telemedicine Association
Talkspace
72
ReGain
7 Cups
73
Common elements
of these sites
 Answer questions and paired by algorithm to

therapist
 Weekly fee for unlimited messaging therapy

 Added fee for adding live sessions in some
multiplier
 HIPAA compliant or so “they” say

 Available on multiple platforms
74
Asynchronous
 Ethical obligations
 Evidence based?
 HIPAA compliant?
 BAA?
 Standards of Care
 Access to entire record?
 Access to where they are located?
 Informed consent?
 Guarantees of cures?
 No matter what, you have to comply with your ethical and

legal obligations.
Cures?
75
All-in-one Synchronous
 TheraNest
 https://theranest.com
 Itherapy
 https://itherapy.com
 Virtual Therapy Connect
 https://virtualtherapyconnect.com
 Doxy.me
 https://doxy.me
76
77
For any platform
 Vet for HIPAA/Statutory/Ethic compliance
 Look at public website – can you fulfill claims
 Who is the founder or on the Boards of the sites
 Check the research listed on the site (is it truly
evidence based)
 Conflicts of interest/pay for publishing
 Vet for how they handle emergencies
 Read therapist reviews or news articles of sites
Asynchronous Communication
in Telepractice
Pros Cons
Quick communication Less thoughtful
Responsive If don’t respond immediately
Private Not Confidential
Easy to change appointments Hacking
Easy to contact patients Short response – dismissive
Provide support A free session
78
Encrypted Services
 Basically using a secret language to send electronic
communication through the vast space of the
Internet
 If not encrypted, then all those aliens might be

able to see the words that we are sending
 To see those encrypted emails, then both parties –

therapist and client has to be in on deciphering the
secret language
HIPAA and Email Encryption

 Only have to be encrypted if beyond internal firewall
 Unless there is an authorization from a patient to send
their information unencrypted outside the protection of
the firewall
 This decision must be backed up by a risk assessment

and documented in writing. Factors to consider are
other risk mitigation strategies used in the practice
 If encrypting should use an appropriate encryption

standard. NIST recommends AES 128,192,or 256-bit,
Open PGP, and S/MIME
79
Encryption and Email
 Self encryption - Way too difficult for us to do on
our own
 Choose not to send sensitive information that might
be seen
 Ask Client if they want encryption or not (HIPAA
2013 permits choice with the client)
 Use a service – Hushmail, Protected Trust, Paubox
 Do you want to use your current email
 Start with a new email
 Use as an add-on
Encrypted Emails Services
https://www.paubox.com/solutions/encrypted-email https://www.hushmail.com/
80
The initial email contact
 Individual might provide detailed information

 Responses might be perceived as starting therapeutic
relationship
 Jurisdictional issues
 Intent to harm self
 Resolution – put a contact us form on website that

indicates for general inquiry for a phone call and to
not provide confidential information in contact us
form.
Encryption and Texting

 Starts with phone security
 Update operating system
 Set a lock screen
 Avoid USB charging stations, use USB
“condoms”
81
Encryption and Texting
 What about Secure, ala encrypted, messaging
service
 WhatsApp (owned by Facebook)
 Confide
 Signal
 iMessage
 PROBLEM – NO BAA, so not compliant
 Need HIPAA compliant texting service
OhMD
82
Tigerconnect
83
Password Protection
Helps ensure confidentiality of communication or other
materials
 Computer
 Phones
 Hard drives
 Stored files
 Communication websites
 HIPAA – must have procedures for creating, changing, and

safeguarding passwords
Don’ts and Do’s

DON’TS DO’s
 Don’t reuse passwords  Use password manager –
REMEMBER THIS PASSWORD
 Don’t write down  Use a phrase
 14A&A41dumaS
 Don’t share
 QuagmireSearsGutenCi
 Don’t use common  Sentence (first two letters)
substitutions  Common elements but
customized to site
 Don’t use common paths
 Play with keyboard
 Make it long
84
Tips for Passwords
 Check the websites you are using
 Two-factor authentication
 Use good security questions
 Change your passwords frequently – UGH
 Don’t use same password for email and e-
commerce site
 Get an antivirus program for backup
Recognizing a Good Password

 A good password?
85
Another Layer of Security –
Use a VPN
 Use a VPN – virtual private network –

 SSTP; IKEv2; and OpenVPN – best ones to look for
 Legality is where you are located
 Pay for it
 Example - NordVPN
86
All this means is …
Electronic Communication Policy
87
The Sticky Widget
SOCIAL MEDIA
88
General Social
Media Use
 Context (May 2019) – 7.7 Billion people in the
world
 4.4 Billion use the Internet

 3.499 Billion active social media users
 On average, people have 7.6 social media accounts
 On average, people spend 142 minutes on social
media
https://www.brandwatch.com/blog/amazing-social-media-statistics-and-
facts/#section-2
Social Media
 Facebook – 2,375 billion
 Instagram – 1 billion
 LinkedIn – 610 million
 MySpace – 15 million
 Snapchat – 190 million daily
 WhatsApp – 1.6 billion
 YouTube – 1.9 billion
89
Why Should We
Use Social Media
Social Media Use

Pros Cons
 Wider audience  Too broad
 Gain new clients  Constantly update
 Provide education  Negative
commentary/feedback
 Help others
 Trolls
 Showcase yourself
 Security/Confidentiality/Pr
 Learn new information ivacy
 Content expert
90
Know your audience
 Who are they?

 What do they do?
 Where do they live?
 What are their demographics?
 What are their hobbies and interests?
Social Media Adoption

by American adults
Pew Research Center
 In 2005 – 5%
 In 2011 – 50%
 Today – 72%
https://www.pewinternet.org/fact-sheet/social-media/
91
Social Media Use by Age
Pew Research Center Source: Surveys conducted 2005-2019
Social Media Use

by Gender
92
Social Media Use
by Race
Social Media Use

by Community
Pew Research Center Source: Surveys conducted 2005-2019.
93
What are people using?
How often are they using social

media?
Pew Research Center Source: Survey conducted Jan. 8 to Feb. 7, 2019

Note: Numbers may not add to 100 due to rounding
94
What does this mean?
 Facebook
 Instagram
 Twitter
Good Uses of Social Media?
95
Keep in Mind
 Confidentiality of clients
 Working with client
 Protected health information
 Boundaries between clients and therapist
Hard NO!
 Do not accept friend requests
 Do not discuss a patient/client/consumer over social
media….removing names is insufficient
 Never send direct messages over Twitter to clients. It is
not HIPAA secure AND who hasn’t accidentally sent a
text to the wrong person or posted a private comment
publicly
 No clinical discussions on social media
 BUT…..what about “likes?”
96
Responding to Comments
Remember: If from client, acknowledging
the post violates multiple regulations
1. Ignore the Post
2. Respond with generic statement that explains
practice/organization privacy rules
3. If patient identifies themselves, call off-line and
discuss to remove post
4. Contact law enforcement if threatening against
specific person
5. Can ask social media platform – but not a lot of
success there
IN THE END A LITTLE NEGATIVE

COMMENTARY LIKELY WON’T RUIN YOU
Comments on Social Media
 Business review sites – can be tricky

 Gather feedback from clients and put on social
media as collective data
 Be prepared that you might have to respond
97
Trolls
98
Boundary Issues
 Personal versus private social media accounts
 Tip – create social media accounts with different
email address to avoid coming up as suggested friend
 To Google or not to Google the client…

 28% of therapists accidentally found info
 48% intentionally found info (non-crisis) w/o awareness
 48% discussed it with client*
 Friend requests/likes
 Email lists
* Kolmes, K & Taube, D. Retrieved on 09/10/2019 from
http://drkkolmes.com/research/#.XXgpIC2ZN24
99
Social Media Policy
 Friending
 Following
 Interacting
 Use of Search Engines
 Google Reader
 Business Review Sites
 Location Based Services
 Email
www.docforeman.com/social-media-policy
Social Media Policy
100
101
102
103
A solution?
Security with
Hardware and Software
 Firewalls – Hardware and Software
 Hardware – protects the computer and the network.
Prevent others from logging into your system
 Software – added protection/controls specific network
behavior of individual apps
 Some argument that these are already built in
 Virus Protection – prevent viruses from being placed

on system
 Third Party Services
104
Hardware
 Cellphones and laptops are frequently lost or stolen
 Encryption is the key to ensure that patient
information is protected if lost or stolen
 Secure laptops at the end of the work day
 Family members should not use your work laptop
 No one else should be permitted access to your
emails
 Children and phones – if you have access to email
on your phone can your child get into it
Software
 Software should be able to block provider’s caller ID at
the request of provider
 Point-to-Point encryption
 Mobile device use – emphasize limits on privacy
 Patient contact information stored on device be
restricted
 Mobile – passphrase or equivalent to open and 2-factor
authentication if possible. Time-out features with
inactivity. In possession of provider when traveling. Have
ability to remotely wipe or disable if lost/stolen
 Videoconference – should not permit multiple
concurrent sessions
105
Software
 PHI and ePHI should be backed up to or stored on
secure data storage locations. Know cloud services
protections
 If transmission data is stored on either device, then

whole disk encryption to the FIPS standard. Pre-
boot authentication should also be used
 Discuss if sessions are recorded and ensure

encrypted storage
Client Centered Factors
 Screening and Suitability of the Client

 Boundary issues
 Multicultural Considerations
 Theoretical Considerations
106
Biggest impediment
MAKE A PLAN
107
Telehealth examples
 Assessment Online AODA questionnaire
 Treatment CBT through VC, monitoring apps
 Med manage Text message reminders for meds
 Continuity Group chats for relapse prevention
 Education Webinars for clients/providers
 Collaboration Interactive video for consultation
Example of Telehealth using Apps
 Clinical assessment/symptom monitoring

 Self-care or non-clinical behavior change and
improvement
 Informational resources
 Resource location and crisis support
 Asynchronous texting and VC apps
 Momentary assessment
108
Mobile app benefits
 Point-of-use availability
 Real-time data collection
 Patient-centered
 Integrate information through the cloud
 Lower costs
 But consider
 Needs, quality of app, security systems, pilot use,
and develop protocols
Luxton, D. D. (2018)
Benefits of Video-based telehealth*

 Increased client satisfaction
 Decreased travel time
 Decreased travel, child, & elder care costs
 Increased access to underserved populations
 Improved accessibility to specialists
 Reduced ER costs
*Maheu, Pulier, Wilhelm, McMenamin, & Brown-Connolly. (2004). The mental health professional
and the new technologies. Erlbaum, NY
109
Benefits of Video-based telehealth
 Faster decision-making time
 Increased productivity/decreased lost wages
 Decreased hospitalization utilization
 Efficacy is on par with in-person care for many
groups
Other benefits
 Enhanced connection because part of their life in the
home
 Can meet significant family members/other data not
previously accessed
 Treatment completed in setting skills will be used
 Direct data collection – such as view the bedroom if
sleep problems
 Can increase the dose/location more flexibly
 Increase in sharing (think Freud)
110
Screening/Suitability
 Evidence based support for type of client

(diagnoses, gender, age)
 Evidence based support for technology (VC, text,
email)
 Evidence based support for setting (home, prison,
hospital)
 Can you utilize the technology while maintaining
adherence to ethical standards/reimbursement
Evidence based research
111
Evidence based research
112
113
114
Patient Contraindications
 Highly anxious
 Severely depressed
 Chemically dependent
 Acting out clients
 Psychotic – recent example
115
Settings
 For the difficult client, settings are very important
 Prison
 In-patient units
 Treatment facilities
 Residential treatment home
 Day treatments
 Schools
 Home
 Identify and resolve conflicting barriers that are clinical or
administrative
 Disruptive children
 Abuser in home
 Emergency contact
116
Settings
 Develop action plans for difficult situations that
could occur across clients
 Firearms in the home
 Substance users in home
 Disruptive children
 Abusive family members
 Collaborate with colleagues on your plans
Pre-session patient education

 Discuss the technology
 In-office tutorial
 Hands on training
 Video instruction
 Handouts
 Online training program
 FAQ’s
 These help to assess whether telehealth is good fit
117
The Intake
 No shortcuts
 Complex cases might require first in-person
 Remind about technology issues that already
addressed in IC
 Identify geographic location, fully history,
medications and medical conditions, mental status,
and stability, substance use, stressors, treatment
history, support system, use of other technology,
suicidal/homicidal intent, previous diagnoses
 Clinical interview
How to begin
 Identify yourself and geographic location
 Ask client to do the same
 Audio/visual check
 Anyone in the room or within hearing distance? Tell them if
someone is in the room with you. Have them show you the
room and you can do the same
 Is there anything going on at your site that I might want to
know?
 If you hear a noise, immediately stop and address
 Remind them that the session is not being recorded and that
you have the same expectation
118
Mental status exam
 Physical description
 Might have to ask about weight and height
 Gait
 Have them walk away, spin and turn back to camera
 Have them perform tasks on camera or write down
answers and show on camera
 Know that you have to manage some aspect differently
than if in-person session
 Slurred words, speaking loudly
 Ask to put fingernails up to screen
119
Developing rapport via VC
 Lean forward to show engagement
 Be aware of visual screen
 Encourage pause or reflection to incorporate the
shifts in VC technology (two people can’t talk at
once)
 Verbalize interpretation of the non-verbals
 Explicit with empathy (no virtual tissue box)
 All your distractions are noticed and can interfere
with trust/rapport
Be mindful of
 Innuendo
 Nuance
 Colloquial expressions
 Use of tech slang
 Other comments that might reflect discomfort
120
Continuous evaluation
 Re-evaluate practicality or comfort with technology
 Interval structure
 3 telesessions
 1 in person
 Use a balancing approach
Assessment
 Advantages and disadvantages

 Utilize a balanced approach when selecting quality of
assessment and access, with close consideration of
the client/patient safety
 Do you have a collaborator/proctor in originating site
 Will this be at home?
 Most are not normed with telehealth modality
121
Online Assessment
Advantages Disadvantages
 Less time-consuming  Slow internet speed
 Standardization of administration
 Variable appearance –
 Less costly
screen size
 Patient preference
 Test-taker authentication
 Easily scored
tougher
 Disseminated to large populations
 Patient dislikes
 Minimize data entry error
 Decreased impact of social  Clinician less proficient in
desirability admin, interp, etc.
Assessment
 Formal tests versus pen and paper tests
 Authorized to use it? Platforms can oversell ease of using
assessments
 Made attempts to get needed information prior to using
telehealth?
 Written conversations with test developers about online
applications
 Computerized administration for digital use
 Mastery of test materials including using a validated
protocol of telehelath based testing (e.g., dementia)
 Ethical requirements for admin, interp, and sharing
 Results can’t overshoot the available data!
122
Timing of Assessments
 At the time of the evaluation
 Beforehand on paper and faxed/mailed/etc.
 Over secure interface on internet (hushmail option
for forms; digital version of assessment)
 Via an app
123
Documenting sessions
 Include all documentation necessary according to
state code/ethics
 Include technology section – how did it work, any

issues, concerns
 Termination note – summary of technology use for

patient in case patient returns to care. Suggestions
for future use
Establishing Boundaries
124
Ethics Code
 Beneficence/nonmaleficence (Principle A)
 Do no harm
 Safeguard the welfare of others
 “strive to be aware of the possible effect of their own
physical and mental health on their ability to help
those with whom they work.”
Standard 2: Competence
 2.03 Maintaining Competence
 “undertake ongoing efforts to develop and maintain
their competence.”
 2.06 Personal Problems and Conflicts

 (a) “refrain from initiating an activity … personal
problems will prevent them from performing their
work-related activities in a competent manner”
 (b) “become aware of personal problems that may
interfere … they take appropriate measures … and
determine whether they should limit, suspend, or
terminate their work-related duties”
125
Standard 3: Human Relations
 3.04 Avoiding Harm
 (a) “take reasonable steps to avoid harming their
clients/patients, students, supervisees, … and others
with whom they work, and to minimize harm where it
is foreseeable and unavoidable”
 Most states incorporate the professional code of

conducts into their state regulations of the
profession.
Professional Boundaries
 Who the client is
 Payment
 Where and when therapy will occur
 Managing multiple relationships
 Termination issues
 Cancellations
 What types of interactions are appropriate
 Self disclosure issues
 Language use
126
Purpose
 provide guidance regarding the nature of the

therapeutic relationship
 help the client and clinician regulate their behavior

 maximize clinical outcomes
 minimize harm
Serves to
 Trusting working alliance
 Modeling assertiveness skills
 Enhancing client’s self worth
 Saves integrity of relationship
 Protects clinicians from harm
 Keeping from multiple relationships
 Help prevent manipulation by pd personalities
127
Traditional Setting
 Place and space  Physical touch

 Time  Language
 Money  Clothing
 Role  Self-disclosure
 Gifts  Sexual contact
Context Contributes to Issues

 Setting and client type
 Focusing on others’ needs
 Long hours/on-call which interferes with life
 Administrative responsibilities
 Lack of or negative feedback
 Time demands
 Demands in our own life
128
Types
Crossings Violations
 Attending graduation  Sexual relationship
 Giving hug after session  Exploitive business
relationship
 Accepting gift
 Dual relationship
 Providing advice on
unrelated matters
 Can be therapeutic,  Always harmful

neutral, or harmful
Telebehavioral factors
 Flexibility of service delivery to prompt more

frequent and more casual interactions and
behaviors
 Due to occurring within homes, coupled with

casualness of medium (text, email, video), could
lead to increased sense of intimacy
129
Time
 Synchronous – late arrivals, weird hours, extension of

hour (last client), out of session contacts
 Asynchronous – extend sessions due to time delay,

off hour contact might lead to expectations of being
instant responder, rapid-fire several times per day,
sets us up to favor some clients over others with
response time
Setting factors
 In office – sense of security and safety, enforces
boundaries
 Flexible location
 Public setting – confidentiality risks (legal/ethical
problems). Distractors which impinges on therapeutic
dynamic of session. If client chooses this then
avoiding tough issues and more casual. Practice
outside of jurisdiction.
 Background distractions
 Casual clothing (friend role)
 Can’t use environment to establish boundary
130
More setting factors
 Inconsistent location for therapist – privacy concerns
 Loud noises in the home – privacy concerns
 Unintentional disclosures in the background
 Use personal pictures and commentary to
introduce self on website – lead to more informal
relationship or a mismatch dynamic.
 Social media – friending, liking, etc.

 Entering client’s home – acting out problems or
reinforcing rigid boundaries
Therapist specific issues

 Working at weird times or on vacation, ill, weekends
 Language used in e-communications
 “Do you have plans this weekend?”
 “Do you have plans to engage in one self-care activity
this weekend?”
 Emoticons or other shortcuts present as less

professional
 Protection of therapist’s work, the client sharing

texts with others
131
Recommendations
 Maintain professional hours/Respect timing of
sessions
 Timely and consistent feedback/Manage excessive

communications
 Private, consistent, professional, and culturally

sensitive setting
 Ensure privacy of non-clients and prevent

unintentional disclosures
Recommendations
 Ensure that telecommunication technologies used
convey professionalism
 Model appropriate self-boundaries

 Ensure privacy of therapist’s work
 Use professional language and consider alternative
interpretations
 Ensure competence in the practice of telemental

health
Drum, K.B., & Littleton, H.L. (2014)
132
Case example
 Licensed psychologist with Pt A - 4 years
 Pt A and therapist exchanged emails – Pt A professed love in
exchange
 Therapist permitted massages during/after session
 Pt A terminated by therapist – an email apologizing and that
never will happen again
 Pt A began blackmailing with surreptitious recordings
 Therapist failed to notify supervisor in 8 months leading up to
termination
 30 days suspension, education, costs
Case example
 Therapist and professor
 Patient A was in professor’s class
 Text messages
 Valentine
 Watch the dog
 References to marijuana
 Reprimanded, education
133
Case example
 Psychologist and Pt A – 9 months
 Email messages
 “reasonably be viewed as flirtatious in nature”
 Visited Pt A’s home
 1 year suspension, education, fees
Case example
 Licensed counselor and Pt A
 “inappropriate text messages”
 In context of setting up an appointment
 Mentioned sunbathing in the nude
 Asked if “something against sunbathing”
 4 hours of education, costs
134
Case example
 License professional counselor and Pt A in-person
and telephonic
 Start of therapy “clear boundaries regarding out of

session contact”
 6 months in – LPC encouraged more emails or calls

 Emails with moniker “Aunt ??”
 LPC initiated texting on personal cell to keep in
contact while on vacation
LPC case
 Suggested attend rally with her, attend several events,
birthday party, emails about having Pt come to home to move
furniture “work in natural habitat”
 In email LPC acknowledged dual relationship – signed “love,
hugs, and good wishes for a confident heart.”
 Pt A asked if friendship remains if treatment ends – LPC said
yes
 Emails at odd hours (midnight) signed “love” by LPC
 Pt A felt LPC no longer wanted therapy relationship but
friendship and terminated, finding new therapist to extricate
self
 Reprimanded, education, costs (suspension hanging over)
135
Case example
 LCSW and Pt A 4 months
 Pt A send text to LCSW indicating a present intention to
commit suicide
 Pt. A successful in suicide, family filed complaint
alleging LCSW failed to save Pt A
 Primary issue was failure to respond to Board
investigation
 Reprimanded and costs
Warning factors or “Red Flags”

 Can not acknowledge possibility of problem
 Ignore signs
 Experiencing significant life stressors
 Physical signs
 Emotional signs
 Isolation or avoiding colleagues
 Overworking
136
 Decreased enjoyment in profession
 Bored/disinterested during sessions
 Feeling overwhelmed or easily irritated
 Hoping for ‘no shows’
 Self medicating
 Seeking support from clients
 Being informed that working too much
 Make excuses for breaching boundaries
When you know you

need some self care …
137
Management Strategies
 Mentally
 Focus on what you find rewarding
 Recognize the hazards
 Anticipate stress
 Restructure cognitions
 Nurture relationships in/out of office
 Creating a thriving environment
 Setting boundaries
 Emotionally
 Fostered through creativity and growth
 Cultivating spiritually
 Personal therapy
 Healthy escapes
138
 Physically
 Tend to the body
 Maintain mindfulness
 Healthy escapes
Recommendations to improve
therapist telehealth experience
 Take breaks between sessions
 Close screens
 Don’t go to another electronic device during break
 Vision - 20/20/20 rule; blue light protector; lighting
 Good ergonomics
 Screen height
 Comfortable office chair
 Purposeful walks – you are no longer walking to the waiting room

 Routine massage appointments
 Honor your sleep time
139
Exercise is a goal!
Resources
 Leaving It at the Office
 John C. Norcross & Gary R. VandenBos
 Counselor Self-Care
 Gerald Corey, Michelle Muratori, Jude T. Austin II, &
Julius A. Austin
140
Multicultural Considerations
 Telehealth opens therapists up to treating those of
different cultures
 APA Ethical Code

 Principle E: Respect for People’s Rights and Dignity
 “be aware of and respect cultural, individual, and role
differences, including those based on age, gender,
gender identity, race, ethnicity, culture, national origin,
religion, sexual orientation, disability, language and
socioeconomic status and consider these factors”
Culturally competent dimensions
 Cultural knowledge
 Attitudes and beliefs toward culturally different
clients and self-understanding
 Skills and use of culturally appropriate

interventions
 APA Task Force (2013)
141
Goals of Culturally Appropriate
Telehealth Services
 Stereotyping versus Generalization
 Values of Cultural and Individual Importance
142
 World View
 Ethnocentrism and Cultural Relativism
143
 Time Orientation
 Inequity versus Egalitarianism
144
Resource
Tasks for telepractice

 All the same considerations as in-person
 Thorough cultural formulation
 Cultural identity
 Conceptualizations of distress
 Psychosocial stressors and resilience
 Cultural features of the client-therapist relationship
 Impact of culture on
 Comfort with mental health care
 Comfort with technology
 Communication, rapport, trust
 Perceptions of confidentiality
145
Cultural Considerations
 Stigma for mental health care
 Different geographic settings require different mindsets
(ex – more firearms in rural than suburbs)
 Cultures with unstable housing, access to care,
scheduling availability
 Language preferences or literacy needs (online English
proficiency tests)
 Vulnerable population consents
 Cultures with less emphasis on maintaining schedules
Cultural Considerations
 What is in the background of screen
 Requirement of translators
 Health care literacy – use of titles, roles
 Norms for communication (storytelling cultures)
 Use of pronouns
 Eliminate inflammatory language – microaggressions
 Intimacy within the culture (camera might distort that)
146
Seek guidance
 Resources within the community
 From collaborators
 From family members
 From medical providers
 Local leaders
Theoretical Considerations
 Find evidenced-based support for theoretical model
 Some are easy to transition
 CBT
 Some are harder to transition
 Play therapy – rely on parents more, shorter sessions,
 There might be some portions that are conducive to
teletherapy no matter the theoretical model used in
therapy
147
We can’t live in the past
Applicable settings
 Outpatient therapy
 EAP’s
 Nursing Homes or Home health care
 Rural Hospitals/VA
 Schools or College counseling centers
 Specialty schools, residential treatment settings,
rehab facilities
148
Transitional Plan
 Choose a good patient
 Consider diagnosis
 Prep them
 Plan in-person sessions at regular intervals to get
better assessment of technology piece
 Use same procedures as in-person
 Start small with small goals
 3 patients within 3 months
 6 patients within 9 months
Reimbursement for
Telepsychology
 Reimbursement
 Insurance – government v. private pay
 Restrictions
 Medicare or Medicaid restrictions
 Centers for Medicare and Medicaid Services (CMS)
 www.cms.gov/telehealth/
 Private insurance restrictions
149
Reimbursement for Services
 Telebehavioral health modifiers that follow code,

 95 (Private insurers - synchronous)
 “synchronous telemedicine service rendered via a real-time
interactive audio and video telecommunications system.”
 02 (Place of Service - synchronous/CMS)

 Not all payers require -02 modifier but be mindful of this
code if you get advice that the Place of Service is incorrect
Resources
 2020 Physician Fee Schedule Final Rule
 Updated annually
 CMS-1715-F_CY2020_List of Medicare Telehealth
Services (excel document)
 2019 STATE of the STATES/Coverage &

Reimbursement July 18, 2019
150
Centers for Medicare &
Medicaid Services Codes
 2020 Physician Fee Schedule Final Rule

 Comes out in November the previous year
 These are the eligible codes for that year
151
ATA 2019 State of the State
152
What about reimbursement?
 2019 Report found
 40 states and D.C. have adopted substantive policies
or received awards to do so since 2017
 36 states and D.C. parity policies for pp– only 21
states and D.C. have coverage parity policies in
Medicaid
 28 states have Medicaid payment parity policies; only
16 mandate payment parity for pp
 Majority have no restrictions on eligible providers and
10 states authorize 6+ provider types
 16 states limit to synchronous while most recognize
RPM and asynchronous
https://www.americantelemed.org/initiatives/
2019-state-of-the-states-report-coverage-and-reimbursement/
CPT Codes
 Whenever going into new territory then you have to

contact the payer in your area
 Remember there are specific codes for certain practices

 Multiple codes for one service (related to time)
 CMS – G codes
 Private insurance – 9 codes
 Telebehavioral health modifiers that follow code,
 95 (Private insurers - synchronous)
 02 (Place of Service - synchronous/CMS)
153
Telehealth during Covid-19
 Center for Connected Health Policy
 Telehealth Coverage Policies in the Time of Covid-
19 to date (3/17/2020)
 Rural and site limitations are removed (no facility fee
for new sites)
 Did not expand list of eligible providers – CP, CSW
 Did not expand modalities (live video) (exception –
Hawaii and Alaska)
 Provides information/links on state changes
www.cchpca.org
Building an online presence

 Blog
 Social media presence
 Digital networking
 Search engine optimization
 Newsletters/emails
 Market a flexible practice (telebehavioral health!)
 Optimize your website for mobile users
 Consider your local audience – are there unique needs
 Patience and perseverance
https://www.therapyappointment.com/blog/marketing-your-mental-health-practice
154
Ethics - Psychologists
 Section 5: Advertising and Other Public Statements

 5.01 Avoidance of False or Deceptive Statements
 5.02 Statement by Others
 5.04 Media Presentations
 5.05 Testimonials
 5.06 In-person Solicitations
Ethics – Social Workers

 4. Social Workers’ Ethical Responsibilities as
Professionals
 4.06 Misrepresentation
 (a) …clear distinction between statements .. actions …
as a private individual and as a representative …
 (c) … ensure that their representations to clients,
agencies, and the public of professional qualifications,
education, … … and take steps to correct any
inaccuracies or misrepresentations of their credentials
by others.
155
Your Public Face…
 Professional Standards
 Represent self accurately
 Stick to your expertise
 Attribute information properly
 Personally review content
 Only reference trustworthy sources
 Never give promises
 Speak for yourself, not your profession
 Be mindful that the information you post will be
shared
APA Ethics of patients

providing testimonials
 5.05 Testimonials
 Psychologists do not solicit testimonials from
current therapy clients/patients or other persons
who because of their particular circumstances are
vulnerable to undue influence
 From current clients

 From past clients
156
NASW Ethics on testimonials
 4. Social Workers’ Ethical Responsibilities as
Professionals
 4.07 Solicitations
 (b) Social workers should not engage in solicitation of
testimonial endorsements (including solicitation of
consent to use a client’s prior statement as a testimonial
endorsement of their particular circumstances, [or] are
vulnerable to undue influence. [sic]
Wisconsin statute - example

 Psy 5.01 Professional Conduct
 (1) Engaging in false, fraudulent, misleading or
deceptive advertising, or maintaining a professional
relationship with one engaging in such advertising
 MPSW 20.02 Unprofessional Conduct

 (5) Using false, fraudulent, misleading or deceptive
advertising, or maintaining a professional relationship
with one engaging in such advertising
157
What to do?
 Ask colleagues, peers, or common referral sources
 Questions to address in testimonial

 Were there any initial obstacles to referring to me?
 What did you learn after you referred to me?
 What did you most like about my approach or how I
handled the referral?
 What other benefits did you notice as a result of referring
clients to me?
 Would you recommend me to others in need of therapy?
Briefly - Marketing Management
 Management with Hootsuite, Tweetreach,

meltwater, Nuvi, and Sysomos
 http://www.hootsuite.com
 http://www.nuvi.com
158
159
160
161
Electronic Records
 Maintain electronic record – assessment, client id,
contact, history, treatment plan, informed consent,
and info about fees and billing
 Treatment plan should discuss the videoconference

 Comply with laws in both states if applicable
 Accurately describe services – video sessions info
 Get ROI if releasing any recordings
 Follow HIPAA
Going Paperless - Regulations

 HIPAA Privacy rule – establishes the standards for
the protection of certain health information
 HIPAA Security rule – operationalizes how to
protect patients privacy with ePHI
 Specific state laws
No unauthorized person can access the personal

information (retention or disposal)
162
HIPAA
HIPAA does NOT stipulate how long medical records

should be retained because each state has its own
laws governing the retention of medical records and
HIPAA does NOT pre-empt them
HIPAA
What does it cover?
CE and BA must maintain the policies and procedures

implemented to comply with HIPAA and records of
any action, activity or assessment for a minimum of
six years from when it was created or last in effect.
Ex. – Policy is revised after 3 years, the original policy

must be kept for a total of 9 years.
www.hipaajournal.com/hipaa-retention-requirements (09/16/2019)
163
Going Paperless –
Ethical Guidelines
 Psychologists who provide telepsychology services
make reasonable efforts to protect and maintain
the confidentiality of the data and information
relating to their clients/patients and inform them
of the potentially increased risks of loss of
confidentiality inherent in the use of the
telecommunication technologies, if any”
2013 Guidelines for the Practice of Telepsychology
Social Work Standards for

Technology
 Standard 3: Gathering, Managing, and Storing
Information
 …when social workers use technology to gather,

manage, and store information, they must uphold
ethical standards related to informed consent,
client confidentiality, boundaries, and providing
clients access to records.
2017 NASW, ASWB, CSWE, & CSWA Standards for Technology in

Social Work Practice
164
Marriage and Family Therapists
Emails must be in medical record

Written policies with same standards as f2f
Teleservices documented (place, times, service)
Separate ROI’s for release of audio/video
2016 Association of Marital and Family Therapy

Regulatory Boards Teletherapy Guidelines
Marriage and Family Therapists
P&P for secure destruction and technologies used
Notify clients of how electronic records maintained,

encryption, etc.
Notify of limits of tech
Written permission for recording teletherapy
2016 Association of Marital and Family Therapy Regulatory Boards

Teletherapy Guidelines
165
Cloud-based Services
 HIPAA and HITECH – a cloud storage service becomes a
business associate if they store PHI on behalf a
healthcare organization.
 Dropbox (Business)
 Box
 Google Drive
 Microsoft One Drive
 Carbonite
Checklist
 Security Rules
 Access Control
 Integrity
 Physical Safeguards
 Facility Access Control
 Workstation Use
 Workstation Security
 Device and Media Controls
Courtesy of McAfee HIPAA and HITECH Cloud Compliance Requirements
166
Checklist
 Administrative Safeguards
 Security Management Process
 Workforce Security
 Training
 Security Incident Procedures
 Contingency Plan
 BAA
 Its not just enough that Cloud service provides

encryption. You also have to do a risk management
analysis.
Ethical Situations
 Dr. Illtry decides to develop a telemental health program
to expand coverage to a rural population in her state
that lacks mental health providers. She reviewed the
Guidelines and attended an all-day seminar by PESI.
She found HIPAA and HITECH difficult to understand but
thought she had a good grip on it. She decides to Skype
with patients in their home on a tablet, given the miles
to a mental health facility. She will use her computer,
not ever connected to the Internet, to take notes and
maintain an electronic file. What does she need to
consider yet? What has she done well? What is she
missing?
167
Dr. Illtry
 During her third session with her anxious patient
Dr. Illtry runs into a glitch with the iPad. It
continually disconnects from the session even
though her settings indicate she is connected to the
internet. She could not find her patient’s phone
number as she was running late to get to her office
so she conducted the session in her own home. She
was able to connect after the fifth disconnection,
but after the session she realized she has a lot
more to consider.
Document Disposal
 ATA 2013 Guidelines for Video-Based Online
Mental Health Services indicate that “policies for
record retention and disposal should be in place.”
 2016 AMFTRB – indicates that the laws of the state

should be followed for treatment, consultation, and
supervision utilizing technology-assisted services …
same standards … as those in traditional (in
person) settings.
168
Document Disposal – Ethical
Guidelines
 Psychologists who provide telepsychology services

make reasonable efforts to dispose of data and
information and the technologies used in a manner
that facilitates protection from unauthorized access
and accounts for safe and appropriate disposal.
2013 Guidelines for the Practice of Telepsychology
Document Disposal -
Regulations
 HIPAA Privacy rule – establishes the standards for

the protection of certain health information
 HIPAA Security rule – operationalizes how to

protect patients privacy with ePHI
 Specific state laws
169
HIPAA
 Privacy Rule – CE must implement reasonable
safeguards to limit incidental, and avoid prohibited,
uses and disclosures of PHI, including in
connection with the disposal of such information.
 Security Rule – CE must implement policies and

procedures to address the final disposition of ePHI
and the hardware or electronic media on which it is
stored and and removed if media going to be
reused
HIPAA
REASONABLE
170
HIPAA
 Examples of reasonable for ePHI:
 Clearing (software to overwrite with non-ePHI)
 Purging (degaussing or exposing to strong
magnetic field to disrupt the recorded magnetic
domains)
 Destroying the media (disintegration,
pulverizations, melting, incinerating, or
shredding)
 OR consult with other businesses
www.hhs.gov/hipaa/ retrieved on 09/16/2019
Questions to Ask Yourself

 Dr. Illtry decides that her telepractice is so successful
she wants upgrade her practice computer. She want to
get an Apple computer that will sync with her iPhone.
She’s heard of all the benefits of using the same
system. She conducts video therapy (with a third party
online provider), in-person therapy, uses electronic
treatment notes and records on the computer, and email
and text with clients primarily about admin issues,
including appointment changes and self work
reminders.
 What does she need to think about regarding disposal
of information on her old computer?
 Self Study Questions
171
Self Study
172
Brave New World
Thanks for participating
173
INFORMATION ABOUT THE SAMPLE INFORMED CONSENT FOR
TELEPSYCHOLOGY
Julie A. Jacobs, PsyD, JD
This sample informed consent for telepsychology has been created to help psychologists comply
with Guideline 3 of the Guidelines for the Practice of Telepsychology, promulgated by the Joint
Task Force for the Development of Telepsychology Guidelines for Psychologists. 1
Psychologists who plan to engage in telepsychology should review the full Guidelines; this
sample form is only one element of meeting the standard of care.
This form is designed to be an adjunct to your normal informed consent document and does not
cover many topics that need to be addressed in order to provide full informed consent to your
clients. It is important for you to ensure that your informed consent document complies with the
ethical requirement that you obtain informed consent from your clients before engaging in
services (Ethical Principles of Psychologists and Code of Conduct, 2017, Standards 10.02, 4.02).
This is not only an ethical requirement but also a good risk management strategy.
This sample form is drafted in general terms and will need to be modified to fit your specific
practice. In addition, it is important for you to be aware of any laws or regulations in your state
that govern the practice of telepsychology, as this form does not strive to comply with any
specific state laws. There may be additional elements required for this informed consent to fully
comply with your state’s requirements. You are strongly advised to have your own attorney
review your informed consent for telepsychology document prior to using it to ensure that it is in
compliance with your state laws and regulations.
Portions of the sample form include bracketed information with instructions for use. Of special
importance is the section on emergencies, which contains some suggested language for
developing an emergency plan with your clients. You are encouraged to modify this section to
reflect the specific plan that you develop for addressing emergency and crisis situations that may
arise during the course of telepsychology.
Feel free to adapt the following draft text for your practice or agency.
1
Joint Task Force for the Development of Telepsychology Guidelines for Psychologists (2013). Guidelines for the
practice of telepsychology. American Psychologist, 68, 791-800. Retrieved from
https://www.apa.org/pubs/journals/features/amp-a0035001.pdf
174
INFORMED CONSENT FOR TELEPSYCHOLOGY
This Informed Consent for Telepsychology contains important information focusing on doing
psychotherapy using the phone or the Internet. Please read this carefully, and let me know if you
have any questions. When you sign this document, it will represent an agreement between us.
Benefits and Risks of Telepsychology

Telepsychology refers to providing psychotherapy services remotely using telecommunications
technologies, such as video conferencing or telephone. One of the benefits of telepsychology is
that the client and clinician can engage in services without being in the same physical location.
This can be helpful in ensuring continuity of care if the client or clinician moves to a different
location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is
also more convenient and takes less time. Telepsychology, however, requires technical
competence on both our parts to be helpful. Although there are benefits of telepsychology, there
are some differences between in-person psychotherapy and telepsychology, as well as some
risks. For example:
- Risks to confidentiality. Because telepsychology sessions take place outside of the

therapist’s private office, there is potential for other people to overhear sessions if you are
not in a private place during the session. On my end I will take reasonable steps to ensure
your privacy. But it is important for you to make sure you find a private place for our
session where you will not be interrupted. It is also important for you to protect the
privacy of our session on your cell phone or other device. You should participate in
therapy only while in a room or area where other people are not present and cannot
overhear the conversation.
- Issues related to technology. There are many ways that technology issues might impact
telepsychology. For example, technology may stop working during a session, other
people might be able to get access to our private conversation, or stored data could be
accessed by unauthorized people or companies.
- Crisis management and intervention. Usually, I will not engage in telepsychology with
clients who are currently in a crisis situation requiring high levels of support and
intervention. Before engaging in telepsychology, we will develop an emergency
response plan to address potential crisis situations that may arise during the course of our
telepsychology work.
- Efficacy. Most research shows that telepsychology is about as effective as in-person

psychotherapy. However, some therapists believe that something is lost by not being in
the same room. For example, there is debate about a therapist’s ability to fully understand
non-verbal information when working remotely.
Electronic Communications
We will decide together which kind of telepsychology service to use. You may have to have
certain computer or cell phone systems to use telepsychology services. You are solely
175
responsible for any cost to you to obtain any necessary equipment, accessories, or software to
take part in telepsychology.
[Below are some optional provisions to add more detail about the use of email/text messaging
and communication between sessions. Modify as appropriate if you have secure, encrypted
email that you use differently with clients or delete if not applicable or redundant.]
For communication between sessions, I only use email communication and text messaging with
your permission and only for administrative purposes unless we have made another agreement.
This means that email exchanges and text messages with my office should be limited to
administrative matters. This includes things like setting and changing appointments, billing
matters, and other related issues. You should be aware that I cannot guarantee the confidentiality
of any information communicated by email or text. Therefore, I will not discuss any clinical
information by email or text and prefer that you do not either. Also, I do not regularly check my
email or texts, nor do I respond immediately, so these methods should not be used if there is an
emergency.
Treatment is most effective when clinical discussions occur at your regularly scheduled sessions.
But if an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to
return your call within 24 hours except on weekends and holidays. If you are unable to reach me
and feel that you cannot wait for me to return your call, contact your family physician or the
nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be
unavailable for an extended time, I will provide you with the name of a colleague to contact in
my absence if necessary.
Confidentiality
I have a legal and ethical responsibility to make my best efforts to protect all communications
that are a part of our telepsychology. However, the nature of electronic communications
technologies is such that I cannot guarantee that our communications will be kept confidential or
that other people may not gain access to our communications. I will try to use updated
encryption methods, firewalls, and back-up systems to help keep your information private, but
there is a risk that our electronic communications may be compromised, unsecured, or accessed
by others. You should also take reasonable steps to ensure the security of our communications
(for example, only using secure networks for telepsychology sessions and having passwords to
protect the device you use for telepsychology).
The extent of confidentiality and the exceptions to confidentiality that I outlined in my Informed
Consent [use whatever title you have for your informed consent document] still apply in
telepsychology. Please let me know if you have any questions about exceptions to
confidentiality.
Appropriateness of Telepsychology
From time to time, we may schedule in-person sessions to “check-in” with one another. I will let
you know if I decide that telepsychology is no longer the most appropriate form of treatment for
you. We will discuss options of engaging in in-person counseling or referrals to another
professional in your location who can provide appropriate services.
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Emergencies and Technology
[Providers must work with their telepsychology clients to develop a plan for dealing with
crisis/emergency situations and technology failures when providing telepsychology services.
These plans should include things such as: how crisis/emergency situations will be addressed
(local resources, hotlines, trusted people identified by the client, etc.); how to confirm client’s
location; how to deal with technology failures during sessions and in crisis situations; how to
deal with billing in the event of technology failures; and similar considerations. Some optional
language is included below – these are only suggestions and should be modified as
appropriate for your specific circumstances.]
Assessing and evaluating threats and other emergencies can be more difficult when conducting
telepsychology than in traditional in-person therapy. To address some of these difficulties, we
will create an emergency plan before engaging in telepsychology services. I will ask you to
identify an emergency contact person who is near your location and who I will contact in the
event of a crisis or emergency to assist in addressing the situation. I will ask that you sign a
separate authorization form allowing me to contact your emergency contact person as needed
during such a crisis or emergency.
If the session is interrupted for any reason, such as the technological connection fails, and you
are having an emergency, do not call me back; instead, call 911, [include any local hotlines or
other resources], or go to your nearest emergency room. Call me back after you have called or
obtained emergency services.
If the session is interrupted and you are not having an emergency, disconnect from the session
and I will wait two (2) minutes and then re-contact you via the telepsychology platform on which
we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call
me on the phone number I provided you (XXX-XXX-XXXX).
If there is a technological failure and we are unable to resume the connection, you will only be
charged the prorated amount of actual session time.
Fees
The same fee rates will apply for telepsychology as apply for in-person psychotherapy. However,
insurance or other managed care providers may not cover sessions that are conducted via
telecommunication. If your insurance, HMO, third-party payor, or other managed care provider
does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee
of the session. Please contact your insurance company prior to our engaging in telepsychology
sessions in order to determine whether these sessions will be covered.
Records
The telepsychology sessions shall not be recorded in any way unless agreed to in writing by
mutual consent. I will maintain a record of our session in the same way I maintain records of in-
person sessions in accordance with my policies.
177
Informed Consent
This agreement is intended as a supplement to the general informed consent that we agreed to at
the outset of our clinical work together and does not amend any of the terms of that agreement.
Your signature below indicates agreement with its terms and conditions.
_________________________ _________________________
Client Date
_________________________ _________________________
Therapist Date
178
The Trust
Sample Electronic Communication Policy*

In order to maintain clarity regarding our use of electronic modes of communication
during your treatment, I have prepared the following policy. This is because the use of
various types of electronic communications is common in our society, and many
individuals believe this is the preferred method of communication with others, whether
their relationships are social or professional. Many of these common modes of
communication, however, put your privacy at risk and can be inconsistent with the law
and with the standards of my profession. Consequently, this policy has been prepared to
assure the security and confidentiality of your treatment and to assure that it is
consistent with ethics and the law.
If you have any questions about this policy, please feel free to discuss this with me.
Email Communications
I use email communication and text messaging only with your permission and only for
administrative purposes unless we have made another agreement. That means that
email exchanges and text messages with my office should be limited to things like
setting and changing appointments, billing matters and other related issues. Please do
not email me about clinical matters because email is not a secure way to contact me. If
you need to discuss a clinical matter with me, please feel free to call me so we can
discuss it on the phone or wait so we can discuss it during your therapy session. The
telephone or face-to-face context simply is much more secure as a mode of
communication.
Text Messaging
Because text messaging is a very unsecure and impersonal mode of communication, I do

not text message to nor do I respond to text messages from anyone in treatment with
me. So, please do not text message me unless we have made other arrangements.
Social Media
I do not communicate with, or contact, any of my clients through social media platforms
like Twitter and Facebook. In addition, if I discover that I have accidentally established
an online relationship with you, I will cancel that relationship. This is because these
types of casual social contacts can create significant security risks for you.
I participate on various social networks, but not in my professional capacity. If you have
an online presence, there is a possibility that you may encounter me by accident. If that
occurs, please discuss it with me during our time together. I believe that any
179
communications with clients online have a high potential to compromise the
professional relationship. In addition, please do not try to contact me in this way. I will
not respond and will terminate any online contact no matter how accidental.
Websites
I have a website that you are free to access. I use it for professional reasons to provide
information to others about me and my practice. You are welcome to access and review
the information that I have on my website and, if you have questions about it, we should
discuss this during your therapy sessions.
Web Searches
I will not use web searches to gather information about you without your permission. I
believe that this violates your privacy rights; however, I understand that you might
choose to gather information about me in this way. In this day and age there is an
incredible amount of information available about individuals on the internet, much of
which may actually be known to that person and some of which may be inaccurate or
unknown. If you encounter any information about me through web searches, or in any
other fashion for that matter, please discuss this with me during our time together so
that we can deal with it and its potential impact on your treatment.
Recently it has become fashionable for clients to review their health care provider on
various websites. Unfortunately, mental health professionals cannot respond to such
comments and related errors because of confidentiality restrictions. If you encounter
such reviews of me or any professional with whom you are working, please share it with
me so we can discuss it and its potential impact on your therapy. Please do not rate my
work with you while we are in treatment together on any of these websites. This is
because it has a significant potential to damage our ability to work together.
*Please note: While this is a Trust product, it is written as a very general and generic
policy. Therefore, you should feel free to modify it in a fashion that is consistent with
your own clinical practice and any available state regulations. If you have any questions
about this policy, please call and speak with one of our risk management advocates at 1-
800-477-1200.
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Social Media Policy
Doc Foreman’s Social Media Policy For Her Work With Therapy Clients
This document outlines my policies related to use of Social Media. Please read it to understand how I conduct
myself on the Internet as a mental health professional and how clients can expect me to respond to various
interactions that may occur between us on the Internet. If you have any questions about anything within this
document, I encourage you to bring them up when we meet. As new technology develops and the Internet
changes, there may be times when
I need to update this policy. If I do so, I will notify you.
FRIENDING
I do not accept friend or contact requests from current or former clients on any social networking site
(Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise
your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic
relationship. If you have questions about this, please bring them up when we meet and we can talk more
about it.
Because I have lived and worked in a rural region, and have a large network of family, friends, and associates
the transparency and visbility of FaceBook and social media is comfortable for me. Any information you see
posted there, if personal, is widely known about me. It is consistent with my values as a therapist to be
appropriately human and accessible. Managing a blend of personal and professional life is a necessary part of
providing therapy in a more rural setting, and in this age of social media. I will never post highly private
aspects of my life, out of respect to my personal needs, and out of respect to the people I work with. You are
welcome to view my Facebook Page and read or share information posted there, but I do not accept
comments from clients there. I will also remove information from clients that may compromise their
confidentiality as I become aware of it. I feel it is best to be explicit to all who may view my list of Friends to
know that they will not find client names on that list.
In addition, the American Psychological Association’s Ethics Code prohibits my soliciting testimonials
from clients. I feel that the term “Fan” comes too close to an implied request for a public endorsement of my
practice.
FOLLOWING
I publish a blog on my website and I post psychology news on Twitter. I have no expectation that you as a
client will want to follow my blog or Twitter stream. However, if you use an easily recognizable name on
Twitter and I happen to notice that you’ve followed me there, we may briefly discuss it and its potential
impact on our working relationship. My primary concern is your privacy. If you share this concern, there are
more private ways to follow me on Twitter (such as using an RSS feed or a locked Twitter list), which would
eliminate your having a public link to my content. You are welcome to use your own discretion in
choosing whether to follow me. Note that I will not follow you back. I only follow other health professionals
on Twitter and I do not follow current or former clients on blogs or Twitter. My reasoning is that I believe
casual viewing of clients’ online content outside of the therapy hour can create confusion in regard to
whether it’s being done as a part of your treatment or to satisfy my personal curiosity. In addition, viewing
your online activities without your consent and without our explicit arrangement towards a specific purpose
could potentially have a negative influence on our working relationship. If there are things from your online
life that you wish to share with me, please bring them into our sessions where we can view and explore them
181
together, during the therapy hour.
INTERACTING
Please do not use SMS (mobile phone text messaging) or messaging on Social Networking sites such as
Twitter, Facebook, or LinkedIn to contact me. These sites are not secure and I may not read these messages in
a timely fashion. Do not use Wall postings, @replies, or other means of engaging with me in public online if
we have an already established client/therapist relationship. Engaging with me this way could compromise
your confidentiality. It may also create the possibility that these exchanges become a part of your legal
medical record and will need to be documented and archived in your chart. If you need to contact me between
sessions, the best way to do so is by phone.
In the future I hope to be accessible on MyHealtheVet, so that Veterans will have a secure way to
communicate with me using electronic messaging.
USE OF SEARCH ENGINES

It is NOT a regular part of my practice to search for clients on Google or Facebook or other search engines.
Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in
danger and you have not been in touch with me via our usual means (coming to appointments, phone, etc.)
there might be an instance in which using a search engine (to find you, find someone close to you, or to check
on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual
situations and if I ever resort to such means, I will fully document it and discuss it with you when we next
meet.
GOOGLE READER
I do not follow current or former clients on Google Reader and I do not use Google Reader to share articles.
If there are things you want to share with me that you feel are relevant to your treatment whether they are
news items or things you have created, I encourage you to bring these items of interest into our sessions.
BUSINESS REVIEW SITES

You may find my psychology practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places
which list businesses. Some of these sites include forums in which users rate their providers and add reviews.
Many of these sites comb search engines for business listings and automatically add listings regardless of
whether the business has added itself to the site. If you should find my listing on any of these sites, please
know that my listing is NOT a request for a testimonial, rating, or endorsement from you as my client. The
American Psychological Association’s Ethics Code states under Principle 5.05 that it is unethical for
psychologists to solicit testimonials: “Psychologists do not solicit testimonials from current therapy
clients/patients or other persons who because of their particular circumstances are vulnerable to undue
influence.” Of course, you have a right to express yourself on any site you wish. But due to confidentiality,
I cannot respond to any review on any of these sites whether it is positive or negative. I urge you to take your
own privacy as seriously as I take my commitment of confidentiality to you. You should also be aware that if
you are using these sites to communicate indirectly with me about your feelings about our work, there is a
good possibility that I may never see it. If we are working together, I hope that you will bring your feelings
and reactions to our work directly into the therapy process. This can be an important part of therapy, even if
you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with
me wherever and with whomever you like. Confidentiality means that I cannot tell people that you are my
client and my Ethics Code prohibits me from requesting testimonials. But you are more than welcome to tell
anyone you wish that I’m your therapist or how you feel about the treatment I provided to you, in any forum
of your choosing. If you do choose to write something on a business review site, I hope you will keep in mind
that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym
that is not linked to your regular email address or friend networks for your own privacy and protection.
182
LOCATION-BASED SERVICES
If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues
related to using these services. I do not place my practice as a check-in location on various sites such as
Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible
that others may surmise that you are a therapy client due to regular check-ins at my office on a weekly basis.
Please be aware of this risk if you are intentionally “checking in,” from my office or if you have a passive
LBS app enabled on your phone.
EMAIL
I do not exchange email with clients. Please do not email me content related to your therapy sessions, as
email is not completely secure or confidential. If you choose to communicate with me by email anyway, be
aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely
that someone will be looking at these logs, they are, in theory, available to be read by the system
administrator(s) of the Internet service provider.
You should also know that any emails I receive from you become a part of your legal record.
CONCLUSION
Thank you for taking the time to review my Social Media Policy. If you have questions or concerns about any
of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my
attention so that we can discuss them.
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Document Disposal – Self Study Questions
1. Do I store patient information on my personal computer, table, or mobile

device?
2. Do I store patient information on a shared computer, tablet, or mobile
device?
3. Do I transfer patient information using an external data storage device (e.g.,
USB drive)?
4. Do I store patient information on a cloud-based service?
5. Do I maintain client contact information on my mobile device?
6. Do I use software program on my computer (e.g., videoconferencing, e-mail
address, IP address)?
7. Do I use a cloud-based service that stores patient information?
8. Do I have a Business Associate Agreement with technology product vendors
who could access patient information?
Note: Adapted from Barnwell, S.S., & Larsen, M.A. (2018) Disposal of data,
information and technologies. In Cambell, L.F., Millan, F. & Martin, J.N. (Eds) A
Telepsychology Casebook: Using Technology Ethically and Effectively in your
Professional Practice. (pp. 99-119, Exhibit 6.1) Washington D.C.: APA.
185
Sample Data Removal Plan
Hardware: Delete all files from laptop; reformat computer hard drive and USB
drives; factory resent or hard reset for mobile device and tablet; ensure that no
patient information remains on encrypted external storage devices by deleting files
and reformatting the drive; recycle hardware with local technology recycling
company or with vender offering rebate.
Software: delete all contacts and call history from text, e-mail, and video-
conferencing programs; uninstall software and mobile apps from all hardware; log
in to any web-based interfaces (e-mail, web management for secure texting) to
delete any stored information; contact the vendors for web-based services to
inquire how to ensure that all deleted information was permanently deleted from
any future access.
Future steps: select software and mobile apps designed for health care; obtain a
business associate agreement from all vendors; consider authoring a policy
regarding data disposal to be shared with clients during informed consent; ensure
that informed consent documents incudes a review of risks and benefits regarding
technology use, as well as some basic information regarding record maintenance
and disposal.
information and technologies. In Campbell, L.F., Millan, F. & Martin, J.N. (Eds) A
186
Ethical Scenario #1
Dr. I. Wannabe is a mid-career psychologist who works in a thriving mental health

practice in a busy mid-level city. The group that he practices out of is attached to a
hospital network so he is accustomed to working with EMR and having most
administrative issues managed by the office’s business manager. While he has
enjoyed his career in this type of setting, he decided to leave the practice and join as
an independent contractor a smaller and more suburban practice. In this practice,
although billing was completed by a group medical billing service, he was
responsible for starting his own practice, including finding referral sources,
scheduling appointments, following-up in crisis situations (no on-call), and
paperwork, documentation, and record-keeping. While he found this exciting, he
was also very overwhelmed with the administrative workload associated with each
patient. He also struggled with playing phone tag with patients to schedule
appointments since he no longer had a secretary to handle scheduling.
Dr. Wannabe decided that email would likely be the best way to easily communicate
with patients that wanted to schedule or change appointments. While he did not
incorporate technology into his practice, he decided this would be the best way to
manage this particular difficulty. He had no interest in having electronic records in
his private practice and using apps during therapy. In fact, he considered himself a
digital immigrant that had no interest in learning about social media, therapeutic
apps, or using technology in mental health. However, Dr. Wannabe decided he
would use emails to communicate with his patients.
Overtime, Dr. Wannabe felt as though his use of emails was reducing the amount of
phone calls that he needed to return and scheduling became easier. He was very
happy that he did not have to use 30 minutes after a long day at work to return
phone calls. Dr. Wannabe did not change his informed consent to treatment to
reflect the use of emails because he did not feel email communications were part of
the therapeutic practice, but more of an administrative task that did not require a
new informed consent.
Dilemma: Dr. Wannabe’s 40-year-old client, C.Me, came to him upon referral from
another psychologist who was leaving the area. The referring psychologist was
encouraged to give C.Me Dr. Wannabe’s email address so the two could schedule an
appointment. C.Me and Dr. Wannabe met for an initial session and C.Me felt as
though Dr. Wannabe would be able to help her. She scheduled weekly appointments
to meet with Dr. Wannabe to work on her relationship problems and emotional
dysregulation.
Initially, C.Me reliably attended therapy and when she wanted to cancel or change
an appointment she would email him. However, over time, her cancellations and
changes occurred more often. Then C.Me would have another period of time with
reliable attendance, only to then go through a time of periodic cancellations. Dr.
Wannabe realized through record review that C.Me tended to cancel or change her
187
appointments after she argued with her mother, which typically resulted in cutting
behavior and excessive alcohol consumption as coping responses. Canceling therapy
was C.Me’s way of avoiding having to discuss her cutting behavior and that she was
typically hung over or still drinking. Dr. Wannabe and C.Me discussed this issue in
several sessions so that she could find better coping strategies for her difficult
relationship with her mother.
While the absences were reduced, they did not disappear. On one such occasion,
after C.Me emailed a request to cancel and change the appointment, Dr. Wannabe
emailed his client back, asking if she had experienced an argument with her mother
and whether she was drinking or cutting to cope with the feelings towards her
mother. He also agreed to move the appointment. C.Me and Dr. Wannabe had a brief
email exchange about her coping strategies after they agreed to a new date. Dr.
Wannabe felt better that C.Me legitimately had to move the appointment due to a
work assignment out of town.
C.Me came into the next scheduled session completely distraught and angry. She
reported that the email used to communicate with Dr. Wannabe was a work email
and that her supervisor had read her recent email exchange with Dr. Wannabe when
C.Me accidentally left the email open after leaving for the night. Her supervisor came
into her office to find some documents and found the email exchange on the
computer. C.Me indicated that her supervisor was very concerned about her mental
health; however, C.Me was more concerned that her supervisor was the office
“gossip” and now it was likely that everybody was going to know her “business.”
In your group, come up with the Ethical Principles or Codes of Conduct in play for
the situation. Then discuss any HIPAA or state laws that were violated, if any. Pick
one person to discuss what went wrong and one person to discuss what Dr.
Wannabe did right. What could he do to improve his practice regarding emails?
188
Resources –
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Barna Group. (2018). American’s feel good about counseling. [Blog Post]. Retrieved
on 09/29/2019 from https://www.barna.com/research/americans-feel-good-
counseling/
Langarizadeh, M., Mohsen, S.T., Tavakol, K., et. al (2017). Retrieved on 09/29/2019
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Craig, D. (2017) It’s time to adopt telemental health or risk losing these nine
patients. [Blog Post] Retrieved on 10/02/2019 from
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patients/
American Psychological Association (2017). Ethical Principles of Psychologists and

Code of Conduct. Retrieved on 09/29/2019 from
https://www.apa.org/ethics/code/
Epstein, Becker, Green (2017). 50-State Survey of Telemental/Telebehavioral

Health (2017 Appendix). Retrieved on 09/29/2019 from
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2017-APPENDIX-50-STATE-TELEMENTAL-HEALTH-SURVEY1.pdf
American Psychological Association (2013). Guideline for the Practice of

Telepsychology. Retrieved on 09/29/2019 from
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NASW, ASWB, CSWE, & CSWA (2017). Standards for Technology in Social Work
Practice. Retrieved on 09/29/2019 from
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33617.TechStandards_FINAL_POSTING.pdf
American Telemedicine Association. (2013). Practice Guidelines for Video-based

Online Mental Health Services. Retrieved on 09/29/2019 from
https://www.integration.samhsa.gov/operations-administration/practice-
guidelines-for-video-based-online-mental-health-services_ATA_5_29_13.pdf
American Counseling Association (2014). Code of Ethics. Retrieved on 10/01/2019

from https://www.counseling.org/docs/default-source/ethics/2014-aca-code-of-
ethics.pdf?sfvrsn=fde89426_5
American Psychiatric Association (2018). Best Practices in Videoconferencing-

Based Telemental Health. Retrieved on 09/29/2019 from
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https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-and-
ata-release-new-telemental-health-guide
https://www.brandwatch.com/blog/amazing-social-media-statistics-and-
facts/#section-2
https://www.pewinternet.org/fact-sheet/social-media/
Foreman, A. (2019) Social Media Policy [Blog Post]. Retrieved on 10/01/2019 from
http://www.docforeman.com/social-media-policy
https://www.hhs.gov/hipaa/for-professionals/privacy/laws-
regulations/index.html
https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/
small-providers-small-health-plans-small-businesses/index.html
https://www.cms.gov
https://psychboard.az.gov/statutes-rules
https://www.paubox.com/solutions/encrypted-email
https://www.hushmail.com/
International Shoe Co. V. Washington, 326 U.S. 310, 319, 66 S.Ct. 154, 90 L.Ed. 95
(1945)
DeMers, S.T., Harris, E.A., & Baker, D.C. (2018) Interjurisdictional Practice, In
Campbell, L.F., Millan, F., Martin, J.N. (Editors) A Telepsychology Casebook: Using
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https://www.americantelemed.org/initiatives/2019-state-of-the-states-report-
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ASPPB. Reducing Regulatory Barriers. (October 2019). Retrieved from

https://www.asppb.net/mpage/micrositehp
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https://www.asppb.net/mpage/background
190
ASPPB Charters (October 2019). Retrieved from
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ASPPB E.Passport (October 2019). Retrieved from

https://cdn.ymaws.com/www.asppb.net/resource/resmgr/psypact_docs/e.passpor
t_quick_guide_v.10..pdf
ASPPB IPC Quick Guide (October 2019). Retrieved from

https://cdn.ymaws.com/www.asppb.net/resource/resmgr/psypact_docs/ipc_quick
_guide_v.10.2018.pdf
ASPPB HIPAA Retention Requirements. September 2019). Retrieved from

www.hipaajournal.com/hipaa-retention-requirements
Association of Marital and Family Therapy Regulatory Boards. (2016). Teletherapy

Guidelines. Retrieved on 10/01/2019 from https://amftrb.org/wp-
content/uploads/2017/05/Proposed-Teletherapy-Guidelines-DRAFT-as-of-
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McAfee HIPAA and HITECH Cloud Compliance Requirements. Retrieved on

10/01/2019 from https://www.mcafee.com/enterprise/en-
us/assets/skyhigh/cheat-sheets/ch-hipaa-compliance.pdf
Barnwell, S.S., & Larsen, M.A. (2018) Disposal of data, information and technologies.
In Campbell, L.F., Millan, F. & Martin, J.N. (Eds.) A Telepsychology Casebook: Using
Technology Ethically and Effectively in your Professional Practice. (pp. 99-119,
Exhibit 6.2) Washington D.C.: APA.
American Academy of Pediatrics. (October 2019). Getting started in telehealth.

Retrieved from https://www.aap.org/en-us/professional-resources/practice-
transformation/telehealth/Pages/Getting-Started-in-Telehealth.aspx
Other General References:
Kolmes, K. & Taube, D. Findings on Therapist-Client Interactions on the Internet:

Boundary Considerations in Cyberspace. Retrieved on 09/10/2019 from
http://drkkolmes.com/research/#.XXgpIC2ZN24
2018 Best Practices in Videoconferencing-Based Telemental Health (April 2018)

information and technologies. In Campbell, L.F., Millan, F. & Martin, J.N. (Eds) A
191
American Psychological Association (October 2013) Telepsychology 50-State
Review. American Psychological Association Practice-Legal & Regulatory Affairs
Luxton, D. D., O’Brien, K., McCann, R. A., & Mishkind, M. C. (October 2012). Home-
Based Telemental Healthcare Safety Planning: What You Need to Know,
Telemedicine and e-Health. Retrieved from Researchgate at https://www.
Reseachgate.net/publications/232248690
Edwards, M. (December 2018). Roadmap for Planning Development of Telehealth

Services. Northeast Telehealth Resource Center. Retrieved on 09/29/2019 from
https://netrc.org/wp-content/uploads/2015/04/NETRC-Roadmap-for-Planning-
Development-of-Clinical-Telemedicine-Services-2014.pdf
The National Association of Social Workers (2017). Code of Ethics. Retrieved on

04/22/2020 from https://www.socialworkers.org/About/Ethics/Code-of-
Ethics/Code-of-Ethics-English.
Walz, G.R., & Bleuer, J.C. (2017). Creative Counselor Self-Care, ACA Knowledge
Center. Retrieved on 04/22/2020 from https://www.counseling.org/docs/default-
source/vistas/creative-counselor-self-care.pdf?sfvrsn=ccc24a2c_4.
Drum, K.B., & Littleton, H.L. (2014). Therapeutic boundaries in telepsychology:

Unique issues and best practice recommendations. Retrieved on 04/23/2020 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4234043/
Recommended Books:
Campbell, L.F., Millan, F. & Martin, J.N. (Eds.) (2018). A telepsychology casebook:
Using technology ethically and effectively in your professional practice. Washington
D.C.: APA.
Corey, G., Muratori, M., Austin II, J.T., & Austin, J.A. (2003). Counselor Self Care.
Alexandria, VA: American Counseling Association.
Luxton, D.D., Nelson, E., & Maheu, M. (2016). A practitioner’s guide to telemental
health. How to conduct legal, ethical, and evidence-based telepractice. Washington
D.C.: APA.
Magnavita, J. J. (Ed). (2018). Using technology in mental health practice. Washington

D.C.: APA.
Norcross, J.C., & VandenBos, G.R. (2017). Leaving it at the office: A guide to
psychotherapist self-care. New York City, NY: The Guilford Press.
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NOTES
NOTES

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Rehab Kids

2-Day Certified Clinical

www.pesi.com/blog | www.pesirehab.com/blog | www.pesihealthcare.com/blog | https://kids.pesi.com/blog

Printed in the United States

Melissa Westendorf, Ph.D., J.D., is a clinical and forensic

As a proactive psychologist and educator, Dr. Westendorf is a

Melissa J Westendorf, J.D./Ph.D.

 “Materials that are included in this course may include

 Publications mentioned in this program are for

 There is no financial connection to any

 Most importantly (and disappointingly) I am not

 Most Americans are 0pen to counseling

……… here to stay

 Affordability, Expertise, and Years of Experience are

 Decreasing stigma (sort of) – 34% of millennials

 Nearly half of those in therapy report a very

 What do you think are the pros and cons of

Langarizadeh, M., Mohsen, S.T., Tavakol, K., et. al (2017)

 More verbal explicitly with empathy

 Can meet significant family members

 Can increase the dose more flexibly

 Ethics Codes/HIPAA/Statutory Guidance

 Clinical Considerations for Telebehavioral Health

 Administrative Issues related to Telebehavioral Health

All existing laws (state and federal) and ethical

 American Psychiatric Association

Relevant Codes or Guidelines

 APA – Guidelines for the Practice of Telepsychology

 Provision of Information to the Public

Ethical Principles of Psychologists and Code of Conduct

Beneficence and Nonmaleficence

 …strive to benefit those with whom they work and

Respect for People’s

Document document document

*sometimes anecdotal or case review

How To Build Competence

 Read Books – I have some referenced at the end

 Privacy – held by the client and it is their right to

 Confidentiality – what the client gives us and we are

 HIPAA violations occur when there has been a

 Permits flow of information for high quality health care

 Covered Entity = Providers who submit HIPAA

 Business Associates = If provider uses a third party to

 Identify and protect against reasonably anticipated

 Protect against reasonably anticipated,

 Ensure compliance by their workforce

 Meant to be flexible due to small and large entities

 The information that must be protected is

 Looking for neglect and willful neglect

Sample Business Associate Contract Provisions

Guidance on Significant Aspects of the Privacy Rule

Small providers HIPAA

Screen shot of the small providers

 When coupled with health information, it becomes

 It does not violate HIPAA for a patient to send you

 Device id or serial numbers

If you had any doubts…

 $1.5 million per violation/large orgs

 Ensure you utilize HIPAA compliant products

 Develop written policies!

HIPAA Under Covid-19

 No cohesive system either between states or within states

2013 APA 50 State Slides

PSYPACT Advisory Group