Ethical and Practice Considerations in Telehealth for Couples Interventions Presented by Nate Rhoad, B.S., Olivia McFarland, B.S., Jennifer Ripley, Ph.D Overview • • • • • • What is Telehealth? Telemental Health General Ethical Considerations E-Hope Couples Consultation Ethical Issues Specific to Couples Work Case Studies A Changing World http://www.apa.org/divisions/div46/technology-1.jpg A Changing World • Advancement in technology o Increased pace and decreased cost • • • Increasing popularity of social media Familiarity with technology Consumer Demand o Needs of younger generation o Individual’s in rural areas Maheu et al., 2012 What is Telehealth? • • The use of electronic info and telecommunication to support and improve clinical health services, health administration, patient info, public health, and professional education and supervision (Baker & Bufka, 2011) Technologies include videoconferencing, the internet, streaming media, store and forward technologies, and terrestrial and wireless communications (Baker & Bufka, 2011) What is Telehealth? • Did you know?… o Concept of Telehealth not a novel one o 1879- Article in the Lancet discussed using phone to reduce office visits (Nesbitt, 2012) o 1925- Cover of Science and Invention shows doctor diagnosing patient by radio (Nesbitt, 2012) o Video teleconferencing used in Dept. of Veterans Affair for almost 20 years (Novotney, 2011) Telemental Health • Terms include “telemental health”, “e-mental health”, and “telepsychology” • Email use with clients more than tripled from 2000 to 2008 among psychologists • • Teleconferencing increased from 2 to 10 percent in same time period Ability to potentially provide services to millions of people who could ordinarily not access psychological services due to immobility, illness, or geographic location o Nearly 80 million live in a “mental health shortage area” Novotney, 2011 Telemental Health • Has been used to treat various psychological problems (Novotney, 2011) o • PTSD, substance use, anger management Is it effective? o 2008 meta-analysis of 92 studies did not find sig. difference between face to face and telemental health approaches o Has been found to effectively treat PTSD symptoms and anger problems o Study of 98,000 mental health patients (Godleski, Darkins & Peters, 2012) o Hospitalization utilization decreased by average of 25% between 2006 and 2010 when teleconferencing was used The Human Element • Is therapeutic alliance diminished when videoconferencing is used? • Study conducted examining the difference in alliance between face to face and videoconference therapy (Germain et al., 2010) • 46 participants diagnosed with PTSD (17 over video, 29 in person) • Assessments analyzing alliance administered five times throughout treatment • Alliance was found to develop similarly in both conditions • Those who had concerns about technology had no trouble building alliance with their therapist • Therapists can impact client’s view by maintaining positive attitude about videoconferencing Effectiveness with Couples • Study investigated the outcomes of 11 couples who participated in solution focused marital therapy (Jedlicka & Jennings, 2001) • Conducted via email • Outcomes were similar to face-to-face therapy, with strength of outcome associated with couples investment in problem solving General Ethical Considerations • Currently, APA does not have official policy regarding use of telemental health However… APA and Association of State and Provincial Psychology Boards (ASPPB) Model Acts of Licensure of Psychologists note that psychological care may be provided electronically or over the phone • • Jurisdictional Restrictions Baker & Bufka (2012) Jurisdictional Restrictions • Telepsychology 50- State Review • States differ in statutes and regulations in place for telepsychology (many states do not have them) • All states have regulations for licensed psychologists who practice telepsychology in states they aren’t licensed in • All states implement a penalty for those who practice telepsychology without license (just as in the general practice of psychology) • http://www.apapracticecentral.org/advocacy/state/telehealthslides.pdf General Ethical Considerations • • • • Informed Consent Safety and Security Online o Email o Videoconferencing- Use of Skype? Reimbursement Concerns Training Baker & Bufka (2012) Ethics Statements Across the “Boards” • American Association of Marriage and Family Therapists • “When using electronic methods for communication, billing, recordkeeping, or other elements of client care, marriage and family therapists ensure that their electronic data storage and communications are privacy protected consistent with all applicable law.” AAMFT Code of Ethics, 2012, 2.7 Protection of Electronic Information • American Counseling Association • “Counselors take precautions to ensure the confidentiality of all information transmitted through the use of any medium.” ACA Code of Ethics, 2014, B.3.e • National Association of Social Workers • “Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible.” NASW Code of Ethics, 1996, Revised 2008, 1.07.m http://www.zurinstitute.com/ethicsoftelehealth.html#aamft Hope Model • Short term strategic • Religion-accommodative • New model: attachment, positive psychology/virtues • Reviewed one of 4 empirically supported treatments for marriage enrichment (Jakubowski et al., 2005) • 20 years of research at VCU (Worthington et al) and 14 years at Regent U. • Two books on it Worthington (2005) Ripley & Worthington (2014) E-Hope Consultation • • • A model based on couple education and enrichment Each couple is matched with a consultant who directs and guides them through the process The couple can choose their own modules and materials to work through o • • Modules consist of worksheets, videos, blogs & Vsee conversation The consultant also suggests relevant materials The consultant meets with the couple two times a month over a period of two months Why Consultation? • • • • Couples should not have serious psychopathology, serious violence, substance abuse, separation, or significant relational problems Emphasis on enrichment rather than counseling If serious distress or issues become relevant, couples will be referred for counseling Consultant supports couple in meeting their relationship goals and growth o couples counseling is to assist with healing and repair from dysfunctional relationship patterns Ethical Issues Specific to Couples Work • • • • • Screening couples for suitability • • Connectivity Issues Referral and Safety Issues Confidentiality Informed Consent • Education Consultation environment Couples may not have as secure of an environment as the consultant (Bischoff, 2004) • Mental Status (Bischoff, 2004) May be difficult to obtain for two individuals • Case Studies • African American Couple • Mid 40s • Seeking online couples consultation due to busy schedule • Main concerns are in the area of communication References Baker, D. C. & Bufka, L. F. (2011). Preparing for the Telehealth World: Navigating Legal, Regulatory, Reimbursement, and Ethical Issues in an Electronic Age. Professional Psychology: Research and Practice, 42(6), 405-411. Bischoff, R.J. (2004). Considerations in the Use of Telecommunications as a Primmary TreatmentMedium: The Application of Behavioral Telehealth to Marriage and Family Therapy. The American Journal of Family Therapy, 32(3), 173-187. Campos, B. (2009). Telepsychology & Telehealth: Counselling Conducted in a Technology Environment. Counselling, Psychotherapy, and Health, 5(1), The Use of Technology in Mental Health Special Issue, 26-59. Germain, V., Marchand, A., Bouchard, S., Guay, S., & Drouin, M. (2010). Assessment of the Therapeutic Alliance in Face-to-Face or Videoconference Treatment for Posttraumatic Stress Disorder. Cyberpsychology, Behavior, and Social Networking, 13(1), 29-35. Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006–2010. Psychiatric Services, 63, 383–385. doi:10.1176/ appi.ps.201100206 References Jedlicka, D., & Jennings, G. (2001). Marital therapy on the Internet. Journal of Technology in Counseling, 2, 1–15. Keeran, D. M. (2009). Effective counseling skills: the practical wording of therapeutic statements and processes. Vancouver, British Columbia, Canada: Counselor Publishing. Maheu, M. M., Pulier, M. L., McMenamin, J. P., & Posen, L. (2012). Future of Telepsychology, Telehealth, and Various Technologies in Psychological Research and Practice. Professional Psychology: Research and Practice, 43(6), 613-621. Nesbitt, T. S. (2012). The Evolution of Telehealth: Where Have We Been and Where are We Going? In The Role of Telehealth in an Evolving Health Care Environment-Workshop Summary. Retrieved from http://www.iom.edu/Reports/2012/The-Role-ofTelehealth-in-an-Evolving-Health-Care-Environment.aspx Novotney, A. (2011). A New Emphasis on Telehealth: How can psychologists stay ahead of the curve-and keep patients safe? Monitor on Psychology, 42(6), 40.