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What is Telemental Health?

“…telemental health is the provision of remote mental health care services (using modalities including videoconferencing, computer programs and mobile applications)...”

Telebehavioral Health
e-Counseling
e-Therapy
Online Therapy
Cybercounseling
On-line Counseling

(Canady, 2016)

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History of Telemental Health

Early Experimentation

1955: Psychiatrist Van Lear Johnson provides group psychotherapy & psychiatric consultation via closed circuit television.
1950s-60s: Federal trials validate use of TMH with rural communities, prohibitive cost prevents wide adoption by individual providers. Federal Agencies, including NASA and the Veterans Administration, continue development of TMH tools and practices.
1968: In Nebraska VA invests in TMH, linking together network of rural hospitals. Model expanded to Massachusetts in same year.

(Adams et al, 2018)

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History of Telemental Health

Expanded Access

Early 1990s: Growth of personal computers, cell phones, and increasingly affordable access to the internet.
1993: American Telemedicine Association established to promote access to medical care via telecommunications technology.
1996: Telecommunications Act funds expansion of high-speed internet access to rural communities.

(Adams et al, 2018)

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History of Telemental Health

Dramatic Growth

1990s – Early 2000s: Widely available internet access and the growing internet of things (IoTs) allows quick and easy access to health and wellness information (Adams et al, 2018).
Present: Increased availability of TMH services in response to dramatic growth in demand

More than a dozen US companies dedicated to providing TMH services (Novotney, 2017).
UK’s NHS saw a 9x increase in utilization of webcam and instant messenger appointments between 2012 and 2016 (Kraemer, 2017).

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PROS AND CONS OF TELEMENTAL HEALTH

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Pros of Telemental Health

As effective as in-person care (possibly more effective) for older adults, children, adolescents, and many underserved populations �(Hilty et al, 2013; Molfenter et al, 2015 as cited in Adams et al, 2018).
Reduced Barriers to Access (Pruitt, Luxton, & Shore, 2014)

Travel costs
Childcare
Accessibility

Greater Contextual Awareness (Pruitt et al, 2014)

Opportunity to observe/serve client in their home environment
Ease of incorporating others into the counseling relationship
Opportunity to incorporate wellness apps and trackers into care planning

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Cons of Telemental Health

Reduced nonverbal information (Pruitt et al, 2014)

Inability to smell alcohol/drugs, reduced opportunities for direct eye contact, etc.

Reduced control of the therapeutic environment (Adams et al, 2014)

Potential for interruptions, reduced client focus, etc.

Technology Challenges (Chou, Bry, & Comer, 2017)

Technology can create physical and digital barriers between clinician and client.
Technological pace of change can be overwhelming to clients and providers.

Information Security & Confidentiality (Adams et al, 2018)

Federally mandated standards of privacy protection & data encryption.
Varying state requirements and legal standards.

Reduced access to Insurance and Medicare reimbursement (Adams et al, 2018)
Inconsistency of Licensure & Practice Standards (Adams et al, 2018)

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LICENSURE & LEGAL CONSIDERATIONS

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General Considerations

No national standard for licensure / credential to practice
Attempts at “national” compacts are in-progress*
Liability Insurance may or may not specifically address TMH, should contact insurance provider for clarification.
General standard: practioner must be comparably licensed in both the jurisdiction they physically practice in, as well as the jurisdiction the client physically resides in.
Some states require in-person appointments (or at least the opportunity for them).

(Adams et al, 2018)

*ACA/CACREP efforts tied to state recognition of Nationally Certified Counselor credential.

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State Specifics

Kansas

Practioners must hold licensure in KS
Practioners must accurately reflect their level of licensure in KS
Practioners must obtain the client’s consent for telemental health services as part of their informed consent process.

Missouri

Practioners must hold licensure in MO
Telemental Health contact hours do not count towards the 1,200 hours of direct client contact required for full licensure in MO as current regulations require client and counselor be physically present in the same room.

(Lerman & Quashie, 2016)

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PROFESSIONAL ORGANIZATIONS & CREDENTIALS

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Professional Organizations

American Counseling Assoc.

Addressed in Code of Ethics
Published Recommendations
No formal interest/work group

American Assoc. of Marriage & Family Therapists

Not Addressed in Code of Ethics
Published Recommendations
Telehealth interest/work group

Industry Organizations

American Telemedicine Association

Est. 1993, 501c3 Non-Profit
Telemental Health interest/work group
Sponsored 50-State survey of Telemental/Telebehavioral Health (2016)

Coalition for Technology in Behavioral Science (new)
International Society for Mental Healthcare Online (defunct?)

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Credentialing Options

Center for Credentialing & Education

Board Certified Telemental Health Provider (BC-TMHP)

National Board for Certified Counselors (NBCC) subsidiary
NBCC Approved CE Provider
Cost: $600 + $45/year maintenance fee + 4 CEUs per year

Telebehavioral Health Institute

TBHI-Certified Telebehavioral Health Professional

Institute Est. 2009, affiliated with ATA, AMHCA, and Clinical Social Work Association
NBCC, APA, ASWB, & NAADAC Approved CE provider
Cost: $397 + 6 hrs TBHI-approved training every 3 years
Advanced certificate offered addressing legal, regulatory, and administrative issues - $1,495

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DISCUSSION & CITATIONS

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Summary

Practical Issues

TMH dramatically reduces some barriers to access while increasing a client’s pool of potential providers.
TMH appears to offer comparable outcomes to in-person therapy.
There is considerable demand for TMH services and providers.
TMH is in its legal and regulatory infancy for most providers.

Professional Concerns

Should we be encouraging our clients to increase their digital footprint?
How much control of the therapeutic environment can (should?) the therapist surrender �to the client?
Who should have oversight of TMH professional ethics and educational standards?

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Works Cited

Adams, S. M., Rice, M. J., Jones, S. L., Herzog, E., Mackenzie, L. J., & Oleck, L. G. (2018). TeleMental Health: � Standards, Reimbursement, and Interstate Practice. Journal Of The American Psychiatric Nurses Association, 24(4), 295–305. https://doiorg.proxy.library.umkc.edu/10.1177/1078390318763963

Canady, V. A. (2016), Telemental health report examines regulations and policies. Mental Health Weekly, 26: 3-5. doi:10.1002/mhw.30620

Chou, T., Bry, L.J., & Corner, J.S. (2017). Overcoming traditional barriers only to encounter new ones: Doses of caution and direction as technology-enhanced treatments begin to “go live”. Clinical Psychology Science & Practice 24: 241- 244.

Johnston, B., Ferrer, D. C., Parish, M. B., Donald M. Hilty, Callahan, E. J., & Yellowlees, P. M. (2013). The Effectiveness of Telemental Health: A 2013 Review.

Kramer, D. (2017, March 20). New figures show almost ninefold rise in online appointments over three years. Independent. Retrieved from https://www.independent.co.uk/life-style/health-and-families/health-news/online-therapy- mental-health-help-services-webcam-appointments-increase-messenger-nhs-depression-a7626496.html

Lerman, A.F. & Quashie, R.Y. (2016). 50-State survey of telemental/telebehavioral health [report]. Epstein Becker Green. Retrieved from: https://www.ebglaw.com/telemental-telebehavioral-survey/

Novotey, A. (2017). A growing wave of online therapy. Monitor on Psychology, 48(2). Retrieved from https://www.apa.org/monitor/2017/02/online-therapy.aspx