What interjurisdictional and risk management issues are to be considered when providing Telemental Health?
What are examples of issues to be considered regarding the mix of cross-cultural interactions and technology, which can create a risk for misunderstanding and miscommunication between mental health care providers and the client with whom they work?
What do AMA and APA guidelines recommend you consider before using online information about a client? (For example social networking page and concern for well-being regarding - suicidal ideation, signs of distress, bullying, etc.)
What is an exercise you might do to overcome your “performing” anxiety and coming across as unemotional and flat during the TMH session?
What common ethical considerations occur in an attempt to balance benefits and non-malfeasance?
In general how is TMH received by the following populations: veterans; adolescents; Caucasians; Asians; and Native Americans?
What do HIPPA Privacy rules consider proper education of patients about their rights?
What are some themes that can arise during a TMH session from the point of view of the counselor’s experience and the client’s experience?
What do studies suggest when TMH CBT is compared to face-to-face CBT in treating depression and anxiety?
What are two differences between TMH and in person counseling?
What points might be covered in an explanation of the technical side of the TMH session?
What are some questions to consider regarding “friending” a client?
What is an advantage of providing Telemental Health to the client in his or her home?
What are potentially unique concerns an adolescent may have regarding the TMH session?
Issues to consider for liability risk management center around an understanding of the legal definition of what constitutes malpractice. What are the generally accepted elements of negligence as to what courts consider in malpractice actions?
What steps need to be part of your TMH Emergency Management Plan?
When using face-to-face therapy, access to a client’s significant others can be difficult. Why is your client’s, culture relative to collectivism or individualist especially important in a TMH session located in the client's home?
For children or adolescents eye contact is an important developmental consideration especially when assessing anxiety depression psychosis, autism spectrum disorders, and attachment disorders. A camera mounted above the monitor will cause the child to appear to be looking downward perhaps suggesting depression or anxiety. Conversely a camera placed below the monitor will make the child appear to be looking upward conveying the possibility of autism spectrum disorder these views might falsely confess they difficulties in relatedness and rapport building. What is the solution?
What are some strategies for building bridges over cultural differences?
When considering the use of email or other forms of electronic communication with patients, explain what else should be considered.
A. 1. Adaptation (or lack of adaptation) of clinical style and process utilizing TMH to accommodate different cultural communication styles.
2. Proper attire and room set up for direct in-home TMH
3. Differing understandings regarding the use of voicemail and expectations about returning calls
4. Alternative meetings of text messaging
5. Differing understandings and expectations regarding immediacy of response to emails
B. Where the client will be when Tele-mental Health services are provided; is their presence in this jurisdiction a temporary or a time-limited situation; or permanently located; can a local emergency contact be arranged
C. Schedule a practice session for yourself, when a news program is on. Turn off the sound on your TV and study a number of news anchor people. Observe nonverbal behavior; facial expressions; body movements; now turn on the sound and listen to how they accentuate their language with extra emphasis and tone to make their point. This is especially helpful if you feel you may come across as unemotional and flat during the TMH session.
D. Questions to ask yourself:
1. Why do I want to conduct this online search?
2. Would my online search advance or compromise the treatment?
3. Should I obtain informed consent from the client prior to online searching?
4. Should I share the results of my online search with the client?
E. Veteran populations find the additional control and anonymity afforded by the TMH setting appealing, as reported by others who have experienced trauma.
--Adolescence have been reported to quickly accommodate to the technology setting and often like the additional “personal space” offered by TMH.
--Caucasian clients may find decreased direct eye contact to be a challenge.
--Asian and Native American clients have been reported to prefer the decreased direct eye contact.
Best Practice: Use regular verbal “check-ins” with clients to ask about their current experience of the technology.
F. Avoid any act that would harm the patient/ client or violate the patient's trust by...
--Establishing a procedure related to clients presenting in crisis
--Practicing within the scope of clinical competence
--Assess need for emergency referral
G. The Counselor Experience can seem to be a two-dimensional experience; accepting cyber counseling as a very different experience; increased focus on the cyber counseling process; counseling relationship lacks emotional connection; need to modify counseling skills
The Client Experience can seem to be more comfortable than face-to-face counseling; unexpected depth of emotions; immersed in the counseling process; empowerment; equal relationship, which is a different type of connection; listening is key; and technology is secondary to process
H. Involves providing a written statement that describes how healthcare providers and other covered entities can use or share their information. This should be included in the initial consultation both verbally and in a written format.
I. 1. Time Management: Because gestures and voice intonation are more important due to the limited scope of the video camera not showing you or the client’s entire body; you may find that you seem to only have about 80% to 90% of the usual clinical time
2. Task Management: Regularly summarize your knowledge of sections of clients history and what they have just said to ensure that you have gotten the information correct, since many nonverbal cues will not be visible to you.
J. The use of TMH CBT was associated with significant reductions in depressive symptoms, as well as improved treatment adherence.
K. --How will "friending" affect the client and the therapeutic relationship if his or her request is denied?
--Explain your policy before an issue arises with clients?
--Is it appropriate to accept “friend” request from a family member of the patient, the mother of a pediatric patient for example? Do you need a written policy?
--Is it ethical to accept “friend” request from some patients but not others? What are the clinical implications of doing so?
L. 1. Has the client utilized TMH previously and what questions do they have?
2. Is the session being recorded? If so, can the client access the recording and does anyone else see the recording?
3. Establish the visual context of where you are sitting. Client might be asked if he or she would like to see the clinician’s office. Clinicians can give clients a virtual tour by moving the location of their camera to assure client that no one else is present; this also gives a visual context to the clinical setting.
4. Encourage the client to discuss any technical difficulties. An audio lag makes it seem as if the clinician and client are talking over each other. The clinician might suggest to the client adding a small pause after each statement.
M. An adolescent may have concerns about the following:
1. security and privacy of the technicians videoconferencing system
2. inability for others to enter the session or observed without their knowing.
3. session will not be recorded and “shared on the Internet” or shown to their parents
4. assuring the adolescent the confidentiality is comparable to what they would experience in a face-to-face session
N. According to the study involving PTSD clients Telemental Health can provide more detailed information about the clients background and interests, leading to an improved therapeutic relationship.
O. An Emergency Management Plan can include the following...
1. Assess for Self-harm or harm to others
2. Review the client’s existing clinical record for history of adverse reactions
3. Assess for suicide risk prior to initiating and during treatment
4. Have a secondary method of immediately contacting the client at the originating site in case of equipment failure
5. Discuss with the patient in the initial session what both parties will do in the event of technical malfunction
6. Discuss all emergency procedures (technical, clinical, and medical emergencies) with the client as part of informed consent
P. If harm to self or others is in question
courts may consider your
a. Duty to warn
b. Breach of that duty to warn
c. Injury as a result of breach of duty
d. Proximity occurring between the breach of duty to warn and the injury.
Q. Asking the client or parents about eye contact can often lead to more relevant clinical data, such as to the child’s development and internal experience whether poor eye contact reflects social anxiety or paranoid thinking.
R. 1. In an individualist culture, the inclusion of extended family and nonblood “relatives” who possess an equivalent emotional bond have been shown to be essential in obtaining the collateral input necessary for accurate diagnosis and treatment
2. In the case of individualist culture the individual may be all that is necessary.
S. Also to be considered is does the patient have the expectation that the therapist will be instantly available… normal response time procedure needs to be outlined.
T. --Become familiar with the local nonverbal communication styles and how these styles might be affected by technology
--Become a student of the history and culture of the population you are serving
--Look for resources in building a functional therapeutic team with staff that might be local
--Assess whether you are the best fit for this client, or whether a referral is needed