Remote therapy brings benefits, raises questions

In 2009 when Marty Fino, Ph.D., semi-retired from private practice in Rutland, Vt., telepsychology was a mere blip on practitioners’ radar screen. Although some clinicians had begun to email at that time, communicating electronically with clients had not become as prevalent as it has in recent years.

The Veterans Healthcare Administration (VHA) has been a forerunner in telehealth practices since the mid-1990s and covers more than 44 clinical specialties, including TeleMental Health.

According to VHA, in fiscal year 2013, more than 278,000 encounters took place to more than 91,000 veterans via telehealth. The scope of these services focused on posttraumatic stress disorder, depression, bipolar disorder, behavioral pain and evidence-based psychotherapy, although all mental health conditions were included.

Since fiscal year 2003, telehealth consultations have increased 24-fold, the VHA noted.

In a locum tenens position in 2013 at the VA in Prescott, Arizona, Fino conducted five telehealth examinations with a veteran in a remote location while medical personnel were on-site in an adjoining room in case of emergency. “Overall for mental health assessments, this was appropriate and worked,” he said.

Although his minimal experience with telehealth was positive, Fino expressed some concerns. “What happens if in the midst of a session the Internet goes down? Does the provider bill for the entire time slot? Will the insurance cover the session? What is ethical in such a case?” he asked.

“We need to explore this and at the same time work out a variety of issues. Is it safe for the patient? How do you protect the privacy of the practitioner and the client? Legality is another issue.”

In the private sector, some psychologists are gradually adopting the use of telepsychology. When Elaine Ducharme, Ph.D., ABPP, private practitioner in Glastonbury, Conn., moved from Florida to Connecticut 12 years ago, she continued to treat a long-time client by phone. Over the years, she has expanded her services to include video via an encrypted video conferencing system.

Telepsychology definitely has a place in practice, Ducharme said. For example, in the past when a client’s child was ill, she would have to miss her appointment. “Now she can do the session at home via phone or video,” she said.

While telepsychology can be effective under the right circumstances, Ducharme pointed out that she would not use this method with a client she didn’t know or with whom she had not already established a comfort level. Her first client encounter is always face-to-face, she reported.

Ducharme noted that some clients have begun sending emails and text messages, mostly to confirm, cancel or change appointments. While this practice helps clients stay in touch, she emphasized the need to establish limits.

“Clients can email and text at any time of the day. After responding late one night to a non-emergency email, I decided that boundaries need to be set,” she said.

Additionally, Ducharme points out to clients that emails and texts are not secure and advises them not to send messages they wish to keep private.

In light of the growing interest in telepsychology, the Association of State and Provincial Psychology Boards (ASPBB) developed the Psychology Interjurisdictional Compact (PSYPACT) that would create “a common, shared legal and regulatory framework for participating states and establish an Interjurisdictional Practice Commission” to oversee telepsychology and temporary out-of-state practice. The proposal has met with some resistance from state associations.

According to Pete Fullerton, communications director for the Massachusetts Office of Consumer Affairs and Business Regulation, which oversees the Department of Professional Licensure, the board held discussions on the provision of services by electronic means at the last two meetings in April and May.

“The Board decided to continue with its current policy that ‘practice occurs in the state in which the patient resides’ and unanimously voted not to endorse the compact. The Board has concerns regarding its ability to assert jurisdiction over and discipline licensees operating in violation of the Board’s licensing statutes and regulations. Without this ability, the Board does not believe it can fulfill its consumer protection mandate,” he said, noting that the Board may revisit the issue later this year.

Michael Goldberg, Ph.D., director of professional affairs at the Massachusetts Psychological Association said, “The MPA has not formally reviewed the compact. We have been under no pressure to do so since we have not heard of any efforts by the Massachusetts Board of Registration of Psychologists to consider it,” he said.

Although the MPA has taken no stance on the issue, Goldberg indicated that telepsychology holds “tremendous potential benefits, including greater flexibility in practice and less overhead expenses for practice. Clinically, telehealth has the potential to provide greater access for patients who cannot travel to a psychologist’s office, such as clients who are sick or injured.”

“Telehealth would support continuity of care for individuals moving out of state and would support treatment for those who travel frequently. Accessing services at more convenient times would be a benefit for many, as would the decreased burden associated with traveling to a clinician’s office,” Goldberg added.

“Patients with unique clinical presentations, such as hoarding, could have better access to in vivo exposure treatments. Likewise, telehealth would likely increase access to urgent assessment services in primary care and other medical settings.”

Goldberg admitted that the practice of telepsychology does pose some potential risks as well. He noted that electronic privacy issues, interruptions because of technology problems, video that might impact the quality of non-verbal communication and clients who record sessions could be problematic.

“However, all the research to date suggests telehealth psychotherapy services are typically as effective as face-to-face services. Telehealth could allow psychologists to practice with clients sitting in other states, which could open new markets to us,” Goldberg said. “However, it also could allow out-of-state clinicians to work in our marketplace.”

When it comes to telepsychology, the client’s interest should be the top priority, according to Ducharme. “For years, we’ve dealt with patients in crisis on the phone. So in some ways this not new,” she said. “This is a great way to provide continuity of care.”