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What is Teletherapy?
One of the newest and most widely accepted terms for referring to health care delivered via technology, “teletherapy,” is being used interprofessionally to provide an inclusive term describing therapy services offered via the Internet and other telecommunication technologies. Those technologies can involve videoconferencing, telephone, text messaging, remote patient monitoring, virtual reality, augmented reality, e-visits, a variety of interactive services available through apps, as well as any combination of the above. Teletherapy is usually provided by a licensed and preferably, a telehealth-certified professional who offers their services to the public using digital tools.
This article reviews the current derivation of the term teletherapy for telemental health, telebehavioral health, telenursing, tele-speech therapy or tele-occupational therapy, or tele-physical therapy, as well as the broader terms telehealth and telemedicine. It turns an unabashed eye to expose the underlying vulnerabilities inherent to a relatively untrained and possibly unwitting workforce being solicited by a multi-billion dollar industry that has mushroomed since COVID. It provides sobering facts to counterbalance the sometimes unbridled enthusiasm by clinicians that can be fueled by investor greed, only to blur professional decision-making.
How Teletherapy Works
In teletherapy, the client or patient may complete an online assessment, select a therapist from the teletherapy organization, or find an individual practitioner who offers teletherapy through a private website or a directory listing. In some cases, these clinicians allow the consumer to schedule their appointments using a HIPAA-compliant or otherwise protected digital calendar that should keep names and other identifying information protected from the public eye of search engines. Prices frequently vary depending on the method of treatment, the amount of investor funding involved, the preferences of institutional buyers such as insurance companies or employers, and whatever a talented marketing team can develop to attract consumers.
Teletherapy is a synonym for telemental health or telebehavioral health, which is the U.S. government’s preferred term for the field, as established several years ago by the Substance Abuse and Mental Health Services Administration (SAMHSA), the behavioral arm of the U.S. Department of Health and Human Services (HHS). See more about the derivation of terms below.
Where Is Teletherapy Available?
Teletherapy is offered worldwide, often legally, but also illegally by clinicians who are not fully licensed in the geographic area of the client or patient. That is, U.S. licensed professionals can and often do offer services in other countries without proper authorization.1 Similarly, professionals from other countries also offer services to U.S. citizens without appropriate licensure, despite the warnings given directly to consumers to curb such illegal practice. For instance, the California Board of Behavioral Science telehealth consumer information page section entitled “Clients Outside of California” states:
California licensees or registrants who wish to engage in telehealth with a client located in another jurisdiction need to check with that jurisdiction to determine its laws related to telehealth, and if licensure in that jurisdiction is required. Several states currently consider a client located in their state to be under their jurisdiction. Therefore, a practitioner needs to comply with that jurisdiction’s laws in order to avoid any potential violations of those laws.
The issue, however, is that licensing boards are ill-equipped to interfere with such illegal practice, given that they were organized in the 1950s when the current model of responding to consumer complaints was the sole mode of mobilizing resources to intervene on behalf of consumers who are harmed. Despite the technological changes that have evolved in the 70 years since their inception, most licensing boards are powerless to intervene unless a consumer complaint is formally registered with their state’s licensing board. The same is true of professional association ethical codes, where resources are primarily allocated to address complaints and educational campaigns, rather than more proactive enforcement that involves policing to put a halt to errant professionals.
Unfettered illegal and unethical practice both to and from U.S. states and Canadian provinces is particularly apparent in the rash of smaller teletherapy platforms that have surfaced since 2021, where it is clear that the new business owners are unaware or unconcerned with the many challenging laws involved. Clinicians nonetheless register to deliver services through these groups in large numbers, apparently unaware that their legal and ethical responsibilities remain the same, regardless of the technology used or convincing arguments of online employers.
Employers also are yet more unfettered, doing whatever investors and marketing agents find successful, as long as fraud is not apparent.
Given teletherapy’s astonishing growth, it is reasonable to assume that teletherapy approaches are as varied as clinicians may choose. Not only can a clinician use an app to help their client track behavior, but that app can communicate with the clinician (thereby becoming telehealth, and subject to legal and ethical jurisdictional and other regulations), but the clinician can use any combination of telephone, audio-recording, text-messaging, remote patient monitoring, e-visits, and other modalities to convey messages and communicate with clients or patients. Permutations abound.
To give an example related to behavioral health, teletherapy may involve cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), psychoanalysis, mindfulness, and almost any other model. Legitimately, however, evidence-based models shown effective with digital administration are required, but whether or not such protocols are used is another matter. Many digital platforms claim to address mental health issues, including depression, anxiety, stress, parenting, trauma, grief, substance abuse, LGBTQIA+ matters, and eating disorders. For professions other than psychotherapy such as speech and language therapy, occupational therapy and physical therapy, different techniques and combinations of strategies have evolved as well.
Teletherapy supporters have also been able to engender public support. In Delaware, Florida, and New York, both public and private sectors have initiated programs that support and focus on promoting teletherapy. These services have met with varied responses, but in general, some have become trusted sources of help and referral for young people, their families, and others experiencing distress, coping with mental illness, or being affected by the current mental health crisis spawned by COVID.
Teletherapy Limitations in the Face of Massive Funding
Teletherapy has more than its share of limitations, mainly due to the unique challenges of virtual care and the (dare we say it?) largely untrained workforce using it daily. We will examine the first of these issues in this article, and we’ll dig deeper into the teletherapy competencies of providers next week in a separate, follow-up article. For now, then, let’s consider the virtual care platform and the platform owner, the employer.
Regarding teletherapy employers, most of them have gravitated to teletherapy because of the profitable market size and diversity of options for specialization – not necessarily because of their affinity for the field. Many will have a story of a family member who suicided or died of opioid addiction, but while occasionally true, to be taken with a grain of salt at this point. What is to be considered are the billions of dollars flowing into teletherapy to fund new teletherapy programs. The numbers are astonishing. In the second quarter of 2021, the American Hospital Association noted that teletherapy services represent 40% of the overall recent investment in telehealth, which Fierce Healthcare estimated in October to be 15 billion dollars in 2021.
Teletherapy platform owners then come from many ranks, primarily outside of healthcare. They share a few things in common: an unwavering focus on the bottom line, hungry investors who want profits ASAP, and an almost desperate need for clinicians to offer immediate services to a growing population of consumers seeking affordable therapy online. Most also pay short shrift to the clinician’s legal and ethical requirements and have developed platforms with bells and whistles that provide maximum convenience to the client but offer minimum protections for the clinician.
What Do Teletherapy Clinicians Need?
Clinicians may want to think twice about agreeing to work on platforms that compromise their ability to perform 100% of the legally required screening functions and deliver care to digital consumers. Agreeing to compromise one’s services because a platform doesn’t allow required functions may have worked before COVID. Still, now that waivers are lifting and compliance requirements are re-instituted, excuses related to naivete will no longer fly. Many more regulatory and ethical board members have gotten savvy about telehealth and teletherapy, and pleading innocence, ignorance, or naivete isn’t likely to pass.
Here are a few sobering facts to consider:
- The more an employer’s platform uses any single or combination of modalities (e.g., a video-based platform, a text-messaging company) and restricts the gold standard, in-person service delivery, the more the liabilities increase for the clinician. That includes all required functions such as screening, assessment, triage, direct care, referral, termination, etc. Issues then extend far more than privacy and security, which seem to have been the main focus for many employers to date.
- Licensed clinicians may not know that when they sign an employment agreement with an online employer, they typically sign agreements that make them liable for the harm that comes to consumers receiving their professional teletherapy services.
- Most of the employment contracts used by online employers disclaim any responsibility for clinical care and instead place clinical responsibility squarely on the shoulders of the unwitting, licensed professional who signs their “engagement contract”. In other words, they make all clinical care the clinician’s problem and wash their hands of it, despite the limitations their platform provides for clinicians to fulfill their requirements.
- A teletherapy platform’s limitations, “protocols,” or in-house training, don’t negate a licensed clinician’s professional duty to operate legally and ethically, as they were taught in the education programs and as they proved they understood when they took their licensing exams.
- If an in-house training offered by an employer isn’t based on published competencies or evidence-based protocols that have been shown effective with a digital audience, they are irrelevant, no matter how much consensus the employer can muster from its internal community and its leaders.
- Platforms that casually invite clinicians to practice over state lines or international borders without appropriately documented licensure at the client’s or patient’s location are misleading the clinician and consumer, who is responsible for knowing better, regardless of the employer’s statements and assurances.
All That Glitters Is Not Gold
Teletherapists working for well-funded startups are often courted with attractive signing bonuses and convenient work hours. Enamored with the many appealing qualities of Uber-like hours and seemingly relaxed clinical, legal, and ethical expectations, teletherapists may neglect to consider how the technology may alter and limit their traditional services. These include screening procedures, informed consent, or mandated reporting they use when practicing in person. It is easy to allow groupthink to rule clinical decision-making when 100 or 1,000 other clinicians engage in abbreviated clinical processes which work for an online employer and “love” it.
- The technology platform, for example, may encourage a clinician to skip a formal clinical intake interview or mental status exam.
- Deviations from what any individual clinician has done in their in-person practice can (and will) be used in court against a clinician if a complaint it lawsuit is filed. Clinicians in such a scenario may be hard-pressed to defend deviations from their own documented practices because their employer didn’t allow them to perform a legally required process. Many clinicians haven’t stopped to consider how easily opposing counsel in a legal battle can subpoena records showing one’s prior practice procedures to show how the clinician has been “sloppy” when delivering teletherapy. Legal or ethical requirements don’t change, regardless of where a clinician works or if an employment situation doesn’t allow for the required process to occur.
- Clinicians may be encouraged to use digitized screening tools such as the PHQ-9 or GAD-7 without using them in person or being legitimately trained on their proper use in graduate school or afterward, in a CME or CE-approved course. Without formal training, the use of any tool for making clinical decisions is verboten, and in this case, essential when considering that digitized versions of test administration and interpretation must be evidence-based. Teletherapists also need to be documenting the evidence-based related to the digital screening and assessment tools they are using in their digital treatment plans.
- They may not realize that their state laws and ethical codes often require such rigor to protect consumer welfare.
- Similarly, teletherapists may be using video conferencing, which long ago (2012-2013) was proven effective for telebehavioral health. Still, the teletherapists may not have undergone the needed training to understand how to use it according to published, peer-reviewed protocols.
- The more significant concern is that some clinicians are using text messaging as a sole treatment modality beyond video conferencing without carefully reviewing, understanding, and systematically applying that specific evidence base to the individuals they treat online.
- The scientific evidence-base for telehealth in general and teletherapy, in particular, has been developing since1959. Telehealth.org alone has documented more than 5,000 journal articles and peer-reviewed textbooks. Free access to this research is available at every clinician’s fingertips. Training programs have distilled it into easily absorbable, topic-specific training for CME and CE hours. There is no legitimate excuse for failing to use appropriate procedures when using any technology currently available for teletherapy.
Who Is In Charge?
Many responsible digital employers provide platforms that most certainly allow the clinician to perform all required functions. They often include licensed clinicians who are published, recognized technologists on their Board of Directors, their Advisory Boards, their Quality Control Officers, Clinical Managers, and other prominent, decision-making roles with their companies, making it visible to the world that they are doing their best to protect all parties involved.
If a clinician seeks digital employment, it is wise to look for such people, and search for their history in places such as Google Scholar, Academia.edu, ResearchGate, or PubMed. See if they have published substantially in the field, as well as the number of and quality of those publications, spoken at national conferences and offered CME or CE training in telehealth, telemedicine or teletherapy. If not, they may not be true technologists. They may be professionals with notable reputations in a specialty area, but not technologists who have an extensive background in bringing in-person care to digital interfaces.
Below are a few other issues to consider:
- The clinical use of each modality (video, telephone, text, email, apps) with clients or patients requires the technical knowledge and experience for using that modality and a thorough understanding of how treatment using that modality can (and will) go wrong.
- The teletherapist must be able to proficiently remedy technical complications in the heat of challenging therapeutic exchanges about delicate topics, and all the while, maintain the therapeutic relationship.
- Teletherapists may make serious mistakes by saying too little or too much about their personal lives or extend sessions beyond typically scheduled times because they are working from home. In contrast, such self-revelations and extended sessions would rarely have occurred in person.
- More importantly, each clinician using any of these modalities is duty-bound by their licensure to be able to demonstrate evidence-based competence for treating their client or patient using condition-specific appropriate (diagnosis-based) treatment plans.
What Do Teletherapy Clients & Patients Need?
Consumers should be sure to ask about the specifics of a practitioner’s professional training leading to CME or CE hours. Similarly, they should ask about the most advanced training and/or any certificates the provider may have earned, before assuming that all therapists are proficient and adequately prepared to deal with the challenges involved when using technology in health service delivery.
In-person expertise does not necessarily transfer to digital competence on the part of the clinician. (The hallmark of good telehealth training is that clinicians leave marveling at how much they didn’t know before the training.) Issues to be addressed on competent teletherapy involve managing the technical challenges that can occur with access, privacy, security, data integrity, human error; superimposed on common clinical challenges related to intake, screening, assessment if appropriate, referral, mandated reporting, handling emergencies, group therapy, supervision, or any number of other specific skill sets required to operate within the constraints of state laws, ethical codes, telehealth practice guidelines or published competencies. While enforcement of some such laws was relaxed for COVID, enforcement has now returned in many cases. This transition leaves clinicians, who flew by the seat of their pants during COVID, at a loss for how to competently deal with clients and patients who have become accustomed to great permissiveness on the part of otherwise responsible professionals, who previously operated within relatively stringent rules and regulations.
Teletherapy clients and patients then need clinicians who know how to choose employers and platforms that allow them to do their jobs without risking the safety of the consumer due to the unwitting involvement in get-rich-quick schemes of the uber-wealthy investors.
Optimistic Teletherapy Outlook & Cautions
Despite teletherapy’s flaws, many health professionals are optimistic about its future as a viable treatment option for the COVID-induced mental health crisis and beyond. It falls on those professionals, then, to be competent at delivering their services through technology and not allow an online employer to be their exclusive source of professional education. Some such vendors offer training that touts the many benefits of their systems but conveniently omit the pivotal legal and ethical issues that would expose the vendor’s inadequacies. Such vendors also have clinicians sign agreements that place 100% of the liability for a client or patient’s welfare on the clinician rather than on the company.
Clinician and consumer beware. Teletherapy based on guesswork, groupthink, or employers who can easily be shown to have financial rather than altruistic motives can be problematic for teletherapists. This is particularly true now when the scientific literature is brimming with proven strategies for improving telepractice, and such information is literally at everyone’s fingertips online. In short, simply transferring one’s in-person practice to a digital modality has now become commonplace but often isn’t necessarily legal or ethical. Employers may create working conditions that prove to pay well and offer many conveniences, but legal and ethical requirements don’t change if the clinician is unable to bridge the digital gap in mandated ways. Unfortunately, many clinicians are not aware of such requirements until it is too late.
Derivation of Terms: History of Telehealth-Related Nomenclature
As an early writer in telehealth, I have had the fortunate position of watching the field mature over the last 28 years. My comments below come from the research I’ve been conducting since my early textbooks.2,3
The many types of professionals now delivering teletherapy include addiction professionals, behavior analysts, behavioral nurse practitioners, counselors, marriage and family therapists, nurses, physical therapists, psychologists, some psychiatrists, speech and language therapists, occupational therapists, and more. Readers wondering if teletherapy is any different from telemental health, telebehavioral health, telenursing, tele-speech therapy or tele-occupational therapy, or tele-physical therapy may be interested to know that the new term is essentially interchangeable with these previously popular terms. The teletherapy term is more inclusive than those used across professions and by licensing boards ruling the multitude of professions listed above.
On the other hand, telehealth is a broader term, one that is inclusive of all aspects of healthcare delivered across distance. With “tele” being the Greek word for “distance,” it follows that non-medical practitioners and their associates have recoiled when required to use exclusionary terms such as “telemedicine” for all professions delivering direct care through technology, such as legislatively mandated a few years ago by New Jersey legislators. Ironically most allied professionals are excluded from offering medical services in those same states but must nonetheless consider their services to be “telemedicine.” Other state licensing codes have used terms such as ‘electronic service delivery” or more profession-specific terms such as “telepsychology” or “distance counseling,” following the age-old tradition of building silos to identify and protect their respective professional turf.
Just as the initially-coined term “medical care” was subsequently replaced by “health care” to reflect and include the many different services offered by non-medical providers serving the same groups of people, “telemedicine” has systematically been replaced by state codes that have adopted “telehealth” as the overarching term to refer to healthcare delivered across distance via technology. Similarly, a new generation of therapists across the world has thrown off the prior restrictions related to profession-specific terminology to embrace what is considered a subset of the broader term “telehealth,” the new kid on the block, teletherapy. A casual review of national association websites, news briefs, and articles will show that they are following suit, replacing more profession-specific terms such as telepsychiatry, telepsychology, and distance counseling with the more inclusive “teletherapy.”
1 Glueckauf, R. L., Maheu, M. M., Drude, K. P., Wells, B. A., Wang, Y., Gustafson, D. J., & Nelson, E.-L. (2018). Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, 49(3), 205–219. https://doi.org/10.1037/pro0000188
2 Maheu, M., Whitten, P., & Allen, A. (2001). eHealth, Telehealth & Telemedicine: A Guide to Startup and Success. New York: Jossey-Bass.
3 Maheu, M. M., Pulier, M. L., Wilhelm, F. H., McMenamin, J., & Brown-Connolly, N. (2005). The mental health professional and the new technologies: A handbook for practice today. Mahwah, NJ: Erlbaum.
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