Practice Innovations

Telepsychology Practice: Primer and First Steps

Jana N. Martin, Fred Millán, and Linda F. Campbell
Online First Publication, March 26, 2020. http://dx.doi.org/10.1037/pri0000111

CITATION
Martin, J. N., Millán, F., & Campbell, L. F. (2020, March 26). Telepsychology Practice: Primer and First
Steps. Practice Innovations. Advance online publication. http://dx.doi.org/10.1037/pri0000111
 Practice Innovations
© 2020 American Psychological Association 2020, Vol. 2, No. 999, 000
ISSN: 2377-889X http://dx.doi.org/10.1037/pri0000111

Telepsychology Practice: Primer and First Steps

Jana N. Martin Fred Millán

The Trust, Rockville, Maryland SUNY Old Westbury

Linda F. Campbell
University of Georgia
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Telepsychology is being increasingly assimilated into professional practice. The knowl-

edge and skills necessary for competent practice are being introduced into training
programs; however, psychologists who are practicing independently have no formal
means to prepare for this expansion in their scope of practice. This primer for practice
leads readers through the clinical, technical, and logistical steps necessary for prepa-
ration, initiation, and participation in telepsychology. Topics discussed include over-
coming barriers and increasing one’s opportunities (e.g., geographical, financial, trans-
portation); competencies, standards of care, and ethical considerations (e.g., adaptation
of informed consent and confidentiality agreements, electronic recordkeeping and
storage); what one needs to know for implementation (e.g., Health Insurance Portability
and Accountability Act and the Health Information Technology for Economic and
Clinical Health Act); interjurisdictional practice (e.g., legal status); action steps; and
resources. Psychologists beginning to incorporate technology into their practices as
well as those with technical competence will note several features that lend guidance
to the basic elements of practice: (a) Risk management tips are offered throughout the
article, (b) an informed consent checklist for self-assessment is presented, and (c) a
checklist for hardware disposal and software removal is detailed. Practitioners who are
curious about telepsychology but do not know how to inquire or where to begin are
offered clear direction and important information on how to incorporate telepsychology
into existing practices or to begin a purely telepsychological practice.

Clinical Impact Statement

This article is focused on the population of practitioners who have primarily
engaged in traditional in-person service and realizes telepsychology can impact
their practices but are not equipped to participate without foundational information.
That information is presented here in a stepwise, practical manner that explains
application and implementation, which contributes to increased competency of the
practitioners.

Keywords: telepsychology, telepsychology practice, risk management, telepsychology

guidelines, interjurisdictional practice

Provision of psychological services has gone office, hospital, community agency, and clinic,
beyond the walls of the independent practice as well as beyond the restrictions of access and

University of Georgia.
Jana N. Martin, The Trust, Rockville, Maryland; Correspondence concerning this article should be ad-
Fred Millán, Graduate Mental Health Counseling dressed to Jana N. Martin, The Trust, 111 Rockville Pike,
Program, SUNY Old Westbury; X Linda F. Campbell, Suite 700, Rockville, MD 20850. E-mail: jana.martin@
Department of Counseling and Human Development, trustinsurance.com

1
 2 MARTIN, MILLÁN, AND CAMPBELL

waiting lists, illness, disability, work, stigma, Security measures evolve as threats and
relocation, and even weather. Telepsychology breaches of protection occur—a highly recom-
has connected clients with psychologists in mended product or service may quickly become
ways that traditional “in-office” therapy could no longer secure. Become familiar with re-
not, enhancing continuity and specialization of sources that review the status of products and
care. services. Consult with those informed about
One tool of telepsychology has been used by changes in technology and protection and reas-
clinicians for many years, yet its users likely did sess often the measures you have taken to en-
not think they were engaging in the practice of sure they are still supported.
telepsychology. Because telepsychology is de- Telepsychology is a viable and valuable re-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

fined as “the provision of psychological ser- source for psychologists and the public. It is
This document is copyrighted by the American Psychological Association or one of its allied publishers.

vices using telecommunication technologies” incumbent on those practitioners who are con-
(Joint Task Force for the Development of Tele- sidering adding telepsychology to their prac-
psychology Guidelines for Psychologists, 2013, tices to understand its potential for providing
p. 791), clinicians who have used telephone, needed, quality services; what knowledge,
mobile devices, and faxes when working with tools, competencies, preparation, and ongoing
training are essential; the guidelines and regu-
clients have been practicing telepsychology!
lations that govern the legal and ethical practice
Advances in telecommunications have ex-
of telepsychology; and risks and risk manage-
panded the practice of telepsychology to in-
ment strategies.
clude providing psychological services using
devices and activities such as interactive video- Risk Management Tip: Psychologists must
conferencing, e-mail, chat, and text, not to men- seek out appropriate training experiences to
tion Internet use with blogs, self-help websites, develop and maintain competence in deliver-
and social media (Campbell, Millán, & Martin, ing telepsychology services.
2018). Interactive communication with clients Ongoing training experiences in areas of clin-
that occurs within real time, such as on the ical, technical, emotional, and cultural compe-
telephone or using videoconferencing, is often tence can be obtained through webinars, work-
referred to as synchronous, while communica- shops, research reviews, and consultation.
tion using e-mails, faxes, or discussion forums Because this is a developing modality of prac-
is considered asynchronous. A more thorough tice, remaining current about developments in
explanation of the advantages and disadvan- technology; ethical, business, and regulatory is-
tages of these two modalities can be found in sues; clinical outcome studies; and factors that
Cooper, Campbell, and Smucker Barnwell impact delivery of services is essential.
(2019).
Telepsychology can be used to augment in- Why Is This a Growth Area?
person psychotherapy sessions or as a primary
method of providing services. Common uses of Individuals seeking psychological services
telepsychology to augment in-person sessions have faced barriers that have often prevented
include telephone sessions to check on progress access, resulting in failure to receive needed
or to deal with an urgent matter, e-mailing sup- mental health care. Telepsychology can reduce
plemental information or links to resources, tex- or eliminate significant challenges to mental
ting appointment information; using mental health care access. Correspondingly, telepsy-
health apps for monitoring or tracking behav- chology also offers opportunities that are not
iors, and having clients complete online testing feasible with in-person services. Several of the
or assessment instruments. major barriers and opportunities are described
below.
Risk Management Tip: Psychologists must
attend to the privacy and security of commu- Geographic Barriers
nication methods—for example, using secure
e-mail for sending Protected Health Infor- Rural life has been identified as a challenge
mation (PHI), encryption for cell phones, for mental health services because of its multi-
and informing clients of the risks. ple-relationship dilemmas, the plight of health
 TELEPSYCHOLOGY PRIMER 3

disparities, physical inaccessibility, and infor- munity activities. These individuals then be-
mation deficits. Given basic technology access, come invisible to their own communities and
videoconferencing is now possible with basic known friends and associates. Telepsychology
technology training for the client regarding se- is an opportunity for individuals to commit to a
curity, confidentiality, and protocol for access gradual reentry into their work and social com-
and data management. The preference for re- munities by engaging in services that do not
mote access remains a facility-based location require that they initially leave their comfort
rather than the home; however, for geographi- zones.
cally limited individuals, access to any commu-
nity facility is often not reasonable. Telepsy- Transportation and Financial Barriers
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

chology, therefore, offers the opportunity for

This document is copyrighted by the American Psychological Association or one of its allied publishers.

mental health services independent of location Individuals living in urban areas can experi-
and physical access, which, in turn, has great ence as much difficulty with transportation as
potential to significantly increase mental health those in rural living. Typically, the transporta-
treatment for this population. tion barriers are no availability, prohibitive ex-
pense, or unreasonable time consumption. Fi-
Lower Socioeconomic Status nancial barriers extend beyond the fee for
service and can double given the cost of trans-
People living in poverty experience multi- portation, length of time away from work to go
ple barriers, some of which are within the to and from the session, and other fees. Navi-
context of the client’s variables and others gating insurance plans, understanding contrac-
caused and maintained by the environment tual parameters, and garnering the persistence to
and individuals within the systems people in successfully overcome both transportation bar-
poverty must navigate. In order to attend in- riers and financial red tape are often factors in
person psychological services, people living
premature termination. Telepsychology re-
in poverty must step outside of their environ-
moves these obstacles, although the cost of ser-
ments in often intimidating and anxiety-
vices remains. However, the removal of other
producing circumstances. They must make
costs and logistical barriers is a significant ad-
their way to an office in an often new and
unknown location; be prepared to engage with vantage in seeking and continuing with mental
staff asking insurance, copay, and other ques- health services.
tions that could be embarrassing; be in the
presence of others in the waiting room and the Attitudinal Barriers
staff who may have all the appearances of
middle-class characteristics; and, once in the Although public information and education
room with the practitioner, be unsure of un- campaigns, as well as other service efforts, have
derstanding what will be happening. The in- made significant inroads on the stigma of men-
timidation factor can be greater than the an- tal health needs, the stigma has not been over-
ticipation of useful help, and services are not come among many who would benefit. Family
sought. bias, cultural beliefs, societal stereotyping, and
the anticipation of shaming and ridicule prevent
Social Isolation many individuals from accessing the services
they need. Individuals who are members of
Individuals who might otherwise seek mental marginalized populations may be reluctant to
health services may live in rural, small town, or seek services given historical exploitation and
urban areas, but if they are experiencing depres- maltreatment. Telepsychology affords privacy
sion, anxiety, or other symptoms that isolate and protection from external sources of criti-
them from their community or from others who cism and from engagement with others regard-
would otherwise be within their support circle, ing services. Individuals who are self-critical,
then physical access to services is irrelevant. however, may still experience some stigma, but
The isolated only become more isolated as they the privacy of telepractice and the competence
withdraw from information access, cultural of the clinician can increase self-acceptance for
events, entertainment, sports, church, and com- services.
 4 MARTIN, MILLÁN, AND CAMPBELL

Physical Limitations Mobility

Marginalized populations include those with As mentioned, interjurisdictional limita-

physical as well as cognitive limitations. Clini- tions still exist and are discussed elsewhere in
cians must carefully assess the appropriateness this article; however, for intrajurisdictional
of telepractice, particularly for those with hear- telepractice, services would no longer need to
ing or speech difficulties, language differences, be discontinued for the length of time the
and cognitive limitations that could be aggra- client or clinician is out of town. Telephone
vating factors related to needed technology communication has, of course, been an inte-
competencies, emergency responsiveness, and gral part of psychological practice for many
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

understanding the limits of confidentiality. With years, but the advent of inexpensive video-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

some exceptions as cited, those with physical conferencing capability makes real-time, syn-
limitations have an opportunity that would be chronous telepsychology available for most
prohibitive for in-person services. individuals.
Risk Management Tip: Make a determi-
Access to Specific Expertise nation about using telepsychology primarily
Specialty practices have been developing in based on appropriateness for the individual
recent years that afford individuals treatment in client.
eating disorders, dialectical behavioral therapy, Once you have decided on using telepsychol-
trauma therapy, substance abuse, and other tar- ogy with a client, document what variables you
geted treatment needs. Those who have over- considered; your thought process, including
come or not experienced the other barriers men- how you will continue to assess the appropri-
tioned may find that practitioners are not ateness of this modality; and your client’s re-
available in their community who can compe- sponse.
tently treat their specific concerns. Interjurisdic- Clearly, telepsychology can overcome many
tional practice remains a limitation depending barriers and increase access to needed services.
on the location of the client and practitioner; Knowing how best to provide those services
however, within a state or jurisdiction, practice ethically and legally is important to ensure de-
across a distance is an opportunity afforded by livery of quality and effective psychological
telepractice that eliminates travel and additional services.
logistical barriers.
Interjurisdictional Practice
Practical/Logistical
As described earlier, the benefits of teleprac-
Traditional practices for in-person psycho- tice include the ability to reach populations
logical services have been accepted over the across state lines that might not have had access
years as ethical and professional protocol. Many to services previously and to provide continuity
of these practices are in and of themselves pro- of services to existing clients. For example, it
hibitive for seeking services. For example, the allows us to treat someone in rural areas where
50-minute hour assumes once a week, typically traveling to treatment centers may be too cum-
a regular time for in-office treatment. Individu- bersome or to continue treating clients who are
als who have multiple jobs, irregular job sched- transferred for extended periods to another state
ules, or no control over their work demands are due to work.
often not able to meet the 50-minute hour con- State policies typically address how you can
vention. Those who have children, family mem- provide telepsychology within the state; how-
bers who are ill, and responsibilities for others ever, clinicians must be aware that each state
may not be able to predictably schedule in ad- has its own set of laws and regulations about
vance. Telepsychology would still require plan- how it permits psychologists from outside its
ning and scheduling; however, the challenges jurisdiction to treat its residents. Some states
presented by additional time requirements and allow provision of services for limited periods
unpredictable variables can be resolved more of time without formal notification of the psy-
easily through telecommunications. chology boards, others require permission/
 TELEPSYCHOLOGY PRIMER 5

notice prior to starting services, and others will Delaware, Georgia, Illinois, Missouri, Ne-
allow out-of-state psychologists to treat its res- braska, Nevada, New Hampshire, Oklahoma,
idents only if the psychologists are also licensed Texas, and Utah). PSYPACT has active legis-
in the state where the client is located (i.e., lation in North Carolina, Pennsylvania, and
where its residents live and its board has regu- Washington, DC, and prefiled bills for 2020 in
latory jurisdiction). Psychologists should be Wyoming and Kentucky.
aware of the requirements and expectations of The Commission, the governing body of
the jurisdiction into which they are practicing. PSYPACT, responsible for its oversight and cre-
These additional considerations may impact a ation of its rules and bylaws, was also established
psychologist’s decision whether to provide the in April 2019. Each participating PSYPACT state
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

services via telecommunication technologies or selects its own commissioner to serve on the Com-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

refer to a local provider. mission and participate in this process. It held its
first meeting in July 2019, where it elected officers
Risk Management Tip: Psychologists are and drafted its bylaws. At the time of this writing,
strongly encouraged to consult with their The PSYPACT Commission has finalized its by-
professional liability carrier, colleagues, and laws and is currently in the process of drafting and
professional association to make a risk man- finalizing rules that will further define require-
agement decision about providing telepsy- ments for practice under PSYPACT. For more
chology services across state lines (DeMers, information, resources, and ongoing develop-
Harris, & Baker, 2018, p. 162). ments about PSYPACT, please go to PSYPACT.
There have been efforts to address the dis- org.
crepancies between states to make the provision
of vital services less constricting for the pro- What Do I Need to Know?
vider while also ensuring services from quali-
There are many opportunities for psycholo-
fied providers for the community. In addition to
gists to use telepsychology as a primary method
psychology, several professions (e.g., medicine,
of providing services or as a supplement to
nursing, physical therapy) have utilized an in- benefit clients, and as with in-person provision
terstate compact structure to meet these needs. of services, there are many responsibilities—
At the time of this writing, the Association of some similar and some different. Fortunately,
State and Provincial Psychology Boards there are many resources to support psycholo-
(ASPPB) has established the Psychology Inter- gists in this new area. Some of those (e.g.,
jurisdictional Compact (PSYPACT), an inter- Telemedicine Guidelines) originate in other
jurisdictional compact that will facilitate the professions and are useful in providing new
practice of telepsychology across participating points of information and guidance for initiating
state lines through Authorization to Practice telepsychology. For psychologists, however, the
Interjurisdictional Telepsychology and allow foundational resources are the profession’s Eth-
for temporary in-person, face-to-face psycho- ics Code, the Telepsychology Guidelines, and
logical practice for up to 30 workdays per year one’s jurisdictional statutes and regulations.
through Temporary Authorization to Practice. These resources support the maintenance of
This agreement between participating states professional practice behaviors, decision mak-
will facilitate continuity of care when the client ing, and the ability to understand and convert
relocates or travels, certify that psychologists ethical in-person practice to telepsychology.
meet acceptable standards of practice, promote In 2011, a joint task force was created by Dr.
cooperation in licensure and regulation between Melba Vasquez, then president-elect of the
PSYPACT states, grant compact states author- American Psychological Association (APA), to
ity to hold licensees accountable, increase con- develop guidelines for psychologists for the
sumer protection across state lines, and promote practice of telepsychology. The task force in-
ethical and legal interjurisdictional practice. cluded and was cochaired by representatives of
PSYPACT became operational in April 2019 APA, ASPPB, and the American Insurance
when the required seventh state (Georgia) en- Trust (The Trust). The task force focused on
acted legislation. There are currently 12 states identifying aspects of the use of telecommuni-
that are part of the compact (Arizona, Colorado, cation technologies that differ from the in-
 6 MARTIN, MILLÁN, AND CAMPBELL

person provision of services. Eight guidelines will highlight the telepsychology aspects of the
were established: Competence, Standards of APA Ethics Code toward the maintenance of
Care, Informed Consent, Confidentiality, Secu- standards of care as detailed in the APA Tele-
rity/Transmission of Data, Disposal of Data, psychology Guidelines (Joint Task Force for the
Testing and Assessment, and Interjurisdictional Development of Telepsychology Guidelines for
Practice. The guidelines, which were approved Psychologists, 2013).
in July 2013, are intended both to educate and to
inform psychologists in their practice in apply- Risk Management Tip: Psychologists con-
ing current standards of professional practice sider clinical, ethical, legal, and risk dimen-
when using telecommunication technologies in sions when considering the practice of tele-
psychology.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

providing psychological services.

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Telepsychology is not a specialty but rather is a Know where to find important guidelines and
modality that extends in-person standards of prac- keep them easily accessible. Remember, too,
tice to telecommunication. Telepsychology does that guidelines and standards are important, but
not draw upon or derive from new ethical stan- so is ensuring your understanding of those re-
dards but introduces the need for awareness of sources, how they are interpreted by other pro-
additional factors, decisions, and actions that arise fessionals, and how they can be applied.
in the context of electronic transmissions (Cooper,
Campbell, & Smucker Barnwell, 2019). Seven of Competence
the eight APA Telepsychology Guidelines (Joint
In addition to clinical competence, which is
Task Force for the Development of Telepsychol-
expected for in-person practice, psychologists
ogy Guidelines for Psychologists, 2013) are, in
additionally engage in education and training to
fact, standards of the Ethical Principles of Psy-
ensure technical competence. Further, psychol-
chologists and Code of Conduct (APA, 2017).
ogists will want to assess their clients’ technical
Competence, Standards of Care (which is nested
competence to participate in telepsychology and
in Competence), Informed Consent, Confidential-
do have the responsibility, not necessarily to
ity, Recordkeeping (i.e., Security and Transmis-
provide but to ensure client competence. An
sion of Data and Disposal of Data), and Testing/
important aspect of self and client competency
Assessment are major sections of the APA Ethics
assessment is the awareness and understanding
Code and are foundational concepts that frame
of the impact language, culture, disability, and
psychologists’ decision making. Interjurisdic-
other diversity factors may have on psycholog-
tional practice is the only Telepsychology Guide-
ical services provided through this modality.
line not inherently represented in the APA Ethics
Code. Given the diverse and broad spectrum of Risk Management Tip: Take reasonable
professional psychology, some may ask if the steps to ensure your intellectual competence,
APA Ethics Code and the Telepsychology Guide- technical competence, emotional compe-
lines apply to all areas of psychology. The APA tence, and cultural competence, as well as to
Ethics Code and the Telepsychology Guidelines protect clients and others from harm.
are written for clarity and utility and for that
reason cannot offer greater specificity for all areas Self-assessment is important, but seeking out
of practice but are meant to be applicable to all. objective feedback with a colleague, a peer con-
Telepsychology Guidelines, albeit not enforce- sultation group, or mentor about your compe-
able, are intended to lend direction for adherence tence level is also important. Psychologists will
to the standards of care. want to assess the appropriateness of teleser-
Psychologists are knowledgeable of the APA vices for each client, determine pros and cons,
Ethics Code principles and standards. Such un- and document their decisions. Should treatment
derstanding provides a strong foundation for effectiveness not be evidenced in telepsychol-
psychologists as they begin their orientation to ogy, psychologists will want to transition to
telepractice. The standards of care for in-person in-person practice or refer the client.
practice are not diminished or altered for tele- Standards of Care
psychology, and therefore, an understanding of
the factors introduced by electronic communi- Psychologists are aware of the growing
cation is essential. The remainder of this section means of electronic communication in addi-
 TELEPSYCHOLOGY PRIMER 7

tion to the gold standard (i.e., synchronous, Informed Consent

face-to-face videoconferencing) such as e-
mail, texting, and telephone. Psychological The APA Ethics Code identifies the key ele-
services are likely to increasingly include so- ments of informed consent that are necessary
cial media platforms. An early step in prepa- elements of professional practice in psychology.
ration for telepractice is a risk-benefit assess- Risk Management Tip: Clinicians should
ment for each client regarding the client’s thoroughly inform clients of what they may
clinical needs, logistical factors, cultural vari- expect in terms of services offered, unavail-
ables, and any relevant factors to treatment able services, access to the practitioner,
effectiveness. Particularly important is an as- emergency coverage, and similar issues.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

sessment of the “medical conditions, mental

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Psychologists are encouraged to review

status, and stability, psychiatric diagnosis,
available resources, including sample informed
current or historic use of substances, treat-
consent documents, and make a checklist of
ment history, and therapeutic needs that may
important areas to cover. Additionally, they
be relevant” (Joint Task Force for the Devel- should document the process as well as any
opment of Telepsychology Guidelines for notable exchanges with the client.
Psychologists, 2013, p. 795). Telepsychology requires new and essential
Risk Management Tip: Conduct a conser- components to informed consent of which psy-
vative assessment of a client’s diagnosis, his- chologists must be aware in order to maintain
tory, and risk level and determine that these standards of care. For example, in-person ser-
factors do not contraindicate providing ser- vices do not present the risk of a client appear-
vices via telepsychology. ing for an appointment at midnight, or technol-
ogy interruption preventing the last half of the
Seek risk management resources, including session, and billing would not vary with each
consultation, which identify high-risk popula- session. Some of the important, newly intro-
tions and other factors that may interfere with duced factors that should be addressed in the
effective use of telepsychology. informed consent include the following: (a)
The most desirable condition for telepsy- Boundaries of communication should be agreed
chology is for the client to be physically on before beginning services. Psychologists
located at a facility in which the requirements might want to establish a separate e-mail and
for privacy, confidential exchanges, and ab- phone number and other means by which clients
sence from distractions are ensured. Psychol- initiate contact. Psychologists who often return
ogists will make decisions about the remote a text message on Saturdays and then fail to do
environment and whether it meets the same so on one occasion could have established the
standards of practice as in-person services. If expectation of Saturday services by clients,
clients are located in personal space, such as which would be a risk factor in an emergency
situation. Acceptance of nonemergency e-mails
one’s home, or in public space, the conditions
and other asynchronous communication estab-
for services can be compromised. If others are
lishes flexible boundaries and reasonable client
in the room, distractions and loss of confiden- expectation of the psychologist’s availability.
tiality can occur, and depending on the level Asynchronous communication for substantive
and quality of the platform used (e.g., video- content should be avoided; exceptions could be
conferencing vs. e-mailing), someone other changing appointments and logistical informa-
than the client could be responding. Unless tion. (b) Technology interruptions are unex-
psychologists have agreements with clients to pected and can interfere with or terminate com-
meet these standards, others could be sitting munication. Psychologists should develop a
across the room influencing the client, chil- procedure to be enacted in these situations. Cli-
dren/adults could be passing in and out of the ents should agree to the procedure and under-
room, and someone else could be texting or stand what to do. Technical competency of cli-
e-mailing the clinician rather than the client. ents comes into consideration in clients’
Monitoring of these conditions is an ongoing knowing how to avoid accidental transmission
process, not an initial assessment only. of messages to others and in exercising vigi-
 8 MARTIN, MILLÁN, AND CAMPBELL

lance in the method of responding. Use of social about initiating or continuing with ser-
media is particularly vulnerable to accidental vices?
misdirection or nonconfidential communication. • Does my informed consent include infor-
(c) Billing for telepsychology services is unique mation about my privacy, security, and
in that sessions may vary in length; psycholo- data storage, transmission, and disposal
gists may bill differently for texting, phoning, policies?
e-mail, and videoconferencing. These variations • Did I establish a fee schedule related to
should be determined in advance of services, telecommunications-based services that
agreed upon by clients, and prominent in the specifies issues related to technology dis-
informed consent. ruptions?
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Risk Management Tip: If third parties are • Was I knowledgeable about emergency,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

billed for services offered via electronic professional, and consultative local re-
means, practitioners must clearly indicate sources for the person I plan to serve re-
that fact on billing forms. motely?
• At the outset of a remote service, did I
Billing codes are standardized, so psycholo- obtain a contact number for my client in
gists are encouraged to consult with colleagues case of technological failure or clinical
and their professional association to ensure emergency (Adams Larsen & Juntunen,
knowledge of and access to current codes, keep- 2018, p. 51)?
ing in mind they may change over time.
(d) Engagement in initiating, maintaining,
Confidentiality
and responding to telecommunications by cli-
ents is much more extensive than in in-person Discovery of in-person service clinical notes
service. Psychologists may include in informed or session content is only at risk for a court
consent the responsibilities of clients to partic-
subpoena. Online content is publicly discover-
ipate in maintenance of standards of practice.
able. Clients must be informed that total confi-
dentiality cannot be assured; however, security
Informed Consent Self-Assessment
measures, privacy settings, and other safeguards
Checklist can be employed.
• Did I inform patients/clients/consultees Risk Management Tip: A careful state-
how I will communicate with them using ment about the limitations of confidentiality
technology, what type of information is should be developed and provided to clients
appropriate to share over this modality, and at the start of treatment. The statement
the time frame they may expect a response?
should inform clients of the standard limita-
• Did I have a plan for how I will react if I
tions (e.g., child abuse reporting mandates),
receive sensitive information (e.g., grounds
any state-specific requirements, and cautions
for mandated reporting) from a patient/
about privacy problems with broadcast con-
client/consultee through technological
communications? versations.
• Did I screen patients/clients/consultees for The threats to confidentiality include thera-
appropriateness with technology-based ser- pist/client misdirection of content (e.g., e-mails,
vices (e.g., clinical, technological, lan- texts), technology failures, use of social media,
guage)? and in-person viewing of electronic messages
• Did I obtain documented informed consent by others in the therapist or client space.
with all patients/service recipients or their
guardians at the outset of services? Risk Management Tip: Follow basic secu-
• Have I identified any particular risks re- rity protocols to ensure that sensitive patient
lated to interventions that have or have not data are never placed at unnecessary risk:
been tested in a technology-based service Password protect the device, secure the de-
delivery? Have I made these risks clear to vices when not in use, and limit use of devices
the patients/clients/consultees so that they to professional activities (Smucker Barnwell
are able to make an informed decision & Adams Larsen, 2018, p. 118).
 TELEPSYCHOLOGY PRIMER 9

No e-mail message is truly and irrevocably ogists acquire additional training and consulta-
deleted. Psychologists should be aware that any tion in utilization encryption, robust passwords,
content written can be retrievable without the and backup systems as essential means of se-
psychologist’s permission. Psychologists who curing confidential data.
use social media for personal and not for pro-
fessional purposes are still at risk given that Risk Management Tip: Seek frequent con-
those who have access to their platforms may sultation from knowledgeable legal, com-
pass photos and content along to someone else puter and server IT, and malpractice experts
who in the thread of viewers may include a (Smucker Barnwell & Adams Larsen, 2018,
client. Inversely, psychologists are cautioned p. 118).
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

against using search engines to acquire infor- Electronic data are applicable to the APA
This document is copyrighted by the American Psychological Association or one of its allied publishers.

mation about clients without a prior explanation Recordkeeping Guidelines (APA, 2007) in that
to the client of why the electronic access to types of data, length of retention, and treatment
client activity is necessary. What does a psy- of data standards for in-person records should
chologist do with adverse information about a be met. Psychologists develop policies and pro-
client that the client does not know the psychol- cedures for disposal of records that ensure con-
ogist has? Psychologists who work with adoles- fidentiality. Cleaning data from hardware before
cents and young adults may be encouraged by reuse and monitoring the existence of malware,
clients to communicate through continually cookies, and other software should also be
evolving social media platforms. A thorough erased (Joint Task Force for the Development of
risk/benefit assessment should be conducted Telepsychology Guidelines for Psychologists,
and contractual agreements with clients should 2013).
be recorded in the informed consent should
these evolving technologies be utilized. Testing and Assessment

Security, Transmission, and Disposal of The major distinctions in assessment between

Data and Information (Recordkeeping) in-person and online administration rest with
two areas of practice: (a) appropriate procedural
For in-person services, psychologists are in use of instruments consistent with the test man-
possession of all client-related data kept in file ual instructions for administration and (b) lack
cabinets until recently. Psychologists would of control of the remote environment. Test de-
need to get permission for records to be viewed velopers and publishers are vigorously engaged
or copied except for a court records’ subpoena. in modifying tests that were meant to be admin-
Online communication, videoconferencing, and istered in person and in the development for
electronic transmissions are all recorded by the online use. Psychologists are aware of the in-
clients as well as by the psychologists. Every tended administrative procedures of all tests
word a psychologist says can be reproduced by utilized and remain consistent with such. The
the client and potentially by others. This would soundness of the validity, reliability, and other
be the equivalent to clients videotaping clinical psychometric properties is critical to the useful-
sessions and storing them at home. Psycholo- ness of test results and recommendations. Re-
gists may include in their informed consent, an gardless of mode of administration, psycholo-
agreement on how data are handled between the gists maintain the integrity of their testing
psychologist and client, and how the client procedures and resulting data by following the
treats and manages online information. instructions of the manual. If a departure is
Unique threats to confidentiality in telecom- required, psychologists will want to explain the
munication include “computer viruses, hackers, why and how a departure was adopted. Fidelity
theft of technology devices, damage to hard to the test instructions and adherence to norms
drives, or portable drives, failure of security are critically important. In-person testing cer-
systems, flawed software, ease of accessibility tainly requires attention to appropriateness of
to unsecured electronic files, and malfunction- norms and other test characteristics in light of
ing or outdated technology” (Joint Task Force diversity factors such as language, culture, so-
for the Development of Telepsychology Guide- cioeconomic status (SES), age, and ethnicity as
lines for Psychologists, 2013, p. 797). Psychol- well as disabilities and impairments. Equally
 10 MARTIN, MILLÁN, AND CAMPBELL

important are these factors in online testing. tions technologies. The following are consider-
Psychologists will want to comment in their ations when deciding to implement
reports on the appropriateness of online testing telepsychology with specific clients and their
if the norms of the online tests do not include particular presenting problems:
the population being tested.
1. Use of telepsychology services should be
Risk Management Tip: Be deliberate in deemed at least as effective as face-to-face
choosing and using technologies and hard- services and should be determined by ev-
ware needed to conduct assessments. Be cog- idence-based findings regarding client
nizant of factors that can arise regarding
variables and application of the techniques
diverse populations (e.g., language, culture,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

or theoretical approaches employed.

impairments) and correct or accommodate
This document is copyrighted by the American Psychological Association or one of its allied publishers.

2. Review available literature to support the

and note those factors and their potential
use of telepsychology with each client’s
impact (Crow & Landry Poole, 2018, p. 138).
specific diagnosis.
Consultation with those who have experience 3. The psychologist should review current
in telepsychology and assessment and in risk laws, state and national, as well as regu-
management is essential, as is continued educa- latory rules in order to ensure that the
tion about how assessments and telepsychology psychologist is engaged in appropriate and
impact each other, modifications that are rec- legal practice.
ommended, and any new normative data. 4. Make a determination of technology use
A significant factor in online testing is lack of primarily based upon appropriateness for
control of the remote site. Even with video the individual client.
capability, clients may have access to cell 5. Develop a plan for using telepsychology
phones, the Internet, or other devices and and technology with clients that outlines
thereby void the results of the assessment. the rationale and process. Discuss the rea-
Coaching, consultation, and other external son for introducing the telepsychology
sources of information could compromise the component with the client and obtain in-
accuracy of scores. Relatedly, distractions that formed consent.
do not enhance performance, such as children 6. Discuss and address new issues of confi-
being present or phones ringing, compromise dentiality and security that arise with the
the testing site. The most desirable solution to introduction of the telepsychology compo-
the remote site challenge is an onsite proctor. In nent in therapy, including securing the
actuality, testing and assessment are character-
area where the patient will be during the
ized by significant limitations at best and should
telepsychology sessions.
be considered with great care. The APA Guide-
7. Practice using the equipment and soft-
lines on Assessment and Evaluation, which in-
ware to ensure the patient is comfortable
clude a section on technology, will be presented
for a vote by APA Council in 2020 and will and capable of engaging in telepsychol-
become another resource for maintaining stan- ogy.
dards of practice. 8. Conduct ongoing monitoring to ensure
In summary, the ethical engagement in tele- that telepsychology continues to meet
psychology is greatly enhanced by utilization of the intended therapeutic purpose.
the resources described here. The extension of 9. Technology competence should be as-
practice introduced by telepsychology presents sured both for the psychologist and the
a challenge to psychologists but also a signifi- client. When evaluating the progress of
cant expansion of access to client populations a client, the psychologist should also
and fulfillment of needed services to those pop- evaluate the use of technology.
ulations. 10. Join or create an ongoing, standing
group of other psychologists who use
What Should I Do? technology in their work to provide
continual consultation and support.
Psychologists should be thoughtful and strate- 11. Conduct periodic assessment of the
gic in deciding whether to use telecommunica- clinical utility of the technology being
 TELEPSYCHOLOGY PRIMER 11

used to determine whether to continue They also need policies and procedures in
its use. place to securely store, transfer, and dispose of
patient data and should use HIPAA-compliant
Psychologists who decide to incorporate vendors and encryption, when possible (Camp-
telepsychology into their practices will be able bell, Baker, Martin, & Millán, 2018).
to answer these questions confidently and com-
pletely: Hardware Disposal Plan

1. How much do I know about the clinical • Delete all files from the laptop computer.
research/professional literature, including • Reformat computer hard drive and USB
guidelines, on using telepsychology? Are drives.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

there better, more secure, or more effec- • Complete “factory reset” or “hard reset”
This document is copyrighted by the American Psychological Association or one of its allied publishers.

tive alternatives? for mobile device and tablet.

2. How much do I know about the legal or • Ensure that no patient information remains
regulatory policies in my state governing on encrypted external storage devices (e.g.,
telehealth? USB flash drives) by deleting files and re-
3. How much do I know about the technol- formatting the drive.
ogy that I want to use in my practice? • Recycle hardware with a local technology
Specifically, what are the benefits and recycling company or with a vendor offer-
what are the risks? ing a rebate.
4. How will I monitor and ensure appropri-
ateness of treatment, technological com- Software Removal/Disposal Plan
petence, confidentiality and security, • Delete all contacts and call history from
knowledge of emergency resources, and text, e-mail, and videoconferencing pro-
continued learning? grams.
5. How will I identify and manage risk? • Uninstall software/mobile applications
from all hardware.
Health Insurance Portability and • Log in to any web-based interfaces (e.g.,
Accountability Act/Health Information e-mail program, web management for se-
Technology for Economic and Clinical cure text account) to delete any stored in-
Health Act formation (e.g., stored patient information,
call logs of prior clinical contacts).
In addition to state and jurisdictional require- • Contact the vendors for web-based services
ments, psychologists must ensure compliance to inquire how to ensure that all deleted
with federal requirements. The Health Insurance information was permanently deleted from
Portability and Accountability Act (HIPAA) and any future access (Smucker Barnwell &
the Health Information Technology for Economic Adams Larsen, 2018, p. 105).
and Clinical Health Privacy & Security Rule re-
quirements extend to all the clients’ data. These
rules govern what disclosures of patient health Staying Informed/Staying Current
information are permitted and provide policies
Psychologists are very familiar with their re-
governing electronic patient health information—
sponsibility to be competent as professionals,
secure transmission, transmission quality, audit
and when practicing telepsychology, technical
trails, and breach notification policies. Psycholo-
competence is added to intellectual and emo-
gists need a business associate agreement with any
tional competence. Keeping one’s knowledge
third party that may have access to patients’ data
base up-to-date is a critical component of being
(e.g., accountant, billing service, practice manage-
competent and is good risk management.
ment software, answering service, cloud storage).
Risk Management Tip: Seek appropriate
Risk Management Tip: Thoroughly review
consultation.
and consult to learn what you do not know,
what you need to know, and what you need to State, regional, and national professional as-
access, and then develop a plan of action sociations are good places to look for paid and
before disposing of data and devices. peer consultation. Psychologists are encouraged
 12 MARTIN, MILLÁN, AND CAMPBELL

to identify those who have experience with te- conduct that apply to psychologists in their
lepsychology in diverse settings and with di- professional roles. As stated in the introduc-
verse populations. They should remember to tion to the code, “Although the Preamble and
include professional groups that focus on telem- General Principles are not themselves en-
etry and consult with their professional liability forceable rules, they should be considered by
provider for risk management guidance, work- psychologists in arriving at an ethical course
shops, and other resources. of action. The Ethical Standards set forth
The ever-changing world of technology and enforceable rules for conduct as psycholo-
of the standard of care for using telepsychology gists.”
in therapy and assessment requires vigilance on • State regulations and guidelines: The practice
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

the part of the practitioner. While certain ele- of psychology is regulated by each state,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ments may remain underlying principles for the which sets forth requirements for licensure.
practice of telepsychology, many elements will Requirements vary from state to state, so it is
also change because of the rapid advances in critically important to be familiar with indi-
technology and evolving legal and regulatory vidual state regulations, especially temporary
requirements (Campbell, Millán, et al., 2018). or guest practice provisions. Many states
Because of these changes, the best guidance for have also developed specific telepsychology
psychologists to stay current and engage in the statutes/regulations. Consult the Business and
competent practice of telepsychology is to iden- Professions Code of your state laws and the
tify seminal documents and informational states in which you wish to practice to ensure
sources, as well as to encourage continuing ed- you are aware of laws governing practice.
ucation and consultation with risk management While there are many sites that present com-
experts and those engaged in the ethical practice pilations of state licensing laws, it is the re-
of telepsychology and its further development. sponsibility of each psychologist to verify
information by consulting state laws directly.
Risk Management Tip: Have a good work- Remember, too, that laws change, so frequent
ing knowledge of the Ethics Code, the Guide- review of state regulations is strongly sug-
lines for the Practice of Telepsychology, and gested.
legal standards governing practice. • ASPPB, https://www.asppb.net: With its mis-
sion “To support member jurisdictions in ful-
At the heart of critical sources of information filling their responsibility of public protec-
are the following: tion” and a vision of “Consistent standards
• Guidelines for the Practice of Telepsychol- that ensure the competent practice of psy-
ogy (Joint Task Force for the Development chology,” ASPPB created PSYPACT, an in-
of Telepsychology Guidelines for Psychol- terstate compact, “to facilitate telehealth and
ogists, 2013), https://www.apa.org/practice/ temporary in-person, face-to-face practice of
guidelines/telepsychology: These aspira- psychology across jurisdictional boundaries.”
tional guidelines are designed to facilitate the ASPPB provides important and updated in-
practice of telepsychology and to improve the formation on PSYPACT legislation, rules,
efficiency, effectiveness, and competence of and implementation in addition to a database
those who practice. The Guidelines include of current licensing requirements through its
Competence of the Psychologist, Standards PSY/Book, formerly known as the ASPPB
of Care in the Delivery of Telepsychology Handbook on Licensing and Certification Re-
Services, Informed Consent, Confidentiality quirements (https://www.asppb.net/page/
of Data and Information, Security and Trans- psybook).
mission of Data and Information, Disposal of • The Trust (https://www.trustinsurance.com):
Data and Information and Technologies, The Trust remains a leading provider of in-
Testing and Assessment, and Interjurisdic- surance and risk management programs for
tional Practice. psychologists, psychology students, and re-
• Ethical Principles of Psychologists and Code lated individuals in the United States. The
of Conduct (APA, 2017), https://www.apa Trust participated in the task force that devel-
.org/ethics/code/ethics-code-2017.pdf: The oped the Guidelines for the Practice of Tele-
Ethics Code identifies standards and rules of psychology (Joint Task Force for the Devel-
 TELEPSYCHOLOGY PRIMER 13

opment of Telepsychology Guidelines for which give guidance to psychologists in their de-
Psychologists, 2013). In addition, the work- cision-making process. Psychologist practitioners
shops and consultation that The Trust offers are on the leading edge in advancing services to
through its risk management program pro- clients/patients in the burgeoning settings in which
vide psychologists with important guidance they practice and in expanding scope of practice.
to help them reduce their risk in the area of Psychologists have choices of the degree, depth,
telepsychology. type, and form in which they participate in tele-
• Another valuable resource is the American psychology. This article is intended to assist in
Telemedicine Association (https://www making these choices.
.americantelemed.org), which provides train-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ing materials and opportunities, discussion

This document is copyrighted by the American Psychological Association or one of its allied publishers.

forums, updates in the field of telehealth, and References

information on current telehealth initiatives.
There are many additional resources to consult. Adams Larsen, M., & Juntunen, C. (2018). Informed
Check with your state as well as national psycho- consent. In L. F. Campbell, F. Millán, & J. N.
logical associations for webinars, legislative up- Martin (Eds.), A telepsychology casebook: Using
technology ethically and effectively in your profes-
dates, and colleagues who may be knowledgeable sional practice (pp. 47– 67). Washington, DC:
about telepsychology. Also helpful is an indepen- American Psychological Association. http://dx.doi
dent telemental health technology comparison site .org/10.1037/0000046-004
(https://telementalhealthcomparisons.com/), American Psychological Association. (2007). Record
which includes a comparison of software for prac- keeping guidelines. American Psychologist, 62,
titioners and other resources. Finally, consulting 993–1004. http://dx.doi.org/10.1037/0003-066X
with an attorney who works with mental health .62.9.993
professionals engaged in telemedicine practice American Psychological Association. (2017). Ethical
and who is familiar with telepsychology practice principles of psychologists and code of conduct
and regulations can be immensely helpful. (with 2010 and 2016 Amendments). Retrieved
from https://www.apa.org/ethics/code/ethics-code-
2017.pdf
Conclusion Campbell, L. F., Baker, D., Martin, J. N., & Millán,
F. (2018, August). Telepsychology: Ethical prac-
Technology transforms daily living in ways not tice through case illustrations tailored for practi-
imaginable even a few years ago. The practice of tioners. Symposium presented at the 126th Annual
psychology is equally impacted, resulting in early American Psychological Association Convention,
career and senior psychologists alike needing San Francisco, CA.
guidance. Students and early career psychologists Campbell, L. F., Millán, F., & Martin, J. N. (Eds.).
are learning to apply standards of practice to their (2018). A telepsychology casebook: Using technol-
familiarity with technology, and psychologists ogy ethically and effectively in your professional
practice. Washington, DC: American Psychological
who are not technology savvy are learning to
Association. http://dx.doi.org/10.1037/0000046-000
apply technology to their expertise in traditional Cooper, S. E., Campbell, L. F., & Smucker Barnwell,
practice. That is, there is room for all to learn and S. (2019). Telepsychology: A primer for counsel-
adapt. This article has walked the reader through ing psychologists. The Counseling Psychologist,
the primary phases of telepsychology practice. A 47, 1074–1114. http://dx.doi.org/10.1177/0011
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ularly one such as telepsychology, which requires Crow, B. E., & Landry Poole, J. M. (2018). Testing
a reorienting of the way psychologists think about and Assessment. In L. F. Campbell, F. Millán, &
standards of care and how they conduct their prac- J. N. Martin (Eds.), A telepsychology casebook:
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chology typically want to know the following: professional practice (PP. 121–140). Washington,
DC: American Psychological Association. http://
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to know? How can I ensure that I am practicing DeMers, S., Harris, E., & Baker, D. (2018). Inter-
within my scope and within the boundaries of jurisdictional practice. In L. F. Campbell, F. Mil-
ethical and legal practice? What should I do to lán, & J. N. Martin (Eds.), A telepsychology case-
proceed? These and other questions are answered book: Using technology ethically and effectively in
here as well as risk management tips offered, your professional practice (pp. 141–164). Wash-
 14 MARTIN, MILLÁN, AND CAMPBELL

ington, DC: American Psychological Association. L. F. Campbell, F. Millán, & J. N. Martin (Eds.), A
http://dx.doi.org/10.1037/0000046-009 telepsychology casebook: Using technology ethi-
Joint Task Force for the Development of Telepsy- cally and effectively in your professional practice
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Guidelines for the practice of telepsychology. logical Association. http://dx.doi.org/10.1037/
American Psychologist, 68, 791– 800. http://dx.doi 0000046-007
.org/10.1037/a0035001
Smucker Barnwell, S., & Adams Larsen, M. (2018). Received February 4, 2020
Disposal of data, information, and technologies. In Accepted February 5, 2020 䡲
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.