Using Telepsychology in a Training Clinic
Mary Alice Conroy
 
The technological revolution suggests that telepsychology may be the big wave of the future and many of us will be utilizing it in years to come. Personally, I am especially excited about the possibility of making specialized expertise available across the country.  APA has recently posted a draft set of guidelines for comment that raised some valuable points for discussion.  
 
In 2011, the APA Committee on Legal Issues (COLI) in conjunction with the APA Ethics Committee presented a symposium that raised some thorny issues to carefully consider in the name of risk management before embarking on this use of this technology. We raised four major areas for consideration: 1) technological competence, 2) distant environments/equipment, 3) emergencies, and 4) inter-jurisdictional practice.
Competence required for this type of practice involves not only the clinical competence to deliver the specific service, but also the technological competence to do so in this way. Is the provider sufficiently comfortable in operating the necessary equipment? Or is technical backup instantaneously available? What will happen if the equipment fails at a critical juncture (as technology seems wont to do)? Is the clinician competent to construct an informed consent that thoroughly informs the client of the system and its risks and benefits? This would necessitate exploring the expanding literature on these issues.
Typically in a clinic setting, the provider has control over the environment, who is present, and any piece of equipment being employed. However, in the telepsychology arena, the provider may not have the same control over equipment being employed at a distant location. Is there a need for a specific equipment protocol? Can you assure that equipment at a distant location will not fail nor be operated improperly?  Is the system sufficiently secure to guarantee appropriate confidentiality? Do you know if the distant equipment can retain a recording of the session? If so, how would you oversee security of the record?  This could be a very thorny issue when student clinicians are involved.  If you are performing any type of assessment using a standardized instrument, can test security be assured? Do you actually know how public the setting may be? Are there third parties potentially present without your knowledge? (Unlike some of my colleagues, I am fine with most third parties provided we all know and agree to their presence.) How easy would eavesdropping be?
Then there is the potential for emergencies to occur. I have heard people say this is not a problem with a particular client.  However, I am sure we have all been part of emergency situations that were not expected to occur. Some have suggested the need for a readily available backup professional at the distant location. In some cases this is rather easily available (e.g., a correctional environment, a residential care facility, a hospital). If the setting is less structured, is the clinician familiar with local resources and can these resources be quickly contacted? In the event the client decides to terminate services (either with or against clinical advice) is the clinician sufficiently familiar with local resources to provide referrals consistent with continuity of care?
One of the more challenging, but increasingly common, issues is inter-jurisdictional practice, generally defined as practice across state lines. Must the clinician be licensed in the jurisdiction from whence they practice or the jurisdiction in which the client is located or both? A number of states have been proactive and put in place specific rules in this regard, others have not. In addition to licensing board rules, there may be case law relating to this issue. Some states (but not all) allow for temporary licensure or a brief grace period before licensure is required in the case of inter-jurisdictional practice over a brief period of time (e.g., the client is on an extended vacation, the client is in a distant facility for the short term). It is also important to be familiar with specific rules of practice in the intended jurisdiction. Many clinicians seem unaware that these vary widely.  For example, in terms of Tarasoff issues (i.e., duty to warn, duty to protect), what would be an obligation in California would be a violation of case law and board rules in Texas. Jurisdictions almost universally have some type of mandatory reporting, but again, there is considerable variability.  For example, in terms of reporting child abuse, some jurisdictions specifically define a “child” as a person who is “currently a child.” Others embrace a broader definition to include adults who report abuse that occurred during their childhood, regardless of current age. And finally, it is critical that the clinician has checked as to the applicability of their professional insurance across state lines and in the use of telepsychology.
There is a lot to consider. It is likely that future rules and guidelines will be written and revised.  However, I believe this is an arena that training clinics will need to embrace in developing competencies for future clinicians.