The brave new world of teletherapy

The historical divide for teletherapy is by far the COIVD-19 pandemic. Then, therapists providing teletherapy were a minority and thought by some to be radical. Almost two years later, those doing in-person therapy are thought of as throwbacks. Yet, therapists have given up their offices, implemented new workflows and software, and signed up with the growing number of online groups like Talkspace, BetterHelp, Cerebral, and others. Therapists have even moved to be coaches versus clinical work (see BetterUp).

Change is good, and teletherapy needed to be welcomed into the mainstream, don’t get me wrong. However, the sudden, abrupt change has left many therapists acting with limited knowledge and minimal training for the digital world. Many clinicians are simply naïve, and I know that sounds harsh. The ethics of providing care and the legal ramifications are much broader than many clinicians have thought. While the Office of Civil Rights (OCR) waived enforcement of HIPAA regulations during the pandemic, the regulations by no means have gone away. Clinicians with limited training and thoughts of how open it is to provide services fail to realize the danger for themselves and their clients.

One specific area for consideration is clinicians who sign employment contracts without reading the fine print for online telehealth providers. They do not know that most of these companies place all the liability for the client onto the clinician by simply saying that the company is choosing the right technology to help the person being seen. Ignorance is not a defense in a court of the law. The digital healthcare employment contracts typically release the company from 100% of the liability related to client/patient care, and that burdens the unwitting clinician with all that liability. Read the privacy statements and the terms of use on Cerebral, Talkspace, etc.

A significant issue is that clinicians often do not know how to choose employers. They are untrained in business law and sign contracts with clauses that are complicated with jargon. Many clinicians do not have the contract reviewed by a knowledgeable attorney and do not want to spend the money for such a review. Many may not even be able to find a knowledgeable attorney even if they could afford one. Many clinicians may not know the disadvantages of being a 1099 subcontractor. They may not have asked their malpractice insurance carrier about providing services across state lines or even out of the USA.

People are complicated. For example, imagine an addicted parent of two adolescents, one who is doing poorly at school and engaged in cutting behaviors. Now, add a recent extra-marital affair and ensuing serious marital discord between the parents. In addition, their manager at work has spoken twice to them about their absences, lack of focus, and increased mistakes at work that could endanger others and cost money to the company. How much can “therapy” or “help” be provided from an online assignment to a therapist? In this case, the therapist has no idea how the assignment is done; think computer algorithms. What happens if they try to get help through a downloaded app? What about failing to improve after six months of daily/weekly text-messaging “therapy?”

Here are a few questions that clinicians should be asking:

  1. How do your handle medical or psychiatric emergencies?
  2. How do you manage abuse reports, duty to warn, and consent when these are not uniform in all states?
  3. Is it reasonable to expect the client to understand the many differences between teletherapy and in-person care and which is more beneficial to them?
  4. Will they articulate complaints if they attribute the failure of therapy to themself or the therapist rather than to the medium’s limitations?
  5. Would it be reasonable for a client who experienced failed teletherapy to conclude that they “tried therapy, but it didn’t work” or say, “I will never waste all that time and money again?”
  6. What if the client did have enough self-esteem to realize that their therapy failure was at least in part because of the delivery method? What can they do?
  7. Is it reasonable to assume that a client who receives unsatisfactory teletherapy knows where and how to complain if they want to do so? Does the therapist even know that?
  8. Would a licensure board even know what to do with such a complaint?
  9. Can the companies be held accountable? And is there a need for a pause at this point?
  10. Am I teaching my clients unhealthy habits regarding confidentiality by continuing to use software systems or recommending apps without vetting them?
  11. Is teletherapy better for the client or the therapist?
  12. What am I doing to improve my competency in teletherapy?
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