11 Jul 2017

Leadership and Communication

In one of his published articles, communication expert John A. Kline said, “If you can’t communicate, don’t try to lead.” But what is effective communication? Effective communication is more than just speaking or writing effectively; effective communication is simply the effective sharing of meaning. And no communication skill is more important than listening. Knowing the basic barriers and shortfalls of communication and doing something about them is a big step in improving our ability to communicate effectively. Kline shares basic insights and real life stories about his lifelong quest to become a better communicator.

Learning Objective
Apply skills that improve my communication skills.

John Kline, PhDPresenter
John A. Kline, (PhD, Iowa 1970) was a college professor, then from 1975-2000 the Air Force expert in Communication and Leadership. In 1986 he achieved Civilian (SES) status equivalent to a two-star general. From 1991 until 2000 he was the Air University Provost with responsibility for faculty, academic programs, libraries, technology, budget and support of 50,000 resident and 150,000 distance-learning students annually. Kline has written several books and many published articles, and is now the Distinguished Professor of Leadership and Director of the Troy University Institute for Leadership Development. He focuses on servant leadership and seeks to make a positive difference in the lives of others.

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06 Jun 2017

Protecting Patient Privacy When the Court Calls

Protecting Patient Privacy When the Court Calls

Psychologists are obligated to protect their clients' records. So what do they do when they are presented with a subpoena or asked to testify?

Over the course of their careers, many psychologists will receive subpoenas directing them to disclose or testify about a client's records or test data. Such requests can put psychologists in a quandary: As practitioners, they are well versed in the ethical, professional and legal obligations related to maintaining patient confidentiality, so how can they release such records?

In an effort to guide psychologists in this area, APA's Committee on Legal Issues recently updated its article on understanding subpoenas, seeking to offer strategies that psychologists may use to respond to subpoenas or compelled court testimony. While this article is not intended to establish standards of care or conduct for practitioners, it seeks to address several common questions psychologists have when responding to such legal requests. It is important to note that this article does not provide legal advice, nor is it intended to be or substitute for the advice of an attorney.

Psychologists who receive a subpoena or other legal process that requires or is likely to require production of client/patient records or test data, manuals, protocols, or other test information are encouraged to consult legal counsel who can review the pertinent law and facts and provide appropriate legal assistance.

Understanding subpoenas

From the legal system's perspective, the more relevant information that a judge or jury considers in a court case, the fairer the decision. To obtain this material, the court may issue subpoenas (legal commands to appear to provide testimony) or subpoenas duces tecum (legal commands to appear and bring along specific documents). A court may also issue a court order requiring a party to provide testimony or produce documents.

Unless the issuing attorney or court excuses the psychologist, the psychologist must respond to a subpoena — that is, to be at a particular place at a particular time. Responding to the subpoena, however, does not necessarily mean that the psychologist must disclose confidential information requested in the subpoena. Before a psychologist does so, he or she should ensure that the subpoena is valid and that the conditions for disclosing confidential information are met — such as with a client's consent, a protective order or other legal mandate. In contrast to a subpoena, when a court order for testimony or documents is issued and any attempt to have the court vacate or modify its order has been unsuccessful, a psychologist may be held in contempt of court if he or she fails to comply with the court order.

Unfortunately, the demands of the legal system may conflict with psychologists' responsibility to maintain client confidentiality. This responsibility arises from tenets of good clinical practice, ethical standards, professional licensing laws, and other applicable statutes and legal precedent. In many contexts, client information may also fall under an evidentiary privilege, which protects the client information from being considered as evidence by the legal fact-finder in the case.

Most state and federal jurisdictions allow a client to prevent confidential material that he or she has conveyed to a psychologist from being communicated to others in legal settings, but there are some variations from state to state and between some state and federal courts, and there are significant exceptions (such as cases where the client herself has put her mental health at issue in the litigation). In general, the psychologist has a responsibility to maintain confidentiality and to assert the psychotherapist–patient privilege on behalf of the client unless the client has explicitly waived privilege or signed a valid release, a legally recognized exception to privilege exists, or the court orders the psychologist to turn over the client's information.

The clinical record, any separately kept psychotherapy notes, client information forms, billing records and other such information usually may be turned over to the court with appropriate authorization by the client or with a court order. Psychologists required to comply with provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) would need a HIPAA-compliant authorization form to release such information, and a separate authorization for release of psychotherapy notes if those notes are developed in strict compliance with the HIPAA definition of psychotherapy notes.

Otherwise, notes of psychotherapy sessions are treated in the same manner as the remainder of the clinical record or file. In cases in which clients do not authorize release of their records, HIPAA details procedures that a psychologist may follow upon receiving a subpoena not accompanied by a court order to disclose those materials. These issues emphasize an important practice tip: At the beginning of treatment, psychologists should inform their clients in the informed consent document and first session discussions of the risk that their confidential information may be disclosed in response to a subpoena or court order.

A request for psychological test data and test materials present other concerns. Although a client's test data (including raw and scaled scores and client responses to test questions or stimuli) may be released in response to a proper subpoena, the disclosure of test materials (including manuals, instruments, protocols and test questions) may require the safeguard of a protective order from the court. The APA Ethics Code requires psychologists to "make reasonable efforts to maintain the integrity and security of test materials and other assessment techniques consistent with law . . ." in order to not threaten the validity of psychological tests and their value as a measurement tools (APA Ethics Code, Standards 9.04, 9.11).

Psychologists have numerous ethical, professional and legal obligations related to the release of client records, test data and other information in the legal context. Many of these obligations may favor disclosure, including, in particular, the general obligation of all citizens to give truthful and complete testimony when required to do so. But there are often conflicting duties and principles that favor withholding such information. These may include obligations to:

  • Clients or other individuals who receive treatment and/or are given psychological tests.
  • The public (to avoid public dissemination of test items, questions, protocols or other test information that could adversely affect the integrity and continued validity of tests).
  • Test publishers, including contractual obligations between the psychologist and test publishers not to disclose test information and obligations under the copyright laws.
  • Other third parties, such as employers.

A special type of third-party obligation may arise in forensic contexts if, for example, a psychologist performed work with a litigant for an attorney. In such cases, the key concern is whether records from that work with the litigant is protected from disclosure under the attorney work product privilege.

Strategies for dealing with subpoenas

Psychologists, in consultation with an attorney if needed, should consider six strategies when issued a subpoena:

1. Determine whether the request for information carries the force of law

The psychologist must establish whether he or she has received a legally valid demand for disclosing test data and client records. For example, to be valid, a subpoena should generally allow sufficient time to respond to the demand for materials and provide for some time for the opposing side to quash such a demand if appropriate. If a demand is not legally enforceable for any reason, then the psychologist has no legal obligation to comply with it and may have no legal obligation to respond.

Even a demand that claims to be legally enforceable may not be. For example, the court issuing the subpoena may not have jurisdiction over the psychologist or his or her records: A subpoena issued in one state, for example, may not be legally binding on a psychologist who lives and works in another state. Or, the subpoena may not have been properly served to the psychologist — some states may require service in person or by certified mail. A psychologist should consult with an attorney in making such a determination.

If the psychologist concludes that the demand is legally valid, then a formal response to the attorney or court is required, whether it is compliance with or opposition to the demand, in whole or in part. A psychologist's obligation to respond to the subpoena is not necessarily the same as those under a court order (see below under "File a motion to quash the subpoena or file a protective order").

2. Contact the client

Clients may have a legally protected interest in preserving the confidentiality of their records. So, if a psychologist receives a subpoena or notice requiring that he or she divulge a client's records or test data, the psychologist may discuss the implications of the demand with the client (or his or her legal guardian). The psychologist may also consult with the client's attorney when appropriate and with the client's valid consent.

When talking with the client, the psychologist should explain which information has been demanded, the purpose of the demand, the entities or individuals to whom the information is to be provided, and the possible scope of further disclosure by those entities or individuals. After that discussion, a legally competent client or the client's legal guardian may consent to allow the psychologist to produce the data. Generally, such consent is required to be in writing, which helps to avoid future conflicts or legal entanglements with the client over the release of confidential tests or other records. The client's consent may not, however, resolve the potential confidentiality claims of third parties (such as test publishers).

The psychologist may want to emphasize to the client that when he or she agrees to release information requested, he or she cannot specify or limit which information is released. Rather, the entire record — including psychotherapy notes, billing records, administrative notes and more — will be available. The scope of the release may be the subject of negotiation among attorneys, however, so if the psychologist believes that a release would harm the client, he or she should voice his or her concerns and object to the release on that basis.

3. Negotiate with the requester

If a client does not consent to release the requested information, the psychologist — often through counsel — may seek to prevent disclosure through discussions with legal counsel for the requesting party. The psychologist's position in such discussions may be bolstered by legal arguments against disclosure, including the psychologist's duties under evidence rules regarding psychotherapist–patient privilege. These rules often allow the psychologist to assert privilege on behalf of the client in the absence of a specific release or court order. (Some possible arguments are outlined in the section below, "Consider possible grounds for opposing or limiting production of client records or test data.") Such negotiations may explore whether there are ways to achieve the requesting party's objectives without divulging confidential information, perhaps by disclosing nonconfidential materials instead. Psychologists may also be able to negotiate to avoid compelled testimony.

4. File a motion to quash the subpoena or file a protective order

If negotiation is not successful, it may be necessary to file a motion for relief from the obligations imposed by the demand for confidential records.

motion to quash is a formal application made to a court or judge to have a subpoena vacated or declared invalid. There may be grounds for asserting that the subpoena or request for testimony should be quashed, in whole or in part. For example, the information sought may be protected by the psychotherapist–client privilege and therefore may not be subject to discovery, or it may not be relevant to the issues before the court (see below in the section "Consider possible grounds for opposing or limiting production of client records or test data"). This strategy may be used alone or in combination with a motion for a protective order.

A motion for a protective order assumes that the psychologist will produce the information asked for by the subpoena but asks that the court protect it from the untoward consequences of disclosing information. The primary focus of this strategy is to prevent or limit the number of people who see sensitive client and test information. A motion for protective order can establish procedures to note the materials as confidential and have them placed under seal, which prevents their disclosure to the public.

Generally, the motion may state that the psychologist is ethically obligated not to produce the confidential records or test data or to testify, unless compelled by the court or with the consent of the client. It may include a request that the court consider the psychologist's obligations to adhere to federal requirements (such as HIPAA) and to protect the interests of the client, the interests of third parties (such as test publishers), and the public's interest in preserving the integrity and continued validity of the tests themselves. The motion might also attempt to suggest ways to minimize the adverse consequences of a disclosure. For example, the psychologist may suggest that the court:

  • Direct the psychologist to provide test data only to another appropriately qualified professional designated by the court or by the party seeking the information.
  • Limit the use of client records or test data to prevent wide dissemination. For example, the court might order that the information be delivered to the court, be kept under seal, and be used solely for the purposes of the litigation and that all copies of the data be returned to the psychologist after the litigation is terminated.
  • Limit the categories of information that must be produced. For example, client records may contain confidential information about a third party, such as a spouse, who may have independent interests in maintaining confidentiality, and such data may be of minimal or no relevance to the issues before the court.
  • Determine for itself, through a nonpublic hearing or a review by the judge in chambers, whether the use of the client records or test data is relevant to the issues before the court or whether they might be insulated from disclosure, in whole or in part, by the therapist–client privilege or another privilege (such as attorney–client privilege).
  • Deny or limit the demand because it is unduly burdensome on the psychologist (see, e.g., Federal Rule of Civil Procedure 45(c)).
  • Shield "psychotherapy notes" if the psychologist keeps separate psychotherapy notes as defined by the Privacy Rule (see Security and Privacy, 2015).
5. Determine whether to testify

If a psychologist is asked to disclose confidential information during questioning at a deposition, he or she may refuse to answer the question only if the information is privileged. If there is a reasonable basis for asserting a privilege, the psychologist may refuse to provide test data or client records until ordered to by the court.

A psychologist who refuses to answer questions without a reasonable basis may be penalized by the court, which may include requiring the psychologist to pay the requesting parties' costs and fees in obtaining court enforcement of the subpoena. For these reasons, it is advisable that a psychologist be represented by his or her own counsel at the deposition.

6. Consider possible grounds for opposing or limiting production of client records or test data

There are several options for resisting a demand to produce confidential client information. They include that:

  • The court does not have jurisdiction over the psychologist, the client records, or the test data or the psychologist did not receive a legally sufficient demand asking him or her to produce the information.
  • The psychologist does not have custody or control of the records or test data that are sought — for example, they may belong to the psychologist's employer, not to the psychologist.
  • The therapist–client privilege insulates the records or test data from disclosure. The rationale for the privilege, recognized in many states, is that the openness necessary for effective therapy requires clients to expect that all records of therapy, contents of therapeutic disclosures and test data will remain confidential. Disclosure would be a serious invasion of the client's privacy. The psychologist is under an ethical obligation to protect the client's reasonable expectations of confidentiality (APA Ethics Code, Ethical Standards, Section 4). There are important exceptions to this protection that negate the privilege. For example, if a client or former client is a party to the litigation and has raised his or her mental state as an issue in the proceeding, the client may have waived the psychotherapist-patient privilege. This varies by jurisdiction, with most jurisdictions holding a broad patient-litigant exception to privilege, with a few construing the patient-litigant exception much more narrowly. It is important that the psychologist be aware of the law in the relevant jurisdiction since this may ultimately control the issue about release of (otherwise) confidential client information. In this circumstance, the fact that a client who is a party to a legal case does not want to consent to release of information may not ultimately be dispositive on the issue. In such a case, the psychologist should discuss the issue of potential patient-litigant exception with the client's attorney, to determine if the records will need to be turned over due to the exception and to obtain any needed authorizations from the client.
  • The information sought is not relevant to the issues before the court.
  • Public dissemination of test information, such as manuals or protocols, may harm the public interest because it may affect responses of future test populations.
  • Test publishers have an interest in the protection of test information, and the psychologist may have a contractual or other legal obligation (e.g., copyright laws) not to disclose such information.
  • Psychologists have an ethical obligation to protect the integrity and security of test information and data, including protecting the intellectual property and unauthorized test disclosure, and to avoid misuse of assessment techniques and data. Psychologists are also ethically obligated to take reasonable steps to prevent others from misusing such information.
  • Some court rules allow the party receiving the subpoena to object to the subpoena's demand or ask that the demand be limited on the basis that it imposes an undue burden on the recipient (see, e.g., Rule 45(c) of the Federal Rules of Civil Procedure, 2014).

Ultimately, the judge's ruling controls in a court. Psychologists who are not violating human rights and who take reasonable steps to follow Standard 1.02 of the Ethics Code and inform the court of their requirements under the Ethics Code will not be subject to disciplinary procedures for complying with a court order directing them to produce information. Protecting patient privacy when the court calls can be complicated. To respond appropriately, psychologists should weigh ethical responsibilities and legal demands. Psychologists who have questions should consult legal counsel.

By APA’s Committee on Legal Issues


This article is condensed from "Strategies for Private Practitioners Coping With Subpoenas or Compelled Testimony for Client Records or Test Data or Test Materials," which appeared in Professional Psychology: Research and Practice, Vol. 47(1), Feb 2016, 1–11. To read the full article, which includes all citations and appendices, go to www.apa.org/about/offices/ogc/private-practitioners.pdf (PDF, 260KB).

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01 Jun 2017

New Threats to Client Privacy

New Threats to Client Privacy

This article looks at the new threats to client data, discusses the ethical considerations psychologists face, and advocates for the foundation of best practices to prevent breaches of client data.

The NSA has built an infrastructure that allows it to intercept almost everything . . . . I can get your emails, passwords, phone records, credit cards.” 

— Edward Snowden

Protecting clients' privacy is clearly one of psychologists' top ethical priorities. To help prevent disclosures of patient information, APA offers specific guidance in its Ethics Code (APA, 2010) and its "Record Keeping Guidelines" (APA, 2007).

Unfortunately, with today's ever-evolving technology, such guidance may not be enough. As Edward Snowden showed the world in 2013, information on cloud storage centers is not secure (Gellman & Soltani, 2013; Greenwald, 2013).

This article gives an overview of the current record-keeping and communication regulations and guidelines, looks at new threats to client data, discusses the ethical considerations psychologists face, and advocates for the foundation of best practices to prevent breaches of client data.

From pen to keyboard

In 1965, Intel Corporation co-founder Gordon Moore successfully predicted that circuit technology would double every two years and lead to exponential growth while reducing the size of everything. This became known as Moore's law.

Since then, personal computers and smartphones have become ubiquitous and nearly 3 billion people have Internet access. This pervasive accessibility affects both practitioners and clients. Today, communication with a client can occur via text and/or email. Metal file cabinets have evolved into encrypted digital containers. Record keeping can be entirely digital.

In response to this revolution, over the years U.S. agencies have sought to provide legislative frameworks for the proper handling of private information. Among them is the Health Insurance Portability and Accountability Act (1996; HIPAA), which sought to increase the accessibility of medical records while maintaining confidentiality. The law calls for health providers to "maintain reasonable and appropriate administrative, technical and physical safeguards" when using electronic health information (HIPAA, 1996).

In 2003, the Department of Health and Human Service (HHS) provided security standards for health-care providers, including psychologists, who transmit private health information. The standards mandate that providers must take precautions to prevent a breach of data and that they conduct risk analyses. These regulations also apply to providers' business associates — practicing psychologists who operate with insurers must follow HIPAA's privacy and security rules and ensure that their business associates do so as well.

In 2009, The Health Information Technology for Economic and Clinical Health Act (HITECH) formalized business associate liability and offered stricter regulations for using client records. This law placed the burden of security on a business associate to meet security and privacy requirements. In addition, business associates are expected to provide notifications of any breaches to the entities they cover and are subject to civil and criminal penalties for the misuse and/or loss of data. For practitioners, this means if they sign a business agreement with a business associate to store client records or materials in a cloud environment, the associate must meet HITECH requirements.

APA's record-keeping guidelines

While APA's Ethics Code provides ethical principles and standards for psychologists, it does not provide specific record-keeping guidelines. That guidance comes from APA's "Record Keeping Guidelines" (2007), which highlight the many interactions that practitioners have with the health-care system and federal regulations, such as HIPAA. For this article, we are particularly interested in guidelines 3, 6 and 9 (of 13), which focus on the topics of security, privacy and confidentiality:

Guideline 3 deals with confidentiality of client records. This recommendation states that practitioners should be aware of the regulatory and legal requirements that involve records.

Guideline 6 outlines the security measures that psychologists should engage in to protect those records. If practitioners create physical records, they should protect them with key and cabinet. If they use digital records, practitioners should properly secure them.

Guideline 9 informs practitioners on the use of electronic records. APA analogizes electronic to physical records and states that practitioners should be concerned with the use of e-mail and other communication tools because of the possibility that they can been seen by others.

These guidelines are not enforceable; they only offer guidance to practitioners.

Unfortunately, neither the federal government nor APA has proffered specific steps that should be taken to increase privacy and confidentiality to meet the challenges created by today's technology. The current guidelines only state that practitioners should use "passwords, firewalls, data encryption and authentication" (APA, 2007, p. 998). Although these recommendations would better secure systems, they do not establish directions and specific methods for creating secure passwords, activating firewalls or using data-encryption techniques, and they do not explain what authentication protocols are.

Providing specific guidelines that are constructed and updated regularly might alleviate part of the burden on practitioners to prepare for and understand growing threats to client privacy.

Threats to client privacy

Many psychologists are embracing email and text messaging to communicate outside of therapy sessions. Some, too, are writing notes in electronic medical records that rely on local, network and/or cloud storage. Others are interested in using smartphone applications and social networking interventions. And numerous practitioners see telehealth as a potential intervention and therapeutic delivery method (Colbow, 2013).

All of these uses of technology increase the risk to client privacy. These risks include:

Risks from individuals and collective actors: On Sept. 1, 2014, The Guardian reported that an individual or small group of hackers "exploited" celebrity Apple iCloud accounts, which stored phone data including emails, address books and photos (Arthur, 2014). Although celebrity data were the main targets, hackers could have compromised other individuals' accounts using similar methods. If a practitioner had chosen to communicate or store any records on Apple's iCloud platform, the information could have been compromised.

Information that is stolen via digital storage services is regularly sold on the "dark Web" — hidden websites that are inaccessible to most Internet users. Some medical records can be purchased for about $50. Similarly, if psychologists communicate with clients via smartphones and similar devices, those communications could be compromised with mobile malware that costs around $150.

Risks from corporations: Companies that provide cloud storage, email and communications services generally make money from mining personal data. Their privacy policies and terms of services can be complex, which can place a significant burden on psychology practitioners. For example, Facebook, like Google, uses social profiles for marketing and to provide users with related information. Facebook has expansive privacy policies to enable it to provide "relevant" advertising and learn about user habits. If a psychologist is communicating protected health information on these platforms, the corporate entity would have knowledge of client contact. Certain companies provide stronger privacy policies for communication. For instance, Apple's iCloud service does not mine emails for content. Most providers do not encrypt emails at rest (on cloud servers), allowing companies to more easily hand over message contents to third parties (Apple Inc., 2014a).

Another concern is data retention. Most cloud storage and communication providers say little about how long they keep their data. This amorphous data-retention policy stands in contrast to APA's record-keeping guidelines, which suggest that client records and data may be destroyed after seven years in the absence of superseding legal requirements. This policy also calls into question a practitioner's ability to maintain and provide confidentiality and proper informed consent when using certain corporate providers. And it is questionable whether practitioners could ever believe that records had been deleted if the cloud provider did not clearly and publicly state its data-retention standards.

Risks from the government: A variety of governmental entities interact with client data. As Edward Snowden and journalist Glenn Greenwald revealed in 2013, NSA analysts were able to access private cloud data centers from Google and Yahoo (Gellman & Soltani, 2013), which could have compromised protected health information and other client data.

Email at public universities is also at risk. Anyone can request the emails of public university staff members through a Freedom of Information Act (1966) request. Although some universities and colleges defend against open access to communication, email-based consultations between providers (that do not contain protected health information) might not be as protected as messages conveyed through patient files and electronic medical records would be.

Client information may also be inadvertently compromised as a result of the Stored Communications Act (1986), which was created before the Internet, email and personal computers became the tools of everyday life. The law states that email left on Web servers for over 180 days is considered abandoned. That "abandoned" data can be requested without formal judicial review. In addition, beyond surveillance by the NSA, the Federal Bureau of Investigation is permitted to access email in certain situations without first notifying the person under investigation (Counterintelligence Access to Telephone Toll and Transactional Records, 2012).

Ethical concerns

Various principles and standards in APA's Ethics Code are imperiled by the use of electronic storage and communications. In particular, psychologists should be aware of Principle E and Sections 2, 4, 6, and 10 of the Ethics Code.

Principle E (Respect for People's Rights and Dignity) provides a foundation for privacy and confidentiality. This principle recognizes the need to protect these rights and to safeguard clients' trust. Because of emerging threats to privacy, client data may be underprotected, regardless of current policies.

Section 2 of the Ethics Code focuses on ethical questions regarding competence. Of specific interest are Standards 2.01 (Boundaries of Competence) and 2.03 (Maintaining Competence). Standard 2.01 posits that psychologists must practice and provide services within their area of competence and that psychologists have an obligation to obtain training and/or support in areas that they are not familiar with, including technology. Shapiro and Schulman (1996) warned that accepting new technologies without critical, expert analysis might test practitioners' boundaries of competence. Similarly, Standard 2.03 outlines an expectation that psychologists will continue their education.

Taken together, Section 2 suggests that practitioners are expected to gain competence or support if they use privacy and security tools. Ethically, it may also be expected that practitioners continue to be informed about the various threats to client data.

Standard 4 may be the most relevant to the issue at hand because it explicitly outlines privacy and confidentiality expectations. As noted earlier, digitizing records and communications may lead to them being accessed by outside entities. This threat primarily affects two standards: 4.01 (Maintaining Confidentiality) and 4.02 (Discussing the Limits of Confidentiality). Section 4.02 establishes an ethical obligation to explain how certain record-keeping and communication practices may limit confidentiality. As a result, if psychologists use text messaging and email with a client, it might be ethically appropriate to talk about how these technologies may result in intrusions on privacy. In discussing the limits, it is important to consider how a client's information could be used against him or her. Psychologist-led discussions should facilitate evaluation of the appropriateness of certain disclosures on the basis of foreseeable client risk.

Section 6 specifies ethical obligations for record-keeping and fees. The standard of interest is 6.02 (Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work). The Ethics Code explains that within any medium, record storage and creation must be kept confidential. Moreover, if a practitioner needs to use shared records (such as in hospital settings), he or she should minimize the use of protected health information whenever possible to improve client privacy. Today's therapeutic interventions are performed in a variety of settings, and as technology becomes an important part of these, maintenance of confidentiality in record keeping comes into question.

Section 10 deals with concerns regarding therapy. According to Standard 10.01 (Informed Consent to Therapy), clients are to be informed of the limits of confidentiality and about communication methods available during treatment. If practitioners are interested in communicating via email and text, clients should be informed about these methods. Without a thorough informed consent process that covers these factors, client confidentiality cannot be properly founded (Everstine et al., 1980).

Best practices

APA's Ethics Code and "Record Keeping Guidelines" inform counseling and record-keeping, but there are additional practices that psychologists can consider to further prevent breaches of confidentiality. To proactively help prevent privacy breaches and maintain client confidentiality, psychologists can:

Develop a threat model: Practitioners should create a threat model to assess each client and his or her practice's associated risk (Barrows & Clayton, 1996; Lee, 2013). The Electronic Frontier Foundation (2014) has suggested that such threat models contain five questions:

  1. What do you want to protect?
  2. Who do you want to protect it from?
  3. How likely is it that you will need to protect it?
  4. How bad are the consequences if you fail?
  5. How much trouble are you willing to go through to try to prevent those?

Practitioners could, for instance, answer those questions with the following responses:

"I want to protect client records and communications."

"I want to protect it from unauthorized government access and individual hackers."

"I am currently working with a public, political figure, who has expressed concerns regarding unauthorized disclosures and leaks of data."

"Considering the public nature of this client, my practice could be threatened and culpable for damages."

"I am willing to spend an additional hour per week to secure this individual's client records on an external, air-gapped computer."

In general, APA's Ethics Code and the "Record Keeping Guidelines" emphasize stronger protections. By asking these five questions, practitioners can reduce accidental and/or targeted attacks on client information.

Encrypt everything: If possible, every client record and communication should be encrypted. When mobile devices are used for client contact, it is important to consider the phone's encryption capabilities. Currently, iPhones, with a good password, can be encrypted and protected from password attacks for about 5.5 years (Apple Inc., 2014b). It is also possible for iPhones to encrypt iMessages (text messages between iPhones), which would only be accessible between sender and recipient. Older phones cannot generally encrypt messages.

The APA Practice Organization (2014) separated computer encryption into three parts: (a) full-disk encryption, (b) virtual-disk encryption and (c) file/folder encryption. Full-disk encryption provides protection for an entire system, but once a password is used, the entire file system is accessible. Virtual-disk encryption is an encrypted container that acts like a digital flash drive and is protected from access through encryption. These containers require a password after logging into the computer. The file/folder encryption option regards individual files. For instance, a Microsoft Office Word file can be password protected.

By using all three of these methods, a stolen computer would be protected at multiple levels and virtually inaccessible.

The chief technology officer of the Freedom of the Press Foundation and technologist for The Intercept suggests disk encryption, firewalls, strong passwords (never renew or use the same) and cryptology to communicate when possible. For example, Apple computers come with built-in full-disk encryption via FileVault. In addition, by using a strong, 8- to 10-character password with special symbols, varied capitalization and avoidance of dictionary words, practitioners can have an encrypted and well-protected computer.

Use HIPAA-compliant cloud providers: Any provider that stores protected health information should publicly document its privacy policy, terms of service and information-handling restrictions.

For instance, Google Apps uses various standardized security certificates to ensure data safety and retention. Even if practitioners choose to be responsible and HIPAA compliant, files should still be encrypted. Devereaux and Gottlieb (2012) recommend that if cloud providers encrypt data, this process should meet the need for "reasonable conduct" and protection of records.

This argument is predicated on trust. A cloud provider that encrypts data but still has access to encryption keys would be forced to decrypt this information if compelled by the federal government. Likewise, if a private employee or contractor was given the key, they could potentially decrypt data unlawfully. Any cloud storage used should be backed up locally and completely encrypted prior to upload. There are a variety of encryption software packages available; one example, a cross-platform option, is TrueCrypt.

Use two-factor authentication: This authentication method requires psychologists to first enter a password and then a six- to eight-digit "token" to log onto a site. If a password were lost or stolen, an attacker would still need access to the token to log in. Without the token, a stolen password would be of no use. Mobile devices can often receive two-factor tokens via text message. Google, Dropbox and Twitter are all examples of companies that offer such two-factor authentication.

Work with air-gapped computers: Psychologists who are working with the most sensitive cases and clients may need greater data protection. Similar to locked and local file cabinets, an air-gapped computer is separated from networked data and Internet access — Ethernet cables and Wi-Fi antennas are disabled or removed. This would likely necessitate a practitioner to purchase a separate computer that would stay permanently disconnected from the Internet and only provide access to files. To share files with another computer, the psychologist would need to manually move them via USB-based external drives, thus lessening the risk of data leaks. Using an air-gapped computer, however, does present a different risk: If the computer's hard drive fails, the data is not backed up on a network, so data loss is more likely.

Modify informed consent: APA's Ethics Code states that informed consent should incorporate a method for securing, protecting and handling data. As Devereaux and Gottlieb (2012) suggest, it is important that an informed consent document properly explain, justify and present accurate risks of data storage and communication. If psychologists agree with their clients that they may use phone, text and/or email communication, the psychologist should inform the client about the increased risk of confidentiality breaches and about ways to reduce such leaks. In the interest of client privacy and autonomy, it may be appropriate to suggest pen and paper if worries about privacy concerns are present.

Conclusion

More than ever, practitioners are considering digital means for client records and communication. But with technological advances, there are greater threats to client confidentiality. Individual hackers have more power than ever to buy and sell private information. Corporate entities are scanning data by default for advertising and marketing purposes. In addition, governmental actors are collecting massive amounts of data (even when protected) for further analysis. With each step, important ethical obligations have been threatened.

As a result, it is vital to approach all cloud-based client work with caution. By following best practices, practitioners can significantly reduce the chance of breaches. At a time when even data stored in "secured" locations is at risk, psychologists should consider the appropriateness of current informed consent practices within the United States. Moreover, practitioners should question whether electronic-transmission surveillance laws are compatible with this field's support for privacy.

While individual practitioners should and do bear the ultimate responsibility for confidentiality and privacy, a unified message from APA might help prevent data storage and communication concerns resulting from poor and/or naïve risk management. Although APA's Ethics Code and "Record Keeping Guidelines" place the responsibility for client confidentiality — in any medium — with practitioners, it is important that an organization provide constant, up-to-date guidance for members.

Future record-keeping guidance would likely benefit greatly from the inclusion of best practices.

Psychologists should not fear technological changes, but they should prepare for the unexpected. By synthesizing the various individual, corporate and governmental actors that threaten client privacy, practitioners should have a newfound understanding and appreciation for security concerns.

Written by: Samuel D. Lustgarten, a graduate student in the counseling psychology PhD program at the University of Iowa, Iowa City. His research centers on the intersection of technology, psychology and client privacy.


This is a condensed version of "Emerging ethical threats to client privacy in cloud communication and data storage," which appeared in the June 2015 issue of the APA journal Professional Psychology: Research and Practice, Vol. 46(3). To read the full article, which includes all references, go to http://dx.doi.org/10.1037/pro0000018.

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01 Jun 2017

Competent, Affirming Practice with Older Lesbian and Gay Adults

Competent, Affirming Practice with Older Lesbian and Gay Adults

With the number of lesbian and gay older adults expected to swell to nearly 7 million in the next decade, psychologists will increasingly be working with these clients.

"I am gay." A 65 year-old man, newly admitted to a nursing home, scribbled this statement on a piece of paper and slid it across the table to his new psychologist. The man held his finger up to his lips, looked cautiously out into the hallway and whispered "shhh" before taking the paper back and ripping it into tiny pieces.

This incident happened just three years ago, despite significant strides in gay rights in the United States. Fear of stigma and outright discrimination in a variety of health-care, institutional and social service settings continue to be documented among aging lesbian and gay (LG) adults, even among those who live in more socially progressive urban areas.

The number of people facing such discrimination is quite large: Approximately 3 million older adults in the United States identify themselves as lesbian or gay, and that number is expected to swell to more than 7 million by 2025.

And research shows these clients are not getting the care they need. The APA Task Force on Bias in Psychotherapy with Lesbians and Gay Men, for example, found that older LG clients may even be inadvertently mistreated by providers due to a lack of knowledge about this population and heterocentrism — the negative attitudes and behaviors associated with any deviation from heterosexuality. Compounding these challenges is that older LG adults are one of the least empirically studied populations in terms of their mental health needs and adaption of psychotherapy to best address those needs.

Historical and cohort effects

Among the most important concepts to consider when working with LG clients over age 50 is that all of them lived through a time when their sexual orientation was labeled immoral, illegal and pathological. Homosexuality was only officially removed from the Diagnostic and Statistical Manual in 1973. Gay and lesbian people who revealed their sexual orientation in their younger years often suffered significant psychological and physical abuse from the larger community, including verbal harassment and social isolation, as well as sexual and physical assaults. These experiences may present themselves in later life as diffuse anxiety, depression, somatic distress or even post-traumatic stress disorder.

APA Guidelines for Psychological Practice with Older Adults encourage psychologists to take into account the impact of being part of a generational age cohort (e.g., baby boomers) because experience and attitudes vary among age cohorts, including attitudes toward mental health services. LG baby boomers experienced significantly different historical events than did earlier age cohorts. For example, the oldest LG elders came of age in the 1950s when President Eisenhower's 1953 Executive Order #10450 called for homosexuals to be fired from government jobs. Few LG individuals openly discussed their status for fear of discrimination and violence since people who were found to be engaging in same-sex behavior could be and were sent to prison or mental hospitals. No federal or state laws protected LG individuals from victimization. The mental health establishment offered "treatments" to change homosexual orientation through certain psychotherapies, electroconvulsive therapy and hormones.

Previous generations of LG persons clearly experienced enormous social pressure to suppress sexual expression or hide sexual orientation. As a result, earlier generations of LG elders — the now oldest-old LG elders — are more likely to have married opposite-sex partners, and in late life have ex-spouses, adult children and grandchildren when compared with LG baby boomers. Compared with their oldest-old heterosexual peers, however, these oldest LG elders have fewer biological relatives available to assist them with instrumental and financial needs related to long-term health care.

In contrast, baby boomers came of age during the gay rights movement catalyzed by the 1969 Stonewall riot in New York City. These baby boomers grew up with the American Psychiatric Association's (1973) policy statement that homosexuality was no longer regarded as a mental disorder and the repeal of many states' laws that criminalized homosexual behavior. Due in part to these events, LG baby boomers may represent the first LG age cohort to be more inclined to seek mental health care. Future cohorts of LG elders (e.g., the millennials) will likely have different experiences compared with current generations of LG older adults, since they came of age when states began to recognize same-sex marriages. In summary, although every individual's experience of stigma and discrimination in relation to minority sexual orientation is unique, cohort effects remain influential.

Diversity among lesbian and gay elders

Aging LG adults who are members of ethnic and cultural minority groups, conservative religious affiliations or rural communities often face additional social stressors. For example, a 74-year-old black lesbian in Chicago may experience ageism, heterocentrism, sexism and racism, whereas a 62-year-old gay Latino man in rural Pennsylvania may face significant social isolation as well as ageism, heterocentrism and racism. Cultural or ethnic-minority LG elders may face additional forms of heterocentric discrimination within their own ethnic, cultural and religious communities. In contrast, some LG minority elders may be assigned positive qualities; Native American "two spirit" elders were traditionally revered and granted special social status.

Most research on LG adults has been collected from white, highly educated gay men living in urban areas. Very little is known about older LG minority elders, particularly in rural areas, who are black or Hispanic or the oldest-old. As a result, practitioners should never make broad assumptions about an older gay or lesbian adult. Similarly, practitioners should never make global assumptions about any client from any minority group.

The influence of ageism, heterosexism and racism (among other stigmatizing factors) upon aging sexual minority group members is likely to be cumulative and perhaps exponential beyond the negative impact of each individual type of discrimination. A study of older gay black men reported significantly higher levels of perceived ageism than older gay white men, significantly higher levels of racism than younger gay black men, and significantly higher levels of homonegativity (overt negativity and hostility in relation to their gay sexual orientation) than both younger black and white gay men (David & Knight, 2008). Unfortunately, stigma, discrimination and social isolation may substantially contribute to health disparities, barriers in long-term care and legal inequalities evident among LG people.

Physical, mental and sexual health disparities

According to the Centers for Disease Control and Prevention (2011), LG adults experience significant physical and mental health disparities compared with their heterosexual peers. Awareness of such discrepancies is vital when working with older LG clients. Concealing one's sexual identity from health-care providers can lead to ineffective or deleterious health care. Various reports indicate that more than 40 percent of LG adults age 50 and older suffer from at least one disability or chronic illness, and are more likely to smoke and engage in binge drinking than their heterosexual peers.

LG elders are also more likely to delay seeking treatment for physical health problems, and to experience increased risk of elder abuse and neglect. LG elders are two times more likely to live and age alone and four times less likely to have adult children to call upon for help and support. In fact, one in five older LG adults reported having no one to call on in a time of crisis, compared with only one in 50 older heterosexual adults (Brookdale Center on Aging, 1999).

Within the context of such limited social support, older U.S. LG adults appear to experience more mental distress than their same-age, heterosexual peers. Nearly one in three older LG adults from a large-scale study of more than 2,300 LGBT U.S. older adults reported that they lacked companionship and felt lonely, and met criteria for clinical depression on a standardized measure. In addition, nearly one in three older LG study participants indicated that they seriously considered committing suicide at some point in their lives, often in response to concerns about their sexual orientation. A study of older LG Europeans revealed similar findings, in which internalized homonegativity and social stigma contributed to mental health issues.

In terms of sexual health, older women in general often encounter vaginal dryness and older men experience erectile dysfunction and prostate changes. Gay male elders face increased risk of infection for HIV and other STDs, and both older gay men and older lesbian women face challenges in terms of poor or limited preventative screenings and clinical care. Although gay men represent about 2 percent of the general population, they account for nearly half of all AIDS related deaths and new HIV infections. Specifically, more than 17 percent of new HIV/AIDS cases occur among adults over age 50, with older men having sex with men, and older black and Latino men, at greatest risk. In addition, within the last decade, new HIV diagnoses among adults over age 50 increased by more than 30 percent. Regrettably, no national HIV/AIDS education programs exist for older adults, much less an aging gay male population.

Older gay men in committed relationships also are more likely to face the diagnosis and treatment of prostate cancer than older heterosexual men. A committed gay man may have to face both his own and his partner's diagnosis of prostate cancer. Like their heterosexual peers, older gay men often have limited and incorrect knowledge about prostate disease, and older black gay men possess the least accurate knowledge. Therapists can encourage older gay men to discuss their prostate health openly with both their medical providers and their own partners. Education about prostate health, as well as its treatment options, remains essential.

A primary concern for older lesbians is a failure to disclose information about their sexual orientation and history to their health-care providers. Despite prevalent myths held by both older lesbians and health-care providers that lesbians are immune to the transmission of STDs, nearly half of older lesbians report having heterosexual intercourse at some point in their lives, and 20 percent of all women who never had heterosexual intercourse are infected with the HPV virus, the primary cause of cervical cancer. Older lesbians should receive educational messages about their individual risk factors for STDs and screenings when appropriate. Therapists can encourage older LG individuals to discuss concerns about their sexual health, and help them communicate more effectively with their health-care providers, who are unlikely to discuss STDs with their older patients, regardless of their sexual orientation.

Caregiving and long-term care

A survey of more than 1,200 LG adults found that LG elders are twice as likely to serve as a caregiver for a parent, family member, partner, friend or neighbor, and spend significantly more hours per week providing that care, compared with their heterosexual counterparts. This finding supports the notion that older LG adults maintain a "family of choice" well beyond biological and legal boundaries. The psychological, physical and financial demands on this population should not be overlooked.

Significant challenges also exist for LG adults in long-term care facilities. Discrimination, including outright hostility and substandard care, is well documented among LG residents in nursing homes and other institutional settings. Professional caregivers hold significantly more negative attitudes toward sexual activity among same-sex than heterosexual residents. Such negativity and hostility can even take the form of physical abuse.

Challenges to living authentically

Both fear of discrimination and fear of living an asexual lifestyle within a long-term care setting lead the majority of older LG adults to report that they want to live independently in their own homes, for as long as possible. To complicate matters, only 22 states have passed laws that prohibit discrimination based on sexual orientation in public or private housing. In other states, a nursing home or public housing administrator can simply refuse to admit an LG individual with no legal recourse available to that individual.

As a result, many LG residents in long-term care, including those who have lived authentically, feel compelled to "go back into the closet." Some LG partners legally change their last name to match that of their partner's, so they can live in the same room as "brothers or sisters." Other LG residents decide to act straight, while others hide personal photos of partners and other mementos to avoid revealing their LG status. A therapist's knowledge of these unique challenges and information about available resources is essential.

Legal issues and a call for advocacy

It is also vital for psychologists and their LG clients to become familiar with changing federal and individual states' laws regarding same-sex marriage, civil unions and discrimination on the basis of sexual orientation so that they understand the benefits they are entitled to in care facilities as well as through government programs including Social Security and Medicare.

In 2013 the U.S. Supreme Court struck down Section 3 of the Defense of Marriage Act (DOMA; United States v. Windsor, 2013). That ruling granted same-sex married couples access to more than 1,000 federal rights, including 401(k) survivor and hardship withdrawal benefits, coverage under the Family and Medical Leave Act (FMLA), COBRA benefits, savings on federal inheritance taxes, veteran's benefits and green cards for binational couples. The DOMA ruling also granted same-sex married partners access to federal Supplemental Security Income, disability, death and spousal benefits. In addition, the federal provisions for Medicaid spend-downs — which are designed to keep a healthy spouse from losing his or her home and becoming bankrupt when paying for the nursing home care of an ill or disabled partner — also now apply to same-sex married couples. In 2015, the Supreme Court further ruled that individual states could no longer deny same-sex couples the right to become married.

Studies show, however, that lesbian and gay adults who live in states that fail to provide protection against hate crimes and employment discrimination based on sexual orientation were significantly more likely to be diagnosed with depression, dysthymia, generalized anxiety, and post-traumatic stress and alcohol abuse disorders than those living in states that did provide such legal protection. Allowing LG clients to express their anger and frustration in therapy about such legalized forms of discrimination is essential. The need for psychologists to advocate for public policies and state and federal laws that prohibit discrimination based upon sexual orientation is urgent and clear.

Adaptation and resilience

Although LG elders represent a unique, at-risk population, they also display evidence of significant adaptation and resilience. More than 80 percent of LG adults report that they engage in some type of wellness activity. A qualitative study of older LG adults suggests that many learn to cope with a stigmatized identity by developing a strong sense of independence, autonomy and inherent self-worth, as well as by establishing interests outside of their families and careers. Some researchers posit that successful coping in response to the stress of coming out may better prepare LG adults for life in an ageist society.

Social support is a critically important part of life that allows someone to adapt and adjust more easily to life changes and crises. One difference observed between LG and heterosexual elders is that LG elders typically garner more social support from friends and "family members by choice" than legal or biological family members. Although long-standing social norms suggest that family members are expected to provide instrumental support (such as financial help and caregiving), LG individuals have historically developed meaningful, supportive friendship networks, in part because their own families may be unsupportive of their sexual orientation. With a broader social network, LG elders are often better equipped to gather different types of support from multiple sources compared with their heterosexual peers.

Implications for practice, advocacy and research

Clinical settings can help LG elders feel more comfortable and accepted in a variety of ways. For example, therapists can change the language on intake and other forms to ask about one's relationship versus marital status, and about family members by choice. They can also alter the physical environment in offices, waiting areas and websites by displaying or linking to magazines that reflect both LG and aging readership (such as Out More and AARP), or with pictures featuring LG couples and families from a variety of ages, racial, ethnic and cultural backgrounds. Therapists also can celebrate National Coming Out Day, World LGBT Pride Day and other LG-affirming events. For example, psychologists played a key role in U.S. Department of Veterans Affairs efforts to make VA health-care facilities more welcoming for LGBT veterans by working to develop more inclusive hospital visitation policies and establishing a policy on respectful care for transgender veterans.

To provide competent practice, psychologists themselves must examine their own attitudes toward both older and LG adults, particularly if coming from a culture or religious affiliation that does not affirm an LG orientation. Therapists also are advised to train staff and post a nondiscriminatory statement that equal care will be provided to all clients regardless of their age, sexual orientation, ethnicity, race, religion, physical ability and attributes, and gender identity. Simple exposure and familiarity with LG elders can reduce stigma and alert minority clients that options are available for competent, affirming care. Fostering the resilience of LG elders, including the nonfamilial exchange of care, participation in formal and informal LG and aging support groups, and increased health advocacy for HIV/AIDS, is highly desirable.

Consistent with the APA Practice Guidelines for older adults as well as those for LG adults, psychologists are encouraged to engage in advocacy for their clients as well as for LG elders at large to promote social justice and civil rights. Specifically, psychologists can advocate for changes in individual states to pass antidiscrimination laws that benefit older LG adults. Such laws would include protections against hate crimes and discrimination in private and public housing, including both nursing homes and assisted-living facilities. Of course, simply passing an antidiscrimination law does not prevent such discrimination; it only provides legal recourse for those affected.

To provide a safe and welcoming environment for LG elders in long-term care, same-sex couples should be able to share a room. To make this happen, staff training and even resident education are likely to be necessary. The VA training model and a staff training curriculum on LGBT elders developed by the National Resource Center on LGBT Aging are good resources.

Conclusion

Significant physical, sexual and mental health disparities exist among older LG adults when compared with their heterosexual peers. As more egalitarian same-sex laws are adopted by a variety of individual states in the United States, psychologists can play a critical role in advocacy for state and local legislation that prohibits discrimination based upon sexual orientation and will benefit the growing population of aging LG adults. Therapists also are encouraged to seek education and training on the unique challenges often faced by older LG adults, and to provide an LG-affirming practice to better serve this burgeoning, diverse population.

Jennifer Hillman, PhD, is professor of psychology at the Pennsylvania State University, Berks Campus.

Gregory A. Hinrichsen, PhD, is assistant clinical professor in the department of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai and clinical associate professor in the department of psychiatry and behavioral sciences at the Albert Einstein College of Medicine.

By Dr. Hillman and Dr. Hinrichsen, both whom are board certified in geropsychology.


This article is adapted from "Promoting an affirming, competent practice with older lesbian and gay adults" from Professional Psychology: Research and Practice, Vol. 45(4), August 2014, 269–277. The full article, which includes case studies and citations, appears at http://www.apa.org/pubs/journals/affirming-competent-practice.pdf.

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01 Jun 2017

Avoiding a Disconnect with Telemental Health

Avoiding a Disconnect with Telemental Health

New technologies are increasing access to mental health care and helping psychologists run their practices more smoothly and efficiently than ever before. But these benefits come with ethical, legal and clinical challenges.

Telemental health offers psychologists a tremendous opportunity: the ability to increase access to psychological care for people who, for a variety of reasons, are not able to meet with a practitioner face-to-face.

Most commonly, telehealth services include providing crisis intervention to clients over the telephone in between in-person sessions, delivering clinical services across long distances via interactive videoconferencing to clients who would not otherwise be able to receive treatment, and using smartphone apps to augment and enhance treatment services provided.

Unfortunately, the great benefits that can come with telemental health also introduce a number of ethical, legal, and clinical challenges. In this article, we present two cases that highlight the benefits and risks of telemental health.

Case #1: Unforeseen ethics concerns

Dr. Ino Vater, a licensed psychologist, sees telemental health as a potentially lucrative way to expand her private practice. She develops a business plan that includes advertising her services via the Internet to tap into new markets. She plans to begin offering email counseling with a guaranteed 24-hour response time at a rate of $25 per email. She also plans to offer online individual and group psychotherapy via Skype.

Dr. Vater announces these new services on her website, stressing her qualifications as a licensed practitioner with over 30 years of experience. Being somewhat technologically savvy, she already has her standard informed consent form on her website for new clients to review and sign electronically. She also has an electronic calendar on her website so new clients can schedule their initial appointment with her directly. Payments are easily accepted via PayPal, so clients can pay in advance for services.

Word spreads quickly and numerous new clients schedule appointments with her for email and videoconference counseling. She is thrilled that people from around the world are seeking treatment from her. She is also excited to see that the clients present with so many different problems. Pleased with all the new business, Dr. Vater continues accepting all new clients and is very gratified that the new business plan she developed is working so well.

Has Dr. Vater overlooked any important ethical, legal and clinical issues? In short, yes. While telemental health can be helpful to many individuals, how it is applied requires careful forethought.

As a starting point, practitioners must understand that all requirements of their profession's ethics code apply to the provision of telemental health services. For example, APA's Ethics Code applies to all professional services provided by psychologists, regardless of their type and whether they are delivered in person, over the phone, via the Internet, or in other ways.

As a result, before Dr. Ino Vater launched her new business plan, she should have considered her:

Competence in telemental health: Competence requires practitioners to possess the knowledge and skills needed to ensure they meet (and hopefully, exceed) the minimum expectations for the quality of professional services provided. Before providing any telemental health services, practitioners should familiarize themselves with relevant guidelines for this practice area, such as those available through the Tele-Mental Health Institute at http://telehealth.org/ethical-statements. APA has also published guidelines at www.apapracticecentral.org/ce/guidelines/telepsychology-guidelines.pdf (PDF, 112KB).

While guidelines do not contain enforceable standards, they represent each profession's consensus statement on telemental health best practices.

Technological competence: In addition to clinical competence, practitioners should also be knowledgeable about the various technologies used in telemental health practice, such as the hardware, software, type of Internet connection, privacy safeguards and security precautions needed to help ensure client privacy. Practitioners should be familiar enough with the systems so that they can adjust the auditory and visual quality of the technology as needed. They should be able to address difficulties that may arise, including the loss of an Internet connection or other interruptions of service, and have a backup plan for making contact should that happen.

Practitioners should also be familiar with the strengths and weaknesses of the software programs they use for clinical services. For example, while Dr. Vater may have over 30 years of clinical experience and may use certain technologies in her personal life, her failure to take courses on telemental health and her use of text-based therapy as an alternative suggests that her professional understanding of telemental health may be limited. In addition, her choice of a nonsecure video platform is inappropriate since Skype is not compliant with the Health Insurance Portability and Accountability Act (HIPAA). Only products that are HIPAA-compliant and meet federal requirements for protecting each client's privacy should be used. Examples of such platforms include Vyzit, VSee, Zoom, Regroup Therapy and Breakthrough.

General telemental health competence: Dr. Vater should have also carefully considered the appropriateness of each technology for each client's particular needs. Research has shown, for example, that using email for counseling and psychotherapy services has many limitations, such as the absence of visual cues and significant potential for miscommunication; the difficulty in assessing and diagnosing individuals one does not have the opportunity to observe; and a lack of empirical support for the effectiveness of email as the primary means of providing such services.

By reading up on the literature, Dr. Vater would have also discovered that some technologies may be effectively used in telemental health with some clients. For example, there is a significant body of literature that demonstrates the value of videoconferencing for providing psychotherapy and counseling to a wide range of clients. Research has shown that the therapeutic alliance in psychotherapy via videoconferencing is comparable to the alliance found in in-person treatment.

There is also a broad literature on the effectiveness of videoconferencing in treating a wide range of mental health issues and concerns. It has been shown to be helpful in treating individuals, couples, families and groups for issues such as anxiety disorders including generalized anxiety disorder, post-traumatic stress disorder and panic disorder (e.g., Germain, Marchand, Bouchard, Drouin, & Guay, 2009; Spence, Holmes, March, & Lipp, 2006; Wims, Titov, Andrews, & Choi, 2010); depression and grief (e.g., Dominick et al., 2009; Ruwaard et al., 2008); and addictions (e.g., Mermelstein & Turner, 2006; Riper et al., 2009); among others. Mental health clinicians should familiarize themselves with this extensive and rapidly expanding literature to ensure that treatments offered have empirical support.

An important aspect of competence requires practitioners to be able to determine which telemental health services and treatment modalities may be appropriate for which clients. Telemental health would be inappropriate, for example, with clients with serious mental illness, including serious depression, suicidality and impulse control difficulties, such as violence and homicidality. Unfortunately, Dr. Vater is welcoming all prospective clients into her telemental health practice, regardless of their needs or circumstances. While some clients may benefit from counseling services offered via telephone or email, some will need videoconferencing treatment, others will need in-person treatment and still others may benefit from a combination of these services. These decisions should be made after carefully screening each potential client to determine the seriousness of a diagnosis, whether or not the client is in crisis, the level of rapport, and the client's motivation for therapy. Screening should also explore whether the client has a support system, whether the client can find competent clinician services, and whether the client has access to a secure and private space for participating in the telemental health services.

The clinician should document the rationale for concluding that a particular client is suitable for telemental health services. Ideally, clinicians will also begin with cases that present the best chance of success from receiving distance services, such as clients who already have an established and positive treatment relationship with the clinician or who are temporarily traveling. Potential clients outside of one's local area who, after careful screening, are deemed to be best served by in-person treatment should be referred to others.

Multicultural competence: Mental health clinicians who provide services via the Internet may easily find themselves violating professional expectations for multicultural competence. For example, since Dr. Vater is accepting clients from around the world, she will be interacting with people from different cultural, ethnic and linguistic backgrounds. Failing to give careful consideration to each client's individual differences may result in more harm than good.

When treating clients from around the world, it is not realistic to expect them to all speak English fluently. Yet, the ability to communicate effectively is essential for counseling to be successful. Similarly, clients may come from a wide range of cultural backgrounds. Even if there are no language barriers, practitioners should possess the necessary multicultural competence to ensure sensitivity to clients' beliefs and practices so these are not misinterpreted or violated.

Clinical competence and telemental health: It may be tempting to accept new clients, regardless of their problems, but of course clinicians should not provide assessments and treatments via telemental health if they are not competent to provide them in person. Mental health services must be provided in accordance with the requirements of the each professional's code of ethics. As a result, if Dr. Vater is conceptualizing her email communications with clients as "advice giving" or "a helping conversation," she may be overlooking clients' treatment needs and expectations. She may also be misrepresenting the services she is providing as something other than psychotherapy. Or she may be calling it psychotherapy when she is providing something else.

Informed consent process: Informed consent is designed to ensure that prospective clients get the information they need to make an educated decision about participating in the services offered. As APA's Ethics Code states, psychologists are required to "inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers."

Practitioners who provide telemental health services will need to modify the informed consent procedures they typically use for in-person treatment for several reasons. For one, it is important to discuss openly with clients the options and alternatives available to them — including in-person treatment and the range of telemental health services — to help them decide which is most appropriate for them. Dr. Vater lists only two telemental health modalities on her website and both appear to be unacceptable forms of treatment for a clinician who is interested in evidence-based or HIPAA-compliant treatment. If clients' treatment needs won't be met by these modalities, she should refer these clients to other competent professionals who can provide the needed services.

In addition, Dr. Vater should discuss her fees up front, including any charges for contact between regularly scheduled appointments, such as phone calls, emails and texts. It also should be made clear whether insurance will cover the services provided. Clinicians need to be aware of appropriate billing codes for telemental health services so they are not inadvertently engaging in insurance fraud by billing these services the same as face-to-face services. Often there is a GT code signifier to show that the service took place via phone or video, although noting phone or video next to the code is recommended so as not to unintentionally mislead the insurance company.

The issues of confidentiality and its limits are especially relevant for clients considering telemental health. The informed consent agreement should cover these issues so that prospective clients understand that absolute confidentiality can never be guaranteed. Clinicians can help protect confidentiality by using encrypted email communications, virus and malware protection, firewalls, passwords and secure Internet networks. Clinicians should inform clients about the factors that can trigger an exception to confidentiality and to whom and in which state information will be released. The informed consent agreement should also include emergency contact information, as well as procedures to follow when interruptions in telehealth communication occur.

Also, since not all individuals have the legal right to give consent to treatment, the provider should first obtain proof that the prospective client is legally an adult and has the right to consent to treatment. In addition, clinicians have a duty to put procedures in place to ensure that someone does not pose as a client to gain access to someone else's psychotherapy — for example, the client and provider can use an agreed upon password exchanged through encrypted media.

Practitioners should see informed consent as an ongoing process. They must obtain a client's informed consent at the outset of the professional relationship, but also continually update it as circumstances change. Any substantive change to how treatment is provided, the risks involved in participating in it, fees or financial arrangements, and the like, should be discussed with clients before changes are made. So, if a client has agreed to videoconferencing for treatment, and over time the practitioner decides that a different treatment modality would be preferable, the informed consent should be updated to discuss the reasons for the change, the other options available, and the risks and benefits of each option.

Case #2: Legal issues and requirements

Dr. Roule Breyker is a licensed psychologist in Montana, practicing in one of the state's four urban areas. Montana is a rural state with an average of only 6.4 persons per square mile. Many of its counties have no mental health professionals.

Dr. Breyker has decided to begin offering telemental health to residents throughout the state to better meet the need for services. His expansion is going so well that he has begun receiving inquiries from potential clients who live in the surrounding states of Wyoming, North Dakota, Idaho and South Dakota as well as from the neighboring Canadian provinces of Alberta, Saskatchewan and British Columbia. He is excited about how word of his telemental health services is spreading and he is gratified to know that he is helping to meet the significant mental health treatment needs of rural communities.

When he shares the news about his expanding work at a meeting with several Montana colleagues, he is shocked to hear their concerns about his interjurisdictional practice. Dr. Breyker states that he is helping people who would not otherwise be able to receive mental health treatment and he expresses dismay at his colleagues' concerns. He abruptly leaves the meeting, chalking it up to his colleagues' professional jealousy.

As noble as Dr. Breyker's intentions are, practitioners who provide telemental health services must be sure that they follow the requirements of licensing laws and regulations of the jurisdictions where they work and where their clients live. Crossing state and national boundaries creates several important legal issues and challenges. They include:

Licensing issues: When using telemental health services to provide treatment to clients within one's state, province or territory, the practitioner follows the dictates of his or her license. But licensure requirements may be less clear when a client lives in another jurisdiction — and so far, not all jurisdictions have addressed this issue in their licensing laws and regulations. In addition, decisions about what is appropriate are subject to idiosyncratic jurisdictional authorities.

This can create a tremendous challenge for practitioners who want to engage in interstate or international practice. An important first step for practitioners is to research the licensure laws and regulations in the jurisdiction where each client is located. If these documents lack clarity on interjurisdictional practice, the practitioner should submit a written request for clarification to that jurisdiction's licensing board. For jurisdictions that require in-state licensure, the practitioner could seek licensure in that state (which may be time-consuming, expensive and impractical) or practice in the other jurisdiction without being licensed there, an option that can place the professional at significant legal risk. Some states will permit clinicians to practice short-term (e.g., a period of 30 days) in a state in which the clinician is unlicensed, if she or he is licensed in another state. Some of these provisions can be found at www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf (PDF, 1MB).

APA and the Association of State and Provincial Psychology Boards are working to resolve the challenge of interjurisdictional practice. They also are attempting to develop interstate compacts similar to those of the nursing profession, which allow nurses to practice in other states with their license from their home state if they follow the laws and regulations of the local jurisdiction. Until such an arrangement is adopted, mental health professionals must be cautious and keep in mind that legal and regulatory requirements may vary from state to state.

The same issues are relevant when providing mental health services across international borders. It is each clinician's responsibility to research any applicable licensing laws and regulations prior to providing professional services in those jurisdictions.

Duty to report: What should Dr. Breyker do if a client in Wyoming discloses in a telemental health session that she is physically or sexually abusing her child? Should he follow the laws in Montana? Or, those in Wyoming (and does he even know them)? Or, should he attempt to follow both states' laws? If he is licensed in both jurisdictions, there may be different requirements.

An important study by Maheu and Gordon (2000) found that of the mental health professionals providing telemental health services whom they surveyed:

  • 75 percent reported providing services across state lines.
  • 60 percent inquired about each client's state of residence.
  • 74 percent were uncertain or incorrect about each state's telehealth laws.
  • 50 percent made advance arrangements for responding to emergencies or crises.
  • 48 percent used a formal informed consent procedure prior to providing online services.

It is vital that Dr. Breyker research the laws relevant to the mandatory reporting of suspected abuse and neglect of minors in each state in which he provides services. But, as is highlighted in the Maheu and Gordon study, one must first find out where potential clients live. Even if Dr. Breyker becomes licensed in the surrounding states or obtains temporary licensing permission to offer telemental health services in these states, he still needs to be knowledgeable about the laws in these states relevant to his role as a treating clinician. In addition, clinicians should be aware that when one reports across state lines, one loses immunity. (Interstate licensure compacts may, however, more formally address this issue.)

While every state has laws regarding the mandatory reporting of suspected abuse and neglect of minors, the laws differ with regard to how abuse and neglect are defined, the threshold to be followed for making reports, in which jurisdiction the report should be filed, the age of majority in that state, and more. Failure to know and follow these laws can place minors at risk unnecessarily. Understanding these laws also is necessary so that practitioners can address these potential limits to confidentiality as part of the informed consent process.

Similarly, all jurisdictions have laws that address mandatory reporting requirements for the suspicion of harm to other vulnerable individuals, such as some older adults and developmentally delayed adults. Yet each jurisdiction's laws are different. Some have focused on different definitions of what it means to be a vulnerable adult; some have different definitions of abuse, neglect, self-neglect and exploitation; and some have different reporting thresholds. Once again, possessing knowledge of these laws in the jurisdictions where clients reside is essential for fulfilling both ethical and legal obligations.

Dangerousness and the duty to warn, protect or treat: Based on the landmark Tarasoff v. Regents of the University of California legal decisions (1974/1976), many jurisdictions have laws regarding the requirement to take action when a client discloses an imminent threat to do harm to an identifiable victim or group of victims. Yet, these laws vary significantly. Some jurisdictions have duty-to-warn laws and some have duty-to-protect laws. Others have duty-to-warn, protect, and treat laws and some have none of these requirements. As a result, a clinician's good-faith effort to protect others from harm may result in inappropriately violating the client's confidentiality and violating state law.

When practicing telemental health across national borders, the issue is further complicated since these issues may be addressed quite differently in another country — or may not be addressed at all.

It is essential that mental health professionals who practice telemental health cross-jurisdictionally be familiar with the laws in the jurisdictions where the clients reside. Yet, in a study by Pabian, Welfel, & Beebe (2009), 76.4 percent of clinicians surveyed "were misinformed about their state laws, believing that they had a legal duty to warn when they did not, or assuming that warning was their only legal option when other protective actions less harmful to client privacy were allowed." This failure to know and follow these laws can have lethal and tragic consequences. Similar to other reporting requirements, knowledge of these laws affects the informed consent agreement with regard to the limits to confidentiality that exist in the treatment relationship.

Issues regarding both voluntary and involuntary hospitalization across state lines are quite complex. In addition to understanding state laws where the client resides, it would be wise to have handy the numbers for local police and the address for the nearest ER when a client engages our services from another location.

Recommendations for telemental health practice

In summary, to practice telemental health in an ethical, legal and clinically effective manner, we recommend that clinicians:

  • Follow all requirements for ethical conduct from your profession's code of ethics regardless of the telemental health medium used.
  • Become familiar with and be guided by relevant telemental health practice guidelines.
  • Learn and follow the relevant telemental health laws in all jurisdictions in which you will be providing clinical services.
  • Assess each potential client's treatment needs to ensure the appropriateness of participating in telemental health and that the most appropriate medium is used. Make referrals to other competent professionals when in the client's best interest.
  • Use a comprehensive informed consent process that addresses all issues relevant to the practice of telemental health.
  • Take all reasonable actions and use all readily available technology to protect each client's confidentiality, such as the encryption of email communications.
  • Only use HIPAA-compliant software programs to provide video conferencing with clients.
  • Only provide clinical services that you are competent to provide based on your education, training and relevant clinical experience.
  • Before providing telemental health services, develop competence regarding all hardware and software you will be utilizing to communicate with clients.
  • Ensure multicultural competence and attend to linguistic and other diversity issues in your online interactions with clients.
  • Learn about and follow all duty to warn and mandatory reporting requirements in the jurisdictions where you are providing telemental health services.
  • Before providing telemental health services, learn about resources in each client's local area and make arrangements there for emergency and crisis situations.
  • Document all telemental health services provided just as you would document in-person mental health services, ensuring that all records are stored securely so that each client's confidentiality is preserved.
  • When unsure if a client should be treated via telemental health, utilize an ethical decision-making model and consult with experienced colleagues.
  • Maintain appropriate liability insurance coverage and confirm that your malpractice insurance policy covers the provision of telemental health services.

By Jeffrey E. Barnett, PsyD, ABPP, an associate dean and professor of psychology at Loyola University Maryland and he is an independent practitioner in Towson, Maryland. Keely Kolmes, PsyD, an independent practitioner in San Francisco.


This article is condensed from "The Practice of Tele-Mental Health: Ethical, Legal, and Clinical Issues for Practitioners," which appeared in the January 2016 issue of Practice Innovations. To read the full article, which includes all citations, go to http://dx.doi.org/10.1037/pri0000014.

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24 Apr 2017

Substance Use Disorders and Addictions Series

Substance Use Disorders and Addictions Series

Over the past few decades great advances have been made towards understanding the psychology of substance use disorders (SUDs) and addictions. This five-part series is designed to provide psychologists and psychology students with cutting-edge information about SUDs and addictive behaviors.

This series is a collaboration with the American Psychological Association (APA) Office of Continuing Education in Psychology, the APA Science Directorate, the APA Center for Learning and Career Development, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the Society of Addiction Psychology (Division 50 of APA). *This series is eligible for CE credit. Earn 2 CE credits for each session.

The five two-hour programs focus on:

Overview of Substance Use Disorders and Addictions

An overview of the basic concepts of substance use and substance use disorders (SUDs) including, a review diagnostic criteria as defined in the DSM-IV, DSM-5 and the ICD-10, and comorbidity between SUDs and other psychological disorders.

Screening, Brief Intervention, and Referral for Treatment (SBIRT) for Substance Use Disorders and Addictions

SBIRT is recommended practice for many addictive behaviors demonstrating effectiveness in reducing risk and promoting movement through the stages of change. This workshop describes screening and brief intervention strategies that can be used to identify risky involvement with alcohol, marijuana, heroin, cocaine, tobacco, nonprescription medications and gambling behaviors.

Understanding People With Substance Use Disorders and Addictions

A look at some of the psychological, biological, and environmental factors that have been linked to the development of substance use disorders. The discussion also seeks to understand the challenges of living with addiction and considers the process of recovery and some of the factors that may help facilitate successful resolution of substance misuse.

Evidence-Based Clinical Practice Guidelines for the Management of Substance Use Disorders

An overview of the VA/DoD Clinical Practice Guidelines recommendations and how they were developed, including discussion of some of the gaps in the evidence base and selected clinical challenges.

Treatment of Substance Use Disorders in the Real World

A look at the most common addiction treatment modalities and content, with specific focus on identifying empirically-based principles of treatment and coordinating care with addiction treatment providers.

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12 Apr 2017

Treatment of Substance Use Disorders in the Real World

This webinar covers the most common addiction treatment modalities and content, with specific focus on identifying empirically-based principles of treatment and coordinating care with addiction treatment providers.

Learning Objective 1
Identify the core components of the most common substance use disorder treatment modalities.

Learning Objective 2
Compare substance use disorder treatment options to make realistic and informed recommendations for patients/clients.

Learning Objective 3
Describe common addiction-related behaviors that patients/clients display and how to address them.

Jessica M. PeircePresenter: Jessica M. Peirce, PhD

Dr. Peirce is a licensed clinical psychologist and an Associate Professor in the Department of Psychiatry and Behavioral Sciences of Johns Hopkins University School of Medicine. She is Associate Director of Addiction Treatment Services, an outpatient methadone maintenance treatment clinic, where she provides direct patient care and supervises the psychosocial treatment of 400 patients with opioid dependence. Her research interests center on improving outcomes for urban substance use disorder patients in and out of treatment, with a specific focus on the relationship between new traumatic events and episodes of PTSD and substance use.

Bruce LieseCourse Director: Bruce Liese, PhD

Bruce S. Liese, PhD, ABPP is Professor of Family Medicine and Psychiatry at the University of Kansas Medical Center, Courtesy Professor of Clinical Psychology at the University of Kansas, and current President-Elect of the Society of Addiction Psychology (SoAP; APA Division 50). Dr. Liese earned his PhD from The University at Albany in 1983. He is a teacher, clinical supervisor, researcher, and clinician.  His work focuses primarily on the diagnosis and treatment of addictive behaviors.  He has been Director of CBT training for a large multi-center NIDA-funded addictions study and over time has supervised hundreds of CB therapists.  Presently he teaches courses on addictive behaviors, psychotherapy, and evidence-based practice in psychology and he supervises more than a dozen psychotherapy trainees.  Dr. Liese has more than 50 publications, and he has co-authored two texts on addictions.  He was Editor of The Addictions Newsletter for ten years, an official publication of APA Division 50.  For his work on this newsletter, Dr. Liese received a President’s Citation from Division 50. He has been chosen to be a member of APA’s Continuing Education Committee, and in 2015 he received the Distinguished Career Contributions to Education and Training award from APA Division 50.

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06 Apr 2017

Evidence-Based Clinical Practice Guidelines for the Management of Substance Use Disorders

The VA/DoD Clinical Practice Guidelines updated in 2015 addresse many of the critical decision points in the management of substance use disorders among adults. The guidelines incorporate findings from a systematic review of empirical literature and other decision domains by the guideline's development panel to support actionable recommendations that can inform shared decision making by patients and providers to promote individualized care. This webinar involves an overview of the guidelines recommendations and how they were developed, including discussion of some of the gaps in the evidence base and selected clinical challenges.

Learning Objective 1
Describe at least four of the clinically important topics that provide a context for SUD care delivery that are not covered in the systematic review or by the evidence-based recommendations 

Learning Objective 2
Identify at least one clinical decision about psychosocial treatment and one about pharmacotherapy for which the guideline development panel found insufficient evidence to recommend for or against a treatment approach

Learning Objective 3
Explain advantages and challenges of measurement based care for individualizing treatment and promoting improved outcomes

Daniel R. KivlahanPresenter: Daniel R. Kivlahan, PhD

Dr. Kivlahan is currently Associate Professor, Department of Psychiatry and Behavioral Sciences, University of Washington. From 1998-2010, he was Director of the Center of Excellence in Substance Abuse Treatment and Education at VA Puget Sound in Seattle where he was an addiction treatment clinician and investigator from 1985-2010. In 2010, Dr. Kivlahan was appointed as Associate National Mental Health Program Director for Addictive Disorders, Veterans Health Administration (VHA) and he served as Director from 2012 until his retirement from VHA in 2015. He co-chaired the work groups that in 2009 and 2015 revised the VA/DoD Clinical Practice Guideline for SUD and has been active in development and validation of quality indicators based on guideline recommendations. Among his over 150 peer reviewed publications are validation studies on the AUDIT-C to screen for alcohol misuse across care settings, reports on SUD and co-occurring conditions including PTSD, and analyses from several clinical trials including the COMBINE Study for combined pharmacotherapy and psychosocial treatment of alcohol dependence.

Bruce LieseCourse Director: Bruce Liese, PhD

Bruce S. Liese, PhD, ABPP is Professor of Family Medicine and Psychiatry at the University of Kansas Medical Center, Courtesy Professor of Clinical Psychology at the University of Kansas, and current President-Elect of the Society of Addiction Psychology (SoAP; APA Division 50). Dr. Liese earned his PhD from The University at Albany in 1983. He is a teacher, clinical supervisor, researcher, and clinician.  His work focuses primarily on the diagnosis and treatment of addictive behaviors.  He has been Director of CBT training for a large multi-center NIDA-funded addictions study and over time has supervised hundreds of CB therapists.  Presently he teaches courses on addictive behaviors, psychotherapy, and evidence-based practice in psychology and he supervises more than a dozen psychotherapy trainees.  Dr. Liese has more than 50 publications, and he has co-authored two texts on addictions.  He was Editor of The Addictions Newsletter for ten years, an official publication of APA Division 50.  For his work on this newsletter, Dr. Liese received a President’s Citation from Division 50. He has been chosen to be a member of APA’s Continuing Education Committee, and in 2015 he received the Distinguished Career Contributions to Education and Training award from APA Division 50.

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04 Apr 2017

Understanding People With Substance Use Disorders and Addictions

Why do some people use alcohol and other drugs, but never develop a substance use disorder? What “causes” addiction? And why do some people cease problematic substance use whereas others do not? The answers to these complicated questions are explored in this webcast. The focus, on some of the psychological, biological, and environmental factors that have been linked to the development of substance use disorders. The discussion also seeks to understand the challenges of living with addiction and considers the process of recovery and some of the factors that may help facilitate successful resolution of substance misuse.

Learning Objective 1
Discuss what is known from the current research about factors that influence the development of substance use disorders.

Learning Objective 2
Explain some of the common clinical case presentations of individuals struggling with addiction.

Learning Objective 3
Acquire knowledge regarding the factors involved in the resolution of addictive behavior.

Presenter: Jennifer Read, PhD

Dr. Read received her BA at Denison University, and her Ph.D. in Clinical Psychology from the University of Rhode Island. She completed post-doctoral training at Brown University’s Center for Alcohol and Addiction Studies. Dr. Read currently is a Professor of Psychology, and the Director of Clinical Training at the University at Buffalo, State University of New York.  Dr. Read’s research focuses on individual and environmental factors that influence problematic substance use. Much of her research has examined how trauma and post-traumatic stress may intersect with substance use, particularly in young adults. She has published over 100 articles on these topics.

Bruce LieseCourse Director: Bruce Liese, PhD

Bruce S. Liese, PhD, ABPP is Professor of Family Medicine and Psychiatry at the University of Kansas Medical Center, Courtesy Professor of Clinical Psychology at the University of Kansas, and current President-Elect of the Society of Addiction Psychology (SoAP; APA Division 50). Dr. Liese earned his PhD from The University at Albany in 1983. He is a teacher, clinical supervisor, researcher, and clinician.  His work focuses primarily on the diagnosis and treatment of addictive behaviors.  He has been Director of CBT training for a large multi-center NIDA-funded addictions study and over time has supervised hundreds of CB therapists.  Presently he teaches courses on addictive behaviors, psychotherapy, and evidence-based practice in psychology and he supervises more than a dozen psychotherapy trainees.  Dr. Liese has more than 50 publications, and he has co-authored two texts on addictions.  He was Editor of The Addictions Newsletter for ten years, an official publication of APA Division 50.  For his work on this newsletter, Dr. Liese received a President’s Citation from Division 50. He has been chosen to be a member of APA’s Continuing Education Committee, and in 2015 he received the Distinguished Career Contributions to Education and Training award from APA Division 50.

 

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23 Mar 2017

Screening, Brief Intervention, and Referral for Treatment (SBIRT) for Substance Use Disorders and Addictions

Addictions, and in particular substance abuse, represent one of the most important health and mental health problems in our nation. Psychologists frequently encounter addictive behaviors in their practice and consultations. However, most often these behaviors are not the focus of the intake or the encounter with the client. Nevertheless, they complicate treatment and consultations. How can every psychologist responsibly and effectively address substance use without having to become an addiction psychologist? The answer is SBIRT, Screening, Brief Intervention and Referral to Treatment. SBIRT has been used in medical and clinical settings for over 10 years and is recommended practice for many addictive behaviors demonstrating effectiveness in reducing risk and promoting movement through the stages of change. This workshop describes and demonstrates screening and brief intervention strategies that can be used to identify risky involvement with alcohol, marijuana, heroin, cocaine, tobacco, nonprescription medications and gambling behaviors. Most effective referral options is also be explored. The webcast enables psychologists in a variety of settings to address and manage client substance misuse and problems with addictive behaviors more efficiently and effectively.

Learning Objective 1
Identify and use brief screening algorithms for a range of addictive behaviors (alcohol, tobacco, illegal drugs, nonprescription use of prescription medications, and gambling).

Learning Objective 2
Provide feedback about screening data and offer a brief intervention to address positive screens.

Learning Objective 3
Provide advice, negotiate goals, and offer referrals for further assessment and/or treatment.

Carlo C. DiClementePresenter: Carlo C. DiClemente, PhD, ABPP

Dr. DiClemente is a Professor of Psychology at the University of Maryland Baltimore County (UMBC) and directs the MDQUIT Tobacco Resource Center, the Center for Community Collaboration, and the Home Visiting Training Center at UMBC. He is known for his work developing and applying the Transtheoretical Model of Intentional Behavior Change and his contributions to understanding motivation and change. He has published numerous articles and books including Addiction and Change: How Addictions Develop and Addicted People Recover, Changing for Good; and multiple professional books The Transtheoretical Model, Substance Abuse Treatment and the Stages of Change), and Group Treatment for Substance Abuse: A Stages of Change Therapy Manua.

 

Bruce LieseCourse Director: Bruce Liese, PhD

Bruce S. Liese, PhD, ABPP is Professor of Family Medicine and Psychiatry at the University of Kansas Medical Center, Courtesy Professor of Clinical Psychology at the University of Kansas, and current President-Elect of the Society of Addiction Psychology (SoAP; APA Division 50). Dr. Liese earned his PhD from The University at Albany in 1983. He is a teacher, clinical supervisor, researcher, and clinician.  His work focuses primarily on the diagnosis and treatment of addictive behaviors.  He has been Director of CBT training for a large multi-center NIDA-funded addictions study and over time has supervised hundreds of CB therapists.  Presently he teaches courses on addictive behaviors, psychotherapy, and evidence-based practice in psychology and he supervises more than a dozen psychotherapy trainees.  Dr. Liese has more than 50 publications, and he has co-authored two texts on addictions.  He was Editor of The Addictions Newsletter for ten years, an official publication of APA Division 50.  For his work on this newsletter, Dr. Liese received a President’s Citation from Division 50. He has been chosen to be a member of APA’s Continuing Education Committee, and in 2015 he received the Distinguished Career Contributions to Education and Training award from APA Division 50.

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