20 Jun 2017

Stop Wasting Time: Keys to Great Meetings

Stop Wasting Time: Keys to Great Meetings

Whether it's a gathering of health-care providers, faculty, students or a mix, here's how to make your meetings productive

Meetings that start late, last too long and accomplish little can stress attendees far beyond that lost hour, says Steven Rogelberg, PhD, of the University of North Carolina at Charlotte who studies meeting science. Research shows bad meetings can lead to job dissatisfaction, employee fatigue and what he calls "meeting recovery syndrome"—time spent cooling off after a frustrating meeting, which often includes destructive commiseration with colleagues.

"The next thing you know, the weight of the crappy meeting is higher, and it can spill over into other areas of work," he says.

How can everyone make meetings more effective, even enjoyable? The best gatherings happen when meeting leaders view themselves as stewards of everyone else's valuable time, says Rogelberg. Good stewards plan meetings thoughtfully, manage group dynamics, find out in advance why people want to meet and promote other people's contributions rather than their own.

Here is more wisdom from experts for attendees and leaders on how to meet-up better.

Be on time. Arriving late to meetings undermines productivity from the start—and upper management members are often the worst offenders, says Daniel Post Senning, co-author of "The Etiquette Advantage in Business" and great-great-grandson of manners guru Emily Post. "Often, they believe the rules don't apply to them."

Lateness may cause more than irritation: In a paper under review, Rogelberg and Joseph Allen, PhD, found that when a person showed up less than five minutes late for a meeting, productivity didn't suffer. But when an attendee or leader showed up five to 10 minutes late, "satisfaction, effectiveness and productivity of the meeting dropped dramatically," says Allen, an associate professor of industrial-organizational psychology at the University of Nebraska at Omaha.

Wallace Dixon, PhD, psychology department chair at East Tennessee State University, leads by example by starting and ending his monthly faculty meeting precisely on time. "If you don't, you insult the people who got there on time, reward the people who got there late and convey to everyone their time isn't that important," he says.

Be prepared. Arriving "late, frazzled, with nothing but a leaky coffee cup doesn't leave a good impression," Senning says. Bring something to take notes with and a steady attention span. Complete any assigned reading in advance. "Nothing is worse than showing up to the meeting and finding that no one has read the documents that [you sent, and] you then have to explain to everyone what they should have read," says Allen.

Make your phone (mostly) invisible. Despite the leave-the-device-at-the-door practice made popular by President Obama and Amazon, in most settings it is considered OK to bring your smartphone to meetings if you keep your attention on the speaker, says Senning. He recommends telling people in advance if you plan to use your phone to take notes or images of PowerPoint slides. But if people are gravitating to their devices in meetings, it may be a sign that the meeting needs to be more engaging, says Rogelberg. "Devices are signals," he says. "Psychologically, the person is trying to regain control of the time."

Diversify the discussion. No one attendee should monopolize the conversation—and no good facilitator should let anyone do it. Dixon says he will pull faculty aside later if they are talking too much in meetings because it bothers other staff and "they will lose faith in you as a leader if you don't handle it," he says. All attendees can share in that responsibility by making an effort to contribute even if public speaking isn't their forte, says Allen. His research has shown that when people make an effort to participate in a meeting—especially when there is a decision-making component—they are happier with the meeting's result and the meeting is more effective.

Move it along. Dixon places a time limit on each discussion item when he plans his faculty meetings and enforces those limits with his smartphone's timer. Another way to prevent run-on discussions and create a sense of urgency, Rogelberg says, is to switch from hourlong weekly or monthly meetings to shorter, more frequent "huddles": 10- to 15-minute meet-ups designed to save time and boost efficiency. If a leader has a difficult time staying on task, any attendee can help move a meeting forward by tactfully redirecting his or her attention to the agenda, says Allen.

Be constructive. Meetings can unravel when attendees cut one another off, dismiss each other, hold side conversations or argue. Avoid such tension, such as by saying, "I agree with some of what you're saying" instead of a short-tempered, "I just don't agree with you," says Brenda Fellows, PhD, of the Haas School of Business, University of California. Along those lines, Dixon advises the department chairs he mentors never to put a contentious issue to a vote in a meeting because it makes people uncomfortable. "Voting only divides, it never unites," he says. "When you resort to a vote, you have stopped talking."

Additional reading

Participate or Else! The Effect of Participation in Decision-Making in Meetings on Employee Engagement
Yoerger, M., Crowe, J., & Allen, J.A. Consulting Psychology Journal: Practice and Research, 2015

Meeting Design Characteristics and Attendee Perceptions of Staff/Team Meeting Quality
Cohen, M.A., Rogelberg, S.G., Allen, J.A., & Luong, A. Group Dynamics: Theory, Research, and Practice, 2011

"Not Another Meeting!" Are Meeting Time Demands Related to Employee Well-Being?
Rogelberg, S.G., Leach, D.J., Warr, P.B., & Burnfield, J.L. Journal of Applied Psychology, 2006

By Jamie Chamberlin


This article was originally published in the December 2016 Monitor on Psychology

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20 Jun 2017

NIH Toolbox Offers Easier Data Collection

NIH Toolbox Offers Easier Data Collection

The set of measures is useful for both researchers and clinicians alike—and can save money and time over traditional tools

For years, neurobehavioral researchers often couldn't compare data across studies or even within the same longitudinal study because they lacked a "common currency" for collecting data on various aspects of research participants' functioning.

"People used all sorts of different measures and assessments," says Molly V. Wagster, PhD, a psychologist who heads the behavioral and systems neuroscience branch in the National Institute on Aging's neuroscience division. And because there were different tests for different age groups, she says, "people had to resort to all sorts of different measures to follow someone over a period of time." Plus, she adds, researchers looking for quick-and-easy assessments sometimes resorted to tools designed for diagnosing disorders, not assessing function.

Now all that has changed, thanks to the National Institutes of Health's creation of the NIH Toolbox® for Assessment of Neurological and Behavioral Function. Developed by more than 250 scientists, many of them psychologists, the toolbox offers brief measures—some already existing and some created especially for the project—for assessing cognitive, emotional, sensory and motor functioning in research participants ages 3 to 85.

Introduced in 2012 and adapted for the iPad in 2015, the NIH Toolbox offers researchers a comprehensive set of tools for collecting data that can be compared across existing and future studies, says Wagster, the lead federal project officer for the toolbox.

The NIH Toolbox saves researchers time, says psychologist Richard C. Gershon, PhD, the NIH Toolbox's principal investigator and a professor at Northwestern University's Feinberg School of Medicine. "You can administer the equivalent of a one- or two-day neuropsych battery in two hours," says Gershon. The complete cognition battery can be administered in about 30 minutes.

The toolbox can also save money, says Gershon. Take the test used to assess people's sense of balance, which could be used to gauge older people's risk of falling. "Our test arguably replaces between $10,000 and $100,000 worth of equipment with a $160 iPad," he says.

Clinical psychologists could find the NIH Toolbox useful, too, says Abigail B. Sivan, PhD, an associate professor of clinical psychiatry and behavioral sciences at Northwestern, who helped develop it. In the future, a clinical psychologist might use the toolbox's assessments to help distinguish between attention-deficit/hyperactivity disorder and anxiety, for example, or between Alzheimer's disease and normal age-related changes in memory, she says. Clinicians could also use the NIH Toolbox to track patients' progress over time, she says.

Available as an app at iTunes, the NIH Toolbox can be downloaded on up to 10 iPads for an annual subscription fee of $500. Users can try it out for free for 60 days.

For more information, visit www.nihtoolbox.org.

By Rebecca  A. Clay


This article was originally published in the December 2016 Monitor on Psychology

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19 Jun 2017

Managing Staff and Organizations in Support of Practice Excellence

Whether you have one part-time clinical or administrative staff member, or you are an owner of a large inter-disciplinary group, you are an employer. Having employees (or independent contractors) adds complexity and responsibility. This webinar focuses on addressing these demands to promote excellence in service delivery via employment contracts, policies and procedures, and mentoring to promote staff development. During this presentation you will learn the following:

• Your practice as an employer
• Are you a "family"? - The importance of contracts, policies and procedures
• Integrating your vision into management decisions
• Hiring staff (challenges, 1099 or W-2, compensation and benefits)
• Ethical and regulatory compliance (HIPAA, 1099, interviewing, sexual harassment, etc.)
• Mentorship and staff development (administrative and clinical)

Learning Objectives 1
List the advantages of having contracts as well as policies and procedures as part of the administrative structure of their practice.

Learning Objective 2
Describe the intersection of running a practice with professional ethics and regulatory obligations.

Learning Objective 3
Discuss the importance of effectively mentoring staff and promoting staff development.

*This program does not offer CE credit.

ZimmermanPresenter
Dr. Jeff Zimmerman has been in independent practice for over 35 years in solo practice and as founding and managing partner of an inter-disciplinary multi-site group. Dr. Zimmerman is a founding partner of The Practice Institute, LLC. He is President of the Society for the Advancement of Psychotherapy, Division 29. Dr. Zimmerman is co-author of The Ethics of Private Practice: A Guide for Mental Health Clinicians. He is co-editor of a soon to be released book entitled the Handbook of Private Practice: Keys to Success for Mental Health Practitioners and is Editor of Practice Innovations, the journal of Division 42.

 

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07 Jun 2017

How to Create and Implement a Vision for Your Practice

Creating a vision is essential for the decision-making that follows as you develop your practice. This webinar focuses on how to create such an over-arching vision and how to use it to guide both clinical and practice/administrative decisions. During this presentation you will learn the following:

• why a vision statement is important
• types of vision statements
• tips for creating your vision
• making your vision real - inside and out
• using vision and values to guide clinical/practice decisions.

Learning Objectives 1
List the advantages of having a practice vision.

Learning Objectives 2
Describe the central elements of a vision statement.

Learning Objectives 3
Write their own practice vision.

*This program does not offer CE credit.

ZimmermanPresenter
Dr. Jeff Zimmerman has been in independent practice for over 35 years in solo practice and as founding and managing partner of an inter-disciplinary multi-site group. Dr. Zimmerman is a founding partner of The Practice Institute, LLC. He is President of the Society for the Advancement of Psychotherapy, Division 29. Dr. Zimmerman is co-author of The Ethics of Private Practice: A Guide for Mental Health Clinicians. He is co-editor of a soon to be released book entitled the Handbook of Private Practice: Keys to Success for Mental Health Practitioners and is Editor of Practice Innovations, the journal of Division 42.

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05 Jun 2017

Research-Based Strategies for Better Balance

Research-Based Strategies for Better Balance

1. Practice mindfulness. Numerous studies have demonstrated that mindfulness has benefits for body and mind, reducing stress and depression and even boosting immune function. It can also be instrumental in maintaining work-life balance. In a study of working parents, psychologist Tammy D. Allen, PhD, found people with greater mindfulness reported better work-family balance, better sleep quality and greater vitality (Journal of Vocational Behavior, 2012). "Cultivating a habit of self-awareness is vital," says John Christensen, PhD, past co-chair of the APA Advisory Committee on Colleague Assistance. "One of the best things we can do is to develop a reflective habit of checking in with ourselves at least a couple times a day, taking note of the emotional ‘weather' without judgment."

2. Look for silver linings. H. Shellae Versey, PhD, a psychologist at Wesleyan University, found that when working adults looked for benefit in negative situations, they experienced fewer negative psychological effects from work-family conflict. The finding was especially strong for women. During stressful periods, for instance, it can help to think of work-family conflict as a temporary strain, and to focus on the payoffs, such as higher salaries and better opportunities. But lowering expectations and downgrading one's goals did not have that protective effect, she found (Developmental Psychology, 2015). The difference, she believes, is that positive reappraisal is a way of taking control, while downgrading goals can feel like giving up. "Lowering aspirations without having another goal or Plan B in mind could be detrimental," she says.

3. Draw from positive psychology. The principles of positive psychology can aid in psychologists' self-care, as Erica Wise, PhD, and colleagues described in an article on psychologist well-being (Professional Psychology: Research and Practice, 2012). Positive emotions can broaden cognitive, attentional and behavioral repertoires, she explains, which boosts resilience and facilitates well-being. One evidence-based way to boost positive emotions is to practice expressing gratitude on a regular basis.

4. Take advantage of social support. Seeking support from other people is critical to well-being. Geertje van Daalen, PhD, at Tilburg University in the Netherlands, and colleagues found that social support from spouses and colleagues can be especially important for reducing conflict from family obligations spilling over into the workday (Journal of Vocational Behavior, 2006). Connecting with professional colleagues can be especially important for psychologists, Christensen adds. "Many psychologists work in their own silos and have little contact with professional peers," he says. "That isolation can be a risk factor for burnout."

5. Seek out good supervisors. Unsurprisingly, sympathetic bosses can also be helpful — something to keep in mind if you're on the hunt for a new job. David Almeida, PhD, at Penn State University, and colleagues found people had more negative emotions and greater stress on days when work obligations interfered with family responsibilities. But those negative effects were buffered by supportive supervisors (Journal of Marriage and Family, 2016).

6. Get moving. A robust body of research has shown that exercise can boost mood in the short term, and in the long term can improve symptoms of depression, anxiety, addictive disorders and cognitive decline.

7. Go outside. Spending time in nature has been linked to improved cognition, attention, mood and subjective well-being. It also appears to reduce symptoms of stress and depression, as Roger Walsh, PhD, a psychologist at the University of California, Irvine, described in a review of lifestyle changes and mental health (American Psychologist, 2011).

8. Make your life meaningful. In his American Psychologist article, Walsh also described the benefits of seeking meaning — whether through religion, spirituality or volunteer service. "We do our best work and live our best lives when we have a sense of meaning — a feeling that what we do extends beyond us and brings good to others," says clinical psychologist Sandra Lewis, PsyD.


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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

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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01 Jun 2017

5 Ways to Avoid Malpractice

5 Ways to Avoid Malpractice

Experts share the most common pitfalls that make practitioners vulnerable to malpractice claims and licensing board complaints — and how to avoid them.

Throughout their careers, psychologists are faced with myriad ethical questions or challenges, potential complaints to licensing and regulatory authorities, and possibly even threats of legal action. According to estimates by The Trust, which provides professional liability insurance and financial security products for psychologists, over a 20-year career, 40 percent of psychologists will receive a licensing board complaint. Significantly fewer, just under 2 percent, will have a malpractice lawsuit filed against them.

But even a letter of reprimand, the lowest form of disciplinary action from a licensing board, can have serious emotional and financial consequences for a practitioner, says Jana N. Martin, PhD, CEO of The Trust.

"The impact of a licensing board complaint can often be pretty severe in terms of continuing to practice because if you're found guilty or in violation, your license can be suspended or revoked," Martin says. "While it's not likely that a successful malpractice suit will have a direct impact on a psychologist's license, it can sometimes have indirect consequences on licensure."

Martin notes that the top reason for disciplinary sanctions from licensing boards — as well as malpractice complaints — is sexual misconduct and other boundary crossing or multiple relationship violations. Other common reasons for discipline include participating in child custody disputes (particularly when it's outside one's area of expertise), breaches of confidentiality, and patient suicide or attempted suicide.

"We're taught in grad school that the No. 1 malpractice offense is inappropriate sexual relationships with clients, and I think many of us have an image in our head about what kind of psychologist would engage in that — and that it's not us," says APA Practice Director of Research and Special Projects Vaile Wright, PhD. "But the reality is that we're all human, so it's important for early career psychologists to make sure they're familiar with these ethical issues and what the Ethics Code has to say about them."

What do you need to know? We've asked several of psychology's leading ethics experts to share their advice on how practitioners can avoid the misunderstandings, hurt feelings and sticky situations that lead to hearings before ethics boards, lawsuits, loss of license or professional membership, or even more dire consequences.

1. Understand what constitutes a multiple relationship

Engaging in a sexual relationship with a client is the multiple relationship most of us think of, but this category is broader than that. It refers to having more than a therapeutic relationship with a client or trainee, "such as hiring your patient to be your gardener or seeing your gardener as a patient," Martin says. This often becomes most problematic in rural settings, but it's an area where a psychologist needs to be cautious and realize that he or she is increasing the probability of a board complaint if he or she engages in these relationships, she adds.

Martin also says The Trust has started seeing more boundary violations related to the use of technology — particularly social media.

"If a psychologist has a Facebook page, the decision about whether or not to allow a client to friend you on Facebook can lead to a multiple relationship and a loss of objectivity on both sides, and confidentiality can also be compromised in that kind of relationship," Martin says. It's important to discuss social media and let clients know the risks of interactions in that space in your informed consent (see Step 2).

2. Set clear guidelines up front

During your first session with a client or patient, establish distinct boundaries as to what services you will provide, and what you can't or won't do, says Stacey Larson, PsyD, JD, APA's director of legal and regulatory affairs.

"A lot of what we see are difficulties with not using a really good informed consent," she says. "It happens with both new and experienced psychologists, particularly those working with children whose parents are divorced or divorcing. They are hired as the child's therapist but then they get drawn into advocating for one parent or the other in a custody dispute, and that's outside the purview of what they do."

Having a comprehensive informed consent is also important when using technology with clients, particularly when it comes to how clinicians deal with emails and texts from clients, Larson says. She encourages psychologists to familiarize themselves with the APA Practice Organization's "Guidelines for the Practice of Telepsychology," and also points to effective informed consent and social media policies by San Francisco-based clinical psychologist Keely Kolmes, PsyD.

Martin agrees, noting that texting with a client — especially if your phone is not encrypted or you are not 100 percent positive the person you're texting is indeed your client — can make a practitioner vulnerable to confidentiality violations.

3. Practice self-care

Psychologists, of course, have much more going on in their lives than their careers. Spouses, friends, children, parents and illness can stress even the most balanced psychologist. The stressors can be particularly acute among early career psychologists who may be experiencing the stresses and excitement of getting married, buying a first home and starting a family, Wright says. The convergence of these stressful personal and professional experiences can often lead to burnout, and perhaps poor judgment.

"All of these new stressors can affect the work that you do, so it's really important for psychologists to think about the importance of self-care, and have strong knowledge of their own limits," she says. That means being able to recognize the warning signs — such as headaches, an upset stomach, a lack of concentration, irritability or anxiety, particularly during sessions with clients or interactions with coworkers or supervisees, which can indicate your personal problems might be seeping into your work. It's at these times that practitioners might be more likely to fall prey to ethical violations, such as inaccurate or careless charting and billing, inappropriate or excessive self-disclosure with a client, or confidentiality breaches, such as leaving client documentation in a public place, Wright says.

4. Make sure you're covered

Too often, business-of-practice issues such as professional liability and how to protect yourself aren't discussed during in doctoral training, Wright says.

"Because of that, I think malpractice insurance isn't always on people's radar," she says. "I know when I was working at the hospital before coming to APA and someone would ask me about malpractice insurance, I would say, ‘Oh, I'm covered by my organization.' But I'm not sure I actually knew what that meant."

She recommends that psychologists who are employed by others understand exactly what their employers' coverage includes, and determine whether there are gaps in that coverage that they might need to fill with their own malpractice insurance policy.

For example, you want to know what your liability limits are, what happens if the legal costs exceed your employer's limits, and if these limits are shared with other defendants. You should also consider that your employer's insurance may need to act in the best interest of the employer, instead of yours. These factors could increase your own personal financial liability if something happens, Wright says. Other questions to ask include whether you are covered for off-duty work, such as volunteering in a professional capacity, and whether your employer's malpractice policy provides license coverage, in the event that a client or colleague files a complaint with the state licensing board against you.

"That's not a lawsuit per se but your license has been questioned and you will likely still need to consult with a lawyer," she says.

When in private practice, it's also important to think about the kind of coverage you need given the work you do and your finances, and then shop around, Wright says. Cheaper is not always better, she says, and she encourages psychologists to factor in policyholder benefits, such as the availability of consultation services, she adds, noting that The Trust's Advocate 800 Consultation Service provides free confidential ethical and risk management consultation from licensed psychologists.

Psychologists who work with high-risk populations such as patients with personality disorders, severe mental illness or who are suicidal may want to increase their coverage, Martin says.

"There are many things that can go wrong very quickly with these patients, leaving psychologists who work with them more vulnerable to board complaints and malpractice claims," she says.

5. Stay connected

Given how often changes occur at the state and federal levels when it comes to laws and licensing board issues, it's critical for psychologists to stay informed, Wright says.

Belonging to professional groups — such as APA's Practice Organization and your state psychological association — that keep members up to date on changes that affect practice is a great way for practitioners to stay informed, she says.

Doing so can also lower your malpractice risk. A 2012 study found that the likelihood of being disciplined by a state board of psychology was lower for psychologists who belonged to their state psychological association (see Resources at bottom). What's more, many state associations also offer a mentorship program where early career psychologists can get one-on-one guidance on malpractice and other business of practice issues from a seasoned practitioner.

Larson also recommends contacting your state's licensing board with questions about state-specific policies, such as those about recordkeeping, confidentiality, general licensure requirements, renewals and continuing education. While APA provides guidance on many of these issues, each state has its own requirements governing how psychologists should practice lawfully and ethically.

"The licensing board seems a little scary at first, but they are the experts on the state law. So if you have a question about what the law asks you to do, they can be a really good resource," she says.

The APAPO, a companion organization to APA, advocates on behalf of practicing psychologists.

Resources

  • Knapp, S., & VandeCreek, L. (2012). Disciplinary actions by a state board of psychology: Do gender and association membership matter. In G. Neimeyer & J. Taylor (Eds.). Continuing professional development and lifelong learning: Issues, impacts and outcomes (pp. 155–158). Hauppauge, NY: NOVA Science Publishers.
  • Knapp, S., Younggren, J. N., VandeCreek, L., Harris, E., & Martin, J. N. (2013). Assessing and managing risk in psychological practice: An individualized approach (2nd ed.). Rockville, MD: The Trust.
  • Pope, K., & Vasquez, M. (2016). Ethics in psychotherapy and counseling: A practical guide (5th ed.). Hoboken, NJ: Wiley.

By Amy Novotney


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11 May 2017

Should you use an app to help that client?

Should you use an app to help that client?

As the use of mental health and behavioral apps grows, psychologists must weigh their benefits and limitations

Today there are more than 165,000 health-related apps worldwide, helping users track their diet and exercise, monitor their moods and even manage chronic diseases, according to a 2015 report by the IMS Institute for Healthcare Informatics. Nearly 30 percent of these apps are dedicated to mental health. While the apps present new opportunities for psychologists to boost patient support and supplement the therapeutic relationship, their sheer number and variety can make it difficult for psychologists to determine which are the most effective, safest and most useful.

"There's been an explosion of apps, and clinicians don't have time to keep up with all of them," says Stephen Schueller, PhD, a clinical psychologist at Northwestern University's Center for Behavioral Intervention Technologies. "It's not their job and it's impossible for them to do it."

But since one in five Americans uses these apps, staying informed about broad trends in app use is important for psychologists, says David Luxton, PhD, co-author of "A Practitioner's Guide to Telemental Health" (APA, 2016).

"If you're not familiar with these technologies today as a clinician, it's time to start paying attention because our patients are demanding them," he says.

Why use apps?

Many practitioners find that mental health apps are a valuable adjunct to psychotherapy because they allow therapists to maintain a better connection with their patients and improve their ability to track clients' symptoms and moods. Some of the most widely used of these apps include T2 Mood Tracker, developed by the National Center for Telehealth and Technology (T2), and Optimism Online, a mood charting app that allows clinicians to monitor client entries and receive alerts to help catch problems as they arise.

San Francisco-based clinical psychologist Keely Kolmes, PsyD, says that many of her clients prefer apps to the paper-based tools that she's used in her practice for years, for recording thoughts and tracking moods.

"Apps help prompt my clients to log things like their mood or whether they exercised or drank alcohol or slept well, so that I can have an accurate picture of their week, as opposed to them trying to reconstruct things on paper the day before therapy or during therapy, which is much less reliable," she says.

Apps are also available to patients 24 hours a day, seven days a week, and can be a great source of educational information, particularly at times when a client's clinician is unavailable. These include several apps by T2, such as PTSD Coach and CPT Coach, as well as Day to Day, which delivers a daily stream of advice, support and other information throughout the day to boost a user's mood. Day to Day is one of 14 apps included in IntelliCare, a suite of apps developed by Northwestern University's Center for Behavioral Intervention Technologies that target depression and anxiety arising from various causes.

While more research is needed, several studies indicate that the use of health apps can also improve patient outcomes and satisfaction. A 2015 meta-analysis led by Harvard Medical School psychiatrist John Torous, MD, for example, looked at 10 studies examining the use of apps in the treatment of mood disorders. The analysis found that patients who used these apps reported improved depressive symptoms (Internet Interventions, 2015). And a 2013 study led by University of New South Wales psychologist Tara Donker, PhD, found that participants who used apps reported the apps were a useful way to get self-help for mental health concerns and disorders (Journal of Medical Internet Research, 2013).

Apps can also help clinicians gather data about their practice, says APA's director of legal and regulatory affairs, Stacey Larson, PsyD, JD. For example, several apps provide HIPAA-compliant note-taking (such as Insight Notes and Mobile Therapy) and can generate graphs or tables showing client improvement as well as areas that still needed to be worked on. "A provider can use them to help determine which interventions are working best and which should be changed, and this information can be shown individually or charted for a practitioner's whole practice, to determine how interventions are working more broadly across their patient population," Larson says.

Potential limitations

Despite their popularity, behavioral health apps are not regulated and many are not research-based, says Marlene Maheu, PhD, executive director of the Telemental Health Institute in San Diego.

"We're scientists—we need to have evidence that something works before we use it with our clients," she says.

Schueller agrees, and encourages clinicians to look for apps that come with documentation of the evidence on which they are based, including research on the intervention underlying the app, such as cognitive-behavioral therapy, as well as research specifically associated with the app itself.

"The most reputable apps are generally those affiliated with academic research institutions or government funding agencies, as they are the most likely to detail the app development and validation process," he says. (See list below.)

Patient privacy and security concerns also need to be addressed any time technology is used in clinical practice. Some apps, for example, allow communication between therapists and patients between sessions—a feature some therapists might want and others might not—and it's crucial that this communication be HIPAA compliant, Maheu says. It's also important for providers to understand what, if any, data are being collected when a patient uses an app, and to make sure patients are informed about this, Larson says.

"Mobile mental health apps can be either passive or active," she explains. "Active apps require direct participation from the patient—such as completing mood logs, self-symptom ratings or recording personal experiences, but passive apps are able to access information independently and gather data through smartphone functions such as GPS without the patient or provider even noticing. Though it may be beneficial, some people may not like the potential invasion of privacy associated with this type of data gathering." And Schueller advises clinicians to show patients how to put a screen lock or password on their phones for additional security.

Integrating apps into your practice

With all of these limitations in mind, how can practitioners ensure the best use of apps in practice? Schueller recommends asking colleagues how they may use apps in therapy, and posting questions on listservs to find out what others have found works best. Several organizations provide resources and reviews of mobile health apps, to help clinicians stay abreast of the most effective and safest technologies. (See list below.) APA and the Center for Technology in Behavioral Science also hosted a webinar in May exploring the role of apps in clinical practice. The organizations received an overwhelming response to the one-hour event, with more than 1,700 clinicians registering for the event, says Maheu, CTiBS president and CEO. Two more webinars are being scheduled for the fall. It's also imperative that psychologists take time to test an app themselves before endorsing it with their clients, Luxton says.

"Install it and try out every single possible scenario inside that app so that you know it very well," he says. And always get feedback from patients on how an app is working for them, Schueller says. "As you start to learn more about which apps are really resonating with the population of clients you're working with, it will help get your practice more in line with what your clients want."

And most important, he adds, clinicians must be mindful of how apps fit into the goals of therapy. "Apps are not a panacea," Schueller says. "There's a lot of enthusiasm here and some of it is warranted. But be cautious; they will not completely fix everything."

APA does not endorse any of the apps mentioned in this article.

Mobile health app resources

By Amy Novotney


This article was originally published in the November 2016 Monitor on Psychology

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21 Apr 2017

A Growing Wave of Online Therapy

A Growing Wave of Online Therapy

The flexible nature of these services benefit clients and providers, but the onus is on psychologists to make sure they comply with federal and state laws

It was an ad on Facebook that first prompted Los Alamitos, California, clinical psychologist Nina Barlevy, PsyD, to visit the online therapy website BetterHelp.com. The company promoted affordable online counseling, available anytime and anywhere, and Barlevy thought joining their panel of therapists might be a great way to supplement her income during slow times in her private practice.

"It looked like a good way to expand my practice here and there in my free time, if I was already going to be on my computer in the evenings or on my days off anyway," Barlevy says.

She went through Better Help's rigorous application process, which included verifying that she was licensed, and began communicating with users in her state via the site's secure messaging platform. The site also offers members the option to schedule live video and phone sessions with their therapists, though Barlevy worked mainly with clients via the site's unlimited asynchronous messaging service. They messaged her about many of the same issues her face-to-face therapy clients were dealing with, including stress, anxiety and relationship issues, among other concerns, and she messaged them back with questions, feedback, insights and guidance. They benefited from easier access to therapy, which particularly helps people in rural areas who may not be able to drive an hour each way to see a therapist face-to-face.

"[It is] a whole lot more appealing to be able to sit at your computer and type back and forth with someone," Barlevy says.

Telepsychology, be it by phone, webcam, email or text message, has been around in one form or another for more than 20 years, used most often by members of the military. But the explosion of smartphone users has created new opportunities for app-based companies to offer more accessible and affordable therapy.

Still, such online therapy creates concerns over patient privacy, as well as legal and ethical issues, including interjurisdictional practice issues, for providers who contract to work for these companies, which may not share the same code of conduct and commitment to do no harm, says Deborah Baker, JD, director of legal and regulatory policy in APA's Practice Directorate. Many of these online therapy companies also are not run by psychologists.

"When you're an individual provider, you can't assume that a business is going to be looking out for your best interest, so you really have to dig a little deeper and check in with your professional association and malpractice carrier to make sure you're complying with the law and with the APA Ethics Code."

Benefits for patients and therapists

The growth in online therapy companies—nearly a dozen have launched in the last several years—doesn't surprise Lindsay Henderson, PsyD, assistant director of psychological services at Boston-based telehealth company American Well, which offers therapy through video conferencing. The ease and convenience of scheduling a therapy appointment online and talking with a therapist from the privacy of one's own home—or wherever one may be—is a huge draw for consumers, many of whom are seeking therapy for the first time in their lives, she says.

American Well's online platform helps "normalize mental health care, especially among generations now who are so accustomed to interacting with people using technology," Henderson adds. "It just eliminates so many barriers."

Research studies, many of which are listed in bibliography format by the Telemental Health Institute, also indicate that telemental health is equivalent to face-to-face care in various settings and an acceptable alternative. While much of the research tests only the use of videoconferencing as the telehealth modality, a few studies, including two published in 2013, have also shown that asynchronous messaging therapy can be as effective as in-person therapy (Journal of Affective Disorders and Cyberpsychology, Behavior and Networking).

Even more encouraging is that when digital interventions are positive, effective experiences for patients, they may go on to seek face-to-face therapy, says Megan Jones, PsyD, adjunct clinical assistant professor of psychiatry and behavioral sciences at Stanford University School of Medicine. A study she led found that college students who needed a higher level of care for eating disorders were more likely to seek it out after participating in a digital body-image program and working with a coach online via asynchronous messaging through the online therapy company Lantern (Journal of American College Health, 2014).

"It can really be a nice first step in treatment for someone who needs more intensive therapy," says Jones, who also serves as chief science officer at Lantern.

Mental health professionals can also reap benefits from joining online care teams. In addition to supplementing practitioners' incomes with new patients, providing online therapy can help them maintain a better work-life balance, Henderson says.

"From the provider perspective, the flexibility of practicing telemental health fits so well into my life and allows me to better meet my patients' needs," she says. "I'm not at a point in my life where I want to be going to an office at 8:30 in the evening, but I will happily go to my home office, lock the door and see a patient at that time."

Employment at online therapy companies isn't limited to providing therapy to clients, either. Opportunities abound and will continue to grow in supervisory and training roles as well as full-time research positions at these mental health technology companies, Jones says.

But tread carefully

Of course, online care is not for every patient or practitioner. Clients with more serious mental illnesses or addictions likely need more treatment than digital therapy can provide. And some clinicians may find certain telehealth modalities difficult, says Barlevy.

"I'm such a people person, so it was tough for me to feel a real connection when I was just messaging with people," she says. "Plus a lot of people just stopped responding, and I felt like there wasn't enough time to really build a relationship. It actually turned out to be more difficult than I imagined."

In addition, some online therapy companies don't have clear guidelines for handling risky situations, such as a patient who may seem suicidal in his or her messaging responses, says Lynn Bufka, PhD, associate executive director for practice research and policy at APA.

While some apps do report that they use a member's IP address to determine their exact location and send police if a therapist is concerned about a member's safety, it's often more difficult to determine a patient's level of risk via a messaging app than face-to-face with them in a therapy room.

"If you're using an online therapy platform and you ask someone if they're suicidal and they say no, is that it?" Bufka says. "Those kinds of clinical issues come up, which is why I think most psychologists seem to feel much more comfortable integrating technology into an ongoing face-to-face or video/teleconferencing relationship versus using only messaging."

Practitioners also need to do their due diligence when it comes to making sure their decision to contract with an online therapy company doesn't run afoul of complying with the Health Insurance Portability and Accountibility Act (HIPAA), state licensing laws and other legal and ethical practices, Baker says. In addition, platforms that allow patients to connect anonymously with therapists may create legal and ethical issues for psychologists.

"My concern is that some of these models are probably start-ups that are launched by people in technology, who have good intentions but haven't fully investigated all the nuances in what's involved in providing health services," she says. "Do they fully understand HIPAA/HITECH, any related state laws and patient confidentiality policies? Do they fully understand that psychologists cannot simply provide services to patients anywhere in the United States?"

Psychologists interested in joining these companies should investigate those issues, and also find out exactly where patients are located if they are providing them therapy services to ensure that they are authorized to do so. Such issues were part of the reason Columbia, South Carolina, clinical psychologist Shawna Kirby, PhD, decided to part ways with an online therapy company she worked for in 2015. After several months as a contracted therapist, she terminated the agreement, due to a series of ethical concerns she had over how the company dealt with interjurisdictional practice issues, consumer privacy, informed consent and therapy termination. When she brought her concerns to the company's clinical director and owners, none of whom are psychologists, she says they brushed off her concerns, and then eventually blocked her from messaging with her clients. "It all seemed more financially driven, rather than care driven," she says.

That's why it's so important that psychologists play a leadership role at mental health technology companies, Jones says.

"These companies need our knowledge and competency at the heart of their decision-making process because we have a very different framework and we understand the responsibilities that we have to users in a very different way than you do if you come from a technology background," she says. "I want to have a peer at any company like ours."

By Amy Novotney


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