11 Jul 2017

Let’s Talk Money, monitorLIVE Event Explores Professional and Personal Financial Wellness

Even though mental health practitioners often cover a wide variety of difficult subjects in their work, money can be an especially challenging topic to broach. So much so, that sessions can begin and end without even addressing fees or payment schedules with clients. Financial wellness is tied to mental health, and we need to learn to talk about it, according to clinical psychologist Mary Gresham, PhD, who recently addressed a group of psychologists gathered in Atlanta, Ga., for APA’s second local networking event, monitorLIVE. monitorLIVE events connect psychology professionals and thought leaders so they can learn about and discuss issues that impact and elevate the discipline.

Dr. Gresham noted that mental health practitioners have models of good marriages and good communication to teach to clients, but they may lack good models of financial wellness. Most leave money matters to finance professionals, even though mental health practitioners should be the ones applying therapy to the field, she said. While financial planners may take a class in coaching, they haven’t studied behavior, relationships, or any of the other deeper issues related to financial wellness. This, Dr. Gresham believes, is where psychologists can step in and effectively address those issues.

One way to begin addressing financial wellness with clients is through the use of schema—a cognitive framework that can help in the understanding of the concept. Doing so will allow you to interpret implicit and explicit beliefs about money and how they can impact individuals’ lives.

Dr. Gresham explained that money beliefs begin early, at about age three or four. She provided an example—a child thinking money grows in one’s pocket. Practitioners can address these misnomers in the context of behavioral finance, developed by the work of Daniel Kahneman and the late Amos Tversky, which examines how individuals make errors in their thought process around money, like believing money grows on trees or, in Dr. Gresham’s example, in a pocket. Behavioral finance explores how rational or irrational one can be about money matters, such as choosing to take one dollar today to immediately satisfy your desire for money, or taking $1.10 next year, which is actually a 10 percent increase, but might not feel like it.

Dr. Gresham went on to say that schema development depends on cultural beliefs, like thinking rich people are bad and poor people are good (or vice versa), or believing that if you work hard, money will come to you. These beliefs affect us, but they are simplistic, and we need to develop them to make them more sophisticated. This necessary development can happen through research on the cultural differences having to do with money, like the particular rules and customs about money that exist within the families of first-generation immigrants,such as not paying interest on a loan, and how those rules differ from cultural norms here in the United States, where borrowers might not like it, but interest is acceptable.

Another area in behavioral finance Dr. Gresham discussed with the audience is financial trauma. Even though many people suffer from financial trauma, whether they’ve lost everything in bad investments, or because of a spouse’s spending habits, there is not enough research on how to assist people with those experiences. “How do you help people come back from financial trauma and rebuild their lives? We need that research,” she said.

During her conversation, Dr. Gresham also touched on gender issues around money, such as women having lower financial levels of literacy than men and the lack of encouragement of women to enter the financial planning field.

She also noted that practitioners must examine money issues in their own lives, pointing out the costs associated with getting an education in the field and the need to understand what it means to be a self-employed business person by learning to communicate fees and by researching market rates, insurance rates, and retirement plans. Dr. Gresham suggested APA’s Division 42 and the book, “Handbook of Private Practice: Keys to Success for Mental Health Practitioners.”

Keep an eye out for future monitorLIVE events coming to a city near you.

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06 Jul 2017

Improving Practice Delivery Series

Improving Practice Delivery Series

From the solo practice to the large group practice, whether for profit or not-for-profit, the concepts presented in this series can help strengthen the organization in which services are delivered. *This series is eligible for CE credit. Earn 1 CE credit for each session.

The four 90-minute programs focus on:

How to Create and Implement a Vision for Your Practice

Learn about creating an over-arching vision for your practice and how to use it to guide both clinical and practice/administrative decisions.

Managing Staff and Organizations in Support of Practice Excellence

Learn how to promote excellence in service delivery via employment contracts, policies and procedures, and mentoring to advance staff development.

Expanding the Scope of Your Practice to Address the Needs of the Community

Keep your practice relevant by positioning it to meet the changing needs of the community you serve.

Practice Health Metrics

Keep your practice thriving and growing by tracking your basic metrics (accounts receivables, referral patterns, productivity, etc.), thus assuring the overall health of the practice for the future.

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27 Jun 2017

Work-life Balance Still a Struggle for Most Psychologists

Work-life Balance Still a Struggle for Most Psychologists

When Pamela Hays, PhD, began her psychology career, she tried to do it all: clinical work, writing, research and teaching. But she couldn't sustain it. After a decade of going full tilt, she developed neck problems and carpal tunnel syndrome so severe she had to start using a voice-activated computer system.

"I was driven," she says. "But I drove myself into health problems I couldn't ignore anymore."

Hays, now a clinical psychologist practicing in Soldotna, Alaska, might be an extreme case. Or maybe not. Work-life balance is something that many psychologists struggle with.

The unfortunate irony is that psychologists know better than anyone the importance of making time for self-care. "We talk about it a lot with patients, but we don't practice what we preach," says Chelsi Day, PsyD, a behavioral health provider at Windrose Health Network in Indianapolis.

Psychologists might even have a false sense of invulnerability, says John F. Christensen, PhD, a psychologist in Corbett, Oregon, and past co-chair of the APA Advisory Committee on Colleague Assistance (ACCA). "We study burnout and think that applies to the people we're trying to help," he says. "In fact, health is on a continuum, with well-being at one end and burnout at the other. And most of us, during a professional career, slide back and forth on that continuum depending on what's going on in our lives."

Finding balance, however, is easier said than done. "The sin of the early 21st century is being nonproductive," Christensen says. "We're conditioned by our culture to equate value with productivity."

Of course, as psychologists well know, no one is as productive as they can be when they are exhausted and overworked. Burnout is a legitimate phenomenon, marked by feelings of emotional exhaustion, depersonalization and a diminished sense of accomplishment. "When we move into burnout, we get impatient, we treat others as objects, and we start treating ourselves as task-processing machines," Christensen says. "Our empathy tank has run dry."

For psychologists in clinical practice, neglecting well-being can even impair professional competence, making the matter an ethical concern. As Erica H. Wise, PhD, a psychologist at the University of North Carolina at Chapel Hill and current co-chair of the ACCA, argues in a recent article, it's much harder to stay competent when you're burned out. "Competence … is an essential ethical obligation and provides a critical link between ethics and self-care," Wise and her colleagues conclude (Professional Psychology: Research and Practice, 2012).

Practical balance

Unfortunately, there's no one-size-fits-all strategy for achieving personal-professional equilibrium. Stressors and obligations are different for everyone, and they also change over the course of an individual's life. "It is important for psychologists to stay attuned to these issues throughout their professional life span, since personal and work-related stressors tend to shift over time," Wise says. "Work-life balance isn't a once-and-done thing."

Some people start by establishing a career with some balance built in. Day, a sport psychologist, recently decided not to pursue an opportunity that she described as a dream job — building a counseling and sport psychology center at a Big 10 school. Although the opportunity thrilled her, after she factored in the long commute, the fact that she'd be on call 24 hours a day and her desire for personal and family time, the job didn't sound quite so dreamy. "Work-life balance is important to me," she says. "I don't want to burn out in 10 years."

After working herself into physical health problems, Hays left academia and moved back to her home state of Alaska to start a clinical practice. She joined a yoga class and a book group, started spending more time with family, and wrote the 2014 book "Creating Well-Being: Four Steps to a Happier, Healthier Life."

But finding balance doesn't necessarily mean you have to change jobs (or move to Alaska). You can start by taking a critical look at your commitments.

Wise recommends doing either formal or informal self-care assessments, which can remind you of your goals and help you figure out which daily activities energize you — and which feel like a slog. "From that, you have critical information that you can factor into your choices about your personal and professional activities," she says.

Jim Davies, PhD, a faculty member at Carleton University in Ottawa, says that for him and many of his colleagues, a lot of work commitments are self-imposed. "They are projects we are passionate about and take on whether we have the time to commit to them or not," he says. "We're too busy because we're overcommitted, not because our jobs are too onerous."

Davies uses a rigid strategy to balance personal and professional time. Every morning, he fills in a detailed spreadsheet with activities for each half hour of his waking day. "Crucially, I also schedule in my breaks," he says — including lunch, coffee breaks and even daily naps. "For me, prioritizing life means putting it in the schedule like all the other important things."

Still, for many people, time management isn't really the problem, says Sandra Lewis, PsyD, a clinical psychologist at Montclair State University in New Jersey and founder of The Living Source, a company that helps clients improve well-being and achieve their goals. "People focus a lot on time management, but I think in terms of personal energy management. If you have enough energy, you make better use of your time," Lewis says. "In the same way we charge our cellphones, we need to charge ourselves."

Yet when we're overextended, even activities that energize us can feel like one more item on an endless to-do list. So Wise suggests taking advantage of smaller moments. You might not have an hour to go to the gym, but you could take a 10-minute lunchtime walk. If you can't fit in a yoga class, take five minutes between appointments to breathe or stretch or meditate. "Find self-care strategies that you can integrate in rather than add on," she says. "Honor the smaller things."

While such strategies are helpful, more needs to be done to change the culture of workplaces from the top down, says Christensen. Too many organizations value busyness and productivity at the expense of their employees' well-being, he says. "Often in this kind of professional workplace, when you're working with other smart, committed people, the way to excel is to overwork."

Christensen has been collaborating with health-care systems in Oregon to measure well-being among clinicians, including physicians and psychologists. He's optimistic that many such organizations are starting to realize that helping employees avoid burnout is not only good for employees, but also for patients and the financial bottom line. That kind of sea change is crucial for making work-life balance more attainable, he says. "The things we as individuals can do will take us only so far."

Meanwhile, Wise argues that instead of focusing only on reducing stress, the field of psychology should do more to promote and maintain well-being broadly. "We need a more positive vision," she says. "As a profession, whether we practice or do research, whether we're being mentors or treating patients, we need to be aware that keeping ourselves healthy is important."

Further reading

  • Hays, P. H. (2014). Creating well-being: Four steps to a happier, healthier life. Washington, DC: American Psychological Association.
  • Walsh, R. (2011). Lifestyle and mental health. American Psychologist, 66(7), 579–592. DOI: 10.1037/a0021769
  • Wise, E. H., Hersh, M. A., & Gibson, C. M. (2012). Ethics, self-care and well-being for psychologists: Reenvisioning the stress-distress continuum. Professional Psychology: Research and Practice, 43(5), 487–494. DOI: 10.1037/a0029446

By Kirsten Weir


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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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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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05 Jun 2017

Healing by Design

Nix the glass table and fill the room with light. These and other research-based design insights for therapists' offices can reap client benefits

As clients enter the Portland, Oregon, office of psychologist Thomas Joseph Doherty, PsyD, they are greeted by the majestic sight of Mt. Hood out an east-facing window, a profusion of healthy green plants, comfortable, supportive chairs and nature-based artwork. Diplomas hang in a corner to advertise Doherty's expertise, and his clean, clutter-free desk adds to the feeling of openness and space. "Ideally your office should have a clean, living, generative sense—one that fosters a renewed sense of physical vitality, alertness and creativity for your clients and yourself," says Doherty, whose practice centers on helping his clients develop what he calls "sustainable" habits like rest, exercise, social support and connection with nature—strategies that help maintain health and performance over the long term. 

Doherty's space is a good example of today's direction in health-care design, which uses research on human behavior and design principles to promote positive interactions between therapists and clients.

"A space should be something that supports you as you try to achieve specific goals," explains Sally Augustin, PhD, an applied environmental and design psychologist and founder of Design with Science, an international consulting firm. For therapy offices, that means creating a calm and refreshing environment to balance the rigorous mental and emotional work of therapy, she says.

Well-designed therapy offices also exude softness, personalization and orderliness, finds research by environmental psychologist Ann S. Devlin, PhD, of Connecticut College, and urban planning researcher Jack L. Nasar, PhD, of The Ohio State University. In their research examining people's reactions to 30 photographs of actual therapy offices, the more a space exhibited those characteristics—cozy elements like comfortable chairs and soft pillows, attractive touches like artwork, and neatness—the better people felt about the offices and the therapists who worked there, they found (Professional Psychology: Research and Practice, 2012).

In addition, good therapy office design should take into account the human instinct to protect ourselves and our territory—a feature that may be particularly important to consider with vulnerable therapy clients, Augustin says. "We are animals, after all," she says. "We do our best mental work when we feel a little bit protected."

So, given such insights how should practitioners design an office from scratch or redo a space that's seen better days? Specifically, therapists should:

Keep it light. The color of the office walls sets a tone. Wall colors in light, soothing colors like sage green or dusty blue promote a sense of calm and relaxation, environmental designers say.

Go with the grain. For reasons that aren't entirely clear, people prefer natural-colored wood with a grain rather than nongrain surfaces, research finds. People also feel more comfortable with wood than with slicker options like glass and chrome, Augustin says. 

That said, there's a limit to how much wood you should use: Research shows that when natural wood surfaces like floors and walls exceed 45 percent of a room's surface, they start losing their stress-busting effects.

Let the sun shine in. Natural light is a big mood booster, so when possible, incorporate windows or skylights, says Dawn Gum, director of interior architecture at the national firm EwingCole. If windows are at eye level, the best views look out on calming, natural scenery, not onto bustling sidewalks or roads with distracting sights and sounds.

If your office lacks windows, use floor and table lamps with soft lighting rather than overhead fluorescent lighting to promote a feeling of comfort and coziness, says Gum. Some lightbulbs even simulate natural light, which can boost the positive ambience of windowless offices.

Embrace the natural. Bringing nature into the office—whether with plants, nature embodied in artwork, decorative objects or views of plant-filled courtyards and landscaped areas—can enhance the healing quality of a space. "Just looking at landscaping has been shown to lower blood pressure," Gum says.

The right nature-based artwork can also give clients a way to muse on life situations, these experts add. Images of a pathway through a serene landscape or a bench in the middle of a pleasingly landscaped garden can foster relaxation or allow clients to make mental associations with the imagery. But, Augustin cautions, avoid nature imagery that's confusing, chaotic or complex. "You want to look at a scene that would be comfortable to enter," she says.

Use positive distractions. Fish tanks in medical offices are somewhat cliché, but they may have empirical merit—they're an example of so-called "positive distractions," a phenomenon noted in many research studies (see Resources below). A glance into the tank, or at other inviting sights like art of pastoral landscapes, can provide a respite from talking about weighty issues. "You want views that draw you in and give the part of your brain that has to focus a mini break," Augustin says.

Promote your expertise. Displaying your credentials might seem self-serving, but clients want to see signs of your expertise, research also finds. In a study by Devlin and her students, participants looked briefly at photos of therapy offices with zero, two, four or nine diplomas on the wall. People rated therapists who worked in offices with four and nine credentials most favorably, with little difference between the two (Journal of Environmental Psychology, 2009).

Have your client's back. An evolutionary perspective can help you make intelligent decisions on what is arguably the most important element in your office: the client chair.

To support people's need for control, consider having chairs that can be moved or are large enough to let people shift to one side or the other and adjust the distance between themselves and the therapist. If any of your clients have histories of being physically violent, make sure chairs are heavy enough that they can't be easily picked up and thrown. Likewise, chairs with backs at shoulder height can facilitate a feeling of protection, environmental design researchers add. Other ways to promote a sense of personal safety include placing a plant behind the chair and positioning chairs so clients can see the door.

A related suggestion: Place small tables next to client chairs, which can enhance clients' sense of "territory" by giving them a place to put personal items. Your clients will appreciate that you've attended to their comfort and convenience, says Lynn Bufka, PhD, APA's associate executive director of practice.

Foster communication. If you use tables in your office for individual or family sessions, research shows that round tables support better communication and sense of control than square or rectangular ones, says EwingCole's director of research, environmental psychologist Nicholas Watkins, PhD. Also, the presence of computers is shown to impede communication, particularly when the client perceives that the provider is paying more attention to the computer than to him or her. Screen-sharing strategies—technology that enables you to project information onto a table, for example, or simply facing the screen toward clients—can promote clients' sense of trust and inclusion, Watkins notes.

Go with the flow. Anything that promotes flow and efficiency in your immediate and larger office space is worth addressing, according to research compiled by APA's Practice Organization. Keeping a clean, uncluttered desk and placing the items you need closest to you—computer, phones and appointment book, for instance—can help you keep a clear head and feel in charge of your space.

Experts also recommend walking through the functions of your day to identify areas of inefficiency for yourself, your staff and your clients. Fixes can be small and no cost—moving the location of your assistant's desk, for example—or more extensive, like knocking out a wall to create better traffic flow.

Not too fancy, not too shabby. When selecting furniture and finishes for your office, keep client demographics in mind, adds Gum. In general, people feel most comfortable with a middle range of furnishings—those that aren't overly fancy or expensive, but not cheap or shabby, either.

"If you're putting in very expensive materials but your clientele is not at the upper end of the socioeconomic spectrum, you can alienate people," says Gum. Conversely, old or poorly made furnishings can make it look like you're not doing well—the wrong message to send clients.

Put your client first. Remember that you're designing your office more for your client than for yourself, Gum emphasizes. Including some personal elements can be subliminally comforting to clients, but make sure they don't overpower a sense of neatness and calm, she advises.

On a related note, make sure your furniture addresses the specific needs of your clients, says Bufka. If children are among your clientele, make sure you have age-appropriate toys and chairs that are the right size. Be sure that chairs are comfortable for people of all sizes.

Including art that demonstrates your openness to different cultures can also be a plus, particularly if you serve multicultural clients, finds research by Devlin and colleagues (Professional Psychology: Research and Practice, 2013). When the team compared reactions of white college students and mainly ethnic minority adult community members to photos of a therapist's office, the community group rated the therapist more favorably when the art was more ethnic in flavor than Western. "If all of the artwork clients see ... represents a tradition different than their own, it is possible for them to feel unwelcome," the authors write.

Hire a pro. Finally, consider hiring a professional to help you, preferably a qualified architect or interior designer who specializes in health care (see "Tapping design help" below). He or she can help you map out how you actually work and how you want to work, and craft your space accordingly. They also know what's available in furniture and finishes, and about the changing landscape of health care, including new technologies.

Investing in good office design isn't just about creating an attractive space, it's about investing in your business and professional calling, adds Gum.

"If it's designed right," she says, "your office can help you deliver care in ways that really do promote your clients' well-being."

Interested in the link between psychology and design? Check out the work of APA Div. 34 (Society for Environmental, Population and Conservation Psychology), which among its foci explores behavior and the built environment. Learn more about Div. 34 at www.apadivisions.org/division-34/index.aspx.

Resources

Center for Health Design
The knowledge repository of research and resources on health-care design topics. www.healthdesign.org/search/articles

Transforming the Doctor's Office
Devlin, A.S. Routledge, 2014. Includes a section on therapists' offices.

Tapping design help

When considering an office redo, seek architects or interior designers with experience in health care and medical offices, advises Dawn Gum, director of interior architecture at EwingCole, an integrated architecture, engineering, interior design and planning firm.

  • For architects, seek professionals certified with EDAC, the Evidence-Based Design Accreditation and Certification, the certification for members of the Center for Health Design.
  • For interior designers, find someone certified by the NCIDQ, the National Council for Interior Design Qualification. Look for designers who work in commercial spaces with a health-care focus.

By Tori DeAngelis


This article was originally published in the March 2017 Monitor on Psychology

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05 Jun 2017

What are the Keys to a Good Electronic Records System?

These systems streamline practitioners' paperwork—and are no longer as intimidating or expensive as they once were

Psychologist Diana L. Prescott, PhD, already uses electronic health records in the integrated health-care work she does at Eastern Maine Medical Center. She even created the behavioral health component of the system for the center's pediatric obesity program. Now she wants to make the shift to electronic health records at the private practice she and her husband David L. Prescott, PhD, run in rural Maine.

"In a small practice, there's not a lot of space to store paper records," says Prescott, a member of APA's Committee for the Advancement of Professional Practice. "And it takes time to file those records." Plus, she says, patients expect electronic records, just like they see in medical offices.

But, she says, figuring out how to make the transition has been a time-consuming struggle. Should the practice buy a server—with all the expense and upkeep that entails—or go for a cloud-based product? The cloud offers protection from fires or burglary, but is it secure enough, especially since a breach of confidentiality could be particularly devastating to the reputation of a rural practice? How long would it take the Prescotts and practice manager Ruth Siebert to learn a new system? Answering these and other questions has proven so difficult that Prescott now hopes to make a decision some time during the new year.

Electronic health records are worth the hassle, says Lynn Bufka, PhD, associate executive director of research and policy in APA's Practice Directorate. In addition to offering "less paper, less filing, less cabinet space," she says, electronic records make it possible to access files remotely. It's easier to share records with patients or other providers when you can just click a button to print a copy or save to a flash drive instead of copying page after page of paper records. And thanks to the security measures you can put in place, such as automatic monitoring of who accesses what information and for how long, electronic records may actually be better at safeguarding confidentiality than paper ones, says Stacey Larson, JD, PsyD, a consultant who works with APA on legal and regulatory issues. "You can see if Joe Schmo accessed the record," she says. "You might not know if someone got into the file cabinet."

The federal government is also pushing the use of electronic health records, with the hope that "interoperable" records that can communicate not just within but across practices and health-care systems will reduce redundancies and improve care by ensuring that all providers involved in a patient's care have access to test results and treatment plans. Down the road, says Bufka, referrals from other health-care providers or even payers may even come via electronic records.

Given those advantages, how can you make the process of selecting a system easier? Bufka and others suggest the following steps:

Conduct a needs assessment. Think about the capabilities your practice needs in addition to such basic functions as billing and scheduling, says Bufka. If your office offers testing services, for example, determine whether the record can store the resulting data. If you'll be storing psychotherapy notes on the system, you'll need "data segmentation," which allows those notes to stay hidden when a record is shared. Also consider who will be using the system. If your practice includes a psychiatrist or another professional who can prescribe, you'll want a system that includes electronic prescribing. You might find other features—an internal email system or a web portal for patients, perhaps—attractive.

Set a budget. Many solo or small practices worry that electronic health record systems will be prohibitively expensive, says Larson. The high prices many people have heard about came from early adopters, she says. "There weren't as many options back then, so they adopted big, big systems," she says. Others may have invested in new servers to run their systems or opted for systems with all the bells and whistles small practices may not need, such as prescribing portals in practices where no one can prescribe, she says. Systems—especially cloud-based ones—are now much more affordable, she says, adding that she has seen ones that cost as little as $50 a month to use.

When you're looking at prices, make sure you're looking at all the costs involved, not just the initial start-up costs. Other costs may include training and monthly subscription fees either for the practice as a whole or per provider.

Ensure patient privacy. "Be knowledgeable about how data are stored," says Bufka. "There's not necessarily a right or wrong answer when it comes to cloud versus localized storage, but you'll want to know the pros and cons."

Privacy is the main issue Prescott is struggling with as she searches for the right system for her practice. Cloud-based products seem very secure, she says, and the vendors would assume much of the responsibility for complying with the Health Insurance Portability and Accountability Act (HIPAA). (With a server-based system, she explains, responsibility for HIPAA compliance rests on the practice.) "Even though there are a lot of arguments that records are more secure on the cloud, many people are uncomfortable with private information being placed in the cloud," she says. "You read in the paper all the time about things being hacked." While keeping records on a server within the building would probably be best for her, she adds, it's a much more expensive option.

Review your options. If you're already using practice management software, ask the vendor about electronic health record software that's compatible so you can stick with what you're already comfortable with, suggests Larson.

If that's not possible, ask colleagues whose practices have needs that are comparable to yours what system they like, says Prescott. A colleague who touted one brand turned out to like it because of its billing feature—a nonissue for Prescott's practice, which requires patients to pay up front.

You can also view options online through an aggregator site, such as www.capterra.com, which brings together information on hundreds of electronic health record systems, including about 150 systems specifically designed for mental health professionals. "You can type in what you want, and it spits back options," Larson says.

Test the system and the vendor's technical support. Be sure to try out an electronic health record system before you commit, Larson emphasizes. Once you've got your choices narrowed down to two or three, contact each vendor and ask them to walk you through their systems. Many will even let you test demos online. "If your practice isn't tech-savvy, choose a system that's more intuitive and has good customer support," says Bufka. Also ask what kind of support you'll have as you learn the system. And remember that you can always call APA and the APA Practice Organization staff for advice. "It has been super-helpful to talk with different staff members about the research they've done," says Prescott.

Additional resources

www.apapracticecentral.org
Visit APA's Practice Central and search for "electronic health records" to watch a video on using electronic health records.

www.HealthIT.gov
Learn more about contracts for electronic health records at the federal government website.

By Rebecca A. Clay


This article was originally published in the January 2017 Monitor on Psychology

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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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