27 Jun 2017

Coaching Adults, Students and Young Kids with ADHD

Coaching helps clients cope with attention-deficit/hyperactivity disorder while helping psychologists flourish without relying on insurers

Children, adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) don't necessarily need psychotherapy, says psychologist Abigail Levrini, PhD. What they often do need is help getting themselves organized and reaching their goals—coaching, in short.

To fill that niche, Levrini founded an ADHD coaching business called Psych Ed Connections in 2008. Demand for her services has been so great that the company now has three offices in two states. And what's good for consumers with ADHD has also been good for Levrini by allowing her to fulfill her dream of building a practice independent of insurance companies.

"I had heard many unfortunate horror stories about psychologists not getting reimbursed for the clients they had seen and worked with," says Levrini. "Fortunately, I have never had to go that route and have been able to make it without it."

Whether ADHD coaching is a full-time business or just a small supplemental income stream, it's a real growth area, says Frances Prevatt, PhD, the Florida State University psychology professor who developed the evidence-based ADHD coaching intervention that forms the basis of former student Levrini's coaching practice. "More and more people are being diagnosed," says Prevatt. "And there aren't that many people who specialize in treating those with ADHD."

A specialized business

Prevatt developed the coaching intervention 14 years ago when she realized she had no place to send students she was diagnosing with ADHD as director of Florida State's Adult Learning and Evaluation Center. "Other than recommending medication and accommodations, we didn't really have anything good to offer them," says Prevatt.

Grounded in cognitive-­behavioral therapy principles, the intervention she developed is an eight-week program that matches clients with doctoral psychology students who serve as coaches as a practicum experience. Working one-on-one, the coaches and their clients identify two or three goals to tackle, such as improving time-­management strategies, managing long-term projects, passing a specific class or even learning to do laundry. Each week, the pair identifies intermediate steps and brainstorms how to overcome obstacles, with rewards and consequences built in to boost motivation. "We're not telling them what to do," says Prevatt. "We're teaching them the problem-solving process."

Levrini was one of Prevatt's coaches at Florida State and studied the intervention for her dissertation. Once she graduated and launched her own practice, she took that model, tweaked it and established it in Ponte Vedra, Florida; Alexandria, Virginia; and Ashburn, Virginia. One key difference is that the coaches are all licensed psychologists and other mental health professionals. Because the Florida office is located in an underserved area, it offers services beyond coaching, but coaching represents at least half its business.

Educating children and adults about the difference between coaching and therapy is a crucial first step, says Levrini, who often compares being an ADHD coach to being an athletic coach for kids. "You'd never expect to be able to just put on a uniform and go out onto a sports field and play effectively on your own, so why should people with ADHD expect that they should just be able to figure out ways to stay organized or manage their lives effectively without help?" she says. "A coach can help you learn the rules of the game, see where your strengths and weaknesses are and help you 'play' more effectively, in sports or in life."

Coaches and clients then meet each week to outline "baby step" actions and track progress on two to four overall goals. These goals must be specific, measurable, action-driven, realistic and time-sensitive, says Levrini. They should also focus on the process of achieving them as well as the outcomes, she adds. "A student with ADHD might procrastinate, stay up until 3 in the morning to work on a project and still get a good grade," she points out. "But doing so generates a lot of stress and anxiety in the process, so it's important not to encourage positive outcomes that are not a result of healthy processes." As in the Florida State program, Levrini's coaches also use external rewards and consequences to help clients who need an extra dose of motivation.

Another twist on the original program is that coaches and clients don't necessarily meet face to face, thanks to Psych Ed Connections's online coaching option. That expands the potential client base to include the entire country or even the whole world, says Levrini.

A helpful sideline

For psychologist Peter C. Thomas, PhD, of Atlanta, a small ADHD coaching sideline represents a way to help his clients while bringing in a little extra income.

In his practice, Thomas focuses on evaluating children for ADHD and learning disabilities and providing psychotherapy to children, adolescents and families. About 20 years ago, he realized his clients needed something more: ADHD coaching.

What people with ADHD need most is help structuring their time, says Thomas. "Having someone to check in with helps them stay focused on what they want to accomplish," he says, adding that his clients tend to be disorganized college students and adults. "Coaching can help them learn to develop the habits that they're having trouble developing on their own."

To get the training he needed to launch his coaching business, Thomas attended a three-day workshop conducted by child psychiatrist and ADHD expert Edward Hallowell, MD, EdD, founder of the Hallowell Centers, which offer ADHD treatment in Boston MetroWest, New York, San Francisco and Seattle. Conducted by Hallowell and other coaches, the workshop focused on the intervention as well as the business aspects of coaching.

As a result of that training, Thomas developed a simple coaching intervention he dubbed FOCUS (From Organized Coaching Ultimate Success). The process begins with coaches interviewing new clients—who come to the service via referrals from other psychologists, psychiatrists, word of mouth and Thomas's own practice—about their problems and goals.

Clients then call their coaches each morning during the work week to discuss the three main goals they want to accomplish that day. Together clients and their coaches discuss how to accomplish those goals and make a plan. The process takes from five to 10 minutes. Clients renew their contracts and prepay with credit cards every two weeks as long as they need, which may be several months or even years. As clients internalize these problem-­solving skills, the calls taper off. To help keep the service affordable, Thomas doesn't provide coaching himself. Instead, he trains psychology graduate students to offer coaching services and monitors their work on an ongoing basis. He then splits the proceeds from the coaching with his coaches.

"It's not a big money maker, but it's slow and steady," says Thomas, who estimates that ADHD coaching represents 1 percent of his income. "It brings a little extra into the revenue stream."

Additional reading

ADHD Coaching: A Guide for Mental Health Professionals
Prevatt, F., & Levrini, A. APA, 2015

ADHD Coaching With College Students: Exploring the Processes Involved in Motivation and Goal Completion
Prevatt, F., et al. Journal of College Student Psychotherapy, 2017

By Rebecca A. Clay


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

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20 Jun 2017

New Licensure Test on the Horizon

New Licensure Test on the Horizon

A new licensure test is on the horizon. What is it and why is it necessary?

The Association of State and Provincial Psychology Boards (ASPPB) announced in March that its board of directors had approved a plan to develop an additional licensure exam that would complement the existing test. The new exam, called the EPPP (Examination of Professional Practice in Psychology) Step 2, would focus on assessing skills, while the existing EPPP would continue to test knowledge.

The announcement about the EPPP-2, which may become a requirement as early as January 2019, is evoking mixed responses in the psychology community.  

"I can definitely support the idea that there is a need to test skills because there are inconsistencies in training, but I'm worried that it will be expensive and yet another hoop that students are going to have to deal with," says Christine Jehu, PhD, chair of the American Psychological Association of Graduate Students (APAGS).

For others, the announcement was primarily welcome and perhaps long overdue news. "The competency movement has been going on for 30 years in psychology, and this new test is very consistent with a number of initiatives APA has been involved with," says Catherine Grus, PhD, deputy director of APA's Education Directorate.

In 2004, for example, APA formed a task force that studied then-current practices in competency assessment within psychology and other health professions. Two years later, the group released a report recommending that psychology develop a mechanism to test knowledge, skills and attitudes. The EPPP tests knowledge, but not skills and attitudes, Grus says.

"There are hundreds of different psychology training programs and practicum and internship sites, all with different supervisors and no common standard," says ASPPB CEO Stephen DeMers, EdD. "We have to find a way to keep the process of education credible and the profession relevant."

While APA accreditation holds schools to a certain standard of education, relatively few states have licensing laws that require psychologists to graduate from an accredited school. Even if all states required graduation from an accredited program, the field still needs to develop a method of screening candidates for licensure, DeMers says. "Accreditation evaluates an entire program, but licensure depends on competency of an individual," he says.

A test of skills is also in line with competency testing models used for other medical professionals such as MDs, says Eddy Ameen, PhD, director of APA's Office on Early Career Psychologists. "Proper competency assessment is an important part of what it means to be a psychologist. It ensures that all who treat the public have a minimum universal skill set."  

DeMers hopes that the EPPP Step 2 ultimately will help psychologists increase their clout when lobbying third-party payers for reimbursement coverage and government agencies for federal programs. "I think we lose opportunities in these areas when we are not demonstrating a maintenance of competence," he says. "For that reason, I think this change is exciting and also necessary." 

The path to a new test

The ASPPB initially explored the idea of developing a skill-based exam in the 1990s when it investigated an approach called latent image testing that was touted as a method of evaluating an applicant's decision-making process during a practice scenario. It was a paper-and-pencil version of today's electronic adaptive testing, which tracks the number of correct responses and how efficiently people move through a test. ASPPB abandoned the idea because it was cumbersome and did not seem to adequately assess the complex decision-making involved in psychology treatment scenarios, DeMers says.

ASPPB revisited the concept of competency testing about eight years ago, and in 2010, appointed a task force to review the literature on the topic. The group started gathering information from other professions (such as medicine, nursing and pharmacy) that were already involved in skill-based assessments and surveyed licensed psychologists to determine the criteria for the skills testing.

The task force suggested that ASPPB move forward with developing a skill-based test that would assess competency in the following areas: scientific orientation, professional practice, relational competence, professionalism, ethical practice and systems thinking.

Who, when and how much?

While there may be advantages to updating the licensing process, ASPPB recognizes another expensive test may seem daunting to new graduates. Many new graduates already carry considerable debt and are paying multiple fees for state boards where they are applying to practice, Jehu says.

ASPPB's goal is to keep the cost of Step 2 comparable to the EPPP, which is about $700, DeMers says. This will be challenging because the new test will likely use more expensive technology than Step 1, such as computer-based simulation, taped scenarios and possibly avatars.

"There will be a lot of upfront costs, but this has to happen and it's our job to make it as low-cost as possible," DeMers says.

In addition to cost concerns, some early career psychologists question whether it is wise to wait until the conclusion of training to weed out potentially incompetent psychologists. "If the goal is to be consistent with other degree programs, then why would we wait until so much later than medical programs, which test individuals throughout their training program as a uniform national standard?" says Samantha Rafie, PhD, an early career psychologist at Bay Area Pain and Wellness Center in California.

DeMers says that once the EPPP-2 is available, it may be possible to begin offering Step 1 before internship. This would mean the first test could be given immediately following coursework when knowledge is easier to recall. This could potentially reduce the need for people to spend money on expensive test preparation materials, he says.

"Moving the first test earlier could also allow students to use loan money to help cover the cost of the test," Jehu says. "There would also be more peer support when studying for the test if students are still at school."

Another question within the psychology community is who will be required to take the test. Rafie is already licensed, and she is concerned that she would have to take EPPP-2 if she wanted to move outside of California to practice. ASPPB will recommend that its member jurisdictions not require Step 2 for previously licensed psychologists with no record of complaints or discipline, DeMers says. For those who will be seeking a license after Step 2 is required, ASPPB will recommend to its member groups that psychologists only take it once to work in any state or Canadian province.

What's next

Before ASPPB will be ready to start offering the test, the organization needs to develop a blueprint for the exam, train psychologists to write the questions and conduct beta testing. They welcome help from psychologists who are interested in writing questions for the test or beta testing it. People interested in helping can email ASPPB Chief Operating Officer Carol Webb at cwebb@asppb.org.

Although the Step 2 is a costly and time-consuming endeavor for both ASPPB and graduates of the future, Grus is optimistic that advantages of updating the testing process will be felt throughout the psychology community.

"ASPPB has to be responsive to a society that trusts psychology to be a profession that is populated by individuals who are well trained," Grus says. "I think Step 2 will establish that psychologists are holding themselves accountable and we value our profession."

By Heather Stringer


This article was originally published in the July/August 2016 Monitor on Psychology

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19 Jun 2017

Managing Staff and Organizations in Support of Practice Excellence

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

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

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

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

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

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

 

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06 Jun 2017

Protecting Patient Privacy When the Court Calls

Protecting Patient Privacy When the Court Calls

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

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

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

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

Understanding subpoenas

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

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

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

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

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

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

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

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

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

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

Strategies for dealing with subpoenas

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

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

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

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

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

2. Contact the client

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

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

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

3. Negotiate with the requester

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

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

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

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

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

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

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

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

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

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

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

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

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

By APA’s Committee on Legal Issues


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

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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

Working with an Accountable Care Organization

Working with an Accountable Care Organization

Arnold D. Holzman and his practice are joining forces with hundreds of physicians.

Ask Arnold D. Holzman, PhD, how he sees the future of psychology, and he lays out a vision of psychologists working side by side with physicians in accountable care organizations — groups of health-care providers who come together to provide care for a particular patient population and enjoy bonuses for keeping their patients healthy. That's why Holzman quickly agreed when an accountable care organization called the Community Medical Group asked his practice for help last year.

The idea behind the accountable care organization was to better serve patients in Connecticut's New Haven and Fairfield counties. But the several hundred physicians involved soon realized they couldn't go it alone.

"They kept coming back to the need for high-quality psychological intervention," says Holzman, co-founder and managing partner of Behavioral Health Consultants, LLC, in Hamden, Connecticut. "Many of the problems that bring individuals to physicians' offices, particularly primary-care offices, are psychologically based."

As a result, the accountable care organization turned for help to Behavioral Health Consultants, which has 11 psychologists and three master's-level clinicians on staff and subcontracts with other mental health professionals — about half of them psychologists — as needed.

Accountable care organizations are springing up in response to the Affordable Care Act, which is intended to improve care and reduce costs by encouraging reimbursement focused on the quality — not the number — of services provided. Physicians share accountability for the cost and quality of care delivered to a patient population, with insurers rewarding improved outcomes and lower costs. The organizations can not only develop their own treatment protocols but also share electronic medical records and back-office functions, such as billing and appointments.

Realizing that integrating medical and psychological services was key, Community Medical Group recruited Behavioral Health Consultants, whose providers already had relationships with many of the physicians in the organization, to provide the psychological services its patients need.

Behavioral Health Consultants and the accountable care organization are currently separate entities, but the two are discussing the possibility of co-located services. That way, says Holzman, patients will see psychologists as "a routine extension of their work with a doctor as opposed to something separate." He hopes that eventually his practice will be able to enjoy such benefits of integration as shared administrative and support services and electronic medical records, joint negotiations with payers, even profit-sharing. "This is a process that will take years," he predicts.

So far, the relationship consists of referrals.

"The problem with more traditional relationships, as many physicians have told us, is they'll often tell patients they should go see someone, but they don't know whom to refer them to," says Holzman. "And they don't know if they got there because there's no [follow-up] communication."

The physicians now tap Holzman and his colleagues when they suspect patients have emotional or behavioral problems that are impairing their health. One young man, for example, came to Holzman after tests could find no medical reason for his chest pain and other symptoms of a possible heart problem. The real issue turned out to be anxiety. "Once we reframed his symptoms as anxiety, we could approach the problem as a psychological one, not a medical one," says Holzman, who used cognitive-behavioral therapy to teach the man how to better manage the stressors in his life and the resulting anxiety.

But Holzman and his colleagues also assist patients with medical problems. In fact, they are developing the accountable care organization's protocol for treating patients who have diabetes along with depression, obesity or other problems, yet aren't following their physicians' recommendations. The protocol will lay out how referrals will be made, as well as guidelines for individual and group treatment and outcome measures so all of the providers can determine whether treatment is successful.

Holzman is also in discussions with insurers who may provide seed money for demonstration projects to show that adding psychologists' interventions keeps patients healthier. "They see our work as potentially reducing their financial exposure if patients get better sooner," he says.

He encourages other psychologists to get involved with accountable care organizations, either by developing relationships with physicians who are members of one or more organizations or by joining practices like his own that have already developed those relationships.

Holzman's background in pain management and health psychology prepared him well for working with an accountable care organization, he says. "When you're trained in pain management, communicating with physician referral sources is second nature," says Holzman, who earned a doctorate in clinical psychology from the State University of New York at Binghamton in 1981.

Such integrated care, he adds, is not only good for patients. It's also good for the bottom line. Because of the new relationship with the accountable care organization, Holzman anticipates substantial growth and expects to bring on many more clinicians and subcontractors.

"That's really the motivation here: to provide high quality service and be successful at the same time," he says.

By Rebecca A. Clay 


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

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01 Jun 2017

Competent, Affirming Practice with Older Lesbian and Gay Adults

Competent, Affirming Practice with Older Lesbian and Gay Adults

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

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

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

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

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

Historical and cohort effects

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

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

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

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

Diversity among lesbian and gay elders

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

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

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

Physical, mental and sexual health disparities

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

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

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

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

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

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

Caregiving and long-term care

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

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

Challenges to living authentically

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

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

Legal issues and a call for advocacy

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

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

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

Adaptation and resilience

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

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

Implications for practice, advocacy and research

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

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

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

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

Conclusion

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

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

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

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


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

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01 Jun 2017

Avoiding a Disconnect with Telemental Health

Avoiding a Disconnect with Telemental Health

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

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

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

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

Case #1: Unforeseen ethics concerns

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Case #2: Legal issues and requirements

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Recommendations for telemental health practice

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

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

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


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

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