Note:
This Update is longer than usual, reflecting the importance and challenges of the topic. We encourage you to save it for a time when you can read it carefully.

Technology advances, particularly in videoconferencing and access to high speed internet connections, have prompted more clinicians to venture into telehealth. Professional organizations and local governments in the USA and the European Union are quickly moving to regulate this growing field. Typically there is a lag time between the development of new technologies and business practices and the adaptation of laws and national organization regulations. This is now the case with telehealth as there is a growing patchwork of laws, regulations, and ethic codes which can be confusing as well as unsettling for practitioners previously unfettered by regulatory bodies.
 
The growing service delivery is so new that it does not even have a common term yet: distance counseling, telemental health, telepsychology, e-therapy, online therapy, text-based therapy, clinical videoconferencing, and telecommunication technologies are just a few terms used to refer to mental health applications within the larger field of telehealth. Telehealth covers a broad range of health care, public health, and health education activities. Telemedicine includes everything from robotic surgery or real time triage to calling a doctor on vacation for a medication refill. Health education examples include phone apps or “wearables” like Fitbit or blood pressure monitors.  
 
Important updates to review include recent changes regarding telehealth in the American Counseling Association  (ACA, 2014) and American Association of Marriage and Family Therapists (AAMFT, 2015) ethic codes, practice standard updates by American Psychological Association  (APA, 2013) and National Association of Social Workers (NASW, 2005 but under revision), and state regulations (2016). The European Commission has an eHealth Action Plan for 2012-2020 which should be considered and Directive 2011/24/EU governs patients’ rights in cross-border healthcare. China passed its first national mental health law in 2012 and extensive telemedicine legislation in 2014.

Specifically it is important to abide by expectations and standards of practice for:

• informed consent (which can now be very specific for therapy)
• professional liability insurance coverage
• competence in technology platform(s) used 
• ensuring that the client is competent in the technology platform(s) used
• technology platforms which comply with the Health Insurance Portability and Accountability Act (HIPAA) and the standard of care it has established
• secure storage of communication and billing
• alternative methods of communicating with a client should technology fail
• ensuring client access to alternative methods of communicating with the provider should technology fail during service delivery or an emergency
• assessing the appropriateness of telehealth with a specific client
• name and contact information for an emergency contact
• documentation for how mental health emergencies will be addressed including risks of imminent harm (this can be especially challenging when clients may reside in locations without mental health/emergency services or cultural expectations of a duty to protect) 
• the interplay of jurisdictions, and
• the requirement for ongoing competence in telehealth given the changing nature of the field and technology.  

Resources The Global Context
The field of telehealth has gone from being a novelty to being a common practice for consulting across national jurisdictions  and in underserved or hard to access areas. Regulations and ethical codes typically lag behind changes in the mental health field and this is no exception. State regulations and national ethical codes have moved decisively into telehealth over the past three years. APA released guidelines for the practice of telepsychology in 2013. ACA added a section on distance counseling in its 2014 ethics code and AAMFT did likewise in 2015. State regulations are catching up as well, which puts clinicians on alert given requirements to abide by local mandates.

The European Union “Commission Staff Working Document on the applicability of the existing E.U. legal framework to telehealth services” was established in 2012. Their eHealth Action Plan 2012-2020 ensures that there will be further regulations and oversight of telehealth. Although China has only recently passed legislation on mental health and telehealth, it is moving aggressively in both areas. Telehealth is seen by the government as an important component in alleviating the overburdened hospital system and accessing central and western China, areas in which it is investing heavily. The World Health Organization outlined recommendations for telehealth in 2010. Access to quality mental health is a component of both the World Health Organization’s Mental Health Action Plan 2013-2020 and the United Nation’s Sustainable Development Goals—and telehealth will likely play an increasingly important role.

Despite the efforts of the global community, mental health needs continue to outpace available services and resources. The World Health Organization estimates that, “Between 76% and 85% of people with severe mental disorders receive no treatment for their disorder in low-income and middle-income countries” while only 35-50% in high income countries receive services. Those who do receive services often have difficulty accessing services or are provided poor quality care (WHO, 2014). “Telehealth provides a unique opportunity to reach those who otherwise would experience seemingly insurmountable barriers to accessing care.” (Luxton, Nelson, & Maheu, 2016, p. x). This is a promising mechanism by which progress may be made toward the United Nations Sustainable Development Goal 3 to “Promote healthy lives and promote well-being for all at all ages” including “mental health” (3.4).
 
Global workers and their supporting organizations should continue to explore how telehealth can serve both the local population and the expatriate community. It is likely that new technologies will continue to make services accessible in ways unimaginable only a few years earlier. Nevertheless, telehealth will increasingly be regulated and standards of good practice with it. 
  Some good practice guidelines and regulations include assumptions that work within the United States or Europe but make little sense when providing services in other countries, especially where health systems and mental health practice are minimal. In China, for example, counselors are prohibited from treating or diagnosing mental illness (Article 23), as these services are limited to psychiatrists (Article 23). Psychotherapy must be performed at a mental health facility (Article 51) and evaluations must be made face-to-face (Article 33). Counselors and all licensed mental health providers who want to engage in telepractice should be aware of their national association’s ethics code and practice guidelines regarding telehealth. In the USA, they also need to be aware of HIPAA guidelines, the State or Provincial regulations where they reside, and the local and national requirements of where the client is located. While some of these codes/regulations may not appear to apply to an individual clinician, the current mental health policy infrastructure require it for the following reasons:
 
Jurisdiction. All the ethics codes and guidelines in the USA include subtle but inflexible requirements that clinicians abide by “the laws and rules of the jurisdiction in which the client or patient or supervisee is located.” (AZ R4-26-109. A.) So while a clinician may follow the guideline or ethics code of his or her profession, failure to follow the requirements of the State or country in which the client resides may result in penalties in the jurisdiction of the client (including litigation) but also sanction by the national professional. The key difference between the U.S. and the E.U. is the “country-of-origin principle;” a service provider in the E.U. is practicing medicine legally if he or she complies with the licensure requirements in his or her own Member State and treats the patient from within his or her Member State.  This is true regardless of whether the patient is located in another Member State and irrespective of the requirements in that other Member State. The “country-of-origin principle” is the exact inverse of how licensure works in the U. S.  (2013, Pirvu & Snyder) since the location rather than nationality is what is emphasized.
 
HIPAA. IN the USA, HIPAA has become the “floor for minimum privacy and security requirements” (Luxton, Nelson, & Maheu, 2016, p. 37) as well as the standard of practice. When involved with litigation HIPAA serves as the best (and possibly sole) practice guideline for clinicians regardless of whether they transmit medical or billing information. In Europe, Directive 2011/24/EU oversees patient rights and the EU has expressed its intent to expand its telehealth policies over the next four years.

Cascading Penalties. Violations in distant locations pose problems for clinicians as local licensing laws, malpractice insurance carriers, and professional organizations all require notification should the clinician be charged or convicted of crimes, ethics violations, or lawsuits. In the worst case scenario, an emergency session with a client traveling in another state (let alone a distant country) or a telepractice with a client residing in Africa, Asia, or South America may result in the clinician violating a local regulation that he/she is unaware and eventually a) losing their license in  one’s home State/Provence, b) being dropped from their liability insurance carrier, c) having one’s  membership revoked by their national organization, and d) being accountable for civil penalties in both the jurisdiction of the client and the clinician. The lack of a uniform penal code in Europe limits how some regulations may be enforced.
 
Nonprofessional Counselors. Increased regulation and oversight means everyone involved with telehealth needs to keep abreast of developments. What was good practice several years ago may be outpaced by technology changes, regulations, and standards of practice. Skype is a good example. It was an early staple in videoconferencing and it became commonly used. It is not considered HIPAA compliant and is no longer considered good practice. Skype did not change. The world around it did. HIPAA became the standard even for individuals who do not fall under its mandate. Lay counselors, coaches, clergy, and other “non-licensed” providers need to realize that in most countries it is illegal to practice medicine (including mental health) without a license. So far, most mental health licensing provides “title protection” and not “practice protection”. In unregulated areas and eras it was permissible to abide by what ethics and standards best fit your practice. These days may be coming to an end. As mental health increasingly positions itself as a health care provider it is increasingly overseen by legal regulatory bodies and considered to be a practice.
 
Resources
--HIPAA  requirements: http://www.hhs.gov/ocr/privacy/
--Center for Connected Health Policy: http://cchpa.org/
--Center for Telehealth and e-Health Law: http://ctel.org/expertise/reimbursement/ 

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Informed Consent: More Requirements and Challenges
Informed consent for telehealth includes all of the requirements for in-person services plus many additional contingencies. Remember, the purpose of an informed consent form is to insure that the client is sufficiently aware of all factors that allow him/her to make a knowledgeable decision about both the service and its mode of delivery.
 
Risk Analysis. Good practice should include documenting consideration of whether telehealth “Is consistent with the client or patient’s knowledge and skill regarding use of the technology involved in providing psychological service by telepractice or with ready access to assistance with use of the technology, and is in the best interest of the client or patient.” (AZ R4-26-110. A.) This requirement is noteworthy because it places some ownership on the clinician for determining that the client is able and willing to use the technology and is able to assist the client in technology matters.
 
Emergency Planning. While handling emergencies across state line in the United States may include little more than local contact information, it can be much trickier when working across national boundaries. Other countries may not have developed or accessible emergency services or may not provide services for suicidal clients or imminent threat situations. Contact information for relatives may be of little use if they reside in a different country. Contact information for neighbors may be of little assistance if they do not speak the same language as the clinician. In all cases contingency plans need to be in place should technology fail. Emergency planning is not intended for when the internet fails during a session while things are going well. What are the client and the clinician to do when communication is lost during a session when the client is decompensating, suicidal, or experiencing intimate partner violence? Political unrest, intruders, and natural disasters are also times when communication may be lost but clients are in acute need of services.

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Looking Forward
Although telehealth is an emerging field with both regulatory and technology challenges, it presents excellent opportunities on many fronts for those seeking to bring services to personnel around the world and to underserved or hard to serve areas. Telehealth provides opportunities for both the expansion of services as well as access to quality, specially care. Mental health care has never been a stagnant field and practitioners should not shy away from working to overcome barriers to service delivery, including through telehealth.

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Select Bibliography
--American Association for Marriage and Family Therapy, (2015). AAMFT code of ethics. Alexandria, VA: Author. 
--American Counseling Association. (2014). The ACA code of ethics. Alexandria, VA: Author.
--American Psychological Association (2007). Record keeping guidelines. Washington, DC: Author.
--American Psychological Association (2010). Ethical principles of psychologists and code of conduct. Washington, DC: Author.
--American Psychological Association (2013). Guidelines for the practice of telepsychology. Washington, DC: Author.
--DeAngelis, T. (2012). Practicing distance therapy, legally and ethically. Washington, DC: American Psychological Association.
--Drum, K. B., & Littleton, H. L. (2014). Therapeutic boundaries in telepsychology: Unique issues and best practice recommendations. Professional Psychology: Research and Practice. 1-7 doi:10.1037/a0036127.
--Luxton, D. D., Nelson, E. & Maheu, M. M. (2016). A practitioner's guide to telemental health: How to conduct legal, ethical, and evidence-based telepractice. Washington, DC: American Psychological Association.
--National Association of Social Workers (2008). Code of ethics. Washington, DC: Author.
--National Board for Certified Counselors (2012). Code of ethics. Greensboro, NC: Author.
--National Board for Certified Counselors (2012). Policy regarding the provision of distance professional services. Author.
--Tuerk, P. W., & Shore, P. (2015). Clinical videoconferencing in telehealth. New York, NY: Springer.

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Dr. Justin Smith, LCSW, LMFT, LP, is Associate Professor of Professional and Pastoral Counseling and Director of the Counseling Program at Phoenix Seminary. He started working with troubled youth in 1981 and has worked full-time with Community Mental Health, Child Protective Services, and the Wisconsin State Hospital.  Dr. Smith is a licensed psychologist with over 25 years of clinical experience.  He is a Clinical Fellow and Approved Supervisor with the American Association for Marriage and Family Therapy and the Clinical Director of the Arizona Association for Marriage and Family Therapy Supervision and Education Committee. Dr. Smith grew up in S. E. Asia and continues to travel addressing member care, Third Culture Kids, couples counseling, trauma, and violence. He has written and spoken nationally on marriage and family therapy, supervision, ethics, trauma, and working with sex offenders.
Email: jsmith@phoenixseminary.edu

Member care is a broad field with a wide range of people who provide it. As this field continues to grow, it is important to offer guidelines to further clarify and shape good practice. Any guidelines must carefully consider the fact of the field’s international diversity [and our globalizing world], and blend together the best interests of both service receivers and service providers. They also need to be applicable to member care workers (MCWs) with different types of training and experience. No one set of standards from a particular country or a particular health-related discipline should dominate. This is a challenging task to undertake, and it is one that must be done in consultation with many others and on an ongoing basis. Trying to differentiate between codes, guidelines, frameworks, and suggestions is yet another important aspect of this challenging task.
 
Good practice in member care involves more than simply identifying the right general ethical guidelines and then trying to apply them in appropriate, situation-specific ways. Rather it is fundamentally a way of thinking through problems, our practices, and the possible consequences of our actions. It is a mentality. It is a mentality. It is not a question of morality, but rather a reflection of the need to develop a pervasive mental mindset for ethics over time through training, experience, and reviewing various scenarios with others.
 
Consider this example about having both an ethical mental­ity and relevant guidelines that shape our practice. A mission worker sends us an email expressing her concerns about her five year old child who is constantly “misbehaving” at home. She is Swiss and lives and works in Uganda. We as member care providers are Brazilian and live and work in Singapore. Four cultures in four countries across four continents are “represented” here.
 
Before we send an email response to the question about how to handle a child’s misbehavior, we want to shift into ethics mode and to “think ethically.” The same goes for any other issues such as consulting about: a depressed team member, an alcoholic relative back in a person’s passport country, residual fears for local staff following a major earthquake, or a manager’s conflict with an organizational policy. We thus pause and ask ourselves how ethics is involved in this matter:
 
--Are there any special jurisdiction issues and special laws regarding the countries involved?
--Who may be seeing our communications, now and in the future?
-- Is there a reliable means of communicating? Which available platform is most appropriate for consulting, for evaluating/assessing, for treating, or for supporting the family in this situation – email, phone call, video conferencing, Facetime, etc.?
-- Is everyone fluent in the same language or will translation be required? Does that impact the medium to be used?
-- Does the worker know how to use the technology, and does her location in Uganda have reliable service?
-- In a crises what is an alternative means of communication for getting ahold of one-another?    
--Do the communication exchanges need to be encrypted?
--Do I respond informally as a colleague or officially on behalf of an orga­nization or as an MCW?
--Do I have enough information to offer input and how accurate is the information that I do have?
--Should I consult with anyone about the situation?
--Which ethical guidelines are relevant [including telehealth guidelines]?
--What may be the consequences of my response/advice?
 
Do the above questions sound familiar? Or do some seem a bit strange to you? Are there other questions that could be asked? The last question is especially important and is something to always consider after we have gone through our usual questions. Remember, there is always an ethical context and ethical mentality that accompany our member care work! And as emphasized in this Update, the context involves a growing body of state, national, and international regulatory requirements along with professional standards that influence and guide how MCWs (and their organizations) of all types and across diverse settings practice telehealth.

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What telehealth tools/guidelines do you use?

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Member Care Associates
MCAresources@gmail.com

Member Care Associates is a non-profit, Christian organisation based in Geneva and the USA.      
We provide-develop supportive resources for workers and organizations in the mission, humanitarian,
and development sectors. Our services include consultation, training, research, and publications.
 

Global Integration (GI)
GI is a framework for actively integrating our lives with global realities. It helps us to connect relationally and contribute relevantly on behalf of human wellbeing and the major issues facing humanity, in light of our integrity and core values (e.g., ethical, humanitarian, faith-based).