It’s a mainstay of therapist social media discussion groups everywhere: “Do I need to get training in online therapy before I can do it?”
When we look to expand our methods of practice, we don’t usually need to ask that question. The paths and requirements are, typically, made clear to us. Telemental health practice is a little different because of all the hard-to-see pieces in it: using new technology, dealing with new regulations, working with new media, and more.
Regardless of the differences, however, it still comes to down to the legal-ethical issue of competence.
The question of training is one that arises any time we decide to start a new modality or style of practice. Specifically, the question is: am I competent to do this? If I am not, is training what I need in order to become competent?
Competence can be gained and expanded through a variety of means besides just training. There is supervision, peer consultation, personal study, and combinations of all four methods. Competence is also maintained through diligence. We consult when we need to, and seek out further training or supervision if and when the need arises.
When it comes to telemental health, many of us are starting at square one. For those at that stage of development, training by experts is likely the quickest and most thorough way to ensure the needed breadth and depth of competence for online work. It’s not the only one, however.
So that brings us to the big question: are any of us required by legal or ethical standards to receive special expert training? First, we will look at standards set by professional organizations. Then we will look for any legal standards we can find.
Professional Ethics and Guidelines on Telemental Health Competence
Let’s look at a selection from the major associations (in alphabetical order):
American Association of Marriage and Family Therapists:
6.6 Training and Use of Current Technology.
Marriage and family therapists ensure that they are well trained and competent in the use of all chosen technology-assisted professional services. Careful choices of audio, video, and other options are made in order to optimize quality and security of services, and to adhere to standards of best practices for technology-assisted services…
American Association of Marriage and Family Therapists Code of Ethics, 2015
American Counseling Association:
Section H. Distance Counseling, Technology, and Social Media
…Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.
H.1. Knowledge and Legal Considerations
H.1.a. Knowledge and Competency
Counselors who engage in the use of distance counseling, technology, and/or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (e.g., special certifications, additional course work).
American Counseling Association Code of Ethics, 2014
American Mental Health Counselors Association:
Telehealth, Distance Counseling and the Use of Social Media
b. Counselors only provide distance counseling when they have had training, experience, and supervision to do so.
American Mental Health Counselors Association, 2015, I.B.6
American Psychological Association:
The APA’s code of ethics does not explicitly address competency in the practice of telehealth (although it does address the need for psychologists to practice only within the scope of their competency, of course.) The APA addresses training in the Guidelines for the Practice of Telepsychology. Importantly, guidelines are aspirational and do not carry the same weight as codes of ethics. They are still indicative of the professional organization’s stance on the issue, however:
Psychologists who utilize or intend to utilize telecommunication technologies when delivering services to clients/patients strive to obtain relevant professional training to develop their requisite knowledge and skills. Acquiring competence may require pursuing additional educational experiences and training, including but not limited to, a review of the relevant literature, attendance at existing training programs (e.g., professional and technical) and continuing education specific to the delivery of services utilizing telecommunication technologies.
American Psychological Association Guidelines for the Practice of Telepsychology, Competence of the Psychologist, Application, 2013
National Association of Social Workers:
1.04 (d) Competence
Social workers who use technology in the provision of social work services should ensure that they have the necessary knowledge and skills to provide such services in a competent manner. This includes an understanding of the special communication challenges when using technology and the ability to implement strategies to address these challenges.
Code of Ethics of the National Association of Social Workers, 2017
Standard 2.06: Competence: Knowledge and Skills Required When Using Technology to Provide Services
Social workers who use technology to provide services shall obtain and maintain the knowledge and skills required to do so in a safe, competent, and ethical manner.
Standards for Technology in Social Work Practice, 2017
National Board for Certified Counselors:
NBCC’s code of ethics does not explicitly address competency in the practice of telehealth (although it does address the need for NCCs to practice only within the scope of their competency, of course.) NBCC addresses training in the Policy Regarding the Provision of Distance Professional Services:
2. NCCs shall provide only those services for which they are qualified by education and experience. NCCs shall also consider their qualifications to offer such service via distance means.
National Board for Certified Counselors, Policy Regarding the Provision of Distance Professional Services, 2012
The AAMFT, AMHCA, APA, NASW, and NBCC citations strongly indicate that education or training are part of gaining competence to perform telemental health services. The ACA citation seems to remain vague on the point until it provides examples for ways to achieve “knowledge and skill.” It gives as examples, “special certifications, additional course work.”
Exactly What Do You Need Training On?
It is clear that all the professional associations cited above see training/education as essential to telemental health competence. They do not state that “training” or “education” always means continuing education programs, certification programs, or even programs focused on telemental health. So the question is raised: exactly what do you need training and/or education on? That should help us decide what areas we need continuing education in.
After a survey of the documents cited above, I came up with a list of competency areas that were addressed by one or more of the professional associations cited:
- Relevant legal regulations. For the majority of US clinicians, this includes HIPAA. However, HIPAA is not the only relevant regulation. For example, nearly every US state has its laws regarding data breaches. Many states also require certain businesses to perform risk analyses. This competency will not only require initial training, but also ongoing education, consultation, and/or study.
- Your licensing board’s rules on telemental health.
- Ethical standards and guidelines of other authorities that apply to you. In this article we covered major national organizations, but not state or other local associations. Your state organization may have its own guidelines or ethical standards.
- Informed consent requirements and standards according to your licensing board and professional organization(s.) All professional standards and guidelines agree that telemental health services require informed consent elements above the usual standards. The extent to which they define specific informed consent standards varies wildly, however.
- How to choose proper software and hardware tools. You don’t know how important this one is until fuzzy video prevents you from seeing that a client is on the verge of tears at just the moment when you’ve decided to perform a challenging intervention. This competency is also important for being able to choose tools that help you do your job of maintaining applicable legal-ethical standards.
- Proficient use of your chosen care delivery technology. When we think of telemental health, we tend to think of meeting by video. That’s not the whole extent, however. Over time, we are more and more likely to prescribe apps or online services and many clinicians do so already. Classical telemental health was more often text-based than video-based, and some clinicians still use that medium. Whatever medium you use, you need to be proficient with it. You also need to be ready to troubleshoot it for clients — that can mean helping them yourself or being prepared to get tech support involved.
- Proficient use of your chosen medium to deliver clinical services. Different delivery media require different therapeutic skills. Online video may be the current option that is closest to sitting in a room with clients, but it’s not the same. Text-based assessments and interventions are an entirely different skill set. Knowing the benefits and pitfalls of your delivery tech can easily mean the difference between effective therapy and loss of clients (or harm to them!) due to flubbed interventions.
- Proficient use of your chosen tools to maintain legal-ethical duties, including confidentiality. This one will extend beyond just the tools used directly for care delivery. It will also include your website, your computer, your smartphone, etc.
- Appropriateness of technology for certain clients and how to assess when distance services are appropriate for a given client. Whatever medium or tools you use, you need to know how to determine when they are or aren’t suitable for any given client.
- How to remotely manage emergencies in a general sense, and how to do so in the locales where clients reside. Simply calling 911 is not likely to be sufficient or appropriate everywhere.
- Cultural and organizational standards and mores in the locales where clients reside.
- The “business” of telemental health. What programs out there hire telemental health pros? How do you get reimbursed? How do you make sure you have liability insurance that covers what you’re doing? Etc.
We can’t guarantee that the above list is an exhaustive catalog of necessary telemental health-related competencies, but it’s pretty close.
Seeing the list should hopefully help readers see that developing competence in telemental health through training is not a simple matter of picking a training and going to it. You will need to assess where your competencies are still deficient and seek trainings that address those areas.
For example, Person-Centered Tech has a highly developed course series on technology and security according to HIPAA and ethics codes. It is 6-7 CE hours long depending on how the learner wants to do it. Many clinicians have taken it in preparation to start telemental health practice. That’s a good thing. But they quickly become aware that the training is excellent for expanding competence on point #1 from the list above, is very good for points #5 and #8, is a little helpful for point #3, and does absolutely nothing to help with any of the other 8 points.
Two things can be gleaned from this:
- When deciding on training programs, first assess which new competencies you need and which of those competencies are best worked on through training. Remember that consultation, supervision, and study are all options, as well. If your licensing board is one of those that requires a specific training program, remember that their required program may not cover everything you need for fully competent practice.
- You may need to seek training or other competency builders from a variety of sources. Note that all the telemental health training programs out there that claim to be comprehensive are comprised of tens of hours of training. There’s a reason for that!
Licensing Boards That Require Training
At the time of writing, we know of two licensing boards that have specific training requirements for licensees who wish to perform telemental health: the Georgia Counseling board and the Arkansas Counseling board. Please check with your own board for your needs. This section is provided as an illustrative example and not an exhaustive list.
The Georgia board requires 6 hours of training→. Note that based on our analysis above, 6 hours of training by itself is probably not sufficient to go from zero to competent.
The Arkansas board doesn’t have a specific number of required hours, but the board will pre-approve training programs that seek it and meet their standards.
The Florida Certification Board has a 20-hour program, with ongoing CE requirements, for the Florida Certified E-Therapist→.
At this time, the US has only one national-level certification that is developed and maintained by an accredited certification body: the Distance Credentialed Counselor (DCC.) The DCC is a product of the Center for Credentialing and Education (CCE), which is a part of the National Board for Certified Counselors (NBCC.) Despite the association with professional counseling, the DCC is designed for and held by the whole cross-section of mental health professionals. Training for the DCC is available from a number of providers. You can find the list of providers here→.
Training, whether backed by a validated certification or not, is available from a variety of places. We recommend you consider which competencies and/or certifications you need training to get, find providers who can help you get that training, and go do it. Happy online therapy-ing!