Therapeutic boundaries in telepsychology: Unique issues and best practice recommendations

Abstract

Technology-assisted mental health services are becoming much more routinely utilized by clients and practitioners alike. Clinicians practicing telepsychology must prepare themselves in order to provide competent care in this ever-evolving context of service delivery. Although much has been written with regards to considerations of ethical and legal practice, practical and logistical guidelines, and the advantages and disadvantages of the delivery of services via the use of technology, little to no attention has been paid to issues related to therapeutic boundaries in the telepsychology relationship. Clinicians must consider how to maintain appropriate boundaries in telepsychology settings in order to prevent harm and optimize treatment gains. Such considerations are also necessary given that it is probable that the telepsychology clinician will encounter novel boundary issues that are unlikely to occur in the traditional face-to-face therapy setting. We discuss the clinical utility of boundaries, potential boundary issues in telepsychology settings, and suggested best practice recommendations to ensure competent, ethical, and efficacious treatment in this novel context of service delivery.

Telepsychology is an umbrella term used to describe the use of telecommunication technologies to provide psychological services via modes such as the telephone, e-mail, text, videoconferencing, mobile applications, and Web-based programs (APA, 2013). Telepsychology services have expanded rapidly over the years and are likely to soon become a routinely available consumer option for receiving evidence-based treatment (Abbott, Klein, & Ciechomski, 2008). As a result, there is a growing literature base regarding considerations in the use of telepsychology. Discussions include potential legal and ethical concerns (e.g., APA, 2013; Baker & Bufka, 2011; Hsiung, 2001; Mallen, Vogel, & Rochen, 2005; Manhal-Baugus, 2001; Midkiff & Wyatt, 2008), practical issues including challenges, opportunities, advantages, and disadvantages (e.g., Maheu, Pulier, McMenamin, & Posen, 2012; Rees & Haythornthwaite, 2004; Yuen, Goetter, Herbert & Forman, 2011), establishing and maintaining the therapeutic alliance (Cook & Doyle, 2002; Rees & Stone, 2005), treatment efficacy (e.g., Barak, Hen, Boniel-Nissim, & Shapira, 2008), practice recommendations (Judge, Abeles, Davis, Adam-Terem, & Younggren, 2011), and guidelines (APA, 2013).

In contrast, although some attention has been paid to issues related to boundaries in psychologists’ use of online technology (e.g., considerations related to being “friends” or “following” clients on social media and therapists searching for information about clients online; see Zur, 2008 and Kolmes, 2012), little to no attention has been paid to therapeutic and professional boundaries specifically within the context of the telepsychology relationship. Such considerations are important as (a) appropriate boundaries facilitate a host of therapeutic aims; (b) boundary issues in telepsychology are likely to present in novel ways; (c) clients and clinicians may not have a clear schema or expectation for what boundaries look like in non-traditional settings, making it more likely that boundary challenges will arise; and (d) idiosyncratic boundaries or a lack of boundaries can lead to harm (Knapp & Slattery, 2004; Simon, 1992). Therefore, in order to ensure that telepsychology services are conducted in a competent, ethical, and efficacious manner, we discuss a number of potential boundary issues that could arise in this novel context and present best practice recommendations for the prevention and management of these issues.

Boundaries, Clinical Utility, and Salient Issues

Boundaries are generally understood to be the rules that govern the therapeutic relationship and which help to differentiate it from that of a business or social relationship (Knapp & Slattery, 2004). Such rules or boundaries include structural elements such as time, place/space, and money, and also content factors such as what actually occurs between the therapist and client (Smith & Fitzpatrick, 1995). Boundaries encompass issues such as who the client is, what payment will be, where and when therapy will take place, when it may be necessary to break confidentiality, how to manage multiple relationships, and issues surrounding termination. Other aspects of boundaries concern how cancellations, rescheduling, and non-payment issues are handled, whether gifts and bartering are permitted, what types of interactions are acceptable, issues related to therapist self-disclosure, and issues related to proximity (physical distance between client and therapist), clothing, and language use (Gottlieb, Youngren, & Murch, 2009; Gutheil & Gabbard, 1993; Zur, 2007).

In general, boundaries are clinically useful as they serve to provide guidance regarding the nature of the therapeutic relationship and help the client and clinician regulate their behavior in ways that maximize clinical outcomes and minimize harm (Borys, 1994; Zur, 2007). Boundaries can also promote a number of other therapeutic aims including building a trusting working alliance, modeling assertiveness skills to the client, enhancing the client’s self-worth (i.e., by respecting the client’s rights and autonomy), as well as ensuring the integrity of the relationship (Borys, 1994; Simon, 1992; Smith & Fitzpatrick, 1995). In addition to providing protection for the client, appropriate boundaries also protect clinicians from harm. For example, appropriate boundaries help prevent clinicians from engaging in ethically risky behaviors such as entering into inappropriate multiple relationships with clients. Appropriate boundaries also serve to protect the clinician from being manipulated by clients (e.g., those diagnosed with a personality disorder) who may attempt to lead the therapist toward a more “special” and less professional relationship (Gutheil, 1989; Simon, 1992; Smith & Fitzpatrick, 1995).

Boundaries are highly important in the treatment relationship, yet they can be difficult to operationalize as they are dependent upon a number of unique factors specific to each client and clinician (e.g., the client’s diagnosis and the clinician’s orientation). Thus, because there is some flexibility in boundaries across clients, contexts, and orientations, the potential exists for boundary issues and challenges to arise. Boundary issues that have been known to arise in traditional settings include those related to place and space, time, money, role, gifts, physical touch, language, clothing, self-disclosure, and sexual contact (Gutheil & Gabbard, 1993).

Furthermore, one can distinguish between two types of boundary transgressions: boundary crossings and boundary violations. The term boundary crossing refers to departures from typically accepted clinical practice, which may or may not be beneficial to the client (Smith & Fitzpatrick, 1995). Boundary crossings include more minor deviations from typical therapeutic practice such as attending a client’s graduation after being invited or giving a client a hug at the final session. Boundary violations on the other hand, are more severe and are departures from acceptable clinical practice which pose a serious risk to the client and/or the therapeutic process (Gutheil & Gabbard, 1993; Simon, 1992; Smith & Fitzpatrick, 1995). Boundary violations commonly include ethical violations such as engaging in a sexual relationship or exploitive business practices with a client (Gutheil & Gabbard, 1993; Williams, 1997; Zur, 2007). Overall, it is generally accepted that boundary crossings have the potential to be therapeutic, neutral, or harmful depending on myriad factors, yet boundary violations are always harmful. Additionally, although the vast majority of psychologists who cross boundaries do so in a way that is considered safe and therapeutic (Gottlieb & Younggren, 2009), the potential exists for successive boundary crossings to lead some down a slippery slope toward boundary violations (Gutheil & Gabbard, 1993). Thus, the provision and maintenance of appropriate therapeutic boundaries is essential and warrants special consideration in telepsychology settings as maintaining boundaries in such settings is likely to present unique challenges.

Potential Boundary Issues in Telepsychology

Two specific factors in the practice of telepsychology have the potential to lead to an increased likelihood of harmful boundary crossings and violations. These are: (a) the potential for the flexibility of service delivery to prompt more frequent and more casual interactions and behaviors; and (b) the assumption that physical distance provides protection from and/or makes the relationship immune to boundary crossings and violations. In considering these factors, we would argue that while the flexibility of service delivery via telepsychology is one of the benefits, if this flexibility is taken to extremes (e.g., clinicians working from public locations or being highly casual/informal in interactions) it can greatly jeopardize the professionalism of the relationship and have deleterious effects with regards to the aforementioned therapeutic aims that proper boundaries facilitate. Additionally, because the client and clinician are now capable of communicating through means typically reserved for social and personal interactions with family and friends (e.g., through e-mail, instant-chat, and video conferencing), telepsychology interactions can occur at any hour of the day or night, and both parties can now virtually enter each other’s homes, there is the potential for an increased sense of intimacy between client and therapist which could lead to boundary challenges (Goss, 2011). Below, we delineate how these and other factors can lead to boundary issues in telepsychology.

Considerations and Issues Related to Time

Time is one of the primary boundaries in psychotherapy. It provides structure by establishing clear markers as to the beginning and end of the therapeutic encounter, and can be reassuring to clients in that they know that they will only have to engage in challenging therapeutic work for a set period only (Gutheil & Gabbard, 1993). Time in the telepsychology world exists in two formats: synchronous communications (in real-time) and asynchronous communications (time-delayed/not in real time; Barak, 1999). Synchronous communications include telephone sessions, audio and video-conferencing, text-based instant-messaging, and online private or group chat. Synchronous communications are much like traditional office visits in that the clinician and client agree upon a set time for an appointment in their chosen medium. Asynchronous communications consist of time-delayed interventions such as e-mail correspondence, pre-recorded audio or video interactions, and previously created online interventions.

Boundary issues related to time are not uncommon in traditional face-to-face therapies and typically arise in the form of early or late arrivals to session, extensions of sessions, holding sessions at odd or inappropriate hours, excessive out of session contacts, and scheduling particular clients for the last appointment of the day (Zur, 2007). These issues can certainly occur in telepsychology settings as well and may be more likely due to the flexibility of the medium, the perception of convenience for both parties, and the potential for a less regulated/structured work environment. There are also some unique challenges with regards to time boundaries in telepsychology, including those related to asynchronous communications.

With regards to early or late arrivals, while telepsychology may help to minimize these issues for the client as the clinician typically does the initial contacting for synchronous appointments, there is an increased risk for the clinician to be late due to equipment not working properly and failures in technology. Extensions of sessions may also be more common as both parties’ schedules may be more flexible causing them to adhere less to structured time frames. In addition, text-based synchronous communications can take longer than verbal communications in a traditional face-to-face setting, which could also lead the clinician to inadvertently extend session times. It is also likely much easier for a clinician to succumb to the temptation to schedule appointments at odd hours in a telepsychology setting, as it may be seen as a convenience for both parties and hours may not be regulated by an employment setting. Additionally, given the increase in access to care, telepsychology clinicians have more opportunity to service clients from various regions and cultures; some of which may not place great emphasis on punctuality (in contrast to more Westernized cultures) and time boundaries may be crossed.

There are also potential boundary issues related to time that can occur in asynchronous communications. For example, while it is acceptable for clients to engage in asynchronous interactions during non-business hours, it may be contraindicated for therapists to do so. Providing feedback during non-business hours may lead clients to expect nearly instantaneous feedback, or view the therapist’s availability as unpredictable. The potential for excessive communication is an additional time-related issue with regards to asynchronous interactions. Because there may be no set session per se, it is typically up to the client to decide when to interact and some clients may interact numerous times a day in a seemingly “rapid-fire” manner. Although there is no right or wrong speed or frequency of interaction, clinical judgment would be necessary to determine what defines excessive communication as it may be detrimental to both parties. For example, it may represent a form of avoidance behavior (e.g., the client interacts in an excessive, rapid-fire manner in order to avoid processing difficult material) and it may also lead to anxiety in the clinician as it can exhaust resources on top of an already full schedule. Additionally, because feedback turnaround time in asynchronous communication is essentially at the discretion of the therapist, the therapist could show unintentional favoritism to certain clients by interacting more often or more quickly with some and delaying interactions with others. Such issues are not likely to arise in traditional office environments as the scheduling of individual appointment times prevents this (e.g., one has limited ability to pick and choose which client of the day to see first and one cannot avoid a client for extended periods of time if he or she arrives to the office).

Considerations and Issues Related to Setting

The place and space of the therapeutic encounter has historically primarily resided in formal office environments (Knapp & Slattery, 2004). The structure of the therapy office provides a number of benefits to the therapeutic relationship including providing a sense of security and safety for clients, as well as helping to enact and reinforce appropriate therapeutic boundaries (Knapp & Slattery, 2004). In contrast, because telepsychology services may not occur within the context of a professional organization or building and the relationship may exist beyond the structure of physical walls, a number of challenges could occur.

One challenge relates to the flexibility of telepsychology and one’s ability to work from anywhere at any time. This flexibility may lead clinicians and clients to interact therapeutically while in public settings. Interacting in a public setting such as a coffee house may initially appear harmless but could have grave consequences. For the clinician, it would risk the client’s confidentiality (e.g., via use of a public, unsecure internet connection or by unintentionally allowing others to see the therapeutic communications) and it could also warrant legal and professional ramifications. For the client, in addition to risking his or her own confidentiality, this could also derail therapeutic benefits as the environmental stimuli could serve as distractors and interfere with the full processing of therapeutic content. Additionally, the client’s choice to interact while in public could be a way to avoid difficult material or make the relationship feel less formal and more social. This increased flexibility related to work setting could also lead clinicians to practice outside of their jurisdictions (e.g., by conducting therapy online with a client located in a state in which the therapist is not licensed). Practicing outside of one’s jurisdiction could lead to ethical and legal difficulties for the clinician.

Other setting specific issues that could arise relate to what is visible and audible to the client when using video and audio equipment. For example, because telepsychology services may be conducted in less formal environments, clinicians may choose to work from non-office settings or wear more casual clothing during video communications and this could undermine the professionalism of the relationship. Indeed, the therapist who delivers video services while dressed in a casual manner or while in a casual space may risk taking on the “buddy” role and may be seen as just another friend with whom the client talks to online (Andersen, Van Raalte, & Brewer, 2001). Additionally, because there is only a limited view of the therapist’s professional environment when video-communications are used, telepsychology clinicians have a more limited opportunity to use the environment to establish boundaries and convey an inclusive and accepting atmosphere. This may be of particular import to those working with minority or underserviced populations.

Inconsistency in the clinician’s telepsychology setting particularly when a video-component is used could also foster boundary-related challenges. Changing the backdrop or filming videos from different locations, even if non-public, could lead to privacy concerns as the client may wonder why the clinician’s environment changes and where he or she is located. Excessive background noise in the clinician’s environment (e.g., noise from pets, children, or hallway traffic) may also cause privacy concerns and be a distractor from therapeutic interactions.

Ensuring the privacy of non-clients (e.g., those with whom the client resides) is an additional issue that may arise when using video equipment. For example, as many clients interact from their homes, they may not consider that family photographs visible to the clinician may result in unwanted disclosures of the identity of loved ones. Additionally, there may be personal objects or content within the client’s home that he or she would rather not disclose to the therapist yet may unintentionally do so. Unintentional self-disclosures could be detrimental to the therapeutic relationship as they could lead to discomfort or embarrassment as well as force the therapist to decide whether the unintentional self-disclosure is therapeutically relevant and should be brought to the client’s attention.

Another setting-specific boundary issue relates to the use of online mediums to promote and describe services. As telepsychology clinicians typically do not physically meet with clients, many use websites to detail services offered, and they may also use other online avenues such as social networking sites to promote and describe services (Kolmes, 2012). Although such mediums can offer the client a window into who the therapist is and what therapy might look like, the content of the online medium can also lead to problems if its role in establishing appropriate therapeutic boundaries is not considered during the design process. For example, perhaps in an effort to appear accessible and convey a warm and welcoming environment, some therapists choose to include personal photographs (e.g., with loved ones, or while on a vacation) and/or autobiographies detailing their interests/hobbies. Although this may help the client gain a sense of who the therapist is, it may also set the expectation for a more social and less formal relationship. This has the potential to be detrimental as it can lead to a mismatch of expectations with regards to the nature of the therapeutic relationship (e.g., the client may think it appropriate to inquire about a therapist’s family or favorite vacation spot after seeing photographs on his or her website). This mismatch can then be difficult to correct and the therapist’s attempts to do so are likely to cause confusion and frustration for the client (Gottlieb et al., 2009).

Additionally, if clinicians use social networking sites such as Facebook to advertise services, clients may end up “liking” the page, or sending the therapist a “friend request.” Accepting friend requests from clients or “following” them on other forms of social media (e.g., Twitter) is likely to lead to complications related to unintentional client self-disclosures and it could also lead the client to see the therapeutic relationship as less formal. Although these issues are not unique to the practice of telepsychology, they could be more salient in such settings as the lack of face-to-face interaction between client and therapist could limit the opportunity and/or make discussing such boundary issues more difficult. In addition, given that they are accustomed to interacting with their therapist via technology, clients receiving telepsychology services may be particularly likely to try to utilize these mediums to engage in therapeutic work (e.g., by posing a therapy-related question on the therapist’s Facebook page) and this could risk their own confidentiality.

A final and important setting-specific issue to consider relates to the fact that the telepsychology clinician is in a sense entering the client’s home. This may create difficulties for clients with histories of disturbed interpersonal boundaries. For example, such clients may regard conducting therapeutic sessions virtually in the privacy of their homes as either more intimate or more invasive than in traditional face-to-face sessions, and boundary issues could result. Indeed, it is possible that for the client who is overly disinhibited in interpersonal boundaries, boundary crossings may arise in the form of acting out behaviors such as dressing in a provocative manner or using language that he or she would not use in a more formal office setting. Additionally, there may be the potential for the client who is highly guarded in interpersonal boundaries to feel threatened by the clinician’s virtual presence in his or her home. The therapist’s presence could potentially challenge his or her sense of safety and lead to very firm/impenetrable boundaries being enacted which may be counterproductive to therapeutic aims.

Considerations and Issues Specific to the Therapist

Lastly, an additional area where boundary issues may arise concerns factors specific to the therapist and includes issues related to challenges to his or her own self-imposed boundaries, issues related to choice of language and wording, and issues related to protection of the therapist’s work. With regards to challenges to one’s own personal boundaries, due to the flexibility that telepsychology services afford, clinicians may find themselves working at times that they normally would not. For example, telecommunication technologies make it much easier for clinicians to continue to work when ill, when on vacation, and during evenings and weekends. Although this may be seen as an advantage in terms of timeliness of service delivery to clients in need, it can have taxing effects on the therapist and potentially lead to burnout. Additionally, clinicians must consider how this may affect the client. For instance, if the therapist video-conferences with a client while on vacation, this could lead the client to feel guilty or like a burden. It is also likely to model poor boundaries and negligent self-care, as well as draw attention to potential issues related to differences in socioeconomic status (e.g., if the client is from a socioeconomic status in which he or she could not afford to go on a vacation).

Language use and choice of words is another way the therapist may unintentionally cross his or her own professional boundaries. Because the client has no way to discern the intonation of text-based messages, there is much room for miscommunication. For example, the question, “Do you have plans this weekend?” could be read as an invitation to spend time together, whereas “Do you have plans to spend time in enjoyable activities this weekend?” conveys a more professional tone with therapeutic implications related to activity scheduling and behavioral activation. Additional boundary issues could arise from the therapist’s use of emoticons (for a description of emoticons see Midkiff and Wyatt, 2008). Emoticons are typically designed to facilitate the expression of affect in a non-verbal setting; however, the therapist’s use of emoticons may too strongly parallel the client’s social and personal interactions and lead the relationship to feel less professional. The same may also be true for excessive punctuation use (e.g., exclamation points) and chat acronyms/text message shorthand.

A final therapist-specific boundary issue relates to the protection and privacy of the therapist’s work. Although a benefit to asynchronous communication and text-based messaging is the recording of a permanent record (Barak, 1999), this is also a potential drawback due to the client’s ability to share the therapist’s feedback with others (Hsiung, 2001). Shared feedback could be taken out of context, edited, misused, or misrepresented which could result in harm to the therapist.

Best Practice Recommendations

Given the potential for unique and challenging boundary issues to arise in telepsychology settings, best practice recommendations for the prevention and management of such issues are offered below. It is our hope that considering the abovementioned issues and observing the following recommendations will lead to the establishment and maintenance of professional boundaries that maximize clinical utility and minimize harm. Additionally, following these recommendations will help to maintain the integrity of the treatment process in the novel and continuously changing context that is telepsychology.

Recommendation 1: Maintain Professional Hours and Respect Timing of Sessions

Although it is acceptable for clients to interact at any hour they choose, clinicians are advised to only conduct therapeutic interactions and schedule telepsychology appointments during normal business hours. A therapist may choose to construct asynchronous feedback for a client at any hour, but that feedback should only be presented during normal business hours. This will help to distinguish therapeutic communications from everyday interactions with others in the client’s life. It will also ensure that therapy is perceived as structured, consistent, predictable, and professional. In addition, as one would in a traditional face-to-face setting, clinicians are advised to respect the timing of appointments and sessions. They are advised to arrive to sessions on time and to ensure that technology is working properly before the start of the session. Additionally, clinicians practicing telepsychology should be mindful of cultural variances related to punctuality and not assume underlying therapeutic significance if clients whose cultures do not place great emphasis on punctuality are late to an appointment. Clinicians may, however, wish to discuss the importance of being on time as it relates to ensuring timely access to care to others.

Recommendation 2: Ensure Timely and Consistent Feedback and Manage Excessive Communications

Clinicians should take care to provide consistent and timely feedback. One to three business days for online program feedback and 24 hours for more instant communications are generally considered acceptable turnaround times (Abbott et al., 2008; Manhal-Baugus, 2001). Clinicians should also discuss feedback turnaround times at the start of treatment so that clients know what to expect. Providing consistent feedback will model accountability and provide clients with a sense of safety, security, and trust. Additionally, in order to avoid showing unintentional favoritism, clinicians should provide feedback in the order that it was received (with the exception of those in immediate crisis or danger). If the client’s speed of communication appears excessive and clinically contraindicated, the clinician should slow his or her feedback response in order to model a more appropriate and therapeutic interaction pace.

Recommendation 3: Ensure a Private, Consistent, Professional, and Culturally Sensitive Setting

In order to protect confidentiality, clinicians should refrain from conducting telepsychology services while in public and clients may be advised to do the same. Clinicians should also advise clients to ensure that video-conferencing takes place in a private space within their homes and to take measures to ensure that others do not intrude on the session, perhaps by simply locking the door. Text-based communication may be helpful to include with video-conferencing equipment in the event that privacy is breeched and the client is no longer able to communicate verbally. It is also recommended that clinicians conduct therapeutic services containing a video component from a consistent environment. This will help to ensure privacy, model stability, and convey a safe and reliable place for the therapeutic work to occur. It will also help prevent clinicians from practicing outside of their jurisdictions. Clinicians are also advised to be mindful of what appears in the camera’s view when using video components, and ensure that the space appears professional. Suggestions for professional backdrops include artwork such as neutral land and seascapes or one’s degrees, diplomas, and certificates (Devlin et al., 2013). In addition, because clients have only a limited view of the therapist’s professional space when using video equipment, clinicians should consider the cultural backgrounds of the populations with whom they primarily work and design a setting that promotes cultural acceptance and sensitivity (Devlin et al., 2013). Taking care to prevent excessive background noise when using audio equipment—perhaps via use of a white noise machine outside of one’s office door—may also help alleviate privacy concerns and ensure professionalism. Lastly, while this may seem like a given, the therapist should always be dressed in a professional manner when video equipment is used.

Recommendation 4: Ensure Privacy of Non-Clients and Prevent Unintentional Self-Disclosures

In addition to ensuring the client’s privacy, clinicians may also wish to inform clients to take measures to ensure the privacy and confidentiality of others (e.g., family members, friends, or roommates) who may be in their environments. Clients may wish to remove any identifying information such as family photographs from the camera’s view when video services are used. Clients should also be advised to anticipate any unintentional self-disclosures that could occur as a result of using a video camera.

Recommendation 5: Ensure that Telecommunication Technologies Used Convey Professionalism

Clinicians should take great care to ensure that telepsychology services used promote professionalism. Websites should make use of professional photographs and include descriptions of services that contain professional language that is free from jargon and grammatical errors. Clinicians may also wish to refrain from including detailed personal information such as their likes and interests. Links to the therapist’s state licensing board and verification of licensure, the code of ethics, and any professional organizations to which the therapist belongs may also be included in order to establish the therapist’s professionalism and credentials as well as help clients to be reassured that the services provided are safe and legitimate. Additionally, clinicians should also consider the professionalism of all of their online activity such as blog, Facebook, and Twitter posts and consider all such activity to be public domain (see Zur, 2008 for suggestions on maintaining professionalism and managing various forms of self-disclosure via the internet). Additionally, if clinicians do use social media, it will likely be helpful to have a policy in place to be reviewed with clients regarding ways in which they will handle non-therapeutic online contacts such as Facebook friend requests and requests to join a therapist’s online forum (for an example of such a policy see Kolmes, 2010).

Recommendation 6: Model Appropriate Self-boundaries

Clinicians should be mindful of a healthy work-life balance and adhere to boundaries that ensure proper self-care. Clinicians should take leave time when ill or vacationing, rather than continuing to conduct telepsychology services during such times. It is also recommended that clinicians avoid the temptation to check asynchronous communications during non-business hours (e.g., during family time or on weekends). Notifying clients of scheduled leave time in advance, indicating when therapeutic communication will resume, and reminding clients of emergency procedures and coverage of care will help clinicians to avoid the temptation to check on clients during non-business hours or when on leave.

Recommendation 7: Ensure Privacy of the Therapist’s Work

In order to promote boundaries related to the therapist’s privacy, the clinician may wish to restrict clients’ abilities to download asynchronous video and audio files to computers, as well as design written program text so that one is unable to copy and paste the content. Although this will not prevent the client from potentially showing the telecommunications to others, it may prevent any editing and misuse/misrepresentation of the therapist’s work. The therapist may also wish to have a policy regarding use and misuse of feedback and make this available to prospective clients prior to the start of treatment. Implementing such boundaries will help reinforce the importance of privacy and confidentiality and also model one’s right to set appropriate limits with others.

Recommendation 8: Use Professional Language and Consider Alternative Interpretations

Therapists who engage in telepsychology are encouraged to re-read their written feedback to clients and consider word choices in text-based communications. Reviewing text communications prior to making them available to clients will help prevent and minimize confusion as well as help ensure that unintentional boundary crossings do not occur because of miscommunications. Additionally, to help distinguish therapeutic communications from that of social interactions, clinicians are advised to refrain from the use of chat acronyms, text message shorthand, excessive punctuation, and emoticons.

Recommendation 9: Ensure Competence in the Practice of Telepsychology

Lastly, as an overarching recommendation, clinicians are encouraged to take measures to ensure competence in the telepsychology services they provide. This includes acquiring the skills and knowledge necessary to comfortably use the technologies being utilized. At a minimum, this should include consultation with information technology professionals, web-design developers, expert clinicians in the field, and the like. Ongoing consultation with experts in the field of telepsychology will also be highly important for clinicians new to the practice, and all clinicians are encouraged to seek ongoing consultation regarding any boundary issues that arise at any point in the telepsychology treatment relationship. Additionally, although it is not yet a requirement for those practicing telepsychology, clinicians would also be wise to further their competence in this context by participating in training programs/continuing education courses which specifically address the provision of services related to telepsychology. Such courses can be accessed by visiting the following websites: apa.org, telehealth.org, www.zurinstitute.com, onlinetherapyinstitute.com, http://drkkolmes.com/for-clinicians/ceus/, and http://www.cce-global.org/DCC. Additionally, some states such as Florida now allow the option for obtaining an add-on credential in telepsychology (for information on this, please see: http://onlinetherapyinstitute.com). Lastly, the psychology field at large has begun to stress the importance of including courses related to telepsychology and the development of a professional online identity in clinical training programs and advances in this area should continue.

Summary

Mental health service delivery via the use of telecommunication technologies continues to expand at a rapid pace. With such advances come new challenges and issues that clinicians must consider in order to provide competent and ethical care in this mode of service delivery. Maintaining therapeutic boundaries within the telepsychology treatment relationship is one area in which challenges can occur. Such challenges include issues related to ensuring that the flexibility of service delivery via telepsychology does not lead to interventions that are less professional or high quality, as well as ensuring that the professionalism of the therapeutic relationship is established and maintained. Additional challenges relate to avoiding a number of temptations that could jeopardize the therapeutic relationship and potentially lead to ethical violations such as conducting therapeutic services while in public settings. However, by being aware of the issues related to these challenges and engaging in a number of proactive strategies, the telepsychology clinician can prevent many of these boundary issues from arising. Proactive strategies to prevent such issues include: establishing and maintaining a professional and consistent office environment, maintaining professional hours, ensuring privacy of clients and non-clients, preventing unintentional self-disclosures, providing consistent and timely feedback, managing excessive communications, and modeling appropriate self-boundaries. Being mindful of the unique boundary issues that can arise in telepsychology will aid clinicians who choose to utilize this form of service delivery. Most importantly, careful attention to boundary issues by clinicians will ensure that telepsychology services are conducted in a manner that is both ethical and efficacious.