By Erin Cusick
Editor's note: Since this interview was initially published in 2014, some information may be out of date.
Since the inception of psychoanalysis, the one-on-one meeting of therapist and client has remained largely unchanged. The practice of therapy is rooted in interpersonal communication, and thus, modern forms of technology that facilitate communication—whether through interactive video, audio, or text—should lend themselves well to the practice of psychotherapy.
Indeed, the popularity and accessibility of telemental health has risen rapidly over recent years, but it still plays a relatively minor role in the mental health field. Many questions linger regarding telemental health approaches and technology in therapy. Could it be the mental health field is reluctant to embrace technological advancements, even those that may enhance therapeutic outcomes? Does a therapist’s inclination toward interactive, interpersonal relationships preclude his or her ability to adapt to and integrate modern technology into a therapy practice? Are mental health professionals technology resistant or even phobic?
Reluctance may play a part in the equation, but layers of complexity come into play as mental health professionals attempt to integrate technology while complying with HIPAA standards, HITECH regulations, and state laws; adapting to health care reform; and maintaining the specific code of ethics that governs their practices. Concerns over whether it's safe to email and text with clients, offer online therapy, or implement a digital practice management system can seem unduly complicated when weighing regulatory standards against the risks involved in adopting new technology in a therapy practice.
Weighing in on some of these concerns, Roy Huggins and Rob Reinhardt answer some of the initial questions therapists may have as they consider whether to upgrade their practices with emerging forms of technology. This is the first interview in a two-part series. Roy Huggins, LPC, NCC, is the owner of the company Person-Centered Tech, a technology-consulting firm for the helping professions. Rob Reinhardt, LPCS, MEd, NCC, is the owner of Tame Your Practice, a business-consulting firm offering guidance on all aspects of running a business, from marketing to technology.
Roy and Rob's upcoming continuing education presentation for GoodTherapy.org, 2014 American Counseling Association Code of Ethics versus HIPAA: Technology in Counseling and Mental Health takes place at 9 a.m. on October 10, 2014, and is available for two CE credits at no additional cost to GoodTherapy.org members.
First of all, what piece of technology do you think has changed therapy the most?
Roy Huggins (RH): I think the telephone was the biggest agent of change. It started the long-yet-inevitable process of taking therapy outside of the private, siloed office and facilitated quick communication between sessions. Email and texting accelerated that change so fast and so big that it got away from us a bit. These are signs of a changing society, and of course, we need to keep up with those changes.
Rob Reinhardt (RR): I wonder if we'll see a singular piece of technology, like the telephone, that will have such an impact again. Perhaps as virtual world/hologram technologies become so advanced that people can meet “in person” without actually being there and, additionally, manipulate the virtual environment around them as part of therapeutic technique. It's more likely it will just be another thing that is a gradual progression. Akin to the impact of the telephone are automated appointment reminders and the ability for clients to schedule and cancel appointments online.
Which forms of technology do you feel every therapist should become familiar with?
RR: First and foremost, therapists should become familiar with the laws (HIPAA/HITECH) and ethics codes guiding their use of technology. These will greatly shape which forms of technology they use and how they use them in their practice. It's one thing when you realize how convenient and helpful Skype can be in your work and another altogether to learn that it presents serious challenges to HIPAA compliance.
Evaluating how technology might aid one’s practice is important, and it's very difficult to pinpoint a singular piece of technology that will benefit every clinician. On the whole, however, I strongly advocate for therapists to consider use of a Practice Management System (which typically integrates an EMR/EHR). A well-chosen practice management system can greatly increase the efficiency of a practice, handling scheduling, billing, and insurance filing while reducing overhead costs and providing improved quality of service to clients. That, in essence, is what makes it such an important item to consider.
RH: Just like Rob, it’s not about specific forms of technology, for me. I really think every therapist should have a basic, working understanding of what a network is. That is, they should understand what a WiFi router does and have a very simple mental picture of how an email crosses the Internet. In my experience, a huge amount of confusion regarding digital confidentiality issues comes from the fact that the movement of digital information is invisible. We can easily conceptualize what happens when we send a letter by post. Most of us can’t conceptualize what happens when we send an email, however. Thus we have a hard time conceptualizing how to use encryption with email, and when encryption is useful or overkill, and the like.
On that note, can therapists safely email with clients? Do the emails need to be encrypted? Does encryption mean secure?
RR: Encryption means that a message is encoded in such a manner that only the person with the encryption key (like a “decoder ring”) can open and read it. While there are no guarantees when it comes to data security, encryption is currently the closest you can come to a guarantee. It's not “required,” but is considered a “best practice.” However, HIPAA provides clients the right to request that protected health information be sent via unsecure (i.e. unencrypted) means.
I strongly recommend that clinicians incorporate statements about encryption, email, and electronic data security into their informed consent since it's our duty to ensure our clients understand the implications of not using encryption. From there, if they choose to receive some information over email, it's important to document that choice and incorporate their signature.
RH: That’s right—HIPAA allows clients to ask us to email them whatever they wish, and we simply need to inform them of the risks of doing so. However, the ACA Code of Ethics has a higher standard of risk-related information-giving and discussion that must be achieved before emailing. Also, many state laws, licensing boards, and professional guidance documents want us to use encryption specifically or technical security measures in general when performing therapy by email (and some boards actually ban email therapy.) These are good examples of how HIPAA is not the only player in determining the standards and regulations involved in our approach to security.
It is not uncommon to conflate “security” with “encryption.” We see this not only in everyday speech but also in some professional guidelines and ethics codes. Security is as much about coming up with sensible policies—such as “I will not leave my laptop on the coffee shop table when I go to the bathroom,” or “I will only use ordinary email with clients to discuss matters of scheduling”—as much as it is about technical security measures, like encrypting emails or putting passwords on smart phones.
The overemphasis on technical measures is one that has long been addressed in the professional security world but is still largely unheeded in mental health. Not to say that encryption isn’t important. Encryption is usually the most important technical measure we have when it comes to protecting the privacy of information. But it is not the same as “security.” I would say encryption is to information security as listening skills are to counseling. It’s essential to nearly every situation, but is not the whole enchilada.
What is the best use of technology you’ve seen a therapist use to help a client?
RR: I hesitate to choose anything as the “best.” Any use of technology, from outcome measures to secure messaging, has the potential to aid in the therapeutic process. One use I've found to be particularly interesting is “Avatar Therapy” or the use of virtual environments to connect with clients who aren't good candidates for “talk therapy.” The use of Avatars, or virtual representations in a computer game or world, can allow someone to express things they struggle with, or embody emotions or other facets of themselves. For example, this has been used with some success to open up dialogue between someone with schizophrenia and one of the voices they have been hearing. Avatars are also being used to help clients on the autism spectrum to learn and practice social skills.
RH: I’ve always been fond of mindfulness-based addiction therapists' use of texting and other messaging tech to help keep their clients on task with randomly sent reminders like, “Look at something natural nearby you and breathe five times.” I remember that in my meditation training, the teacher quipped about how he can’t follow us around and keep reminding us to be mindful. Modern communications tech can do that to a certain extent, however.
What suggestions do you have for therapists who are beginning to integrate technology into their practices, such as digital records or electronic communications with clients?
RR: They should start by having a clear understanding of their reasons for implementing technology. With my consulting clients, I always suggest they start with their short- and long-term visions for their private practice. What do they want their practice to look like next year and five years from now? From there, technology can be an integral part of the plan for creating that vision rather than something they're doing just because everyone else is. All too often I've run into mental health professionals who have implemented a specific technology product because they've heard raves from colleagues, only to find that it isn't actually a good fit for their practice. A lot of time, energy, and money can be saved by having a clear plan up front.
RH: Absolutely, along the same lines, I would say they should make sure to take an intentional and holistic approach to adopting tools for their practices. We are encouraged by mass-market advertising and personal habit to pick up new gear and software willy-nilly or simply based on loyalty or herding (e.g. “I got an iPhone because that’s what my friends have”). As consumers, this may be perfectly fine. As clinicians, we want to consider how our tools are providing benefit to clients and/or to ourselves and how we’re making sure we’re not doing harm by using them. Keeping in mind one’s needs as a clinician, the legal regulations from HIPAA/HITECH and state laws, and the standards set by ethics codes and professional guidelines will likely be a part of doing that.
Thank you both! This has been a valuable and insightful conversation, and we look forward to following up with more questions regarding ethics, security, and technology in part II of this series next week: "Technology and Therapy, Part II: Ethics and Security."