The chapter begins by elucidating the definitions and background of telemental health after which it proceeds to explicate the technological tools which are necessary for the practice of telemental health delivery, by providing a brief history of telemental health. This section also deals with the technological tools required for telemental health delivery including video teleconferencing, internet connections and website designs.
The effectiveness and usefulness of telemental healthcare are discussed in the following section where the uses of telemental health through video conferencing are discussed in different scenarios of counseling. The next section discusses the important ethical and legal issues affecting the delivery and services of telemental health are discussed from the perspective of counselors and professional as well as clients who receive this form of treatment. Finally, the paper will compare the traditional face-to-face counseling with online counseling and the limitations on telemental healthcare.
Introduction and Background
With the rapid advancements in the filed of communication, digital technology, satellite television, computers and the internet, life has become faster than ever. People have become busier and are constantly looking for ways and means to reduce time and costs to conduct business, educate, and for other essential services. The latest advancements in the arena of communication have made the world a smaller place and terms such as ‘distance learning’, ‘distance education’, ‘e-buying’, ‘e-selling’ becoming an integral part of life. Accordingly, the health care industry which is an important domain has also evolved and communications technology has been greatly impacted by this technological revolution and has become a fundamental aspect of human life and areas of health care deliverance (McLaren, 2003).
The express developments in the filed of communication, particularly the cell phone and the internet have today brought about a revolution in the manner in which business is conducted, the world over. Geographical barriers have been transcended and the world community is becoming smaller than ever. One such health care system which can be executed with the help and aid of the technological devices and advancements in communication is telemental health.
Telemental health has by defined Jerome et al. (2000) as the execution of health care “over a distance” with the aid of “electronic and communication technology” (p. 407). A more descriptive definition is provided by VandenBos and Williams (2000) who state that telehealth involves the “provision” of “real-time service” even in the event of physical separation of the client from the health care provider, with the aid of “some communication device” (p. 490). The deliverance of mental healthcare also known as telemedicine takes place through the “transmission of data over distance” and is a useful and effective link between the healthcare provider and the patient (McLaren, 2003).
The term telehealth has been distinguished from telemedicine as the former is a broader and more comprehensive term which “encompasses” all the aspects of health care (Stamm, 1998). Some researchers prefer the term telehealth to telemedicine since it incorporates health care providers who have been trained in non-medical environments including psychologists, nurses, psychotherapists, social workers and other providers of mental health care (Conrad, 1998).
The National Institute of Medicine (1996) defines telemedicine as the means of providing health care to patients with the help of “electronic information and communication technologies” when there are physical boundaries between the patient and the health care provider. Telemedicine entails the communication of medical data over a distance, using the means of communication devices such as the telephone, computer and the internet.
The concept is not novel and the first call for help via the medium of the telephone was made to an associate of Alexander Graham Bell by a person who had spilled acid and needed help (McLaren, 2003). In 1906, the electrocardiograph was invented by Wilhelm Einthoven (1906) who began to conduct trials and experiments of remote consultation using the medium of the telephonic network. Medical telecommunication soon began to be experimented on an individual basis during the 1950s and 1960s with the advancement of technology and communication devices.
The medium of television was also used as early as 1955 when live transmission of therapy sessions to students was successfully attempted by Wittson & Dutton (1956) at the Nebraska Psychiatric Institute. The 1990s witnessed numerous experiments and trials with distant consultations with the help of videoconferencing or special cameras. Research affirms that the early applications and tools for the conduction of telehealth were through closed circuit cameras with television links for delivering mental health care at a distance (Preston, 1993). However, the major move towards telehealth and deliverance of healthcare to remote locations witnessed an upsurge with the rapid advancements in the fields of technology and communication and the inexplicable growth of the internet in the 1990s.
The facility of telemedicine especially telepsychiatry has been reported to be particularly beneficial as it can be used in different settings including clinics, clients’ residences and even prisons (Rothchild E, 1999). The scope of telepsychiatry in providing telemental health services to deaf people has been proved to be immense (University of Rochester). Research has proved the scope and effectiveness of telemental health and its “enormous opportunities for clinical care, education, research and administration” due to its feasibility and wide ranging “models of care and consultation” due to which it “satisfies patients and providers” (Hilty et al., 2002).
Technology used in Telemental Health
Since telemedicine primarily involves the “transmission of data over a distance”, it is necessary to “link the health care provider with the patient’s home” (McLauren, 2003) so that there is an exchange which enables the counselor, doctor or professional to communicate (directly or otherwise) with the patients or clients. The deliverance of healthcare to patients at remote places is possible due to the several technological tools and methods which are available in the field of communication.
The telephone is the most commonly used application for telehealth and with the unprecedented growth in the use of cell phones telehealth communication through the telephone is most likely to rise (Vandenbos & Williams, 2000). The other more commonly used tools and applications for the effective deliverance of mental healthcare at a distance are audio and video conferencing, the telephone postal services and e-mail or the internet through the chat room (McLauren, 2003). Telehealth can also be carried out through the traditional non internet based tools such as closed circuit television or satellite transmissions. The two fundamental kinds of technology used in telemental health are ‘store-and-forward’ and ‘video conferencing’ (Grisby, 1997; Stamm, 1998).
This technology is commonly used in telemental health and is second only to the telephone in its wide usage and feasibility. The primary data is stored and saved into the computer and can be forwarded to another person at any given time. This technology does not necessitate the synchronous presence of either the sender or the receiver as the data can be created, shaped, shared and applied through the medium of e-mail, faxes, photographs or even radiological images (Coiera, 1997).
The essential requirements are a computer and an internet connection for the education, administration and telemental health delivery and services to patients and clients. The store-and-forward technology can also be practiced through exchange between participants, for instance the self-help groups which can be found on-line, guided by professionals (Stamm, 1998), and through popular websites which are accessible to individuals who use the internet and provide important information on health and fitness.
The use of video conferencing is more commonly used in telepsychiatry and the actual term “video conferencing” also popularly known as “video link” has been borrowed from the domain of business and denotes the transmission of real and live sound and moving pictures (McLauren, 2003). Video conferencing enables the transmission of real time audio and video data for direct and face-to-face interaction between the participants and essentially requires computers, monitors and cameras. Other terms used for this technology are inter-active television (IATV; Jerome & Zaylor, 2000), Videoconferencing technology (VCT).
Stamm (1998) notes the four types of VTC units; dedicated VTC systems, desktop computers with telephone line connections for data transmission, desktop computers with internet connections for data transmission and retrofit units which use televisions and the telephone for transmission of data.
The primary reason for preferring video conferencing for mental healthcare delivery is due to the reduced healthcare costs and the time and energy saved in commuting, which automatically makes the consultation process simpler and easier (McLauren, 2003). An important advantage of telemental healthcare is the fact that the patients can easily choose to end the session without actually offending the interviewer (Kavanagh & Yellowlees, 1995). Teleconferencing is also believed to benefit family and child conferencing as families would be able to access the consultation and counseling sessions without having to visit the hospitals or clinics due to the fear or stigma associated with it (Straker et al., 1976).
Elford et al, (2000) affirm that many users prefer video conferencing in telemental healthcare as this has the ability to reach patients in remote geographical locales, without the actual need for face to face interviews and sessions. Telemental health through video conferencing is also gaining immense popularity in prison houses for the deliverance psychiatry counseling and consultations and has been effectively used in the prisons of America in the states of Texas and Ohio.
Thus it is apparent that the use of video conferencing is beneficial to the users of this technology due to the easy availability and access to the required information and the deliverance of telemental healthcare in remote places where the services had been unavailable previously in addition to the reduced costs.
Effectiveness and usefulness of Telemental Health
Telemental health has witnessed tremendous growth and development since the 1990s, due to the widespread use of the internet. With greater cost effectiveness and user friendliness of the information and communication technology, telemedicine and deliverance of telemental health services has become a more practical and viable option to the participants. The National Association of Home Care (1999) affirms that there are more than twenty thousand home care providers in America who serve patients with critical illnesses. Research also confirms that America alone, there are half a billion home-health visits by nurses every year (Goldberg, 1995).
With the rising costs in health care, traditional home care could prove to be very expensive and economically unfeasible for America (Little 1992; Laboratories 1996). In contrast, telemedicine allows professionals to diagnose, treat and even monitor patients without actually having the participants commute for communication, and has the potential to reduce costs substantially (Barrett and Brecht 1998).
Telemental health delivery can take place very easily and cost effectively as it requires fulfillment of four basic necessities; technology such as work stations and medical devices or peripherals, communication links such as the Internet and the telephone, health care professionals and patients who can function online and policies and protocols (Coiera, 1997). Since the common technologies used for telemental health include the telephone, internet, home computers, fax machines and software, all of which are not very expensive and can be easily purchased from the local stores (Jerant & Epperly, 1997).
Proponents of telemental health argue that the costs of using such services are highly cost effective as they could serve patients and clients in geographically remote places (Winslade, 1995). Telemental health services which do not require active interactions between the service providers and the clients can effectively communicate without actually being ‘physically’ present reducing the physical dependency of service givers. Since access and communication between patients and professionals is simpler and easier, the professionals would be able to see and monitor their patients more often (Winslade, 1995).
Telemental health services with the aid of the internet and videoconferencing would enable not only patients but also family care givers to access health professionals in the comforts of their homes without actually having to visit them. The senior and the elderly patients or those who are persistently unwell would not have to worry about traveling and waiting endlessly at the clinics. The families and caregivers of these patients would also benefit tremendously due to the reduced fear and apprehension of the elders traveling alone or the inconvenience and troubles of having to take these patients to visits their respective health care professionals (Winslade, 1995).
The scope of telemental health care is more pronounced in areas pertaining to child and adolescent psychiatry through the technological toll of video conferencing (Pesamaa et al., 2004). Experiments in the field of tele psychiatry pertaining to child and adolescent care began in the early seventies and continued through the nineties and its first use was reported by Jerome (1986) in child and adolescent psychiatry. Research confirms the use of videoconferencing in child and adolescent psychiatry for “clinical work and education” purposes (Pesamaa et al., 2004).
In the domain of clinical work, there have been several reports where telepsychiatry has been used for several purposes “in the treatment of depression, anorexia, conduct disorder and attention deficit hyperactivity disorder (ADHD) (Pesamaa et al., 2004). Additional use has been realized in the potential of videoconferencing to help children who are in crisis (Erner, 1999a, 1999b). Success has also been recorded in the use of communications via videoconferencing, between two professional for treating children with conduct disorders for which only a single session of videoconferencing was required (Hilty et al., 2000; Miller et al., 2002).
The use of video conferencing and face-to-face meetings has been found to be effective in diagnosing and treating children with psychiatric problems (Elford et al., 2000; Nelson et al., 2003) the use of videoconferencing for conducting group therapy on children aged 8 years to 14 years with depression has also been found to be extremely successful (Nelson et al., 2003). Additionally, high levels of satisfaction were noted among the parents and children who participated in the psychiatric treatments through videoconferencing (Elford et al., 2000; Kopel et al., 2001; Mitchell et al., 2000).
Videoconferencing has been found to be particularly helpful in family therapy. Through the means of videoconferencing, the professional uses the traditional methods of family therapy. The medium of videoconferencing enables all the family members to take part in the therapy and facilitates their input (Dwyer, 1973). As a result, interaction and support was possible from all the members of the family which would otherwise have been difficult in a traditional face-to-face encounter, since the patient was far away from the family.
Since regular session involving all the family members is essential, family teletherapy has immense promise, as it allows the family members to be present in all the sessions which would be somewhat difficult if they had to travel together at the same time due to practical obstacles. In family therapy session, it is important for the therapist and the family members to listen to the others, enhancing the important listening skills of the participants (Elford et al., 2000; Nelson et al., 2003). The use of teletherapy for family counseling can also be highly effective in the establishment of co-operative relationships between the family members by discussion involving the major problems of the family including obedience, the roles of children and parents and other such critical issues. (Fisher, 1989)
Research in the field of telepsychiatry by Hilty et al. (2002) points to its many uses of being “generally feasible” since it “offers a number of models of care and consultation, in general satisfies patients and providers, and has positive and negative effects on interpersonal behavior”. Hilty et al., (2002) also confirm the potential of telepsychiatry in its ability to bring “enormous opportunities for clinical care, education, research and administration”. Researchers have reported positively and affirmed that patients and clients have illustrated satisfaction of clients in consultation and practice of telemedicine (Callahan et al., 1998).
Thus it is apparent that the use and potential of telemental health and videoconferencing for treating children and adolescents residing in remote places is immense. The potential of videoconferencing in conducting therapy sessions for children and adolescents has immense promise due to the saving in costs, time and the need to travel. Family consultations and therapies could be carried out effectively without the participants having to leave their homes. However, there are several ethical and legal concerns of using this technology and videoconferencing, which have been discussed in the following section.
Ethics and Legal Issues in Mental Health Delivery
In spite of the numerous uses and potential of telemental health delivery, there are some serious concerns and issues related to it. One such issue of prime importance is the ethical and legal aspect of telemental health delivery. The need for a separate code of ethics for telemental health counseling has been recognized by American Psychological Association (APA, 1997) which affirmed in a statement called the “APA Statement on Services by Telephone, Teleconferencing, and Internet” that “the Ethics Code is not specific with regard to… any electronically provided services as such and has no rules prohibiting such services” (p. 1).
The need for developing standards and ethics for telemental health counseling was also realized by Courtalnd Lee (1998) who states that “WebCounseling is inevitable because as long as the technology is there, people are going to use it” (p. 2).
Acknowledging the necessity of developing ethics standards, Lee (1998) applauded the NBCC for setting the standards of Webcounseling and accepts that the ACA had received “a good foundation to do that” from the NBCC. The Governing Council of the ACA consented upon the setting the guidelines for the “Ethics Standards for internet Online Counseling” (Shaw & Shaw, 2001) suitable for “the use of electronic communications over the Internet to provide online counseling services” which were to be used “only in conjunction with the ACA Code of Ethics and Standards of Practice” (ACA, 1999, p. 1)”. It should be noted that the standards of the ACA are stricter on online counselors as compared to any other standards or guidelines (Holmes, 2000).
Telemental health counseling also known as “Webcounseling” is defined by the National Board for Certified Counselors as “the practice of professional counseling and information delivery that occurs when client(s) and counselor are in separate or remote locations and utilize electronic means to communicate over the Internet” (Bloom, 1997, p. 2). The standards and guidelines of the NBCC were updated in November 2001 in which there is clear classification between “Face-to-Face and Technology-Assisted Distance Counseling” (NBCC, 2001).
With unprecedented human traffic on the internet, it is believed that one hundred and twenty eight million Americans access the net out of which nearly two-thirds search the internet for health related information (Shaw & Shaw, 2006). According to Courtland Lee, former president of the American Counseling Association (ACA) telemental healthcare or online counseling must be “ethically sound” and requires a concrete code of ethics for making it professional (Lee, 1998). Researchers have also stressed on a “bond of trust between the counselor and the client” as an integral part of the ethics of the counseling field (Cohen & Cohen, 1999) since the clients are dependant on the professional for the treatment of difficult issues relate to their mental health (Bayles, 1989).
Dependence and liability
Cohen & Cohen (1999) assert the importance of honesty and competence as the prime qualities which are crucial for establishing a trustworthy relationship between the client and the professional. It is therefore necessary for professional who work with the aid of internet and videoconferencing to provide their qualification details to the clients (Koocher and Keith-Spiegel, 1998). The degree of the professional is a primary credential which would enable the clients to effectively gauge the competence of the counselor and whether the institution from where the degree has been obtained is accredited. Additionally, secondary credentials are also vital for the clients to determine whether the counselor has the necessary licensures and certifications to practice and serve clients.
The professionals are also accountable to the clients for being available at the specified time and cannot abandon the client for which they could be answerable in a court of law. Abandonment refers to the failure to be available to for pre-decided appointments, the failure to respond to emergency requests for treatment, the failure to provide qualified substitutes during vacations or periods of absence and the termination of the counseling session and relationship by the counselor or the professional (Corey et al., 1998).
Duty to warn and protect
The ‘duty to warn and protect’ has become an essential component of online counseling following an incident in which the counselor was held liable after the client had carried out a murder threat which was made in the presence of the counselor during the session (Kagle & Kopels, 1994; Pergament, 1998). Counselors are therefore required to identify those clients who have the potential to harm others so that the persons at risk of being harmed can be duly protected (Bednar, Bednar, Lambert, & Waite, 1991). To accomplish this, counselors are required to have all the details of the clients including their names and complete addresses before initiating the sessions of counseling with the clients, so that the respective authorities can be informed about the clients’ details in a timely manner, failing which, the counselor could be held liable (Shaw & Shaw, 2006).
Additionally, counselors are also obligated “to protect clients who pose a danger to themselves” since they may be aware of the suicidal tendencies of clients and “the evaluation and management of suicidal risk are essential responsibilities of any counselor” (Shaw & Shaw, 2006). Fujimura, Weis, & Cochran (1985) assert that counselors are expected to recognize and take seriously any “cry for help” signals from the clients and must posses the crucial knowledge to appropriately mediate in such situations. In order to effectively take care of all such situations, counselors are expected to have a “signed informed consent that clearly states situations in which confidentiality must be breached” from clients (Shaw & Shaw, 2006).
Ethical issues in Telemental counseling for children and adolescents
Research and studies confirm that adolescents who access the internet more repeatedly have a greater probability of being “depressed and socially isolated” (Hughes, 1999; Kraut et al., 1998; Sanders et al., 2000; Shaw & Shaw, 2006; Weitzman, 2001; Young & Rogers, 1998). This makes it more likely for teenagers to seek telemental support and treatment for severe problems including depression and anxiety through the medium of the internet and may display tendencies of suicide. Therefore, there is an ethical concern over the use of the internet by adolescents and children below the age of 18, who could be using telemental online heath services.
Research confirms the likelihood of teenagers in the age group of twelve and seventeen using accessing the internet (Pew Internet & American Life Project, 2001) which increases the probability of adolescents using professional telemental counseling services. Telemental health counselors and professional must take due precaution and have written consents to be signed by parents or guardians in case of users below eighteen years of age. As a preemptive measure, telemental health counseling sites must have the necessary procedure to identify the age of their clients and considering the possibility of the adolescents to lie, online professionals must also take appropriate measure to affirm that they are dealing with adult clients and in the cases of adolescents, with the consent of their guardians (Shaw & Shaw, 2006).
Issue of Confidentiality in Telemental health
Telemental health counseling has been under close scrutiny for the issues of confidentiality or rather the lack of it and the domain of mental health obligates professionals to safeguard the information and identity of their clients (Corey et al., 1998). Telemental health online counseling and treatment involves the use of e-mails and the internet through websites, which can be accessed by administrators, government agencies and companies, to monitor customer usage (Rose, 1995; Wilson, 1995) and employee usage (American Management Association, 1997; Dickson, 1998; Levine, 2000).
There is additional risk to the security and confidentiality of clients and patients from unsecured websites (Glossbrenner, 1990) and computer hackers (Doligez, 2002). As a result of these multiple problems, it is difficult to assure confidentiality to telemental clients (Rahav, 1994) and patients and Verisign (2002) necessitates the minimization of such risks to by providing secure sites through the means of Secure Safety Layer.
There is no “single uniform regulation” for Telemental or online counselors and “all counselors are subject to the state laws and local statutes in their area of practice (Shaw & Shaw, 2002). However, telemental counseling involves not only the “Internet counselor’s location” but also the “Internet client’s location” (NBCC, 2001) which necessitates respect to the laws of the counselor’s state as well as the sate of the client (ACA, 1995). Owing to the “wide variability inherent in the jurisdiction of online counselors” (Shaw & Shaw, 2002), standards for online counseling have been adopted by the National Board for Certified Counselors (NBCC). The primary intention of “creating standards for counseling over the Internet” is “curtail unprofessional growth of the techniques” (Morrissey, 1997) and effectively reduce the risks and dangers to the “Webcounselors and Webclients alike” (Bloom, 1997).
Online Counseling versus traditional Face-to-Face Counseling
Ever since telemental health or online counseling has been initiated, there have been numerous arguments regarding the effectiveness of online counseling as compared to Face-to-face counseling. While some opponents of telemental health counseling declare that it has no future, its opponents assert that counseling and technology has immense potential due to the overlapping between the two domains.
Sussman (1998) points out the benefits of telemental health services to those clients who are located in geographically remote areas and can avail of these services through the medium of the internet. Sussman (1998) also asserts that the availability of online telemental health services would be beneficial to those clients who are physically disabled and to those who are seriously ill, due to which leaving the homes for such services would be difficult and sometimes impossible.
Proponents also assert that telemental health services are specially advantageous to clients who would not be comfortable using traditional counseling (Alleman, 2002; Grohol, 2001; Morrissey, 1997). There are some clients who would not be comfortable facing counselors and would prefer to express themselves and communicate through the written format rather than verbal communication (Grohol, 1999b, 2001; ISMHO, 2000).
However, researchers have pointed out some disadvantages of telemental healthcare and assert that the medium of internet and technology makes it difficult for clients to maintain their confidentiality and put them at an additional risk of being exposed (Sussman, 1998). There are also issues regarding the lack of effective nonverbal communication including the eye contact, body language, the tone, posture and the facial expressions, which play a vital role in gauging the state of the client, in addition to the misunderstandings which could be created through this medium (Bloom, 1997, 1998; Grohol, 1999b; ISMHO, 2000; Lee, 1998; Sussman, 1998).
Thus, it is believed that online counseling may not be suitable for certain kinds of serious problems which necessitate real presence of the counselor and the client. Some of such problems have been identified as issues relating to sexual abuse, clients having problems due to violent relationships, eating disorders and other serious psychological problems (Bloom, 1997). The ACA (1995) outlines online counseling is not suitable for clients having suicidal and homicidal tendencies.
Bloom (1997) points that there are dangers associated with online counseling owing to the different jurisdiction lines of different states. Besides, online or internet counseling would not facilitate the development of a therapeutic relationship between the professional and the client as is done in face-to0face counseling (Bloom, 1998; Morrissey, 1997). Sussman (1998) also raises the issue of the problems in handling emergency situations through online or internet counseling.
Thus we see that telemental healthcare has tremendous potential in the globalized world, in which there is much emphasis on saving time, costs and energy. By virtue of its ability to fulfill all these conditions, telemental healthcare delivery can prove to be extremely beneficial and purposeful. However, there are some concerns regarding the legal and ethical aspects, which if resolved successfully, telemental healthcare could very well become the optimal counseling and mental healthcare service of the present as well as the future generations.
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