Top 8 Reason NOT to do Telebehavioral Health
Updated: Oct 30, 2020
So you may have noticed that I am very pro-technology and pro-telehealth. I believe that telebehavioral health opens many (virtual) doors and allows access to services one might otherwise miss. Especially during the challenges imposed by COVID-19, telebehavioral health appears to be a glimmer of good news among a plethora of barriers.
While telebehavioral health has been demonstrated to be effective for a wide range of clients with a wide range of presenting concerns, it isn't a good fit for everyone. Some reasons for this poor fit are about the technology not allowing for adequate or minimal care for certain conditions, while others may relate more to client circumstances or even preference. So here they are--my top eight reasons NOT to do telebehavioral health (in no particular order).
Elevated risk for suicide or self-directed violence. This one may seem like a no-brainer to many people, but perhaps not to others. After all, who is in need of therapeutic services more than those who are struggling with thoughts or intentions to harm themselves? Let's get them connected with a competent therapist! However, the technological challenges of telebehavioral health, including the potential for a poor or lost connection or limited access to emergency resources, makes this a poor fit. Better to have a therapist in the flesh who can work with the delicate issues of self-directed violence and can respond to emergencies as needed.
Elevated risk of harm to others. Similar to the reason above, if a client is dealing with significant impulse control difficulties, particularly regarding impulses to harm self or others, telebehavioral health is likely to be a poor fit. But they should definitely be getting care! It is important that care be received face-to-face with a competent therapist.
Inadequate internet. These days high-speed internet access is wide-spread, but it is not universal. Perhaps this is no better illustrated than by the challenges faced by some families as their children's schools transition to (at least) partial distance learning models. It is important for a therapist and client to communicate smoothly, and usually this includes non-verbal communication as well, such as facial expressions, body movement, and positioning. Video teleconferencing uses a lot of data, and can be inhibited by slow or spotty internet connections. Lag, staggering audio, or even dropped calls can make therapy frustrating or even impossible. Most of the time internet speeds typically seen with cellular network hotspots are adequate (as is cable modem, satellite internet, or fiber optic networks), and most people probably do have access to adequate internet.
Inadequate device. Again, it seems these days that just about everyone has a high-powered smart phone in their pocket, a tablet computer, a laptop, and many other internet capable devices. But just like we discussed above, not everyone has access to such devices. Therapy can be difficult enough without the added stress of technological issues interfering with the work you need to do. Most of the time a smartphone or tablet computer is adequate for telebehavioral health sessions. Even better, a laptop or desktop computer with a webcam and physical keyboard can make it easier to engage in treatment exercises and complete assessment forms and other "paperwork." And of course the device should support audio for verbal communication.
Therapist not licensed in client's state. Admittedly this one gets a little into the technicalities of licensing law. Professional licensing is done at the state level--meaning that states have jurisdiction to determine who may legally practice as a behavioral health provider in their state. This is to protect you! Usually the place where the client lives, or more accurately where the client will be physically located for the therapy session, is considered the "originating site" of the telebehavioral health session. Think of it as a virtual house call rather than a virtual office visit. Because of this, most states require that a telebehavioral health provider must be licensed in the state where the client is located. Technology is marvelous at connecting people across the world, and certainly across state lines, and it opens up all sorts of opportunities to access care online. It can be tempting to just get on an online call regardless of where the client and therapist physically are. Or it may even be tempting to jump onto your scheduled session while on vacation, a business trip, or while visiting family. And often this may be totally fine. But be prepared for your therapist to ask at each session where you are physically for safety reasons, for connection alternatives in the event of technology failure, and to make sure they are in compliance with licensing law.
Client does not have access to a private physical setting. It is important that a therapy client feels comfortable and trusting enough to open up and talk about pretty personal, sensitive, and potentially distressing issues. This is significantly more difficult if they might be overheard, or worse, if their session may be intruded upon or even sabotaged by others. I say sabotaged, but really this doesn't have to be intentional or mean-spirited. Distractions, demands, noise, etc all take focus away from the point of the session: you! So I strongly recommend that telebehavioral health clients set aside a private space (at least a private room with a closed door--maybe even their parked car if that is all there is) with no other distractions, including television, email, texts, other electronics, children, significant other, pets, etc. Additionally I strongly recommend the use of headphones both to improve sound quality and to protect confidentiality of your information!
Client prefers in-person therapy. As with most of the items on this list, this one also seems obvious. And given the choice, perhaps many people would prefer to meet with a therapist in person but may feel like their choices are limited in the current COVID-19 restrictions. So for some, telebehavioral health is an acceptable alternative while we all wait for life to return to normal. But for others, in-person therapy feels like the only option given their specific concerns, situation, or access to technology. THAT PREFERENCE IS VALID. You are completely allowed to feel this way! And fortunately there are therapists that are still able to see clients in person. It may be a little more challenging than in the past to find a therapist with available in-person sessions available, but they are out there! Try searching on psychologytoday.com or therapyden.com for a therapist that meets your needs.
Therapist is not able to provide a HIPAA-compliant, secure telebehavioral health platform. This one is tougher for a potential client to judge easily. The Health Information Portability and Accountability Act (HIPAA) with its related security requirements mandates that communications that include personal health information (PHI) be secured against intrusion or access from unauthorized others. Basically that means that whatever communications platform your therapist uses should meet the security requirements of HIPAA, usually including a "business associates agreement" (BAA) restricting access to or use of personal data by the software provider. Several common communications platforms (for example Skype, Hangouts, Facetime) do not necessarily provide the required security in their common, publicly available forms. Some of these platforms offer a higher-security version of their software for use in telehealth applications. Your therapist should be familiar with HIPAA requirements for telehealth as well as be able to discuss with you what security practices they use to safeguard your privacy and confidentiality. Otherwise you might consider seeking services elsewhere. (For what it is worth, Helam Behavioral Health uses Simple Practice as its primary telehealth platform and Doxy.me as a backup, both of which are HIPAA compliant. BAAs are on file for both platforms.)
Honestly I tried to come up with a top 10 list. Ten seems like a more common size for a top X list. :) But frankly I had a hard time thinking of that many reasons not to do telebehavioral health. I freely admit that overall I think telebehavioral health is a fantastic way to access high-quality care in a convenient, private, safe manner for most clients. But you may be wondering if it is right for you.
If you have questions or concerns about whether telebehavioral health is a good fit for your personal circumstances, talk to your therapist about those concerns. They can help you consider the pros and cons specific to you. If you are looking for a therapist and want to discuss telebehavioral health as an option, an initial phone consultation can be a great way to decide together if telebehavioral health is right for you.