Tuesday, July 1, 2014

Telemedicine and Our Future Care

Large areas of the United States are isolated from a variety of medical and other therapeutic services.  How far some towns are from any or little in the way of therapeutic resources contributes to a lack of help to people in need. How can a family get help for a child  or, indeed, the entire family, if the nearest mental health provider is 50 miles away or even 25 miles distant? Guidelines are currently being provided for psychologists  and a physicians' group is also lobbying for changes in Federal laws in order to provide aid in areas where a physician or medical specialist is not currently licensed. 

The logic behind these changes makes perfect sense when you consider that there are areas where a specialist may be needed but none practices in that area. Think geropsychiatrists and you have one specialist that is hard to find in major areas. Suppose there were a sexual abuse survivor, could they find adequate services in their area? Chances are that in vast areas of this country they could not. What then should they do? 

When I was teaching doctoral students this situation did arise in the western portion of the U.S. The student, who was a practicing therapist in a rural community, had a young woman who was requesting specialized services, services which the therapist did not have training or expertise to provide. The dilemma for the therapist was that, even if she wanted to provide therapy, she could not find someone with the experience who could provide supervision to her. 

Without supervision, what could she do? The decision would have to lie entirely with her and, although this was an extremely uncomfortable situation, the therapist felt obligated to do something for this woman. So, she arranged to speak weekly with a specialist several states away who agreed to provide some form of supervision. It was an expensive phone call and the client was being seen on a pro bono basis. The therapist was now experiencing a serious financial drain on her resources. 

Would this be acceptable in all circumstances? The legality of this question must be taken up by each state's licensing board and we have no way of knowing how it would turn out. Compassion, however, must be a major element of the therapeutic alliance and this therapist was willing to risk whatever might come her way in order to help this woman.

Every area cannot provide all the services needed by people living in these communities. Should they be denied services simply because both the Federal government and states' licensing boards have not entered the 21st Century? It would seem counter to everything we believe. Everyone, no matter where they live, should have services available to them.

A portion of the APA guidelines indicate: "At the present time, there are a number of jurisdictions without specific laws that govern the provision of psychological services utilizing telecommunication technologies. When providing telepsychology services in these jurisdictions, psychologists are encouraged to be aware of any opinion or declaratory statement issued by the relevant regulatory bodies and/or other practitioner licensing boards that may help inform them of the legal and regulatory requirements involved when delivering telepsychology services within those jurisdictions.."

A quick read on this statement, therefore, means that the psychologist is on their own and must carefully research all the relevant laws and board regulations applicable to their particular situation. But will this be sufficient? I can envision situations where, with the best of intentions, a psychologist could be sued by an unhappy client and such a case will be closely watched. If there were something like the "Good Samaritan" laws used in accident situations where medical personnel or anyone else provides emergency services, it might make the situation more palatable.

The case calls to mind a dilemma which arose in a graduate class years ago. A student, not mine, asked the professor what he should do in a particular situation. The situation? The student, in a therapeutic setting where he was being supervised, had been told by a client that he had killed someone 10 years ago. Should the student make legal authorities aware of this? The prof suggested that the student contact the APA because, clearly, psychologists are required to report present and future crimes, but what about prior crimes? You may think they have to report, but would this come under the same provisions as things revealed within the confines of the Roman Catholic confessional? Is there some sort of protection which must be exercised?

How did the APA respond to the student? They told him that he must do what he must do. Oh, that makes it eminently clear, doesn't it? The case resolution was never discussed beyond this point and no one knew what he did regarding this past crime. We would have expected a bit more clarification here from the organization that is supposed to offer such assistance. How will they respond in the future when issues of teletherapy come up?

The issue of telemedicine/teletherapy is relevant and technologies such as Skype offer something more than would be feasible via a phone conversation. Will we see changes and, if so, what restrictions will be imposed? Such use of technology can only help those in need. Of course, I have not dealt with the probable difficulties of billing and receiving insurance reimbursement for these session. That will be another thorny issue.