Competencies in

Teletherapy
Table of Contents
1. Purpose of this Guide 1

2. About the Authors 2

3. Introduction 3

4. TDC Survey Results 4

5. Training Needs/Wants 6

6. Benefits of Telehealth 7

7. Challenges of Telehealth 8

8. Ethical & Legal Considerations 9

9. Modalities: Pros & Cons 11

10. Decision Tree Screening 13

11. Initial Session Checklist 14

12. Session Checklist 15

13. Risk and Crisis Management 16

14. References 17

15. Notes 18

https:/ therapistdevelopmentcenter.com/products/telehealth-competencies-bundle-9-hours
 About Therapist Development Center
Founded in 2010 by Amanda Rowan, LCSW, the Therapist Development Center
has assisted 100,000+ social workers and MFTs pass their licensing exams.
Our mission is to provide relevant, engaging, and meaningful training and career
support to mental health professionals through quality licensing test preparation
and continuing education.

Purpose of this Guide

The purpose of this guide is to provide a comprehensive and clinically relevant
overview of teletherapy. In addition to reviewing the legal and ethical requirements,
the guide also provides a historical context, a survey on the current attitudes and
competencies of teletherapy, review of benefits and challenges, comparison of
pros and cons of teletherapy vs in-person, decision making tree to determine
appropriateness of teletherapy, overview of crisis management and check lists for
legally required teletherapy informed consent.

How TDC Created this Guide:

Step 1 Step 2 Step 3 Step 4 Step 5
Conduct an Create a survey Administer survey Create a guide and Share training
initial review of to assess current to 80,000 + mental training based on with mental health
research and knowledge, practices health providers survey and research professionals and
established & before training nationwide. results. provide needed
best practices. needs. support.

therapistdevelopmentcenter.com 1
Authors
Amanda Rowan, LCSW
Amanda Rowan is an LCSW and the founder and CEO of the Therapist
Development Center. Amanda graduated with honors from Dartmouth
College, where she majored in Neuroscience. She earned her Master of
Social Welfare degree at UCLA. Since founding the Therapist Development
Center in 2008, Amanda has prepared more than 50,000 therapists
nationwide to pass their state licensing exams. She is a certified Gestalt
Therapist who has worked with a wide variety of clients in various settings
over the past 20 years. She is a highly effective instructor with a passion
for collaborating with seasoned therapists who understand what works
because they do it daily.

Michelle Seely, LMFT

Michelle Seely (LMFT) is a licensed therapist with a private practice in
Los Angeles. She is an experienced teacher of gestalt and meditation and
has trained and supervised licensed therapists and associates in the US and
internationally. She has served on the core faculty at the Pacific Gestalt
Institute for over a decade. She is a contributing author to the academic
anthology, The Relational Heart of Gestalt Therapy (Routledge 2022).
She was trained to teach Mindful Self-Compassion (MSC) by the program’s
developers, Kristin Neff, and Chris Germer, and has taught privately and
with InsightLA Meditation. She is the past president of the Gestalt Therapy
Institute of Los Angeles (GTILA), where she also served on the executive
board for eight years.

Amanda and Michelle are the creators of the hEdge

t ps:/ therapistdevelopmentcof
enter.com/proLife
duct/6-hours-edge-lifeModel,
-introduction-treating-suicidality a
humanistic approach to suicide management.

therapistdevelopmentcenter.com 2
Introduction
Telehealth History

Meaningful Use CARES Act paves way for

regulations promote healthcare providers to
Birth of interoperability between quickly implement
internet health organizations. telemedicine services.

1990's 2009 2010 2020 March 2020 2021

HITECH Act fiscally COVID-19 pandemic puts Telemedicine utilization

supports healthcare spotlight on telemedicine wanes as people return
technology globalization. and increases utilization 50%. to pre-pandemic lifestyle.

Share of outpatient visits delivered by telehealth, 2019-2021

40%

Mental health and

30% substance use
disorder visits

20%

Other outpatient
10%
visits

0
March 2019 March 2020 March 2021
- - -
Aug. 2019 Aug. 2020 Aug. 2021

SOURCE: KFF and Epic Research analysis of Cosmos data

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 TDC Survey Results:
3,667 Respondents
1. What is your current license status? 3. What populations do you work with:
a Licensed Clinical 1,527 41.6% a. Children (4-12) 1,250 34.1%
Social Worker
Licensed Marriage b. Teens (13-18) 1,931 52.7%
b and Family Therapist 1,073 29.3%
c Licensed Professional 24
c. Adults 3,196 87.2%
Counselor/Clinical Counselor .7%
Licensed Master d. Couples 1,081 29.5%
d Social Worker 381 10.4%
e. Elderly (60+) 1,278 34.9%
e Associate Marriage
and Family Therapist
241 6.6%
Associate Social
f Worker 237 6.5% 4. Have you received training
g Associate Professional 20 0.5% in telehealth?
Clinical Counselor
Yes No
h Other 164 4.5% 42.2% 57.8%

5. If yes, how would you rate the

2. What modalities of treatment do telehealth training you have
you use to deliver therapy? received? Never taken a
In-person Adequate formal course
a Private practice office 865 23.6% 28.6% 58.8%
b Agency-based office 1,115 30.4%
c Comm-based: schools,
rec center, prison
702 19.1% Inadequate Excellent
7.2% 5.5%
d Home visit based 375 10.2%
Telehealth 6. How would you rate your current
e Video conference 2,383 65% comfort level providing telehealth
(i.e. Zoom, Facetime)
f Phone 1,453 39.6% to clients?
g Text 293 8% Not Comfortable Somewhat comfortable
8.8% 25.6%
h Email 240 6.5%
Mental health platform
i (i.e. Betterhelp, Talkspace)
578 15.8%
I am not currently providing Comfortable Very comfortable
j therapy to clients
385 10.5% 36.0% 29.6%

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TDC Survey Results
3,667 Respondents

7 Rate how competent you feel for each of the following

1=not competent at all -- 5 = completely competent Average
0 1 2 3 4 5
a. Your ability to meet the legal requirements
3.6
for telehealth
b. Your ability to meet ethical standards for
3.9
telehealth
c. Your ability to conduct a full assessment
3.8
via telehealth
d. Your ability to explain the risks of telehealth 3.7
e. Your ability to explain the benefits of
3.8
telehealth
f. Your ability to determine the appropriateness
and effectiveness of telehealth for diverse 3.5
client populations
g. Your ability to utilize technology 4.1
h. Your ability to manage crisis situations,
including suicide, DV, and child/elder/ 3.4
dependent adult abuse

i. Your ability to document your telehealth

3.9
sessions and interventions
0 1 2 3 4 5

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Training Needs/Wants
What is absolutely mandated for documentation of a telehealth
session, what factors should be considered when determining
when telehealth is appropriate / not appropriate as the method
of therapy.

I would like to see a better telehealth consent document and work

on presenting it to the client before the initial session or during.

Clear guidelines regarding crisis situations, such as suicidal client,

DV, child, elder, dependent adult abuse.

I would like to learn more about our legal and ethical duties to
find emergency resources near our clients.

Generalized training about consistently gauging who qualifies for

telehealth services without infringing on self-determination and
how to transition clients from in-person to telehealth or vice versa.

Training on how to assess more effectively via Telehealth. Training

on how to refer to higher level of care more effectively. Training on
helping clients who have withdrawn into a Telehealth safety bubble
to be willing to go outside. Most importantly: training on how to
handle emergency situations with Telehealth clients.

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Benefits of Telehealth

Geographic Decreases
Efficiency
Convenience Costs

Increased Accessibility

Expands reach Increases Increases Increases

of therapist Responsiveness Continuity Compliance

The show rate is much higher due to the

increased ability for a client and/or a therapist
to attend if one is ill, but not bedridden. Another
positive is being able to see some of the client's
home environment and a client often "shares"
special spots or things one has in one's home
which is therapeutically helpful.
I treat OCD using exposure with response
prevention. It can actually be helpful to have
client at home so we can do exposures where
they are often afraid! Can also help with people
who are afraid to leave home.

I loved meeting all my patients' pets

Pros
It's great for older adults and it's cut
and watching them provide comfort
back on my cancelations.
when they're in distress.

Telehealth has been extremely positive in my

rural area of serving. It has greatly reduced no
show rates particularly for folks experiencing
transportation difficulties.

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Challenges of Telehealth

Impersonal Insecure Isolated

Decreased Quality of Care

Compromises Limits Increases Redefines

Therapeutic Assessment and Potential therapeutic
Alliance Inventions Disruptions boundaries

I’ve worked with mental health agencies in the

past that provide MH services without screening
clients for appropriateness of telehealth and also
having high caseload requirements with minimal
breaks (5mins) and limited regard for self-care
of clinicians.

It gets very frustrating when the One of my client's, 14-years-old,

internet connection is unstable. mom told me that he was actually
I've had calls freeze at the WORST
times!
Cons playing games on his cell phone
while talking to me.

My negative experience occurred when someone Not all clients are open to telehealth. Some
was eve dropping while I was doing assessment clients do not engage in telehealth session as
with a client. well as they do in an in person session.

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Ethical and Legal Considerations
NASW Code of Ethics
With growth in the use of communication technology in various aspects of social work practice,
social workers need to be aware of the unique challenges that may arise in relation to the
maintenance of confidentiality, informed consent, professional boundaries, professional
competence, record keeping, and other ethical considerations.

In general, all ethical standards in this Code of Ethics are applicable to interactions,
relationships, or communications, whether they occur in person or with the use of technology.
For the purposes of this Code, “technology-assisted social work services” include any social
work services that involve the use of computers, mobile or landline telephones, tablets, video
technology, or other electronic or digital technologies; this includes the use of various electronic
or digital platforms, such as the Internet, online social media, chat rooms, text messaging,
e-mail and emerging digital applications.

Technology-assisted social work services encompass all aspects of social work practice,
including psychotherapy; individual, family, or group counseling; community organization;
administration; advocacy; mediation; education; supervision; research; evaluation; and other
social work services. Social workers should keep apprised of emerging technological
developments that may be used in social work practice and how various ethical standards apply
to them.

(d) Social workers who use technology in the provision of social work services should ensure
that they have the necessary knowledge and skills to provide such services in a competent
manner. This includes an understanding of the special communication challenges when using
technology and the ability to implement strategies to address these challenges.

(m) Social workers should take reasonable steps to protect the confidentiality of electronic
communications, including information provided to clients or third parties. Social workers should
use applicable safeguards (such as encryption, firewalls, and passwords) when using electronic
communications such as e-mail, online posts, online chat sessions, mobile communication, and
text messages.

CAMFT Code of Ethics

Marriage and family therapists recognize that ongoing technological developments promote
availability and access to healthcare and expand opportunities to provide their services outside
of the therapy office. When utilizing Telehealth to provide services to clients/patients, marriage

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 and family therapists consider the welfare of the client/patient, the appropriateness
andsuitability of the modality in meeting the client’s/patient’s needs, make appropriate
disclosures to remain current with the relevant laws and regulations.

6.1 TELEHEALTH: Marriage and family therapists take precautions to meet their responsibilities
to clients/patients who are not physically present during the provision of therapy. Prior to utilizing
Telehealth, marriage and family therapists consider the appropriateness and suitability of this
therapeutic modality in meeting the client’s/patient’s needs and do so competently. The
suitability and appropriateness of Telehealth includes consideration of multiple factors such as
the client’s/patient’s familiarity with the modality, the issues to be addressed, the therapeutic
orientation, and other pertinent factors.

6.2 COMPLIANCE WITH TELEHEALTH LAWS: Marriage and family therapists, prior to
engaging in Telehealth, are familiar with the state and federal laws governing Telehealth and
ensure compliance with all relevant laws.

6.3 DISCLOSURES: Marriage and family therapists inform clients/patients of the potential risks,
consequences, and benefits of the Telehealth modality, including but not limited to issues of
confidentiality, clinical limitations, and transmission/technical difficulties.

6.4 ELECTRONIC MEDIA: Marriage and family therapists are aware of the possible adverse
effects of technological changes with respect to the dissemination of client/patient information,
and take care when disclosing such information. Marriage and family therapists are also aware
of the limitations regarding confidential transmission by Internet or electronic media and take
care when transmitting or receiving such information via these mediums.

Legal Considerations
Telehealth has been defined as “the mode of delivering health care services and
public health via information and communication technologies to facilitate the diagnosis,
consultation, treatment, education, care management, and self-management of a
patient's health care. Telehealth facilitates patient self-management and
caregiver support for patients and includes synchronous interactions and
asynchronous store and forward transfers."

Additional Legal Considerations:

Health Insurance Portability and Accountability Act (HIPAA) regulations apply
Adherence to established Standard of Care

Mental health providers should check with their state’s legal requirements regarding the
practice of telehealth.

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Modalities Pros and Cons
In-Person

Modality Pros Cons

In-person - private Privacy Travel/Time for patient

practice, agency-based Consistency Stigma/public space
office Safe environment Physical/Mental
Human connection limitations
Felt sense of client Costlier for therapist and
Nonverbal client
Communication/ Harder to schedule
assessment couples and families
Clear boundaries

In-person - Convenience for Stigma

community-based: patient Lack of privacy
schools, hospital,rec In-environment Harder to choose or
center, prison Easy to access change a practitioner
Immediacy Termination dictated by
Greater community environment
outreach

In-person - home visit Immediacy Diffuse boundaries

based Convenience Lack of privacy
In-environment More time / money
Greater ability to consuming for therapist
assess by seeing Safety issues
client’s environment
Ease of doing family
therapy

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Modalities Pros and Cons
Telehealth

Modality Pros Cons

Telehealth - video Convenience Diffuse boundaries

conference (i.e. Zoom, In-environment Lack of privacy
Facetime) Including collaterals Technology problems
Affordability Impersonal
Accessibility Security risks
Flexibility Impeded assessment
Visual Attention issues

Telehealth - phone Convenience Impersonal

Immediacy Absence of nonverbal
Less expensive communication
Impeded assessment
Issues with privacy

Telehealth - text Convenience Impersonal

Accessibility Absence of verbal and
Immediacy nonverbal communication
Higher chance of reaching Security risks
certainpopulations (DV
victims, teens)

Telehealth - email Convenience Impersonal

Affordability Asynchronous
Accessibility Slow response time
Data breaches

Telehealth - Mental Health Low overhead Conflicting Business

Platform (i.e. BetterHelp, Access to clients practices
Talkspace) Security Concerns
Confidentiality
Scope of competence
Billing issues

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 TELEHEALTH SCREENING
When determining whether telehealth (TH) is appropriate for a given client (CT), therapists
should screen for safety and crisis issues (suicide, DV, child/elder abuse) and identify potential
barriers (ex. time, lack of transport, travel, severe symptoms) to in-person (IP) therapy in order
determine and document justification for telehealth as a treatment modality. In cases where
the CT is homebound, therapists should consider home visits (HV) when clinically indicated.

Q: Is CT comfortable
No In-Person
with telehealth?

Yes

Q: Can CT access a safe,

In-Person No
secure connection?

Yes

Q: Is there a lack of
Yes 100% TH
local therapists?

No

TH crisis with
Yes Q: Is there a crisis?
local referrals

No

Q: Is the CT
homebound?

No Yes

Q: Are there Q: Is it
barriers? permanent?

Yes No Yes No

TH or Hybrid Hybrid TH + HV Hybird TH + HV ->IP

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Initial Session Checklist:
Informed Consent for Telehealth
Provide the client with therapist’s license or registration name and number
Inform the client about the use of telehealth as a mode of delivering psychotherapy
Discuss benefits and alternatives to telehealth
Explain that the therapist will continuously assess for the appropriateness of
telehealth and that the therapist maintains the right to terminate teletherapy if it is not
in the client’s best interest. Discuss possible in-person services
Inform the client ( verbally and/or in writing) of potential safety issues that may arise during
telehealth and document the conversation in the record
Discuss mandated reporting laws and review actions the therapist would take in the
event of a life-threatening medical emergency, including self-harming behaviors
and/or threat to others
Explain that if the client abruptly ends the session while in crisis, the clinician will
call the client and if the client does not answer the phone, the clinician reserves the
right to call 911 or local emergency services to request a welfare check
Provide crisis phone numbers and resources in the client’s area, including
emergency services
Establish a safe word the client can use if they need to disconnect from telehealth
for safety or privacy reasons and actions the client and/or therapist should take in
response
Document the client’s emergency contacts
Inform the client (verbally and/or in writing) of the potential risks and limitations of
receiving treatment via telehealth and document such conversation in the record
Discuss common technological challenges and talk about steps to take in the event
of connectivity issues
Discuss possible unauthorized access to confidential information
Talk about limitations to client’s privacy during treatment
Discuss the importance of confidentiality and help the client create a private, safe
and undisturbed environment
Clarify that telehealth is not for emergencies but rather routine mental health care.
Obtain the client’s verbal or written consent for telehealth services
Document the consent in the client’s record
Review state-specific laws and document adherence
Inform the client of documentation requirements and how records will be stored and
protected

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Session Checklist:
Maintain the Standard of Care
Document date of the session
Document client’s name
Document client’s location
Document client’s phone number
Assess whether telehealth services continue to be appropriate for the client
Confirm emergency contacts for the client and ask if anyone else is in the room or
house/apartment with the client
implement industry best practices to ensure client confidentiality and privacy of the
communication
Make sure that the telehealth platform used is secure (e.g. transmission of voice
and video is encrypted)
Ensure that storage of voice or video data if present is secured
If using personal computer antivirus software and/or firewalls must be up to date
If using a personal device, such as a cell phone, the most recent security update for
the device must be installed
Assess for any safety concerns
Evaluate local resources and update as needed
I like these recommended questions for each session, too:
1. Where are you?
2. Is there anyone in the room with you or who can hear you from nearby?

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Risk and Crisis Management
Danger to self
Screening for suicide should take place during the screening process and
informed consent
Client’s determined to be high risk (a plan and/or access to means) should be
giving suicide prevention hotline number and personalized safety plan that should
include mobilizing additional supports and removing means
Client’s experiencing severe anxiety or other distressing symptoms are frequently
unable to attend sessions, so suicide prevention interventions are frequently
done via telehealth
Allows for increased contact and collateral sessions

Danger to Others
Be aware of State-specific laws/regs
https://www.ncsl.org/health/mental-health-professionals-duty-to-warn
Identify local police contact if legally required to make a Tarasoff report

Child Abuse and Neglect

Be aware of State-specific laws/regs
Know where to report - local child protective services
Limited ability to assess signs remotely

Elder/Dependent Abuse and Neglect

Be aware of state-specific laws/regs
Know where to report - local child protective services
Limited ability to assess signs remotely

Domestic/Interpersonal Abuse
Screening for suicide should take place during the screening process and
informed consent
Know where to report - local child protective services
Limited ability to assess signs remotely

therapistdevelopmentcenter.com 16
References
Simon MA. Responding to Intimate Partner Violence During Telehealth Clinical Encounters.
JAMA. 2021;325(22):2307–2308. https://doi.org/10.1001/jama.2021.1071
doi:10.1001/jama.2021.1071

Stoll J, Müller JA, Trachsel M. Ethical Issues in Online Psychotherapy: A Narrative Review.
Front Psychiatry. 2020 Feb 11;10:993. doi: 10.3389/fpsyt.2019.00993. PMID: 32116819;
https://doi.org/10.3389/fpsyt.2019.00993
PMCID: PMC7026245.

California Association of Marriage and Family Therapists. (2019). CAMFT Code of Ethics
(amended effective December 2019, June 2011, January 2011, September 2009, July 2008,
May 2002, April 1997, April 1992, October 1987, September 1978, March 1966).
https://www.camft.org/Membership/About-Us/Association-Documents/Code-of-Ethics

National Association of Social Workers. (2017). NASW code of ethics. Retrieved November 30,
2023, from https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Mulvaney-Day N, Dean D Jr, Miller K, Camacho-Cook J. Trends in Use of Telehealth for Behavioral
Health Care During the COVID-19 Pandemic: Considerations for Payers and Employers.
https://doi.org/10.1177/08901171221112488e
Am J Health Promot. 2022 Sep; 36(7):1237-1241. doi: 10.1177/08901171221112488e.
PMID: 36003014; PMCID: PMC9412131.

Kaiser Family Foundation. (2022). Telehealth Has Played an Outsized Role Meeting Mental
Health Needs During the COVID-19 Pandemic. Issue Brief. Retrieved from
https://www.kff.org/coronavirus-covid-19/issue-brief/telehealth-has-played-an-outsized-role-meeting-mental-health-needs-during-the-covid-19-pandemic/
https://www.kff.org/coronavirus-covid-19/issue-brief/telehealth-has-played-an-outsized-role-
https:/ www.kf .org/coronavirus-covid-19/issue-brief/telehealth-has-played-an-outsized-role-meeting-mental-health-needs-during-the-covid-19-pandemic/
meeting-mental-health-needs-during-the-covid-19-pandemic/

therapistdevelopmentcenter.com 17
Notes/Re�lections

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