Luxton, Nelson, and Maheu present an excellent overview of best practices for
the telemental health professional. This text is incredibly timely, as the use of
distance technologies is ever-changing in the professional clinical landscape.
This is a must-read for both seasoned practitioners and practitioners in training.
—Jeremiah L. Peck, PhD, Western Seminary, Portland, OR
Written by a team synonymous with distinction in telemental health (TMH)
care, this revised edition takes an interdisciplinary look at what has changed
since the COVID years, including best practices, evidence-based recommen-
dations, and artificial intelligence. It is hard to imagine a better book on
TMH for practitioners, researchers, consultants, and mental-health-related
graduate students.
—Richard P. Long, PhD, Approved Supervisor and Clinical Fellow, American
Association for Marriage and Family Therapy (AAMFT), Alexandria, VA
If you’re a health care professional, use this guide to discover the best ways to
ensure accessible, quality, and safe telemental health care. It is easy to read,
well-organized, and thoughtfully written by professionals who have clinical,
educational, and research experience. They help us see virtual care from a
360-degree perspective. Trainees and early- and advanced-career professionals
will find it extremely useful.
—Donald M. Hilty, MD, MBA, Professor of Psychiatry and Behavioral
Sciences, University of California, Davis; Chief Medical Officer, Heritage
Oaks Health System and Universal Health Services, Sacramento, CA; and
Editor, Journal of Technology and Behavioral Science
Contents
Foreword—Gerald P. Koocher ix
Acknowledgments xi
Introduction: Telemental Health Moves From the Margins Into
the Mainstream 3
1. Concepts, Principles, and Benefits of Telemental Health 11
2. Overview of Telemental Health Technologies 19
3. Ethical, Legal, and Risk Management Considerations 31
4. Establishing a Telemental Health Practice 47
5. Safety and Emergency Planning and Management 59
6. Providing Direct Clinical Care 73
7. Conducting Psychological Assessments 87
8. Telesupervision and Training in Telepractice 99
9. Ethical Telepractice With Historically Underserved
Populations 111
10. Optimizing Practitioner Skills and Resilience 125
11. Conclusion: A Call to Action and Telemental Health
Leadership 131
vii
viii • Contents
References 139
Index 165
About the Authors 175
INTRODUCTION
Telemental Health Moves From the Margins Into
the Mainstream
The capability to provide behavioral health services with telecommunications
technologies has greatly expanded avenues for behavioral and mental health
professionals to provide quality care. This capability, referred to as telemental
health (TMH), has extended to nearly all aspects of behavioral health service,
including the research and delivery of treatment, assessment, psychoeducation,
training, supervision, and consultation. As with other forms of care, access
barriers to telehealth do exist, despite increased availability and affordability
of webcams, videoconferencing (VC) software, and high-speed network con-
nections. Still, recent years have seen increased access to remote care through
traditional hospital, clinic, and office-based referrals or directly to the home.
Other available technologies include mobile device apps and interactive web-
sites (Armstrong et al., 2021; Luxton, 2017a; Luxton et al., 2011; Maheu
et al., 2013; Mohr et al., 2013). Cultural responsiveness when suggesting and
using apps and other novel health technologies is also increasingly important
as specialized apps enter the marketplace (Armstrong et al., 2019; Hilty,
Crawford, et al., 2021; Luxton & Hudlicka, 2021).
https://doi.org/10.1037/0000374-001
A Practitioner’s Guide to Telemental Health: How to Conduct Legal, Ethical, and
Evidence-Based Telepractice, Second Edition, by D. D. Luxton, E.-L. Nelson, and
M. M. Maheu
Copyright © 2024 by the American Psychological Association. All rights reserved.
3
4 • A Practitioner’s Guide to Telemental Health
At no other time in history have telehealth technologies been so widely
implemented than during the SARS-COV-2 (COVID-19) pandemic (Luxton,
2023). VC technology was used for telework, remote education, and pro-
viding health care and other services on a worldwide scale. For example,
a report from the U.S. Department of Health and Human Services found
that the share of Medicare visits conducted via telehealth in 2020 increased
63-fold, from approximately 840,000 in 2019 to 52.7 million in 2020 (Samson
et al., 2021). On the national and state levels, governments loosened tele-
health regulations and requirements to meet overwhelming needs. The
benefits of TMH during this pandemic were apparent. VC allowed for health
care visits without the possibility of exposure to the virus, both in session or
during travel to sessions. Persons who were in quarantine could also receive
services while at home.
Moreover, VC-based TMH helped meet the increasing public behavioral
health needs. The realities and fears of a global pandemic increased stress on
individuals and communities. Government restrictions including lockdowns,
social distancing, masks, and vaccine mandates were also associated with
an increase in anxiety and mental health problems. People worldwide were
forced to cope with grief and loss without the solace offered by assisting a
loved one’s transition or honoring them at funerals (Czeisler et al., 2020;
Ganesan et al., 2021; Radfar et al., 2021).
The pandemic forced the vast majority of behavioral professionals to
adopt VC-based capabilities in a matter of days. Many professionals already
using VC scaled up their operations to meet the needs of their clients. The
use of VC was also expanded in diverse settings, such as in prisons and jails,
where health care providers and forensic evaluators conduct their work
(Luxton, 2018). Unprecedented numbers of clients were served across geogra-
phies and in their homes. This great VC “retooling” and “scaling up” required
that professionals and their clients develop basic skills on the procedural,
technical, legal, and ethics requirements of TMH.
To maximize the capability and benefits of VC TMH, professionals now
need to understand and implement the latest in competencies to optimize
their practices. Guesswork is no longer necessary or appropriate. Using these
technologies requires adequate training and experience to develop the com-
petencies (knowledge, attitudes, and skills) that are foundational to delivering
professional levels of care. Most issues associated with competent practice
parallel those of conventional in-office services. However, professionals must
(a) extend competencies associated with existing skills practiced in traditional
settings and (b) develop new skills that bridge the gaps created by tech-
nology. For example, TMH practitioners must complete a proper intake and
Introduction • 5
assessment but using instruments and procedures appropriate for remote
administration through technology. They must establish informed consent,
obtain emergency contact(s), be prepared to involve emergency or support
services, document essential elements of the procedure, and conduct appro-
priate follow-up. The physical distance between the clinician and the client
or patient1 using technology can create palpable challenges, all of which are
manageable when following best practices. For example, it is easy to hand
out consent forms or administer paper-and-pencil assessments in person,
but with a few additional steps, a completely legal informed consent can
be obtained through telehealth. Just as with in-person services, TMH pro-
fessionals need to know how to conduct practice consistent with the ethical
standards, guidelines, and recommendations that apply to their specific pro-
fession and the needs of their patient populations. Each behavioral profession
has general ethical standards and sometimes guidelines. Some organizations
have produced guidelines specific to telehealth practice.
Complying with legal requirements and managing risks are required for
TMH practice. Providers must determine whether TMH services are allowed
in any designated environment and understand the unique accreditation,
licensure, and legal requirements of the jurisdiction where the client is located.
The use of telehealth technologies also can present liability, even with the
briefest of contact (e.g., email or text message). Practitioners must be aware
of intra- and interagency policies, including guidance on what and how
particular services should be provided and the limits of those services. Another
essential requirement is informed consent, which must address patient safety,
mandatory reporting requirements (e.g., duty to report suicidal or homicidal
clients, mandated reporting of abuse to minors, elders, or partners), as well
as privacy and data security.
In today’s ever-evolving technological landscape, practitioners need to know
which technologies are available and appropriate, and how to optimize them.
Telepractitioners also need to be sensitive to issues in clinically unsupervised
settings—settings without clinical staff on site, such as when care is provided
directly to a client in their home at the time of the contact. Furthermore, TMH
psychological assessment requires particular attention to factors influencing
the reliability, validity, and integrity of remote assessments and measures.
For example, unbeknownst to the professional, a family member may secretly
be present during part or all of the assessment procedure, clients can easily
We use the terms client and patient interchangeably throughout the book and
1
recognize that one term is often preferred over the other depending on the health
care setting or type of care being provided.
6 • A Practitioner’s Guide to Telemental Health
look up answers while online, or some assessments may be taken over a
week rather than at a single sitting.
Behavioral health services provided via technology also create a different
context for the therapeutic process, including unique benefits and challenges.
For example, telepractice extends the reach of service to underserved groups
and diverse populations that may have limited previous contact with behav-
ioral health services and with technology. Thus, clinicians must be familiar
with working with clients from diverse backgrounds (Hilty, Gentry, et al., 2020).
There are also potential complications that can arise during telepractice.
For example, the clinician facing a delicate mandated reporting situation
must be aware that an emotionally charged confrontation of a client about
potential abuse may be more difficult to manage via VC. Such a client may
easily and quickly respond to abuse-related inquiries by simply turning off
the computer. Such clients are unlikely to respond to attempts for further
contact. Working via technology, then, also requires understanding how
technology alters a professional clinical relationship and how to compensate
for such alterations. Telehealth requirements vary from state to state and
must be considered. Without proper training, clinicians may unwittingly
put patients and themselves at risk by treading into new terrain without
nullifying their malpractice insurance by being unaware of these teleprac
tice issues.
As previously mentioned, various professional associations in the behavioral
sciences have developed ethical standards and/or guidelines for telepractice.
Standards and guidelines help move TMH forward by increasing practi-
tioner confidence and setting minimum standards for ethical and compe-
tent practice. They provide necessary high-level guidance but often lack the
level of detail or practical recommendations needed by behavioral health
practitioners. Therefore, TMH trainees and practitioners can benefit from
a practice-friendly, “how-to” guidebook that includes many essential issues
included in standards and guidelines but also provides recommendations for
conducting telepractice that draws not only from relevant legal and regulatory
codes and clinical acumen but also provides best-practice suggestions based
on the scientific literature and the hundreds of model TMH programs in the
field. That is why we published the first edition of this book in 2016.
Throughout this second edition, we have updated our best-practice recom-
mendations and guidance for conducting competent, ethical, and evidence-
based TMH. We add information about the potential of TMH to support health
care and other workers hit hard by pandemic demands and losses while
hundreds of thousands of our colleagues deal with the skyrocketing behav-
ioral health needs among youth and other distressed groups. We provide
Introduction • 7
suggestions for how TMH can be sustained beyond the public health emergency
and strategies for thriving TMH practices. In particular, we’ve expanded our
discussion of best practices to encompass a greater diversity in settings and
populations. We have organized our chapters as follows.
Chapter 1 introduces key definitions, the scope of TMH, and an overview
of the benefits of TMH for professionals who are new to it and for experienced
professionals who desire to expand and maximize their TMH practice.
In Chapter 2, the reader will find an overview of currently available
telehealth technologies with a focus on VC technologies and supporting
software. This chapter also includes an overview of technologies that can be
used to augment VC-based TMH (e.g., mHealth apps, assistive technologies,
and other emerging technologies).
Chapter 3 describes legal, regulatory, and ethical issues in telepractice
in public and private practice settings. The informed consent process is
addressed, including compliance with various federal and state requirements
related to telepractice. Privacy and data security issues are also discussed.
Chapter 4 walks the reader through the practical steps needed to estab-
lish a thriving TMH practice. Needs assessment and other administrative
processes are outlined to help identify problem areas and critical resources
before engaging with clients. Other topics addressed in this chapter include
necessary documentation procedures.
Chapter 5 outlines how to develop safety plans for TMH services pro-
vided to clinically supervised (e.g., in a setting with trained support staff) and
unsupervised settings (e.g., the home of clients). Topics include assessment
of the appropriateness of TMH, emergency protocols, roles and responsibil-
ities during emergency management, and risk management.
Full attention is given to the process of initiating and conducting TMH
clinical sessions in Chapter 6. The extensive body of literature surrounding
telebehavioral and telemental health clinical competencies is outlined, includ-
ing identifying basic capabilities of potential clients for telehealth, through
establishing and maintaining therapeutic rapport, creating a welcoming tele
practice environment. We share advice concerning the best positioning of
VC equipment (e.g., eye gaze) as well as troubleshooting technical problems.
Special considerations are offered for conducting in-home TMH and guidance
for integrating other technologies (e.g., behavioral health apps).
Chapter 7 summarizes methods to ensure reliable and valid psychological
assessments and testing conducted via telehealth technologies. We discuss
selecting appropriate measures/tests, ensuring optimal assessment conditions
and procedures when using telehealth technologies, and delivering assessment
results remotely.
8 • A Practitioner’s Guide to Telemental Health
Chapter 8 provides information on supervision and consultation services
via telehealth technologies. We summarize the evidence base supporting
remote supervision and teleconsultation, giving examples across a wide variety
of trainees (e.g., predoctoral, postdoctoral, continuing education) and training
settings.
Chapter 9 covers advanced topics regarding strategies to promote clinical
competency and multicultural responsivity with diverse groups across the
lifespan. We describe telepractice’s potential to connect individuals with pro-
fessionals with expertise in working with specific populations (e.g., LGBTQ
and intersex populations or individuals with rare medical disorders). We
emphasize a patient-centered approach, considering how cultural factors and
the broader community may influence the telepractice encounter and sustain-
able TMH service.
Chapter 10 adds information about how to optimize practitioner skills
and resilience. We discuss how to carry over skills from in-office services to
the TMH medium, and we also provide tips for maintaining your well-being
as a telepractitioner.
In Chapter 11, we issue a call to action and leadership to practitioners of
TMH. We summarize those areas of ongoing concern that present barriers to
fuller adoption of TMH and describe some future developments we see on
the TMH horizon. Our hope is to inspire confidence among mental health
providers and to encourage the continual pursuit of professional learning as
technological applications become ever more sophisticated.
We’ve written this guidebook for the new telepractitioner who wants to
get started, the seasoned practitioner who seeks to continue to enhance their
TMH practice, the supervisor who engages in telesupervision, and the clinical
manager or administrator interested in training a clinical team. The guide-
book’s practical recommendations also apply to TMH providers regardless
of discipline or theoretical orientation. In many of our recommendations,
we have made conscious attempts to be inclusive of the broader health care
arena across prevention and the behavioral components of chronic illness,
including behavioral medicine, integrative medicine, and health psychology
perspectives. Also, although this guidebook primarily uses examples of regu-
latory requirements and guidelines from the United States, it is intended for
the international behavioral and mental health researcher and practitioner
communities.
While we recognize that telephone, email, text messaging, and other
communication technologies are used in practice (American Psychological
Association, 2010), this guidebook focuses primarily on VC to give the
interested clinician a quick yet broad overview of how to proceed with this
particular modality. The researcher, educator, or practitioner interested in
Introduction • 9
these other telehealth modalities is encouraged to see our list of resources
available at the book’s website, under the Resources tab: https://www.
apa.org/pubs/books/practitioners-guide-telemental-health.
VC-based TMH has proven to be an invaluable tool during this unprece
dented time in history, and we can only expect the technology to continue
to improve and expand in its use. There is an expanding empirical literature
base that supports the clinical effectiveness of TMH, including overall user
acceptability and satisfaction among both clients and care providers (Pruitt,
Luxton, & Shore, 2014; Wright et al., 2020). In addition, public and private
insurers are increasingly supporting the use and reimbursement of some
telehealth-based services. The capability to conduct behavioral services via
telecommunications technologies has provided behavioral health profes-
sionals with opportunities to serve more people, specialize in areas of greatest
professional development and interest, decrease office expenses, and enjoy a
mobile lifestyle from anywhere on the planet. We encourage you to send us
feedback about this book and relevant case examples from your experience
by emailing us.
Eve-Lynn Nelson, PhD,
[email protected] Marlene M. Maheu, PhD,
[email protected]