eCounseling for EAPs

Consumer demand for behavioral health services continues to increase. However, the pool of qualified and licensed counseling professionals is failing to keep up with demand. This trend is especially true in more rural areas of the United States that have low concentrations of behavioral health providers.

Not surprisingly, use of employer-funded Employee Assistance Programs (EAP) is also on the rise; currently 77% of employers provide these services to their employee populations.[1] EA programs continuously struggle to find qualified behavioral health providers in rural and remote areas of North America. An exceptional challenge is locating providers who can assist those with mobility issues, inadequate transportation, and other obstacles that would prevent an individual from attending a face-to-face EAP session.

Traditionally, behavioral health treatment and EAP practice have required clients to travel to the provider’s office for face-to-face counseling interactions. Requiring clients to travel to counseling or a higher level of care such as psychiatry is more expensive in terms of cost and time, especially in rural and remote areas. EAP is a viable solution to preventing these higher costs that often discourage employees from seeking the help they need.

This failure to get the kind of timely assistance an employee requires also impacts employer organizations in terms of an increase in lateness, absenteeism, presenteeism, and generalized decreased productivity. All of these issues, of course, impact an employer’s bottom line. In many cases, individuals will wait until the situation escalates to crisis proportions, resulting in increased cost due to emergency room visits, hospitalizations, and higher levels of care in general. Unfortunately, despite the confidentiality of EAP sessions, except in emergency situations, some employees are hesitant to take advantage of EAP services for fear that seeking counseling might adversely affect their job or career, or perhaps their personal standing within the community.

In addition to the barriers to face-to-face counseling that are experienced in remote and rural areas, the workplace landscape beyond 2014 looks significantly different than it ever has. There are now four generations that make up a typical workforce. That includes the Millennial or Generation Y (born 1977-1994), which is entering the workforce in numbers that have not been seen since the Baby Boomers (born 1946-1964) came of age.

Millennials are achievers who are sophisticated and technology-wise with a “must have” attitude regarding the latest electronics. Millenials as a whole demonstrate a preference for communicating through the use of texting or Skype type programs over face-to-face interactions; they do not have land lines and may not even use a smartphone for talking. These tech-savvy employees need and will continue to need solutions that work for their generation and lifestyles and eCounseling fits that bill well. Millennials are possibly the one generation in the workplace that does not experience the stigma of getting help with a personal issue. Offering innovative communication technologies that include eCounseling provides the easy access to assistance and support that will be crucial as Millennials become business leaders and as Baby Boomers retire and exit the workplace.

What is eCounseling?

eCounseling is a subset of telemedicine or telehealth. Broadly defined, “telehealth is the use of a variety of communication technologies between health care practitioners or between practitioners and the service users (clients) for the purposes of diagnosis, treatment, consultation, education and health information transfer.[2] Others use the term telehealth or e-health “to describe any health related service that is provided remotely via technology-assisted media such as telephone, computer, or Internet.”[3] eCounseling, also known as “telepsychology,” is “the provision of psychological or counseling services using telecommunication technologies” that may include telephone, mobile devices, interactive videoconferencing, email, chat, text, and Internet (e.g., self-help websites, blogs, and social media sites.)[4] During and after an eCounseling session, these telecommunication technologies can be used in various combinations to enhance and improve the counseling session. For example, the behavioral health provider and client may be able to continue communicating using a secure online chat program if a videoconference is interrupted due to a software malfunction. A provider might use email to follow up with a client’s progress after the eCounseling session. Given the versatility and effectiveness of these technologies in connecting a mental health provider and a client, it is easy to see how telepsychology/eCounseling will become a mainstream channel for the delivery of behavioral health, education, and self-help programs.

Advantages of Telepsychology or eCounseling

Counseling services delivered through eCounseling offer many advantages to both the client and the counselor. As telecommunication technologies have advanced, equipment costs have dropped, compared to face-to-face interactions. eCounseling can provide services to greater numbers of clients across larger distances at relatively low costs.[5] Moreover, these technologies offer the opportunity to increase client access to counseling services. eCounseling offers providers an effective and affordable vehicle to connect with clients limited by geographic location, medical condition, psychiatric diagnosis, financial constraints, physical handicap (limited mobility), lack of transportation, and other barriers.[6] We are living in an increasingly mobile world. eCounseling allows a therapist to stay in touch with clients who might otherwise drop out of counseling due to relocation or frequent travel. Additionally, eCounseling overcomes time constraints of a normal face-to-face office visit. Technology lets a provider connect with clients 24 hours a day. Providers also may benefit from the time savings, reduced overhead costs, and improved treatment outcomes through expanded availability to their clients.

As stated earlier, people who live in rural areas have additional constraints, and “experience significant disparities in health status and access to care compared to their urban counterparts.”[7] Not surprisingly, most health professionals choose to open practices in urban or suburban settings with higher density populations. Economically and logistically, this makes sense. Without innovative technological solutions access to care will continue to be a significant problem in rural and remote areas as the aging population expands. This problem of access will certainly intensify over the coming years as Baby Boomers retire.

The geographic misdistribution of providers is more pronounced regarding access to specialist providers.[8] eCounseling expands the choices of available providers and specialties to people in rural communities. eCounseling also may help some potential clients overcome their fears, or the stigma associated with seeking help with their emotional well-being issues. For some individuals, seeking help from a behavioral health professional is associated with a character weakness or other stigma. Access to eCounseling allows individuals who may be reluctant to seek help from a behavioral health professional to do so in the privacy and comfort of their own home. Their home may offer a more safe and secure environment where they will experience greater ease in discussing sensitive personal issues. Use of online counseling technology, especially in rural or small town settings, may help prevent dual relationships that can occur when providers and clients encounter each other in their small community. Some rural communities are so small that individuals fear that their problems or the situations they will discuss during their sessions with the counselor may already have been shared with their counselor via the town “grapevine.”

eCounseling also provides an avenue for clients to more readily connect with a provider when there is the need to speak in their native language.[9] A client may prefer, and may find it easier to communicate and discuss sensitive issues with a provider who speaks and understands the nuances of his or her own language and culture. Moreover, a provider who understands the norms of a particular culture or religious faith will be better equipped to offer solace and advice to that client. eCounseling and technology can make these connections possible and, more importantly, effective in helping clients to deal with mental health issues.

Other Considerations

Before entering in the practice of eCounseling, every behavioral health professional should consider the legal requirements and ethical standards to which they must adhere. Potential providers of this service need to be aware that the same ethical and professional standards of care that apply to face-to-face sessions also apply to sessions that are conducted electronically. Electronic communications, if not used properly, may not be completely secure from those trying to spy on or intercept communications.

In the United States, use of the proper technologies and security protocols are absolutely necessary to ensure compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). A major goal of HIPAA’s Privacy Rule is to “assure that individuals’ private health information (PHI) is properly protected while allowing the flow of health information needed to provide and promote high quality health care and protect the public’s health and well being.”[10] To maintain a client’s confidentiality during an eCounseling session, the communication technology used for the session must be secure and compatible with HIPAA standards. Some providers currently engage in eCounseling sessions with clients using the popular program Skype or other similar and free web-based communication platforms relying on similar voice over Internet technology. However, this practice is not HIPAA compliant. Among other requirements, the HIPAA privacy rule requires that the communication software have the following capabilities:

  • access control,
  • audit controls,
  • person or entity authentication,
  • transmission security,
  • business associate access controls,
  • risk analysis,
  • workstation security,
  • device and media controls,
  • security management process, and
  • breach notification.

The use of any technology lacking these capabilities to deliver eCounseling services raises many HIPAA concerns.[11] Such products do not allow a verifiable audit trail, or indicate when a breach of information occurs. There is also no way to verify the security of the transmission. Lastly, such products lack integrity controls.[12] Providers should be aware of the increased risks of HIPAA violations when using such products for telecommunication involving any health communications. Although secure, fully-encrypted internet communication technologies come with higher cost and greater logistical challenges nonetheless; they are recommended as the best course of action and should be used rather than free platform technologies that fail to comply with HIPAA regulations.

There are other potential breaches of privacy that may occur during eCounseling sessions that have nothing to do with the communication technology. Potential breaches of privacy and confidentiality may occur in the client’s home when a family member inadvertently overhears a counseling conversation or walks into the room during a session. “[Providers] are encouraged to assess carefully the remote environment in which services will be provided to determine what impact, if any, there might be on the efficacy, privacy, and/or safety of the proposed intervention offered via telepsychology. Such an assessment of the remote environment may include the following:

  • a discussion of the client’s situation within the home or within an organizational context,
  • the availability of emergency or technical personnel or supports,
  • the risk of distractions,
  • the potential for privacy breaches, or
  • any other impediments that may impact the effective delivery of telepsychology services.”[13]

At the very least, the behavioral health provider should discuss these potential issues with the client so that the client may take the necessary precautions to protect the confidentiality and privacy of the eCounseling session.

Informed Consent

Behavioral health professionals must obtain informed consent that specifically addresses the unique concerns related to the services provided. The process of obtaining informed consent and offering a clear description of the eCounseling service “sets the stage for the relationship” between the mental health provider and the client.[14] As the client and the remote environment are assessed, obtaining informed consent ensures that the client is aware of the problems that may occur during the eCounseling session and affirms their desire to continue with the sessions.

Interjurisdictional Practice of Telepsychology in the United States

The practice of eCounseling across state lines in the United States is a controversial topic. According to the US Department of Commerce, only recently have states begun to address the issue of out-of-state physicians engaging in telehealth practice. [15] As of 2014, the psychology profession does not have a “mechanism to regulate the delivery of psychological services across jurisdictional and international borders”; however, it is “anticipated that the profession will develop a mechanism to allow interjurisdictional practice given the rapidity with which technology is evolving and the increasing use of telepsychology/[eCounseling] by psychologists working in the US federal environments such as the US Department of Defense and the Department of Veterans Affairs.”[16] Although the communication technologies associated with eCounseling allow a behavioral health provider to work with clients anywhere, state licensing laws generally do not permit out-of-state counselors to provide eCounseling to in-state residents. In most states the practice requires that a behavioral health provider is licensed not only in his or her own state, but also the client’s state. According to Dr. Joseph McMenamin, JD, MD, “It is important for practitioners to be aware of how members of licensing boards see themselves. They see themselves as the police. Their goal is to protect the public.”[17] In other words, state professional licensing boards want to make sure the client knows the applicable state board should he or she need to make a complaint and, more importantly, the applicable licensing board has the jurisdiction to impose sanctions on the behavioral health providers who have violated legal or ethical codes in the course of the eCounseling sessions. A strong argument can be made that when providing eCounseling services, the “service” is furnished both where the behavioral health provider is located and also where the client is located.[18] Thus, the provider must be licensed in both locations.

Recommendations

Any behavioral health provider who is about to engage a new client via the Internet must assess the client and prepare for emergencies that may occur during the session. Specifically, prior to the onset of eCounseling sessions, the provider must make reasonable efforts to identify and understand how to access emergency contacts and resources available in the client’s local community to assist with any type of crisis intervention.[19] The provider also must discuss with the client, and provide clearly written instructions, on what to do in an emergency situation such as risk of suicide or risk of hurting another person.[20] If a client repeatedly experiences crises or emergencies, which suggests that in-person, face-to-face sessions are clinically appropriate, the provider musts take reasonable steps to connect the client to a local mental health provider or begin face-to-face sessions.[21] The provider must continually assess the effectiveness and appropriateness of the eCounseling sessions in treating the client and take clinically appropriate actions if the client is in need of a higher level of care.

Generally, it is recommended that providers refrain from using free voice-over-Internet software, such as Skype, for eCounseling sessions because they don’t comply with HIPAA rules. Rather, providers should invest in the purchase of secure, encrypted technologies that have been created to comply with HIPAA privacy rules. Lastly, it his recommended that US providers only provide eCounseling services to clients within their own state or states in which they are fully licensed to practice independently.

While these concerns are of particular importance, providers in the United States can learn much from Canada where eCounseling services have been provided for many years. eCounseling services in Canada are not restricted by the individual state licensure laws present in the US. Canadian firm Morneau Shepell was one of the first EAPs to offer counseling sessions through video-based services. Their program is based on five foundational pillars:

  • Privacy Standards: Include electronic safeguards; legal concerns.
  • Engage the End User: Simple to use; accessible; engages the participant.
  • Clinical Best Practice: Short-term problem resolution; goal oriented; meaningful risk assessment and appropriate referral.
  • Manage High Risk Issues: Service includes a protocol for emergency support.
  • Up-front Disclosure about Exclusion Groups: Define who is best suited for this type of clinical service and who is not.[22]

These foundational pillars set a framework to provide eCounseling services across borders.

In the US, as a result of the current limitations resulting from state licensure laws, companies are seeking eCounseling options that comply with those laws. One example, Arcadian Telehealth, partners with US EAP vendors to offer video counseling for EAP participants who are unable to attend in-person sessions. Arcadian has developed a national network of state licensed video enabled clinicians in order to deliver HIPAA compliant eCounseling. Showing many of the features EAPs need, this product allows clients to access video counseling at home, whether using a desktop or laptop computer (PC or Mac) tablet or smartphone (iPhone or Android). The importance of mobile access to EAP services is clear from the results of a 2013 Pew Internet & American Life Project poll. It showed 60% of the population in the US now has smartphones that can be used to access eCounseling in the absence of a laptop or PC, and that number is continuously rising.

Issues for EASNA members to consider related to eCounseling include the US requirement to deal with multiple state licensing boards (a regulation that pre-dates the many significant technology and lifestyle changes experience in the last decade), instead of a national standard—a proven model already in use in Canada. EASNA’s Best Practices Committee, which developed this white paper, has encouraged our Advocacy Committee to pursue either a new federal regulation or reciprocity across state lines. Such a change would be beneficial to EAPs and their clients as eCounseling becomes a fully accepted method of providing counseling services to those who opt for this twenty-first century delivery modality.

 

[1] Society for Human Resource Management. (2013). 2013 Employee Benefits: An Overview of Employee Benefits Offerings in the U.S. Retrieved from https://www.shrm.org/research/surveyfindings/articles/documents/13-0245%202013_empbenefits_fnl.pdf on August 2, 2014.

[2] Pong, R., & Hogenbirk, J. (1999). Licensing Physicians for Telehealth Practice: Issues and Policy Options. Health Law Review, 8(1), 3-3.

[3] Campos, B. (2009). Telepsychology & Telehealth: Counselling conducted in a Technology Environment, Psychotherapy, and Health, 5(1), The Use of Technology in Mental Health Special Issue, 27.

[4] Committee on National Security Systems. (2010). National information assurance (IA) glossary. Retrieved from https://www.cnss.gov/Assets/pdf/cnssi_4009.pdf on July 10, 2014.

[5] Campos, B. (2009) Telepsychology & Telehealth: Counselling Conducted in a Technology Environment. Counseling, Psychotherapy, and Health, 5(1), The Use of Technology in Mental Health Special Issue, 34.

[6] Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. US American Psychologist, Vol 68(9), Dec 2013, 792. Retrieved from https://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/guidelines/telepsychology_guidelines_ap.pdf on June 25, 2014.

[7] Egede L. E., Frueh C. B., Richardson L. K., Acierno R., Mauldin P. D., Knapp R. G. Rationale and Design: Telepsychology Service Delivery for Depressed Elderly Veterans. Trials. 2009;10(22):1–14. [PMC free article][PubMed]

[8] Herbert, J. D., Goetter, E. M., Forman, E. M., Yuen, E. K., Erford, B. M., Milillo, J. J., Goldstein, S. P. (2012). Crossing the line: Interstate delivery of remote psychological services. The Behavior Therapist, 35 (8), 147.

[9] Herbert, J. D., Goetter, E. M., Forman, E. M., Yuen, E. K., Erford, B. M., Milillo, J. J., Goldstein, S. P. (2012). Crossing the line: Interstate delivery of remote psychological services. The Behavior Therapist, 35 (8), 147.

[10] Summary of the HIPPA Privacy Rule, Introduction. Retrieved from https://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html on June 19, 2014.

[11] Quashie, R. (2012). Is Skype HIPAA-Compliant? TechHealth Perspectives – Strategy, Analysis, and Commentary on Current and New Health Technologies. Retrieved from https://www.techhealthperspectives.com/2012/06/22/is-skype-hipaa-compliant/ on June 19, 2014.

[12] Quashie, R. (2012). Is Skype HIPAA-Compliant? TechHealth Perspectives – Strategy, Analysis, and Commentary on Current and New Health Technologies. Retrieved from https://www.techhealthperspectives.com/2012/06/22/is-skype-hipaa-compliant/ on June 19, 2014.

[13] Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. US American Psychologist, Vol 68(9), Dec 2013, 795. Retrieved from https://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/guidelines/telepsychology_guidelines_ap.pdf on June 25, 2014.

[14] Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. US American Psychologist, Vol 68(9), Dec 2013, 795. Retrieved from https://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/guidelines/telepsychology_guidelines_ap.pdf on June 25, 2014.

[15] U.S. Department of Commerce, Telemedicine Report to Congress (Washington, D.C.: Department of Commerce, 1997). Retrieved from https://www.ntia.doc.gov/legacy/reports/telemed/index.htm on June 29, 2014.

[16]Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. US American Psychologist, Vol 68(9), Dec 2013, 793. Retrieved from https://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/guidelines/telepsychology_guidelines_ap.pdf on June 25, 2014.

[17] Dr. Joseph McMenamin was the final presenter at the American Psychological Association’s 119th Annual Convention in Washington DC, Aug. 4-7, 2011. Retrived from https://www.fenichel.com/licensing2011.shtml on July 12, 2014.

[18] American Psychological Association Practice Organization (2010). Telehealth: Legal Basics for Psychologists. Good Practice, 41,2-7. Retrieved from https://www.apapracticecentral.org/ on June 23, 2014.

[19] Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. US American Psychologist, Vol 68(9), Dec 2013, 794. Retrieved from https://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/guidelines/telepsychology_guidelines_ap.pdf on June 25, 2014.

[20] Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. US American Psychologist, Vol 68(9), Dec 2013, 794. Retrieved from https://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/guidelines/telepsychology_guidelines_ap.pdf on June 25, 2014.

[21] Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. US American Psychologist, Vol 68(9), Dec 2013, 794. Retrieved from https://c.ymcdn.com/sites/www.asppb.net/resource/resmgr/guidelines/telepsychology_guidelines_ap.pdf on June 25, 2014.

[22]Wittes, Paul & Veder, Barb, Spanning Borders, EAPA Vol. 43 no.4 – 4th Quarter 2013

Posted on EAP Best Practices, eCounseling