mental health professionals to provide mental health services during this emergency (U.S. Department of Health and Human Services, 2020). It is possible that these experiences with online counseling will further expand the use of distance counseling. In addition, counseling supervision was provided via synchronous videoconferencing platforms in universities that traditionally only used face-to-face formats.
Competency
In many situations, counselors are responsible for identifying and demonstrating competency when determining their scope of practice. There are, however, specific laws or regulations for determining minimum standards. Some state licensure boards have identified minimum training standards through continuing education credits or university training, whereas other boards have not clearly articulated expectations. It has been a challenge for regulatory entities to stay current with the rapid evolution of technology and technological practices. It is clear in all situations that counselors must always function within their areas of competence and be able to provide evidence regarding their competence and adequate training. This is especially challenging as technology is constantly changing, and best practices in technology-assisted mental health services are in their infancy. ACA (2014) notes that “counselors who engage in the use of distance counseling, technology, and/or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (e.g., special certifications, additional course work)” (Standard H.1.a.).
In addition, counselors must make clients and supervisees aware of the training, limitations, and protections offered by the counselor or supervisor (American Association for Marriage and Family Therapy, 2015). The Association of Marital and Family Therapy Regulatory Boards (AMFTRB; 2016) identified a minimum of 15 hours of initial training, including the appropriateness of teletherapy, teletherapy theory and practice, modes of delivery, legal/ethical issues, handling online emergencies, best practices, and informed consent. In addition, it requires five continuing education hours every 5 years. NBCC offers a nationally recognized credential, the board certified-telemental health provider (BC-TMH), who might be useful in training and the demonstration of skills. This provides counselors an opportunity to demonstrate formal training or skill attainment as a telemental health provider (Center for Credentialing and Education, 2020).
Residency
When counselors engage in technology-assisted counseling, they should be aware of the laws and regulations in their state of practice as well as the client’s state of residence. In most situations, counselors must adhere to the laws and regulations of both states (ACA, 2014; AMFTRB, 2016; NBCC, 2016b). When clients or counselors travel out of their state of residency (physically or virtually), counselors should be aware of the state’s definition of residency, as each state defines residency differently. Some states allow a client’s residency to be defined by the client’s home address, whereas others define residency as the physical locations of the counselor and/or client at the time of service delivery (AMFTRB, 2016). Some states allow for travel, but they may define the number of days outside of the home state. In this situation, an attorney and the licensure boards for the states in question should be consulted to fully understand the legal definition of residency. Once counselors have identified the legal regulations for their region, they should document their findings as well as their activities in their counseling records (NBCC, 2016b).
When counseling clients who are outside of the United States, it is important to identify the counseling regulations for the counselor’s home state as well as the country and/or region in which the client is living (ACA, 2014). It might be important to identify how mental health services are defined and regulated in the region, as the terms counselor or therapist might have different meanings in different regions. When counselors or clients reside on a military base, the regulations may also be very different. Many U.S. military bases are considered sovereign territory and possess their own regulations regarding licensure. Another factor to consider is where the counseling services are offered, either through a mental health office or through a chaplain’s office. Chaplain or faith-oriented services are sometimes subject to different rules, laws, and regulations, which has implications for confidentiality.
Several resources are available to assist counselors providing telebehavioral health services. ACA provides resources regarding client/counselor residency on their website (https://www.counseling.org) and specifically in the Government Resources section (https://www.counseling.org/government-affairs/government-resources-for-counselors).
Assessing Appropriateness for Technology-Assisted Services
Counselors must recognize that not all clients will be well served through telebehavioral health services; therefore, it is imperative for them to assess a client’s appropriateness for technology-assisted services prior to beginning distance counseling. The ACA Code of Ethics states that “counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client” (ACA, 2014, Standard H.4.c.). Counselors must recognize that distance counseling services are not appropriate for every client; in those situations, they should consider offering face-to-face services or providing appropriate referrals for those clients. This assessment of client appropriateness should be an ongoing process to ensure the client is using technology in an appropriate manner (ACA, 2014; Stolsmark, 2015). It is important for counselors to assess several categories of appropriateness, including access to and knowledge about technology, counseling space and netiquette, emotional stability, and safety and emergency risk management. It is recommended that counselors meet with clients in person when possible to conduct this assessment, to verify their identity, and to conduct an initial informed consent interview. When an in-person session is not possible, a synchronous videoconferencing session might be appropriate (AMFTRB, 2016). It is important for clients to understand the risks and limits to confidentiality prior to engaging in an initial session using technology. Clinicians should consider the following areas of appropriateness prior to engaging in virtual clinical services with clients.
Access to and Knowledge About Technology
Technology-assisted counseling sessions are most effectively conducted with clients who are very comfortable using similar technologies. It can be risky or stressful to use technology in the counseling session when the client has not used it in the past or when appropriate supports are not in place. In some cases, rural agencies have opted to send out technologists or case managers to assist clients in their homes during initial sessions when they are new to using virtual technology. Other providers have constructed telehealth rooms in their agencies that are monitored by administrative staff to support connections with counselors who are off-site. It is helpful to provide clients with a list of the required technologies prior to the first session. This list might include a computer with the capacity necessary to handle a teleconferencing program, a webcam with microphone, headphones with an integrated microphone, and an Ethernet-accessed internet connection. It is recommended that clients and counselors use Ethernet cables to connect to the internet, as wireless internet may not be secure and risk confidentiality breaches. It is also helpful when both clients and counselors use a virtual private network as a means to secure and protect confidentiality. HIPAA-compliant encrypted software should this time of crisis; however, it also recognized the need to continue to safeguard privacy:
If telehealth cannot be provided in a private setting, covered health care providers should continue to implement reasonable HIPAA safeguards to limit incidental uses or disclosures of protected health information (PHI). Such reasonable precautions could include using lowered voices, not using speakerphone, or recommending that the patient move to a reasonable distance from others when discussing PHI. (Office for Civil Rights, 2020,
