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TECHNOLOGY IN
EXPOSUREHow Scottie Beams Us Up, And Other Clinical
Applications
Sara Smucker Barnwell, PHD
April 10, 2015
© MAL SSB 2013
Welcome
Your presenter
Sara Smucker Barnwell, PhD
Offers telemental health training across
disciplines
Provides technology enabled exposure in
private practice and institutional settings
Appointment at UW, former VA provider
Committees on telehealth, technology
© MAL SSB 2014
Agenda
• Definitions, practical examples
• Telephone, videoconferencing technologies in
exposure
• Mobile applications, mobile monitoring in exposure
• Virtual Reality in exposure
• Regulation, guidelines and ethics for technology use
• Practical considerations
© MAL SSB 2013
Disclaimers*
• During a technology presentation, technology will generally always fail
• Offer best practice recommendations based on clinical work, literature review and regulatory experience
• Aim to offer guidance in a developing area
• Always review state regulations
• Consult with your own legal counsel
• Not legal advice nor clinical advice
*The digital fine print
© MAL SSB 2014
Disclosure
Consultant with Virtually Better, Inc.
WSPA Telehealth Committee
© MAL SSB 2014
Definitions and Examples
© MAL SSB 2013
Jargon!
© MAL SSB 2013
Operational definitions
Telecommunications Technology:
Telecommunications is the preparation, transmission,
communication, or related processing of information by
electrical, electromagnetic, electromechanical, electro-
optical, or electronic means (Committee on National
Security Systems, 2010)
© MAL SSB 2014
Exposure is a clinical tool
© MAL SSB 2013
Operational definitions
Videoconferencing:
Real-time, generally two way transmission of digitized
video images between multiple locations; uses
telecommunications to bring people at physically
distinct locations together for meetings. Each individual
location in a videoconferencing system requires a room
equipped to send and receive video (ATA, 2009)
© MAL SSB 2013
Operational definitions
Mobile Device:
Handheld computing device made for portability
Often web enabled
Diversity of functions (e.g., telephony, computing,
Internet)
Diversity of platforms (e.g., Apple, Google/ Android,
Windows)
© MAL SSB 2013
Operational definitions
Mobile Application:
Application software designed to run on smartphone,
tablet or other mobile device. Specific to device
platform (iPhone/iPad, Android, Blackberry, etc.)
© MAL SSB 2013
Operational definitions
Virtual Reality:
Immersive multimedia/ computer generated
environment that simulates physical presence in
environments real or imagined
Can recreate taste, sight, sound, smell touch
Currently available in over 60 VA hospitals, clinics,
affiliated medical centers and university clinics (ICT,
2014)
© MAL SSB 2013
Operational definitions
Virtual Reality:
Can involve large-scale immersion (e.g., light stage,
body sensors, that of equipment to simulate diversity of
movements, smells tastes)
Can involve small scale application (e.g., adaptation of
a mobile device
Head mounted displays vs. immersive technological
environments
© MAL SSB 2013
Operational definitions
© MAL SSB 2013
Moving up the SUDS hierarchy
© SSB 2015
Exposure Based Therapies
© MAL SSB 2013
What is it
Exposure therapies:
Psychotherapy technique for anxiety-spectrum disorders
Planful exposure to feared stimuli
Predicated on concept of desensitization and successive
approximation/ behavioral shaping
Progression up hierarchy of feared cues vs. flooding
Typically accompanied with relaxation/ breathing
retraining
© MAL SSB 2013
Types of exposures
In vivo: Exposures carried out in real situations
Imaginal: Exposures carried out in rehearsive
imagination
Interoceptive: Exposures carried out with focus on
physical experiences
Virtual Reality: Exposures carried out in computer
simulated environments
© MAL SSB 2013
Theoretical mechanisms
Habituation: Natural reduction in fear response with
repeated exposure
Extinction: Overwriting previously learned fear
associations
Emotional processing: Developing new interpretations
and meanings for feared stimuli and fearful responses
Self-efficacy: Increased perception that one is capable
of tolerating feared stimuli and responses
Kaplan, & Tolin (2011)
© MAL SSB 2013
Empirical support for diverse
diagnoses
• PTSD
• Panic Disorder
• Phobias
• Social Anxiety Disorder/ Social Phobia
• Obsessive Compulsive Disorder
• Health Anxiety
• Substance Abuse/ Dependence
• Other anxiety-spectrum disorders
© MAL SSB 2013
Examples of exposure therapy
• Prolonged Exposure (PE) for PTSD
• Cognitive Processing Therapy for PTSD (CPT)
• Eye Movement Desensitization Reprocessing (EMDR)
for PTSD
• Barlow & Craske (2006) Panic Protocol
• Yadin, Foa, & Lichner (2012) OCD Protocol
• Hope, Heimberg, & Turk (2010) Social Anxiety
Protocol
© MAL SSB 2013
Exposure therapies with
Veterans
• Strong national emphasis on evidence based
treatment
in VA/ DoD
• 2010 Clinical Practice Guidelines for PTSD VA/DoD
• Funding mechanisms oriented toward evidence based
PTSD care
© MAL SSB 2013
Exposure therapy in private
practice
• Strong implementation of technology-facilitated care
• Medical Home Model
• Telehealth programming
• Home VTC
• Virtual Reality increasingly available
• Mobile applications
• Big data/ behavior therapy integration
• Trending towards exposure and technology
© MAL SSB 2013
Technology in Exposure
© MAL SSB 2013
Why augment usual exposure
with technology
Natural marriage to bring patient and clinician to
environments better suited to exposure targets
Evidence base for non-inferiority for:
• Telephone
• Videoconferencing
• Virtual Reality
Emerging understanding of:
• Mobile monitoring
• mHealth/ mobile applications
The email question
© MAL SSB 2013
Exposure and technology
Opportunity for technology to bridge gaps in practical
barriers to exposure work. Consider:
• Limited time to plan and complete in vivo
• Limited resources to enact exposure (e.g., airplane
tickets)
• When triggers are inherently dangerous (e.g., drug
use, heights)
• When triggers are not accessible (e.g., combat
environments)
© MAL SSB 2013
Examples of use
• Seattle VA pioneers OCD treatment through in home
videoconferencing group focused on exposure
• Mobile monitoring in homework tracking/ measure
physiological responses to exposure
• Mobile devices to organize complex exposure
protocols (e.g., PE Coach, PTSD Coach) or assist in
skill building (Breathe 2 Relax)
© MAL SSB 2013
Integrating Telephone and
Mobile Devices in CareHow Stuff Works
© MAL SSB 2013
Telephone: Landline
• 60% of American homes have landline
• HIPAA privacy does not prohibit
• Security concerns differ
• Fewer concerns regarding user location
• Fewer interactions with recording/ transcription
• Not invulnerable to interception
© MAL SSB 2013
Mobile devices
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Mobile Device
Smart Phone
Mobile broadband access
US Mobile Access
© MAL SSB 2013
Mobile devices
Increasingly used by general public
Socialization, decision-making, information seeking online
Independent of therapy, behavioral emphasis
Weight loss applications
Mindfulness applications
Complement to therapy
PTSD Coach
PE Coach
© MAL SSB 2013
Mobile devices
© MAL SSB 2013
Mobile devices
Different underlying technologies
API’s change constantly
Unique risks:
Privacy (volume, location, points of interception)
Recording
Analysis of data
Online interactions, location
© MAL SSB 2014
Mobile devices
• Password protection
• Data storage (local vs. online)
• Carrier
• HIPAA permits
• NSA
• Snowden/ NYT
• Capabilities vs. what is being done
© MAL SSB 2013
Exposure and the
Telephone/ Mobile Devices
© MAL SSB 2013
Therapy and the telephone
Telephone-based therapy
• Well-established method
• Typically augments exposure care
• May be stand alone care
• Historically used to check in between sessions,
administrative
© MAL SSB 2013
Exposure applications
• Therapist guided in vivo exposures (especially first
exposures)
• Therapist guided skills training after session
© MAL SSB 2013
Clinical recommendations
• Thoroughly establish protocol beforehand
• Establish safety plan
• Local resources
• Optional safety person
• Establish patient location at each call
• Consider interspersing with in-person or video
© MAL SSB 2013
Technical recommendations
• Decide what type of telephony you will use
• Landline vs. Mobile vs. VoIP
• Communicate risks
• Shared or independent with personal use
• Recommend separate if you can use it
• If using VoIP
• Consider turning off transcription/ text alerts
• Consider whether you will answer unknown numbers
• If using mobile
• Consider where/ when you will answer device
• Password protect
• Do not share
© MAL SSB 2013
Case Vignette: Telephone
© MAL SSB 2013
Mr. Spock
• 55 year old divorced man
• Diagnosis of OCD
• Engaged in Distress Tolerance/ Response Prevention
• Challenges with operationalizing/ Triggers not
available in outpatient setting (e.g., specific areas
of home)
• Able to “bring” therapist to homework
© MAL SSB 2013
Telephone intervention
• Set in vivo targets in prior session
• Set emergency plan in advance
• Determine where, when, how
• Purpose: review mechanics, cue for engagement,
coaching
© MAL SSB 2013
Successes and challenges
Operationalized homework
Phone call as avoidance?
Boundary setting
Reimbursement
What are your concerns?
© MAL SSB 2013
Exposure and
Videoconferencing
© MAL SSB 2013
Videoconferencing basics
• 25% of Americans have inadequate mental health care
access (APA, 2009)
• Significant literature for best practices
• ATA Best Practices (2009), Evidence Based Practice
(2009), Telepresenting (2011)
© SSB 2013
Videoconferencing
© MAL SSB 2013
Applications in exposure
• Exposure therapy to clients with access limitations
• Innovative exposure in home or on site (e.g.,
hoarding)
• Guided skills training in home or on site (e.g.,
breathing retraining in
crowded environment)
• Better opportunity to utilize natural exposure
• Better opportunity to engage in flooding protocols
© MAL SSB 2013
Videoconferencing and
rapport
• Technology disruption
• Eye contact/ body position
• Emotion/ animation
• Candor regarding moments when technology interferes
© SSB 2013
Videoconferencing: Patient
environment
• Individual v. group
• Secure, private space
• Availability of Internet (better than dial-up)
• Web camera
• Computer/ mobile device
• Adequate memory/ processing speed (<5 years old)
© MAL SSB 2013
Videoconferencing: Patient
environment
Consider where exposure occurs
Consider whether you want a mobile device moving
outside an area with an established safety plan
Consider jurisdictional concerns
© MAL SSB 2013
Videoconferencing: Provider
environment
• Clinical space
• Lighting
• Background
• Adequate technical infrastructure
• More important for provider than patient
• Recommend redundancy when possible
• Technical support availability
• Where is the provider during exposure
© MAL SSB 2013
Provider satisfaction
© MAL SSB 2013
Videoconferencing and HIPAA
considerations
• HIPAA compatibility
• Privacy rule, not security rule
• Marketing term
• Encryption
• Business Associate’s Agreement
• Data treatment
• Reaction if breeched
• Some companies argue that if they are only a conduit
• Some companies “listen in” for security
© MAL SSB 2013
Videoconferencing
Publicly available vs. health care products
Encryption
Data infrastructure
Different underlying technologies
How does the data get from Point A to Point B
Who can see it
© MAL SSB 2013
Videoconferencing: Selecting
a software
• Varying costs (free - $300/month; many $100/mo)
• Access vs. information security
• Informed choice
• Ease of patient use
© MAL SSB 2013
Videoconferencing: Selecting
a software
• Look for encryption
• Consider how data is transmitted
• Who can see the information
• Will company provide a Business Associates Agreement
• Do they “listen in”
• Do they provide transcripts, IM, recording
© MAL SSB 2013
Videoconferencing: Selecting
a software
• Technical support availability
• Ease of use
• For you
• The population you serve
• How will patients receive access
• Financial considerations
• Investment vs. risk
© MAL SSB 2013
Videoconferencing software
features
• Screen sharing
• Psychoeducation
• Exposures
• Homework review
• Split screens
• Multi-calls
• Privacy features
• “Locked” rooms/ password protection
• Ability to see who is in a room before you join
© SSB 2013
Unsung benefits
© MAL SSB 2013
What not to do
© SSB 2013
CASE VIGNETTE:
VIDEOCONFERENCING
© MAL SSB 2013
Mrs. Uhura
• 31 year old married woman
• Sought treatment for depression and anxiety after
birth
• Diagnosis of panic triggered by ambiguous cues
interacting with son
• Not actively suicidal/ concern for harm to child
• Not able to bring child to hospital
• Lived in home with private space, hardware, Internet
© MAL SSB 2013
Intervention
• Assess video appropriateness
• Technical
• Clinical
• Establish emergency plan
• Test installation/ tech use
• Delivered 21 sessions of treatment for depression and
anxiety that included exposure to cues related to son
(e.g., toys, allowing spouse to care for child, being
away from child)
• Graduated to in-person care
© MAL SSB 2013
Successes and challenges
Engaged in care in a way that was accessible
Ultimately, engagement in person care was challenging
(some part attributable to anxiety)
Messy
Reimbursement
Monitoring of child welfare (other cases)
What are your concerns?
© MAL SSB 2013
Delivering Care with
Virtual Reality
© MAL SSB 2013
Why VR
• Non-inferiority literature (not superiority) in
exposure
• Benefits for time, cost
• Low engagement clients in exposure
• Safety
• Availability of triggers/ exposure stimuli
© MAL SSB 2013
Integrating VR
• Access to large scale equipment through VA/ DoD
• Myriad vendors offer smaller scale solution
• USC, Skip Rizzo
• Barbara Rothbaum, Virtually Better
• DoD, National Center for Telehealth and Technology
• Phobioua, many others
• Vendors at national conferences
• Gaming driving this space (Oculus Rift, others)
© MAL SSB 2013
How it works
• Typically akin to Prolonged Exposure (VRET)
• Client engages in breathing retraining, conducts
trigger hierarchy
• In vivo exposure between sessions
• Start with imaginal, build to VR
• Some imaginal, but also VRET to access difficult to
engage, reproduce
• Can bridge to imaginal exposure
© MAL SSB 2013
How it works
Diversity of stimuli
Interactive visual environment
Audio
Many products have olfactory, tactile option
© MAL SSB 2013
Case Vignette: VRET
© MAL SSB 2013
What it looks like
• Many products in this space
• Demonstration of one available at Madigan
• Not endorsing one over another
• Live demonstration
• https://www.youtube.com/watch?v=GzdDVq0Zo4c
© MAL SSB 2013
Mr. McCoy
• 20 year old Iraq Veteran
• Combat trauma, loss of friend
• Prior episode of care, underengaged
• Treated at joint military base/ VA
• VRET protocol with specific combat scenario recreated
© MAL SSB 2013
Successes and challenges
No VR environment is perfect
Video game concerns
Helped with underengagement
Practical
What are your concerns?
© MAL SSB 2013
Integrating Home
Monitoring in Care
© MAL SSB 2013
Home monitoring
• Capturing patient data at a distance
• Biometric data (FitBit, cardiovascular care)
• Behavioral data (ADHD assessment, BA, medication compliance)
• Major growth area
• Integration to form new types of care
• Wearables
• Online monitoring/ interactive
• Difficult to speak about one category
© MAL SSB 2013
Wearable monitoring
© MAL SSB 2013
Intervention examples
• Heart rate monitor during imaginal exposure
• Tracking heart rate during in vivo exposure/ GSR
• Record ratings in PE Coach
• Use of Pedometer and other metrics in Behavioral
Activation
© MAL SSB 2013
Master Crusher
11 year old boy assessed for ADHD
Dramatic inconsistencies in collateral reporting
Use of HR monitor, pedometer and GPS to identify
actual differential between reactivity at home and at
school
© MAL SSB 2013
Successes and challenges
More accurate reporting/ less bias
Patient engagement
Can be fussy
Costly
Difficulty getting data in HIPAA appropriate way
What are your concerns?
© MAL SSB 2013
Home monitor take away
• Consider how/ if to integrate into practice
• Exposure therapy relies on habituation to stimuli/ direct
monitoring
• Not exclusive to exposure work
• Consider application in
assessment/intervention/homework
• Try using it yourself, if you haven’t already
© MAL SSB 2013
Common Threats to Security,
Privacy and Confidentiality
© MAL SSB 2013
Confidentiality vs. privacy vs.
security
Privacy: “The condition or state of being free from
public attention to intrusion into or interference with
one’s acts or decisions.”
Patient treatment is not public information
Confidentiality: “means the principle that data or
information is not made available or disclosed to
unauthorized persons or processes.”
Patient data is not released without their permission
Security: “Administrative, physical, and technical
safeguards related to information software system”
How patient data is protected
© MAL SSB 2013
Privacy
© MAL SSB 2013
Security, privacy and
confidentiality:
• Technology brings unique opportunities
• Difficult to speak to all technologies due to significant
differences between them
• Providers are not engineers
© MAL SSB 2013
Challenges
Technology brings unique risks
Confidentiality Breech:
Smartphone bill received at home and viewed by spouse –
including phone numbers of clients
Privacy Breech:
Staff FB post with a location tag that she’d seen notable
client
Security Breech:
Virus on computer at work sent group email to all patients
who approved email reminders for appointments – all
recipients could see all addressees
© MAL SSB 2013
Caveat user
© MAL SSB 2013
Security, privacy and
confidentiality in exposure
Where is the treatment room (e.g., office, car, store)
Where is the patient’s treatment room
Where is your office?
How planful are you for contingencies?
How well do you understand the technology you use?
How well do you understand where the client is/ who is
near?
© MAL SSB 2013
Best practices
Determine what services you will provide via technology
Consider stand alone vs. augment
Interactive or static?
In-person meeting when required and when possible
(e.g., consent, identity)
Which client populations, risk profile
© MAL SSB 2013
Best practices
Select a technology
Meets your clinical needs
Understand if data is encrypted
Consider where the information goes/ is stored/
who access
Who owns the data
Consider investing in technologies designed for
healthcare, use encryption, do not interact with
data, breech history
© MAL SSB 2013
Best practices
Secure physical location and hardware
Secure shared hardware and software
Disposal plan
Provide training to staff
Use of professional equipment
Interaction of private use of technology
Plan for adverse events (e.g., virus, hacker, theft,
damage)
© MAL SSB 2013
Best practices
Capture informed consent (written or online)
Recruit clients as advocates for own privacy
Use technology properly
Secure wi fi, when appropriate
Use dedicated, password protected profiles and
accounts for interactions with providers
No forwarding, recording, etc.
© MAL SSB 2013
Guidelines and Regulations
© MAL SSB 2013
Laws & regulation
• Minimum requirements for practice
• Technology emerging integration into law
• Most psychologists are NOT lawyers
• Be mindful that jurisdictions DIFFER
• Consult best practice guidelines
• Consider your employment setting policies and
procedures
• Consider that federal laws may apply (i.e., HIPAA,
HITECH)
© MAL SSB 2013
Regulatory considerations
Are there jurisdiction requirements (local, state,
federal, international) related to technology and
practice of psychology?
Where does care occur?
Is there reimbursement issues related to technology use
in practice of psychology (i.e., billing of testing)
© MAL SSB 2014
What is interjurisdictional
practice?
Providing care outside your licensure jurisdiction via
technology
• Can occur when either the provider is in a non-licensed
jurisdiction, or
• When the client is in a jurisdiction that the provider is
not licensed in and receiving services
Salient but not exclusive to telehealth
© MAL SSB 2013
Interjurisdictional
requirements
Currently there is no federal licensing law
ASPPB PSYPACT
© MAL SSB 2013
IJP
© MAL SSB 2013
Ethical Guidance
© MAL SSB 2013
Ethics
• Less ethical and empirical guidance for technology
enabled exposure
• VR literature dates to 1990s
• If exposure is a gold standard, then tech is alchemical
• Guidelines documents provide assistance
• APA, ATA, forthcoming WSPA
• Collegial consultation (professional judgment)
• Document who, when, content
© MAL SSB 2013
Ethics
© MAL SSB 2013
Emergency management
© MAL SSB 2013
Emergencies
© MAL SSB 2013
Emergencies
• Often heightened concern in exposure
• Clients receiving interactive remote care have
emergency plan
• Consider what you will do in case of medical or
psychiatric emergency (e.g., local hospital, wellness
check, others).
• Problems that do not meet mandated reporting threshold
but cause concern
• Availability of support person
© MAL SSB 2013
Best practices
• Determine level of client and clinical stability you are
comfortable with
• Screen clients accordingly
• Use with existing clients
• Screen clients for technical knowledge/ availability of
appropriate endpoint (e.g., quiet, private)
• Consider what services you are comfortable providing
over what modalities
• In vivo over video vs. response prevention over phone
© MAL SSB 2013
Best practices
• Create unique emergency plan for each exposure
technology patient
• Consult with others doing similar work
• Look around you!
• ATA SIG
• VA
• TMH Institute
• Develop templates, esp. informed consent
• Document this plan within the client record, keep
available for review
© MAL SSB 2013
Educating clients and
informed consent
© MAL SSB 2013
Consent at home
© SSB 2013
Introducing clients to
technology
Education as predictor of technology success
Education regarding exposure part of most manuals
What is your ability (time, competence) to train clients
Impact on client selection for technical experience
Consider creating a 1-page document reviewing:
How this augments standard exposure therapy
How to use
Appropriate use
Troubleshooting/ technical resources
© MAL SSB 2014
Informed consent for new
service
• Apprises clients of the risks and benefits
• Provides education to the client of service boundaries
and limits
• Use clear language for variety of levels of technical
sophistication
© SSB 2013
Informed consent for new
service
• Be prepared to discuss exposure and technology
facilitating it
• Be explicit regarding your technology experience (or
inexperience)
• Be prepared to answer questions/ find answers
• Capture documented informed consent
© MAL SSB 2013
Informed consent
© MAL SSB 2013
Educating clients of risks
• Apprising clients of risks (esp, privacy, confidentiality)
• Use of technology introduces risk/ what steps taken to
mitigate risks
• Whether/ how information is recorded and stored
• This information can be subpoenaed
• Who can access stored information
• Impact on emergency management
© SSB 2013
Educating clients of service
benefits
• Unique exposure opportunities
• Access
• Geographic, medical issues, financial concerns,
convenience
• Specialty otherwise unavailable
• Dual role (esp., in rural communities)
• Convenience (e.g., cost, asynchronous)
© SSB 2013
Educating clients of service
limits
Usual limits of confidentiality apply
Consider any unique to the modality (e.g., email,
text)
Confidentiality limited by security of technology
(e.g., system problems, authorized access by
administrators, potential discovery by other users)
Limits of what you address clinically over modality and
your response
How you will respond to inappropriate technology
use
© SSB 2013
Educating clients of service
limits
• Address whether this is stand-alone service or augment
• Especially relevant for in office visits augmented with
at home exposure
• Crisis management capacity and plan
• Availability for response/ time frame
• Client responsibilities
• Role in security (e.g., forwarding, recording)
• Client technical requirements
© SSB 2013
Educating clients of service
limits
• What to do in case of technology failures
• Clinically (imaginal?)
• Practically
• Conflicts in jurisdictional rules/ how it will be handled
• Capturing documented informed consent
© SSB 2013
Educating clients of service
limits
Billing information
Service fee
Technology fees
How billing will be handled if service disrupted
How information security breach with be managed
How service termination will be managed
© SSB 2013
Enlist clients as advocates for
security
• Password protect computer, mobile device used for
exposure
• Secure WiFi
• Do not record without consent
• Abide by agreed upon strictures, alternate options
• Being alone in remote treatment room
• Ask questions
© MAL SSB 2013
Integrating technology
enabled exposure into your
practice
© MAL SSB 2013
Determining which therapies
Which exposure-based therapies?
PE, VRET, OCD protocol, Panic protocol
Which modalities?
Telephone?
Video?
VRET?
Mobile Apps
Others?
© MAL SSB 2013
Which clients
Popular factors to consider (esp. for remote service):
• Care engagement
• Care access (e.g., distance, medical, financial)
• Patient preference
• Clinical issues (e.g., diagnosis, avoidance, substance abuse, treatment history)
• Clinical stability (i.e., likely emergency)
• Ability to meet in-person
• Client care environment (e.g., office, home)
• Insurance/ reimbursement
• Privacy/ stigma
© MAL SSB 2013
Social exposure
© MAL SSB 2013
Which clients
• Technical ability of client
• Your ability to teach client
• Age, gender, education or technology experience are not
as important as a good explanation
• Does the client possess technical resources
• Computing device
• Adequate internet speed
• Hardware/software
• Mobile device, phone
© MAL SSB 2013
Not the perfect client
© MAL SSB 2013
Handling emergencies
• Clients receiving interactive remote care have emergency
plan
• May be more lenient when augmenting in person care (VRET)
• Consider what you will do in case of medical or
psychiatric emergency (e.g., local hospital, wellness
check, others)
• Problems that do not meet mandated reporting threshold
but cause concern
• Availability of support person
© MAL SSB 2013
Best practices
Determine level of client and clinical stability you are
comfortable with for exposure and technology
Screen clients accordingly
Draft policies (informed consent, emergency templates)
Screen clients for technical knowledge/ availability of
appropriate endpoint (e.g., quiet, private)
Consider what services you are comfortable providing
over what modalities
PE over videoconferencing; augment CPT with phone
© MAL SSB 2013
New social phobia treatment
© MAL SSB 2013
Selecting your technology
Look for products made for healthcare
Mobile phone encryption
Videoconferencing for healthcare
Mobile Apps by reputable vendors (Universities, DoD,
others)
Obtain a BAA when appropriate/ possible
Consult with your legal counsel
Malpractice attornies
Document your decisions
© MAL SSB 2013
Questions and Answers
© MAL SSB 2013
