Psychologists are no strangers to using the telephone in their practices. Initial appointments are arranged over the telephone as are cancellations and reschedules. Prospective patients call us to get information about our practices, expertise, and availability. Via the telephone we often talk to our patients who are dealing with emergencies and suicidal crises between scheduled appointments. These are well-established non-controversial professional activities that involve the use of the telephone with our psychotherapy patients.

Some community agencies offer mental health telephone hot lines to help people cope with crises. Community resources accessed by telephone often act as referral sources and at other times dispatch emergency personnel. Employee assistance programs also use the telephone to provide brief supportive, educational, assessment and referral services. There are employee mental health service programs where treatment is conducted via telephone with no in-office assessment, consultations or psychotherapy (Reese, Conoly and Brossart, 2002). Let us turn to situations, where for a brief period of time, psychotherapy sessions with an established patient will be conducted using the telephone. Some examples are: a patient is pregnant and is ordered by her physician to have complete bed rest; the patient who is recovering from surgery, a flu, other medical situations or some phobic patients that may prevent a patient from coming to the therapist's office for psychotherapy sessions. In all of these situations the patient may want to continue his/her psychotherapy over the telephone for a temporary period of time.

How would one define 'ongoing' or 'established therapeutic relationship'? Generally, an established relationship exists when an evaluation or assessment has been completed, the patient, and psychologist have agreed upon a treatment plan and there is a treatment alliance.

Well established therapeutic relationships that have existed for months or longer may have a temporary period of telephone psychotherapy when a patient is away for an extended business assignment or personal trip and wants to continue psychotherapeutic sessions. Sometimes a psychologist may not able to come to his/her office for sessions, for example when h/she is out of town traveling or is out of the office due to injury or illness that impairs the psychologist's mobility. If mutually agreeable, therapy can continue on the telephone and an interruption in the treatment can be avoided.

Another temporary or transitional use of the telephone might be when a patient moves away for school or work or other circumstances, and requests continued therapy sessions while moving and before a new psychologist has been selected and a treatment relationship has been established.

What about the situation where there is an established therapeutic relationship and the patient or psychologist has permanently relocated? In this situation it is not expected that office sessions will be resumed on an ongoing basis. If mutually agreed upon, it is assumed that most sessions will be conducted over the telephone until termination. There may be occasions when the patient returns to where his/her psychologist practices or the psychologist may return from time to time to where h/she formerly practiced for a few in-office sessions. Even when other psychotherapists are available, the patient may want to maintain his/her psychotherapy through telephone sessions and not change therapists. If other aspects of the clinical situation seem consistent with maintaining the relationship, I consider this to be an appropriate therapeutic posture and a legitimate way to meet the patient's needs. Specific clinical issues such as the patient's history of early loss, dependency, separation and abandonment experiences, and what it means to the patient to continue on the telephone or transfer to another therapist need to be addressed in therapy sessions.

It is my view that in situations where a therapeutic relationship exists it is professionally appropriate to discuss the possibility of continuing psychotherapy using the telephone and thereby maintain continuity of care that would benefit the patient. This is especially so when the choice is to continue on the telephone rather than disrupt therapy. However, I want to emphasize that there are clinical situations where it would not be appropriate, nor in the patient's best interest to provide telephone psychotherapy. For example, in most instances the impulsive, alcoholic or drug dependent person who rapidly cycles between depressive episodes to manic episodes might be a high-risk person to continue with on the telephone on an ongoing basis. Thus, decisions about providing psychotherapy via telephone need to be made on a case-by-case basis. In so doing many ethical and clinical issues must be considered. Decisions about providing telephone psychotherapy must be made with risk management in mind. We must guard against loosing sight of the welfare of and benefit to the patient when deciding to provide telephone psychotherapy services and managing risk. The use of the telephone in situations noted above is quite common. VandenBos and Williams (2000) reported that 69% of the professional psychologists surveyed in their study provided individual psychotherapy by telephone. It has been my experience that mental health professionals who have provided psychotherapy in one or more of the circumstances described above report great uncertainty about how appropriate it is for them to do so. When they tell me about their telephone contacts with patients they talk to me as if they are confessing a secret, hinting that they feel they are doing something that is forbidden and against the rules. Thus it will not surprise us to learn that therapists who do telephone therapy often feel that they are violating the "rules" of therapy. The circumstances under which continuing on the telephone is appropriate must be further delineated.

Thus telephone therapy is a common practice but one that is shrouded in secrecy, guilt and shame. I think these affects are due to a lack of clear guidelines about what are appropriate parameters surrounding the use of the telephone in psychotherapy. I think we all would feel better and more settled if we had a clearer sense of appropriate parameters when providing psychotherapy over the telephone. It is important to note that using the telephone to deal with routine psychotherapy practice management and patient crises do not lead to similar atmospheres. It is only when we are providing psychotherapy sessions over the telephone that this atmosphere of uncertainly prevails.

My suggestions regarding telephone therapy do not apply to those psychologists who do coaching, executive consultation or educational activities over the telephone. And they do not address the question of diagnosis, initial treatment planning or beginning a psychotherapeutic process over the telephone when the psychologist has had no face-to-face office consultation with the patient. Maheu and Gordon's (2000) survey of behavioral e-Health practitioners provide (they did not specifically ask about telephone psychotherapy) some information about telephone psychotherapy. Their respondents were psychologists and other mental health practitioners and included services such as therapy, counseling, education and advice for behavioral health problems. They report "… although three quarters of respondents offered service to people living in a state other than where they were licensed or registered, they were unaware of state and federal laws regulating the electronic delivery of behavioral health services. Likewise, three quarters expressed ethical concerns about providing behavioral health services on the Internet but only half obtained consent or made arrangements for a sudden crises." (p. 486). If these data are at all indicative of psychologists who provide telephone psychotherapy, many are not effectively managing risk.

Factors that could enter into the psychologist's decision to transition to telephone sessions when an established psychotherapeutic relationship is in place would include the patient's motivation and desires; therapist's comfort with this treatment approach; the current phase of treatment; diagnostic considerations; stability of patient; nature of the alliance, and other factors. It is my opinion that psychologists should not be categorically prevented from offering telephone psychotherapy. When conducting telephone psychotherapy, the ethical standards relevant to psychotherapy must be applied. However, in addition, special care must be given to those ethical standards that are unique to working on the telephone such as confidentiality of the sessions and appropriate arrangements for responding to crises.

Some of the impediments to providing telephone psychotherapy include the absence of a CPT code for non face-to-face sessions; jurisdictional ambiguity regarding licensure; and lack of third party payment. Such impediments need to be removed so that we can meet the legitimate needs of our patients. Psychologists need to be proactive in removing these impediments.

There must be clear guidance for psychologists to offer such services: a) in an ethical and professional manner, b) in a manner that maintains confidentiality and privacy, and c) that provide for crises management. The following suggestions are recommended for psychologists who provide or are planning to provide psychotherapy by telephone. In addition, in an excellent article, Barnett and Scheetz, (2003) discuss telehealth and provide useful recommendations..

The most recent version of the APA Ethics Code (2002) does not explicitly address telephone psychotherapy. Fisher and Fried (2003) note that the ethics code "… applies to all activities, all persons, all settings [italics added], and all communication contexts that are encountered, or used in one's role as a psychologist" (p. 104). The Code's (APA, 2002) list of communication contexts includes telephone transmission (p. 1061). The Ethics Code Task Force concluded that a special section addressing telehealth services including telephone psychotherapy was not needed. However as Fisher and Fried (2003) state "The use of such technology is considered both an innovative way to provide services as well as a medium that demands unique approaches to ethical decision making" (p. 110).

Psychologists who conduct telephone psychotherapy would benefit from reviewing the APA Ethical Principles and Code of Conduct. I recommend applying the suggestions for professional conduct when doing psychotherapy by telephone. We must remember that the APA Ethics Code (2002) has as its goals, (see Preamble) "… the welfare and protection of the individual and groups with whom psychologists work…" (p. 1062). Thus, the Ethics Code is permissive. In some instances the best way to insure that the patient's welfare is being met would be to provide telephone psychotherapy. The most relevant areas in the APA Ethical Standards to consider when providing telephone psychotherapy are: competence, informed consent, privacy and confidentiality, termination and abandonment.

An ethical consideration is the issue of not abandoning patients and also maintaining continuity of care as the psychotherapy situation changes. Another ethical consideration is that of informing the client of the experimental/innovative aspect of telephone psychotherapy. Another ethical responsibility is to provide and document informed consent about telephone psychotherapy.

I suggest that psychotherapists discuss with their patients, issues regarding the confidentiality and privacy of telephone sessions. It is the obligation of the psychologist to point out the potential for reduced security and privacy of telephone sessions. The psychologist should obtain a signed informed consent agreement that documents the patient's awareness of the potential risk of a breach of confidentiality when one has telephone psychotherapy sessions. Confidentiality and disclosure of mental health information would be governed by HIPAA or state regulations of the jurisdiction in which the psychologist practices or the patient resides.

I suggest that in ongoing telephone psychotherapy the psychologist should arrange, in advance, for back up with appropriate facilities for crisis management and support in the community in which the patient is living. This would include knowing about the emergency mental health services available in that community, as well as inpatient psychiatric programs, detoxification programs, and psychopharmacological consultants. Informing oneself about availability of, and access to, emergency services where the patient resides may be facilitated by contacting a colleague in the community and obtaining information from him/her in advance of initiating treatment by telephone. In terms of regulatory and jurisdictional issues, at this time there is no clear course of action. An important question is whether a psychologist needs to be licensed in both states. Many state attorneys general would claim regulatory jurisdiction over psychological practice in their state, no matter where the psychologist is when he/she delivers services (Koocher & Morray, 2000). I suggest that one way to cope with this situation is to contact the licensing board or other appropriate agency in the state that the patient resides or is visiting and request in writing a waiver of state license on a case by case basis.

Of course one could be licensed in the state in which the psychologist resides, as well as each state in which h/she provides psychological services. This could be financially burdensome for the psychologist who might have telephone patients in several jurisdictions. Being licensed in several jurisdictions requires that the psychologist knows the laws in each state and renews his/her license in each state. Another burden is maintaining appropriate records in accordance with the requirements of each state. This includes meeting the state specific continuing education requirements.

Third-party reimbursement is another impediment to the feasibility of offering psychotherapy services using the telephone. There is no reimbursable CPT code that could be used by psychologists that does not require " face to face" sessions. With no CPT code listed, one cannot bill third-party payers for telephone psychotherapy. I suggest that psychologists negotiate with insurance carriers, on a case-by-case basis, for payment for telephone psychotherapy. In such negotiations, continuity of care and the patient's best interest must be emphasized. When insurance reimbursement cannot be negotiated, the psychologist must communicate clearly with patients regarding policies pertaining to self-pay and the patient's responsibility for their psychotherapy fees.

I think the lack of a CPT code that effects reimbursement and an absence of clarity on jurisdictional issues adds to psychologists' feeling that they are breaking the "rules" when conducting psychotherapy over the telephone. We must develop guidelines that recognize that both brief and ongoing telephone psychotherapy services are within the boundaries of generally accepted ethical practice and that psychologists providing such service are acting in an ethical manner and within generally accepted standards of practice.

Psychologists would be wise to begin to advocate for changes in state licensing laws, CPT codes, and third-party payment rules. In the mobile society in which we live, we will find that providing psychotherapy services over the telephone becomes increasingly more commonplace and frequent.

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. Washington, DC: Author.

Barnett, J. E. & Scheetz, K. (2003). Technological advances and telehealth: Ethics, law, and the practice of psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 40, 86-93.

Fisher, C. B. & Fried, A. L. (2003). Internet-mediated psychological services and the American Psychological Association Ethics Code. Psychotherapy: Theory, Research, Practice, Training, 40, 103-111.

Koocher, G.R. & Morray, E. (2000). Regulation of telepsychology: A survey of state attorneys general. Professional Psychology: Research and Practice, 31, 503-508.

Maheu, M. M. & Gordon, B. l. (2000). Counseling and therapy on the Internet. Professional Psychology: Research and Practice, 31, 484-489.

Reese, R.J., Conoly, C.W. & Brossart, D.F. (2002) Effectiveness of telephone counseling: A field-based investigation. Journal of Counseling Psychology, 49, 233-242.

VandenBos, G. R. & Williams, S. (2000). The Internet versus the telephone; What is telehealth, Anyway? Professional Psychology: Research and Practice, 31, 490-492.

Martin Manosevitz is a diplomate in clinical psychology and in psychoanalysis. He is in independent practice in Aspen Colorado. He was formerly a professor of psychology at the University of Texas at Austin. He is currently the Treasurer of Division of Psychoanalysis (39), and co-chair of the Committee for the Advancement of Professional Practice's Integration Work Group. Correspondence should be addressed to Martin Manosevitz, PO Box 7976, Aspen, CO. 81612. E-mail mmanosev@earthlink.net.

I thank my colleagues: Jeffrey E. Barnett, Stephen Behnke, G. Paul Boone, and Mary E. Pharis for their helpful comments.

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