Eye contact is an important source of clinical information. A client’s eye contact can convey information about the client’s psychological state, such as increased anxiety or depressed mood. In an assessment, eye gaze may be a clue to certain developmental or psychiatric disorders, such as autism or psychosis. For the provider to accurately assess the client’s eye contact, the provider must ensure that their own and the client’s camera are angled properly (Luxton et al., 2014). If eye contact is averted because of the camera position, a provider may mistake this for a symptom rather than a technical problem. If a provider thinks there is a problem with the camera, they must communicate that to the client and allow for readjustments. The following is an example of how to discuss eye contact with a patient. This discussion would typically occur within the first session. Therapist : Some things are different when video chatting than when you are in the same room as a person. Eye Emergency Management Managing emergencies is a vital component of an overall plan to provide telemental health services because the client will not be in the same room as the practitioner. Some examples of types of potential emergency situations include the following: If a client reveals suicidal or homicidal ideation and then leaves the room or turns off the video monitor, if the practitioner witnesses harm to a client on video, or if a health crisis occurs during the telemental health session. The practitioner is not on-site; thus, establishing an emergency protocol is very important. This information should also be included in the consent form for treatment. Establishing an emergency protocol should be done prior to starting services (Swenson et al., 2016), as previously outlined. The practitioner may need to include medical personnel at the site where the client is located (i.e., the originating site). If therapy is provided at the client’s home, the therapist should have family and social support contact information. The therapist should also include contact information for law enforcement, ambulance services, the nearest hospital and/or emergency department, and local mental health or mobile health crisis teams (Swenson et al., 2016). Client safety is a concern for clinicians regardless of the modality of treatment. Providers who offer therapy through telemental health services have additional considerations to ensure that clients are protected in the case of emergencies. Kramer and Luxton (2016) offer specific recommendations for handling emergencies and protecting clients. ● Clinicians should know the jurisdictional requirements for civil commitment laws and duty to warn where clients are located. Guidelines for reporting and committing vary by jurisdiction. Ethical Practice Ethical issues related to confidentiality, dual relationships, and boundaries are also important considerations. An additional issue for practitioners to consider is the competency of the online clinician with whom clients might be working. It is important to know their educational background, certifications, and professional experience (Dolgoff et al., 2012). The American Telemedicine Association recommends certain steps to ensure ethical practice among clinicians who use telemental health services (Swenson et al., 2016). These practices include the following. ● Verify the identity (full name and ID) of the client on the video screen.
contact is a little bit different. I am going to do my best to look at the camera [therapist looks at the camera] so that it gives you the feel of eye contact. However, also please know that when I am looking like this [looking at the patient], I am actually looking at your face and paying close attention to what you are saying. Does that make sense? Patient : Oh yeah, I never really thought about that, but yes, that does happen when I chat with my family. Therapist : Yeah, it can be a little different. So please let me know if it doesn’t seem like I am looking at you because eye contact in a therapeutic relationship can be really important. I can adjust my camera, or we can problem solve in another way. Do you feel comfortable telling me if my eye contact seems to be off due to the technology? Patient : Yes, I can let you know. Therapist : Fantastic, thank you. Let’s get started. ● Practitioners should know the specific emergency procedures for the site, such as a clinic, school, or corrections facility, where telemental health treatment will be provided. ● The clinician, client, and/or family members should identify a local support person who can be involved in an emergency situation if needed. ● Therapists should know the local jurisdictional requirements for mandatory reporting laws for children, youth, and dependent adults. Clinicians who provide services using telemental health should be just as concerned about client safety protocols as those who provide face-to-face services. They should establish additional precautions to ensure that both the client and clinician have a plan in case an emergency arises. Jurisdictions may have specific requirements set forth by governing bodies, but even if there are no specific guidelines, therapists should have written procedures in place. Self-Assessment Question 2 Which of the following components should be included in a safety plan for telemental health sessions? a. Ensuring the client’s sobriety and appropriate attire during session b. Discussing the presence of firearms or other weapons before beginning clinic based services c. Verifying the privacy of the client, especially in cases of domestic violence d. Having a backup communication plan in case of lost connection ● Provide the client with the therapist’s license information and qualifications, either on websites and/or in materials sent to the client. ● Verify the client’s location and comply with all jurisdictional licensing requirements. This is important for emergencies, mandatory reporting laws, and duty to warn. As noted previously, these requirements are tied to the client’s location, not the therapist’s location (Swenson et al., 2016). The practitioner should be cognizant of issues that may compromise confidentiality, such as speaker volume, which could allow others to hear the conversation; window location, which could allow others to see the client’s face during a session; and the presence of others, especially
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