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Using Technology Based Tools in Behavioral Health
Best Practices for Improving Access
Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director: Counselor education
Based in part on TIP 60: Technology Based Therapeutic Tools (SAMHSA)

CEUs available at:

– Explore the benefits and drawbacks to technology assisted counseling
– Learn about some of the different technology tools available
– Identify ways technology can be used in your practice to enhance client success and be culturally responsive
Why Use It
– Mobile devices are becoming universal in our culture.
– The use of electronic media and information technologies in behavioral health treatment is rapidly gaining acceptance.
– Technology allows alternative models of care to be offered to clients with specific needs that limit their ability or interest in participating in more conventional settings
– Privacy
– Pain
– Time
– Technology-assisted care (TAC) can reach many people otherwise unable to access services
Why Use It
– Accessible in a wide variety of settings, including
– The home
– Community organizations
– Schools
– Emergency rooms
– Healthcare providers' offices
– Mobile devices

Why Use It
– Make services accessible to those who could not otherwise seek services
– Shame/stigma
– Overcrowded programs
– Travel/transportation
– Time
– Childcare
– Some reduced cost can be passed on to the client
– Facilitates coordination of services and care management between providers

Why Use It
– Meet the needs of the adult learner
– Provide more comprehensive services (“Clinician Extenders”)
– Individual patients can participate in online, moderated forums/groups
– All patients can access web or app based exercises, activities and videos outside of “session”
– May encourage clients to reach out more often (i.e. watch a video or review a forum in the middle of the night)
– Many online support forums are free and maintained by someone else. (Similar to support group meetings facilitated by churches, crisis centers etc.)

Why Use It–Adolescents
– Millennials & Gen-Z grew up communicating through chat and are most comfortable with those modalities
– Several studies underscore the acceptability and appeal to youths of computer-delivered interventions
– Significant barriers to adolescents' participation in addiction treatment may be addressed by internet-based addiction services
– Many youths report interactive computer learning environments preferable to traditional learning environments because computer-based learning allows them to solve problems actively and independently and receive individualized feedback
Why Use It – Elderly/Aging
– A growing body of research has highlighted the utility of technology for health promotion among aging populations
– Computerized tools designed to enhance cognitive skills through exercises that target problem solving, attention, memory, and abstract reasoning have been shown to have promise in populations with SMI as well as among individuals with substance use disorders
– Lack of nonverbals, sometimes even in video chat
– Lack of immediate feedback when done asynchronously (forums, online activities)
– Asynchronous interaction needs to be addressed in patient responsibilities and regularly reviewed for appropriateness.
– Clients who do not type well may find text-based interventions frustrating.
– Non-video-based methods of providing services can create legal and ethical issues when there is no ability to verify who the clinician is speaking to.
– Secure logins and a “secret” phrase can help, but don’t prohibit the client from sharing that information with someone else
The Downside
– Billability
– Some insurance will not reimburse.
– Under Medicaid, in 2013, 39 states covered telehealth services As of 2013, these procedures were reimbursable for telemental health:
– Individual psychotherapy (CPT codes 90804 – 90809)
– Individual and group health assessment and intervention
– Smoking cessation
– Another article indicates that at least 19 states mandate some form of reimbursement for telehealth services including from private insurers. Article 2
– Most providers will only reimburse for interactive video-based counseling
– Psychotherapy coding clarifications, telemedicine code modifier (2016)

– Additional HIPAA and HITECH compliance regulations including maintaining signed business associate agreements
– Skype is not compliant
– Gmail is not compliant
– Second Life is not compliant
– Home offices must maintain HIPAA HITECH security protocols
– Deducting cost of home office from taxes has historically been considered an audit flag. The same is not true for virtual services provided from a free-standing business office

– Assessment
– Detox monitoring (by physician)
– Individual
– Couples/Family (even extended family)
– Group (traditional and IOP)
– Drug screening (breathalyzers, sweat patch, saliva, hair)
– Or partner with local labs to do observed urine drops
– Therapist extenders (journals, logs)

Ways to Use It
– Email
– Smartphone/tablet applications (apps)
– Online forums and targeted social networking sites (i.e. )
– Informational web sites and blogs
– Video and telephone chat
– Virtual Reality/Immersion Therapy
– Virtual Art Therapy

Telephone and Video
– Several studies have demonstrated the feasibility, acceptability, and efficacy of using telephone-based counseling interventions targeting substance use among youths
– Clients may participate in counseling sessions more if they are offered in a distance telehealth environment as an alternative or an adjunct to in-person settings
Self-Directed, Web-Based, and Computer-Based Therapeutic Tools
– Computer-based programs that are not Web based may have utility in specific settings where Internet access is limited, such as in criminal justice settings and certain residential treatment programs.
– Web-based, self-directed therapeutic tools offer a number of advantages, including
– The ability to update centrally and deploy content within a given program as needed
– The ability to track user activity within a program over time via unique login information
– Aggregation of user activity data across client groups
Computer-Based Self-Directed cont…
– Used for assessment and behavioral health service provision for:
– Diabetes
– Eating disorders
– Substance use disorder prevention
– HIV/AIDS prevention
– Methadone maintenance treatment
– Literature reviews underscore the effectiveness of such interventions in producing health behavior change.
– Comparisons of computer-delivered interventions with person-delivered interventions generally report comparable outcomes
Computer-Based Self-Directed cont…
– Computerized treatments for mental disorders have been most widely developed and extensively used for anxiety, traumatic stress, and depressive disorders
– Computer programs have successfully implemented such mental health techniques as:
– Cognitive restructuring
– Relaxation training
– Systematic desensitization
– An interactive, Web-based intervention called the Therapeutic Education System delivers cognitive–behavioral therapy treatment for individuals with substance use disorders and may be as effective as traditional counseling.
Web-Based Text Communication: Email, Chat, Forums, Email Lists, Social Networks

– Chat rooms typically refer to open “rooms” online in which
– Individuals can come and go as they wish
– Communicate synchronously with any or all participants in the chat room.
– Many behavioral health chat rooms are moderated by a clinician who posts comments, guides discussions, and may screen comments before allowing them to post.
– Whether chat rooms are overseen by clinicians or by peers, they typically include guidelines for participation, with designated moderators who monitor content
Online Support Groups
– Online support forums are typically organized in a bulletin board format that allows users to post anonymous, text-based communications.
– Online support groups typically enable asynchronous communication, as do email lists
– Patients Like Me ( offers Web-based exchanges of information among clients related to numerous health conditions and disorders, including types of depression ranging from major depressive disorder to postpartum depression
Email and Text Chat
– Email can be used for
– Routine contacts, such as setting appointments
– For therapeutic purposes, such as following up on counseling sessions
– To send motivational messages encouraging clients to engage in specific therapeutic activities between sessions
– Actually conducting some portion of counseling.
– Emails and texts can be automated or generated by providers (or clients) to send daily prompts
– Chat counseling in chat rooms or via instant messaging typically require more abbreviated interactions but are often more “real-time”
Text Messages and Mobile Devices
– Services provided via mobile devices in real time offer the opportunity to provide in-the-moment interventions
– One-sided text messages, for instance, from provider to consumer, have shown considerable utility in promoting treatment compliance and self-monitoring of health behavior, such as healthy eating and exercise.
PTSD Coach

– PTSD Coach is an app created by the VA's National Center for PTSD and helps users learn about and manage symptoms that commonly occur after trauma.
– Features include:
– Reliable information on posttraumatic stress disorder (PTSD) and treatments that work.
– Tools for screening and tracking symptoms.
– Convenient, easy-to-use skills to help clients handle stress symptoms.
– Direct links to support and help.
– Continuous accessibility; the app is available to clients as long as they have an appropriate, enabled device.
– As of February 2014, PTSD Coach has been downloaded 138,000 times in 84 countries.
Virtual Reality &

– A search for VR in the search engine in early May 2014 yielded 190 clinical trials with topics such as:
– Exposure therapy for PTSD
– Rehabilitation after a stroke
– Weight loss through the use of a Second Life
– Medical and scientific training and education
– Wearable sensors
– Physical conditions (e.g., pain and memory conditions)
– Behavioral conditions (e.g., anxiety, autism spectrum disorder, ADHD, smoking cessation, fear of flying)

Online Social Networks
– Can be problematic due to:
– Their general lack of HIPAA compliance
– The tendency of clients to post private information in public forums.
– Additionally, providers who use such networks are faced with how to act on their legal and ethical duties in such venues.

Legal & Ethical Issues
– The use of technology in therapy may be contraindicated for individuals experiencing significant emotional distress or complex situations (such as domestic violence)
– Text-based communications between providers and clients are protected under HIPAA, HITECH, CFR 42 Part 2 and some state laws
– Text transcripts can be subpoenaed from providers or ISPs (They aren’t considered psychotherapy notes (yet))
– offers a number of resources for healthcare providers related to using mobile devices in a way that helps protect and secure client health information.
Essential Elements of Informed Consent To Participate in TAC
– Services process and alternatives:
– Whether communication will be synchronous or asynchronous
– Response standards and scheduling
– Frequency of interactions
– Misunderstandings (text-based and video-based risks)
– Alternative treatments or delivery approaches
– Individuals who may have access to clinical information including technical staff
Informed Consent
– Potential benefits of the service
– Confidentiality of communications and records
– Privacy and privacy risks
– Ways for clients to protect their privacy
– Roles and credentials of all individuals involved in service delivery
– Emergency procedures
– Charges and Payment
– Service Disruptions
– Regulatory Agencies and Grievances

– Telemental Health is here to stay
– Many self-directed programs are extremely useful for all ages and a multitude of diagnoses, especially for early intervention
– The use of virtual technologies enables a clinician to individualize treatment to increase compliance, accessibility and effectiveness
– There are many ethical, regulatory and legal issues surrounding the use of electronic devices in any aspect of counseling.

Other Resources
– Center for Technology and Behavioral Health