Therapeutic boundaries in telepsychology: Unique issues and best practice recommendations

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Text-based synchronous communication can take longer than spoken in-person communication, which may lead clinicians to extend sessions unintentionally.

“text-based synchronous communications can take longer than verbal communications in a traditional face-to-face setting, which could also lead the clinician to inadvertently extend session times.”

May combine two claims.

Two features of telepsychology may raise the chance of harmful boundary crossings and violations: flexible service delivery encouraging more frequent and casual interactions, and the belief that physical distance protects the relationship from such problems.

“Two specific factors in the practice of telepsychology have the potential to lead to an increased likelihood of harmful boundary crossings and violations.”

• Also stated in: § Potential Boundary Issues in Telepsychology · plain

  “These are: (a) the potential for the flexibility of service delivery to prompt more frequent and more casual interactions and behaviors; and (b) the assumption that physical distance provides protection from and/or makes the relationship immune to boundary crossings and violations.”

May combine two claims.

When telepsychology flexibility is extreme, it can damage professionalism and undermine the therapeutic goals that good boundaries support.

“if this flexibility is taken to extremes (e.g., clinicians working from public locations or being highly casual/informal in interactions) it can greatly jeopardize the professionalism of the relationship and have deleterious effects with regards to the aforementioned therapeutic aims that proper boundaries facilitate.”

May combine two claims.

Maintaining proper boundaries is essential and deserves special attention in telepsychology because it likely poses unique difficulties.

“the provision and maintenance of appropriate therapeutic boundaries is essential and warrants special consideration in telepsychology settings as maintaining boundaries in such settings is likely to present unique challenges.”

May combine two claims.

Boundaries guide the nature of the therapy relationship and help both parties regulate behavior to improve outcomes and reduce harm.

“boundaries are clinically useful as they serve to provide guidance regarding the nature of the therapeutic relationship and help the client and clinician regulate their behavior in ways that maximize clinical outcomes and minimize harm (Borys, 1994; Zur, 2007).”

• cites Borys, 1994Not checked yet

  Not checked in the free run.

• cites Zur, 2007Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

These time boundary problems can also happen in telepsychology and may be more likely because of flexibility, convenience, and a less structured work setting.

“These issues can certainly occur in telepsychology settings as well and may be more likely due to the flexibility of the medium, the perception of convenience for both parties, and the potential for a less regulated/structured work environment.”

Classified as probably not a substantial claim.

Boundaries are hard to define operationally because they depend on each client's and clinician's unique characteristics, such as diagnosis and theoretical orientation.

“Boundaries are highly important in the treatment relationship, yet they can be difficult to operationalize as they are dependent upon a number of unique factors specific to each client and clinician (e.g., the client’s diagnosis and the clinician’s orientation).”

May combine two claims.

Time boundary problems in traditional in-person therapy commonly include early or late arrival, longer sessions, odd hours, excessive between-session contact, and scheduling certain clients last.

“Boundary issues related to time are not uncommon in traditional face-to-face therapies and typically arise in the form of early or late arrivals to session, extensions of sessions, holding sessions at odd or inappropriate hours, excessive out of session contacts, and scheduling particular clients for the last appointment of the day (Zur, 2007).”

• cites Zur, 2007Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Telepsychology has grown quickly and is expected to become a common way for consumers to receive evidence-based care.

“Telepsychology services have expanded rapidly over the years and are likely to soon become a routinely available consumer option for receiving evidence-based treatment (Abbott, Klein, & Ciechomski, 2008).”

• cites Abbott, Klein, & Ciechomski, 2008Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

Appropriate therapeutic boundaries support multiple therapeutic goals.

“appropriate boundaries facilitate a host of therapeutic aims”

• cites Borys, 1994Not checked yet

  Not checked in the free run.

• cites Zur, 2007Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Telepsychology clinicians may more easily schedule appointments at odd hours because it seems convenient and their hours may not be set by an employer.

“It is also likely much easier for a clinician to succumb to the temptation to schedule appointments at odd hours in a telepsychology setting, as it may be seen as a convenience for both parties and hours may not be regulated by an employment setting.”

May combine two claims.

Boundaries also advance goals such as a trusting alliance, client assertiveness, self-worth, and relationship integrity.

“Boundaries can also promote a number of other therapeutic aims including building a trusting working alliance, modeling assertiveness skills to the client, enhancing the client’s self-worth (i.e., by respecting the client’s rights and autonomy), as well as ensuring the integrity of the relationship (Borys, 1994; Simon, 1992; Smith & Fitzpatrick, 1995).”

• cites Borys, 1994Not checked yet

  Not checked in the free run.

• cites Simon, 1992Not checked yet

  Not checked in the free run.

• cites Smith & Fitzpatrick, 1995Not checked yet

  Not checked in the free run.

May combine two claims.

Because telepsychology uses social and personal communication channels, allows contact at any hour, and lets each party virtually enter the other's home, it may increase intimacy and create boundary challenges.

“telepsychology interactions can occur at any hour of the day or night, and both parties can now virtually enter each other’s homes, there is the potential for an increased sense of intimacy between client and therapist which could lead to boundary challenges (Goss, 2011).”

• cites Goss, 2011Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Boundary crossings can help, be neutral, or harm, depending on many factors.

“it is generally accepted that boundary crossings have the potential to be therapeutic, neutral, or harmful depending on myriad factors”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Telepsychology gives clinicians more access to clients from different regions and cultures, some of whom may not stress punctuality, which may lead to time boundary crossings.

“given the increase in access to care, telepsychology clinicians have more opportunity to service clients from various regions and cultures; some of which may not place great emphasis on punctuality (in contrast to more Westernized cultures) and time boundaries may be crossed.”

• AssumptionRests on an assumption: The paper assumes that some clients from non-Western cultures place less emphasis on punctuality.

May combine two claims.

Sessions may run longer in telepsychology because both parties' schedules are more flexible and they follow structured time frames less closely.

“Extensions of sessions may also be more common as both parties’ schedules may be more flexible causing them to adhere less to structured time frames.”

May combine two claims.

Telepsychology may reduce client lateness because the clinician usually initiates synchronous appointments, but it raises the risk that the clinician will be late from equipment or technology failures.

“while telepsychology may help to minimize these issues for the client as the clinician typically does the initial contacting for synchronous appointments, there is an increased risk for the clinician to be late due to equipment not working properly and failures in technology.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Time boundaries give psychotherapy structure by marking the start and end of sessions and can reassure clients.

“Time is one of the primary boundaries in psychotherapy. It provides structure by establishing clear markers as to the beginning and end of the therapeutic encounter, and can be reassuring to clients in that they know that they will only have to engage in challenging therapeutic work for a set period only (Gutheil & Gabbard, 1993).”

• cites Gutheil & Gabbard, 1993Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

For clients, public interaction can risk their confidentiality and reduce therapeutic benefit because environmental distractions interfere with processing.

“For the client, in addition to risking his or her own confidentiality, this could also derail therapeutic benefits as the environmental stimuli could serve as distractors and interfere with the full processing of therapeutic content.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Restricting clients' ability to download files and copy text may prevent editing and misuse or misrepresentation of the therapist's work, though it does not stop clients from showing the material to others.

“Although this will not prevent the client from potentially showing the telecommunications to others, it may prevent any editing and misuse/misrepresentation of the therapist’s work.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Because telepsychology is flexible, clinicians may work at times they ordinarily would not.

“With regards to challenges to one’s own personal boundaries, due to the flexibility that telepsychology services afford, clinicians may find themselves working at times that they normally would not.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

Video-conferencing while on vacation probably models poor boundaries and poor self-care and highlights socioeconomic differences between therapist and client.

“It is also likely to model poor boundaries and negligent self-care, as well as draw attention to potential issues related to differences in socioeconomic status (e.g., if the client is from a socioeconomic status in which he or she could not afford to go on a vacation).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Since clients cannot perceive intonation in text-based messages, miscommunication is very likely.

“Because the client has no way to discern the intonation of text-based messages, there is much room for miscommunication.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Excessive communication is another asynchronous time issue because without set sessions clients choose when to interact and some may send many messages per day.

“The potential for excessive communication is an additional time-related issue with regards to asynchronous interactions. Because there may be no set session per se, it is typically up to the client to decide when to interact and some clients may interact numerous times a day in a seemingly “rapid-fire” manner.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Awareness of these issues plus proactive strategies allows the telepsychology clinician to prevent many boundary problems.

“However, by being aware of the issues related to these challenges and engaging in a number of proactive strategies, the telepsychology clinician can prevent many of these boundary issues from arising.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Clients who receive telepsychology, being used to interacting with their therapist through technology, may be especially likely to attempt therapeutic work through those media.

“In addition, given that they are accustomed to interacting with their therapist via technology, clients receiving telepsychology services may be particularly likely to try to utilize these mediums to engage in therapeutic work (e.g., by posing a therapy-related question on the therapist’s Facebook page) and this could risk their own confidentiality.”

• AssumptionRests on an assumption: Clients receiving telepsychology are accustomed to interacting with their therapist through technology.

Probably not a substantial claim: may not pass S3 (load-bearing).

A client who is highly guarded in interpersonal boundaries may feel threatened by the clinician's virtual presence in the home.

“Additionally, there may be the potential for the client who is highly guarded in interpersonal boundaries to feel threatened by the clinician’s virtual presence in his or her home.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Unintentional self-disclosures can harm therapy by causing discomfort or embarrassment and forcing the therapist to decide whether to address them.

“Unintentional self-disclosures could be detrimental to the therapeutic relationship as they could lead to discomfort or embarrassment as well as force the therapist to decide whether the unintentional self-disclosure is therapeutically relevant and should be brought to the client’s attention.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Giving consistent feedback models accountability and gives clients a sense of safety, security, and trust.

“Providing consistent feedback will model accountability and provide clients with a sense of safety, security, and trust.”

Classified as probably not a substantial claim. May combine two claims.

The telepsychology clinician effectively enters the client's home, which may create difficulties for clients with a history of disturbed interpersonal boundaries.

“A final and important setting-specific issue to consider relates to the fact that the telepsychology clinician is in a sense entering the client’s home. This may create difficulties for clients with histories of disturbed interpersonal boundaries.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

Careful attention to boundary issues by clinicians ensures that telepsychology is delivered ethically and effectively.

“Most importantly, careful attention to boundary issues by clinicians will ensure that telepsychology services are conducted in a manner that is both ethical and efficacious.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Excessive background noise in the clinician's environment may raise privacy concerns and distract from therapy.

“Excessive background noise in the clinician’s environment (e.g., noise from pets, children, or hallway traffic) may also cause privacy concerns and be a distractor from therapeutic interactions.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Conducting services from a consistent environment helps prevent clinicians from practicing outside their jurisdictions.

“It will also help prevent clinicians from practicing outside of their jurisdictions.”

May combine two claims.

Because video shows only a limited view of the therapist's professional environment, telepsychology clinicians have less chance to use the setting to establish boundaries and convey an inclusive, accepting atmosphere, which may matter especially for minority or underserved clients.

“because there is only a limited view of the therapist’s professional environment when video-communications are used, telepsychology clinicians have a more limited opportunity to use the environment to establish boundaries and convey an inclusive and accepting atmosphere. This may be of particular import to those working with minority or underserviced populations.”

May combine two claims.

When a client's expectations of the therapeutic relationship do not match the therapist's, correcting the mismatch is difficult and the therapist's attempts to do so probably produce confusion and frustration in the client.

“This mismatch can then be difficult to correct and the therapist’s attempts to do so are likely to cause confusion and frustration for the client (Gottlieb et al., 2009).”

• cites Gottlieb et al., 2009Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Emoticons are generally intended to convey affect in a setting without nonverbal cues.

“Emoticons are typically designed to facilitate the expression of affect in a non-verbal setting;”

• cites Midkiff and Wyatt, 2008Not checked yet

  Not checked in the free run.

May combine two claims.

Working at such times can burden the therapist and may lead to burnout.

“Although this may be seen as an advantage in terms of timeliness of service delivery to clients in need, it can have taxing effects on the therapist and potentially lead to burnout.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Boundary problems with social media are not unique to telepsychology, but they may be more prominent there because the absence of in-person contact reduces the chance to discuss them.

“Although these issues are not unique to the practice of telepsychology, they could be more salient in such settings as the lack of face-to-face interaction between client and therapist could limit the opportunity and/or make discussing such boundary issues more difficult.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Telecommunication technologies make it substantially easier for clinicians to keep working while ill, on vacation, and during evenings and weekends.

“For example, telecommunication technologies make it much easier for clinicians to continue to work when ill, when on vacation, and during evenings and weekends.”

Classified as probably not a substantial claim.

Such favoritism is unlikely in traditional offices because scheduled appointments prevent choosing which client to see first or avoiding a client for long periods.

“Such issues are not likely to arise in traditional office environments as the scheduling of individual appointment times prevents this (e.g., one has limited ability to pick and choose which client of the day to see first and one cannot avoid a client for extended periods of time if he or she arrives to the office).”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

If a therapist video-conferences with a client while on vacation, the client may feel guilty or like a burden.

“For instance, if the therapist video-conferences with a client while on vacation, this could lead the client to feel guilty or like a burden.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

In asynchronous telepsychology, clients may appropriately communicate outside business hours, but therapists doing so may be inadvisable because it can create expectations of immediate feedback or unpredictable availability.

“while it is acceptable for clients to engage in asynchronous interactions during non-business hours, it may be contraindicated for therapists to do so. Providing feedback during non-business hours may lead clients to expect nearly instantaneous feedback, or view the therapist’s availability as unpredictable.”

May combine two claims.

Telepsychology flexibility may lead clinicians to practice outside their licensed jurisdictions, which can cause ethical and legal problems.

“This increased flexibility related to work setting could also lead clinicians to practice outside of their jurisdictions (e.g., by conducting therapy online with a client located in a state in which the therapist is not licensed). Practicing outside of one’s jurisdiction could lead to ethical and legal difficulties for the clinician.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Inconsistent telepsychology settings, especially on video, can create boundary problems; changing backdrops or filming from different places may raise privacy concerns because clients may wonder why the setting changes and where the clinician is.

“Inconsistency in the clinician’s telepsychology setting particularly when a video-component is used could also foster boundary-related challenges. Changing the backdrop or filming videos from different locations, even if non-public, could lead to privacy concerns as the client may wonder why the clinician’s environment changes and where he or she is located.”

May combine two claims.

Because telepsychology may occur in less formal environments, clinicians may work from non-office settings or wear casual clothing on video, which can undermine professionalism.

“because telepsychology services may be conducted in less formal environments, clinicians may choose to work from non-office settings or wear more casual clothing during video communications and this could undermine the professionalism of the relationship.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Conducting video-based therapeutic services from a consistent environment helps ensure privacy, models stability, and conveys a safe, reliable place for therapy.

“This will help to ensure privacy, model stability, and convey a safe and reliable place for the therapeutic work to occur.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

Excessive punctuation and chat acronyms or text-message shorthand may likewise make the relationship feel less professional.

“The same may also be true for excessive punctuation use (e.g., exclamation points) and chat acronyms/text message shorthand.”

May combine two claims.

Clients with disturbed interpersonal boundaries may experience virtual sessions held in their homes as more intimate or more invasive than in-person sessions, which could produce boundary problems.

“For example, such clients may regard conducting therapeutic sessions virtually in the privacy of their homes as either more intimate or more invasive than in traditional face-to-face sessions, and boundary issues could result.”

May combine two claims.

Online promotional content can help clients understand the therapist and therapy, but can cause problems if its role in setting boundaries is ignored during design.

“Although such mediums can offer the client a window into who the therapist is and what therapy might look like, the content of the online medium can also lead to problems if its role in establishing appropriate therapeutic boundaries is not considered during the design process.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

For a client who is overly disinhibited in interpersonal boundaries, boundary crossings may appear as acting-out behaviors such as provocative dress or language not used in a formal office.

“Indeed, it is possible that for the client who is overly disinhibited in interpersonal boundaries, boundary crossings may arise in the form of acting out behaviors such as dressing in a provocative manner or using language that he or she would not use in a more formal office setting.”

May combine two claims.

Shared feedback may be taken out of context, edited, misused, or misrepresented, which may harm the therapist.

“Shared feedback could be taken out of context, edited, misused, or misrepresented which could result in harm to the therapist.”

Classified as probably not a substantial claim.

Turnaround times of one to three business days for online program feedback and 24 hours for more instant communications are generally regarded as acceptable.

“One to three business days for online program feedback and 24 hours for more instant communications are generally considered acceptable turnaround times (Abbott et al., 2008; Manhal-Baugus, 2001).”

• cites Abbott et al., 2008; Manhal-Baugus, 2001Not checked yet

  Not checked in the free run.

May combine two claims.

Telepsychology can occur outside a professional building and beyond physical walls, which can create setting-related challenges.

“because telepsychology services may not occur within the context of a professional organization or building and the relationship may exist beyond the structure of physical walls, a number of challenges could occur.”

May combine two claims.

A therapy office gives clients security and safety and helps establish and reinforce appropriate boundaries.

“The structure of the therapy office provides a number of benefits to the therapeutic relationship including providing a sense of security and safety for clients, as well as helping to enact and reinforce appropriate therapeutic boundaries (Knapp & Slattery, 2004).”

• cites Knapp & Slattery, 2004Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

A client may choose to interact in public to avoid difficult material or to make the relationship feel less formal and more social.

“Additionally, the client’s choice to interact while in public could be a way to avoid difficult material or make the relationship feel less formal and more social.”

Classified as probably not a substantial claim. May combine two claims.

The clinician's virtual presence may challenge such a client's sense of safety and lead to rigid, impenetrable boundaries that work against therapeutic aims.

“The therapist’s presence could potentially challenge his or her sense of safety and lead to very firm/impenetrable boundaries being enacted which may be counterproductive to therapeutic aims.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

Reviewing text communications before clients receive them helps prevent and reduce confusion and helps avoid unintentional boundary crossings caused by miscommunication.

“Reviewing text communications prior to making them available to clients will help prevent and minimize confusion as well as help ensure that unintentional boundary crossings do not occur because of miscommunications.”

May combine two claims.

Public interaction can risk the client's confidentiality for clinicians through unsecure internet or visible communications and can bring legal and professional consequences.

“For the clinician, it would risk the client’s confidentiality (e.g., via use of a public, unsecure internet connection or by unintentionally allowing others to see the therapeutic communications) and it could also warrant legal and professional ramifications.”

May combine two claims.

With video, protecting non-clients' privacy is an issue; clients at home may unintentionally reveal loved ones' identities through visible family photos or personal objects.

“Ensuring the privacy of non-clients (e.g., those with whom the client resides) is an additional issue that may arise when using video equipment. For example, as many clients interact from their homes, they may not consider that family photographs visible to the clinician may result in unwanted disclosures of the identity of loved ones.”

May combine two claims.

Including personal photos or autobiographies on online profiles may create expectations of a more social, less formal therapy relationship, leading to a mismatch that is hard to correct and may confuse or frustrate clients.

“some therapists choose to include personal photographs (e.g., with loved ones, or while on a vacation) and/or autobiographies detailing their interests/hobbies. Although this may help the client gain a sense of who the therapist is, it may also set the expectation for a more social and less formal relationship.”

• Also stated in: § Considerations and Issues Related to Setting · hedged

  “This has the potential to be detrimental as it can lead to a mismatch of expectations with regards to the nature of the therapeutic relationship (e.g., the client may think it appropriate to inquire about a therapist’s family or favorite vacation spot after seeing photographs on his or her website). This mismatch can then be difficult to correct and the therapist’s attempts to do so are likely to”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

A therapist's use of emoticons may resemble the client's social and personal interactions too closely and make the relationship feel less professional.

“however, the therapist’s use of emoticons may too strongly parallel the client’s social and personal interactions and lead the relationship to feel less professional.”

Classified as probably not a substantial claim.

Accepting client friend requests or following clients on social media probably produces complications involving clients' unintended self-disclosures.

“Accepting friend requests from clients or “following” them on other forms of social media (e.g., Twitter) is likely to lead to complications related to unintentional client self-disclosures and it could also lead the client to see the therapeutic relationship as less formal.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Accepting client friend requests or following clients on social media may lead the client to view the therapeutic relationship as less formal.

“Accepting friend requests from clients or “following” them on other forms of social media (e.g., Twitter) is likely to lead to complications related to unintentional client self-disclosures and it could also lead the client to see the therapeutic relationship as less formal.”