telebehavioral health

Telebehavioral Health: What Practitioners Should Know

By Ina A Ramos, Ph.D.
The MayaTech Corporation


Telebehavioral health (TBH) is the remote access to therapeutic social, emotional, and behavioral counseling services. This is a rapidly growing field that allows patients to access physicians, clinicians, and other behavioral health professionals for support using the internet through video conferencing, email, online chat, phone call, or SMS messaging. TBH allows practitioners to bridge the divide that keeps so many folks from receiving the care they need, including removing time and expense barriers. This is especially true for rural communities; however, TBH has proven to be effective for underserved communities of all kinds. TBH’s diversity and flexibility makes its services a comparable yet more accessible form of behavioral health treatment for people across the country.

In 2014, the Coalition for Technology in Behavioral Science (CTiBS), organized a TBH Competencies Task Force to develop evidence based TBH competencies for all BH professions. The competencies are meant to be consistent, discrete, measurable, interprofessional, and help to establish criteria for addressing the growing needs for TBH workforce training and evaluation. There are seven TBH competency domains established by the CTiBS with three levels of knowledge, skills, and attitudes that focus primarily on video teleconferencing but are applicable to other technologies (e.g., email, telephone, mobile apps, texting).

Practical Implications

One of the most influential organizations paving the way for TBH is the Telebehavioral Health Institute (TBHI). TBHI is devoted exclusively to addressing the emerging opportunities and challenges of organizations and practitioners seeking to thrive in any area of telehealth, including but not limited to TBH, telemental health, digital health, mHealth, e-health, telepsychiatry, telepsychology, distance counseling, online therapy, and coaching. To provide further insight on the TBH field, we interviewed Dr. Marlene Maheu, executive director of the TBHI, which is located in San Diego, CA. The TBHI was formed in 2009, and offers training and consultations in more than 76 countries. Dr. Maheu specializes in researching, developing, and delivering tailored telehealth professional training for commercial payers, clinical groups, professional associations, and directly to professionals.

CTiBS Seven TBH competency domains and competency levels

Dr. Maheu shared some benefits of practicing TBH. She states, "TBH gives clinicians autonomy over their schedule such as the number of hours they work from home as well as their location; since they don’t have to travel, they could practice from anywhere. A provider in the state of Maryland can see clients in Maryland no matter where they are. This is true 99.9% of the time; however, providers should always seek guidance from their licensing board before assuming a position, as boards are changing rapidly. And it’s always a good practice to get response in writing."

When considering the benefits of using specific technologies (videoconferencing, text messaging), Dr. Maheu states, "Video conference is the most heavily researched and reimbursable by insurance companies, as it provides more data to work with. Studies show that videoconferencing sessions have the same outcomes as in person sessions for most people when the setting is controlled. As for other technologies, telephone sessions are not currently reimbursed by insurance and text messaging providers have yet to establish how informed consent is legally obtained. There are additional unaddressed issues with text messaging. First, you can't have a discussion in text messaging. Clinicians are licensed but you cannot follow the law if you do not have a discussion (i.e., protocol for termination). Second, there is no way to know who’s actually texting. It could be one person or multiple, is a battered wife being forced to say things by her husband, and there could be language barriers. Next, there is not a sufficient therapeutic frame around text messaging. Some clinicians are agreeing to incorporate video clips in the text messaging, but this format doesn’t have the therapeutic frame found to be effective. Last, if clients make complaints or there is a negative outcome as a result of the interaction, the clinicians are liable, not the companies hosting the platform."

Dr. Maheu also recognizes the importance of culturally competent care in TBH. "Assuming practitioners have had cultural humility/sensitivity training, they are tasked with checking their own assumptions about their understanding of the person. Information can be gathered using intake forms and practitioners can utilize tests, like the Implicit Association Test, to help sensitize themselves to some issues. Taking it a step further, they should do an assessment of the geographic area they will work in to assess other geographic issues at play not captured by intake forms (e.g., social isolation). Using instruments is good but they must be accompanied by practicing good cultural sensitivity. Practitioners must consider things like, 'Are other people present or not?', 'Are they looking you in the eye or not?', 'Does a wife appear without a husband or not?', 'Are clinicians using language in the context that an immigrant understands?'. The Implicit Association Test is one tool practitioners can use to sensitize themselves to attitudes or beliefs they may hold."

Dr. Maheu offered sage advice for practicing TBH over state lines. She states, "Generally, a person can practice across state lines under two conditions: by passing a juris prudence exam (test of state law) OR by petitioning the state to continue working with an individual currently under your care who moves to a new state. In the second case, registration is typically defined by state law as 30 to 60 days of permission to work in a state with an identified named patient. As previously discussed, practitioners must have conversations with the licensing board. No one should try to interpret their regulations for themselves or for anyone else. And remember to always get their position in writing."

Dr. Maheu had this to share for any practitioners considering a future TBH, "All that’s needed is a license! A few boards have required additional training, but it’s very much like doing family therapy which doesn’t generally require a separate license." When asked if there were areas of research that MFP fellows should consider, she states, "Technology should not dictate the practice! For example, if you’re looking for transportation, the vehicle you select (e.g., car vs. SUV vs. tractor trailer) will depend on what are you carrying. As such, fellows should determine what clinical population they want to serve and then what technology can best serve that population. Graduate students should consider researching TBH competencies. There is a wealth of information available on the TBHI website."

In summary, TBH has proven to be a great resource for practitioners of all kinds. It just comes down to ensuring you are being mindful of licensing and practice regulations, as well as what makes the most sense for the populations you are serving. For more information on TBH, use the following resources: