Telebehavioral Health — New Digital Directions for Social Work Education
By Christiane Petrin Lambert, MA, MSW, LICSW
Social Work Today
Vol. 19 No. 3 P. 10

As behavioral health and social work evolve, educating students in the delivery of telebehavioral health care with knowledge of the evidence base and adherence to ethical standards is the mission of many new initiatives.

Since the formation of social work as a distinct professional discipline in the late 19th century, educators have carefully considered the core concepts of the field that are essential to prepare new practitioners. As per its published mission statement, the mission of the Council on Social Work Education (CSWE) commits to ensure and enhance the quality of social work education for professional practice. As the context of social work practice changes with new social developments, a healthy tension arises between the community need and demand for new practice models and the field’s commitment to critical examination of emerging approaches, consideration of the evidence base, and adherence to ethical standards. One rapidly emerging practice approach is telebehavioral health (TBH).

TBH involves the delivery of clinical social work services through means of video conferencing in either real-time or “store and forward” services, where the client and clinician are at different geographic locations (Maheu, 2018). Other forms of technology-based practice include texting, e-mail, mobile applications, avatars, social robots, and other various forms of biofeedback (Reamer, 2013). TBH can involve treatment through technological options only, or hybrid combinations with in-person treatment. Each form of media presents nuances for practice. The 2015 model regulatory standards published by the Association of Social Work Boards (ASWB) address this trend: “Social workers who choose to provide electronic social work services shall do so only after engaging in appropriate education, study, training, consultation, and supervision from people who are competent in the use of this technology” (ASWB, 2015).

Current Educational Options for TBH
Schools of social work are faced with the challenge to simultaneously examine and teach emerging approaches. Part of the trend toward TBH is a national shortage in the behavioral health workforce that leaves some communities at a critical loss. Though rural communities face geographical challenges in accessing behavioral health services, individuals and families in urban and suburban settings also face barriers to treatment. As guidance to social work educators, Jo Ann Regan, PhD, MSW, vice president of education for the CSWE, points to Competency 1 of the 2015 Educational Policy and Accreditation Standards. “Social workers understand emerging forms of technology and the ethical use of technology in social work practice” (CSWE, 2015). Regan notes, “Technology is impacting the way we live and the way we practice. We have to be making sure people know how to use the technology ethically, such as ensuring confidentiality.” She further reflects that the increasing use of online learning orients students to technology-based approaches.

Marlene Maheu, PhD, founder and executive director for the Telebehavioral Health Institute, has been practicing and training TBH skills and concepts since 1994. Most recently, she and several colleagues developed the Interprofessional Framework for Telebehavioral Health Competencies (Maheu et al., 2018). The framework includes 149 competencies organized by seven domains, including clinical evaluation and care, virtual environment and telepresence, technology, legal and regulatory issues, evidence-base and ethical practice, mobile health technologies such as applications and social media, and telepractice development. Maheu explains, “TBH is not an entirely new treatment. It is a tool to extend the treatment that practitioners already give.” Maheu notes the importance of identifying competencies that span behavioral health fields—her team examined ethical codes from across disciplines. She says that social work leaders were directly involved in the development of the framework.

In researching what a sampling of schools of social work are offering across the country, current TBH instruction can be organized along a continuum, from embedding concepts within established curricula to developing whole courses and field experiences dedicated to TBH. Some schools offer a series of courses or certificate programs, with skill development either through field internships or simulation/role-play experiences. The level of involvement with TBH in the curricula seems to be influenced by several factors, such as the needs and demands of the surrounding community, the geographic realities of the state’s landscape, opportunities for funding to support new curricula development, and faculty practice experience in TBH methods.

Along the Continuum
Initial stages along the continuum involve adding TBH concepts to existing curricula to provide an overview and experiential opportunities for students in TBH service delivery. The Rhode Island College School of Social Work (RIC SSW) was awarded a Health Resources and Services Administration (HRSA) grant that involved developing one class session devoted to TBH. As interim dean, a professor, and principal investigator for the grant, Jayashree Nimmagadda, PhD, LICSW, notes, “This is our first baby step. We are treading carefully with a full understanding of ethical considerations, as well as making students aware of technological advancements.”

Warren Miller, PhD, LICSW, LCSW-C, LCSW, SAP, BCD, is an assistant professor at RIC SSW and has been practicing TBH for five years. He was recently awarded a faculty scholarship to conduct a study of student knowledge and interest in TBH. The next step would be to offer training for students to develop the competencies, including simulations with actors as clients. Miller notes that the field of social work is at the early stages of involvement with TBH, and he has been able to find more literature on how to teach telehealth practices from the fields of nursing and medical sciences. The vision involves the development of a “Clinic Without Walls” in collaboration with community partners. “The time is now for social work educators to train students on what their potential futures in the profession will involve. TBH is here and is growing rapidly. It is essential for students to understand that technology can be used to deliver social work services in an ethical and effective way,” Miller says.

Similarly, Simmons University in Boston received a federal workforce development grant that has supported their transition to include TBH in their practice curriculum. Cali-Ryan Collin, LICSW, assistant project director for the HRSA-funded grant programs at Simmons, says that federal grant funding provided the support to teach students about providing integrated behavioral health for underserved populations with TBH as a component. Simmons has specifically partnered with community sites, including Heywood Healthcare in Athol and Gardner, MA, a rural community that lacks access to behavioral health services. Through the HRSA grant, Simmons partners with Heywood to provide an experiential learning opportunity for students with the TBH technology. Practitioners from Heywood videoconference into the classroom to speak to students about TBH practice, demonstrate the technology, and answer questions. Simmons faculty reworked one of their advanced clinical courses, Social Work Practice in Healthcare, adding a focus on work in rural communities, and devoted one class session to TBH. Collin notes that, at this point, the concepts in the course are more to raise awareness of the possibility offered through TBH to reach underserved populations, not teach the skills. However, she adds, “We would love to get to the point of teaching TBH skills.” Collin also relays that students report that they love learning about TBH. “There is a huge need to expand education to prepare students for this growing area of practice … to impact health disparities that are encountered by people who don’t have access to the more traditional health care options,” she says.

In the Midwest, Michigan State University (MSU) School of Social Work embeds discussion of TBH practices in established coursework, typically with discussion based on the new Technology Standards for Social Work Practice (NASW, CSWE, ASWB, & Clinical Social Work Association, 2017) as well as the updated regulatory standards published by ASWB (2015). There are more options for studying what MSU terms “cyber social work” through continuing education, including six separate courses with focuses such as ethical considerations; treating grief, loss, and anger virtually; today’s digital culture; and using technology to provide clinical supervision. MSU’s field office noted one placement in a large health system that requires students to practice TBH one day per week, with training, monitoring, and supervision provided by the site. There must be careful consideration with fitting TBH in the curriculum, as faculty members are already time-challenged to cover core and advanced topics in practice classes. Paul P. Freddolino, PhD, a professor and director of distance education and technology, notes, “My concern is that the absence of required content on telehealth 1) puts our students at a disadvantage in the ever-changing employment market that increasingly utilizes information and communication technology (ICT)–based tools and 2) deprives them of the opportunity to have serious discussions—as students, not employees—about the clinical and ethical issues related to telehealth.” Freddolino served on the ASWB taskforce that developed the 2015 regulatory standards for technology. MSU plans to begin a year-long curriculum review with inclusion of more “cyber social work” in both the micro and macro programs a likely outcome.

Mary Dallas Allen, PhD, MSW, an associate professor, MSW program coordinator, and Alaska LEND (Leadership Education in Neurodevelopmental and related Disabilities) without Walls social work faculty at the University of Alaska Anchorage, described TBH as an essential program delivery model because of Alaska’s geography and unmet social service needs. Allen says, “Health and behavioral health service delivery is spread across a large geographic area. There are many communities in Alaska that are not accessible by roads.” She explains that many practitioners travel from community to community, supplementing in-person sessions with tele-approaches to control the cost of travel and provide consistency in services. “Nothing will ever replace a face-to-face meeting. Given certain barriers, we had to ask ourselves how we can make the best of the technology that we have.” Tele-approaches also connect rural and urban practitioners. The use of technology is so ubiquitous that the MSW program is now completely “distance delivered,” with no more in-person classes. Allen highlights that students become competent in the use of technology throughout the program, “which connects students from across communities and reduces the divide between rural and urban.” The program offers a three-credit elective course, Innovative Practices in Telehealth, in collaboration with the Masters in Public Health program—also completely distance delivered. The course provides an overview of telehealth with an emphasis on TBH practice in Alaska. Students can practice skills in the context of field placements in agencies that offer TBH, since so many of them do. Allen reflects, “TBH holds promise for providing services and for individuals, families, and communities. However, there are disparities to accessing the infrastructure needed to have a robust TBH delivery system that then creates social justice issues. I believe the field is moving in the right direction, but we still need to keep working on it.”

Advanced Initiatives
Further along in TBH curricula development, schools with more experience and history with TBH link multiple courses in practice and skills. David Wilkerson, PhD, LCSW, an assistant professor at the Indiana University School of Social Work, began research into telehealth practices to guide the development of an online psychoeducation group. With initial support of a $15,000 curriculum enhancement grant, Wilkerson led the development of three courses in social work and TBH. As of January 2019, students who have completed all three social work courses can take a fourth course offered through School of Informatics to complete an E-Social Work Practice Graduate Certificate. An article about the first course defines “e-social work [e-SW] practice—the term coined for ICT-mediated telehealth and telebehavioral health practices that encompass the profession’s core values and ethical standards toward better client outcomes and social change” (Wilkerson, Wolfe-Taylor, & Kinney, in press). Wilkerson and colleagues found that students in the course are positively impacted in their confidence and practice efficacy. “There was also a significant increase in e-SW practice skills as it pertains to engagement with clients, practicing with a patient through technological means, and ethical e-SW practices.” Wilkerson notes that, in one of the three classes, student skills are assessed via simulation using a structured clinical examination system that was developed by his colleague, Samantha Wolfe-Taylor, MSW, LCSW, e-SW project coordinator. Wilkerson hopes next to collaborate with community agencies to scale up TBH interventions to provide field practicum opportunities for students and training for agency staff.

Perhaps furthest along the TBH continuum is the University of Southern California’s (USC) Telehealth Online Clinic within the Suzanne Dworak-Peck School of Social Work that hosts an average of 30 interns each year. “The clinic is an in-vivo learning environment to train students for the coming world in which 30% of behavioral health services are offered through a TBH platform,” says Marleen Wong, PhD, MSW, LCSW, senior vice dean of field education, endowed David Lawrence Stein/Violet Goldberg Sachs Professor of Mental Health, executive director of Telehealth Clinic, and clinical advisor to the Family Nurse Practitioner program at USC. Wong explains the impetus for the clinic was Los Angeles (LA) County’s request for alternative practices to reach underserved communities, such as youth and families in LA’s “conflict zones,” areas with high rates of poverty, crime, multiple gang territories, etc.

Sarah Caliboso Soto, MSW, interim director and a clinical assistant professor for field education, explains that all students complete a semester-long Virtual Field Practicum focused on skills development and practice. Once placed at the clinic, students are provided a six-week, 100-hour rigorous training that consists of online modules, live sessions, role-plays, and observations with specialized training in evidence-based practices. “Clinical faculty provides close guidance and supervision to keep a good pulse for what all of our students are doing,” Caliboso Soto says. All providers are trained to identify crisis resources available in the client’s location, and supervisors are able to intervene during sessions if an emergency arises.

Wong explains that the clinic serves as both a teaching and research environment, providing an opportunity for faculty to study telepractice models.

Carolina Peralta Ventura, MEd, associate director of field education and telehealth operations director for the Telehealth Online Clinic, notes several lessons learned: the importance of operations and clinical staff working together to best serve clients, the richness of relationship that can develop between a client and clinician through TBH, the benefit of using hybrid approaches to guide clients in the use of technology, and the value of telesuites, private spaces linked with the necessary technology in community settings.

Caliboso Soto notes that more than 200 students have completed internships with the clinic, and several are now running clinics around the country.

Wong stresses the importance of honoring generational needs. “Young clients and students today were born into a cultural landscape of technology. We must be responsive to the needs of our communities and preparing our students in new ways to meet those needs,” she says.

Future Implications for TBH in Social Work Curricula
Frederic Reamer, PhD, a member of Social Work Today’s Editorial Advisory Board, chaired the Taskforces for Technology Standards for Social Work Practice and Model Regulatory Standards for Technology and Social Work Practice, as well as the taskforce that wrote the Code of Ethics adopted in 1996, and served on the taskforce that updated the code in 2017. The resulting standards were approved and published through NASW, CSWE, ASWB, and the Clinical Social Work Association. The standards use a humanistic framework to ensure that ethical social work practice can be enhanced by the appropriate use of technology (NASW, 2017; Reamer, 2018). Reamer also serves as a professor at the RIC SSW and teaches ethics and risk management, including in the use of technology. Reamer says, “At this point in history, social work educators need to take a hard look at the range of technological approaches in social work practice and develop frameworks to help students distinguish formats, protocols, and service delivery models that meet the profession’s ethical standards and standards of care.” As positive examples, he highlights the innovative approaches being used by the VA and the U.S. military to bring behavioral health services to soldiers in remote areas. “It is our responsibility to acquaint students with the diverse ways that technology is being used [and] the benefits and risks involved, and ensure their familiarity with the regulatory, ethical, and practice standards by which they can discern approaches that adhere to the time-honored values of the profession,” Reamer says.

Social work educators from around the country reinforce the primacy of the human connection in practice. When geography, societal barriers, and other factors limit access to an in-person connection, TBH extends the reach of social work practice. The field of social work has an opportunity to shape this practice innovation by ensuring that students develop competence and confidence in the use of the technology, upheld by the core values of the field.

— Christiane Petrin Lambert, MA, MSW, LICSW, works in community clinical practice, serves as a consultant for program planning, development, and evaluation, and is adjunct faculty at the Rhode Island College School of Social Work.

References
Association of Social Work Boards. (2015). Model regulatory standards for technology and social work practice: ASWB International Technology Task Force, 2013-2014. Retrieved from https://www.aswb.org/wp-content/uploads/2015/03/ASWB-Model-Regulatory-Standards-for-Technology-and-Social-Work-Practice.pdf.

Council on Social Work Education. (2015). Educational policy and accreditation standards for baccalaureate and master’s social work programs. Retrieved from https://www.cswe.org/getattachment/Accreditation/Standards-and-Policies/2015-EPAS/2015EPASandGlossary.pdf.aspx.

Maheu, M. (2018). Telebehavioral Health Institute. Retrieved from https://telehealth.org/.

Maheu, M. M., Drude, K. P., Hertlein, K. M., Lipschutz, R., Wall, K., & Hilty, D. M. (2018). Correction to: An interprofessional framework for telebehavioral health competencies. Journal of Technology in Behavioral Science, 3, 108-140.

National Association of Social Workers. (2017). Highlighted revisions to the Code of Ethics. Retrieved from https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Highlighted-Revisions-to-the-Code-of-Ethics.

National Association of Social Workers, Council on Social Work Education, Association of Social Work Boards, & Clinical Social Work Association. (2017). NASW, ASWB, CSWE, & CSWA standards for technology in social work practice. Retrieved from https://www.socialworkers.org/LinkClick.aspx?fileticket=lcTcdsHUcng%3D&portalid=0.

Reamer, F. G. (2013). Social work in a digital age: Ethical and risk management challenges. Social Work, 58(2), 163-172.

Reamer, F. G. (2018). Ethical standards for social worker’s use of technology: Emerging consensus. Journal of Social Work Values and Ethics, 15(2), 71-80.

Wilkerson, D. A., Wolfe-Taylor, S., & Kinney, M. (in press). Adopting e-social practice: Pedagogies for student decision-making practice self-efficacy. Journal of Social Work Education.