Helping Give Away Psychological Science/Telepsychology

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The coronavirus pandemic is causing a lot of clinics and clinicians to move to using telehealth. The rules around it are changing rapidly, as well. This page gathers information about how and what is involved in terms of practical considerations for the clinician, as well as tips and suggestions about how to make it work effectively. We have a suggestion box here where you can drop links, add ideas and comments. You also can make edits directly on this page or on the Discuss page if you are comfortable with editing.

Guidelines for conducting mental health services with technology[edit]

Getting started[edit]

Telepsychology is defined as the provision of psychological services using telecommunication technologies, which include telephones/smartphones, video conferencing, email, texting, and self-help materials (blogs, social media, etc). The services can be delivered synchronously, with multiple parties interacting in real time or asynchronously, with parties responding to one another at their convenience.[1]

Telepsychology offers convenience and can be helpful for coaching patients/clients between appointments. There are also circumstances during which it is not possible to see patients in person and telepsychology is necessary for continuity of care. This is an overview, including resources with more detailed information, to help practitioners provide telepsychology safely, effectively, and in alignment with professional standards.

In order to build competence in telepsychology. Consider taking an online course to familiarize yourself with telepsychology and read American Psychological Association, American Psychiatric Association, and APPIC guidelines on the topic. Additional resources can be found on APA’s website.

Consent for telepsychology[edit]

It is important to introduce the idea of telepsychology and to give your patient/client an opportunity to ask questions about it and to make a choice about whether telepsychology is right for them.

  • Ask whether the patient/client has ever seen a doctor on a phone or computer. If the patient has not used telehealth, it may be helpful to refer to common lay technology (i.e., Facetime, Skype, or Zoom) and explain key differences.
  • Let patients/clients know why telepsychology is being used. For example, “mental health clinicians are using technology to meet with patients during the COVID-19 outbreak so that everyone can stay as healthy as possible,” or “I am using this so I don’t have to use a face mask to see you today.”
  • Let patients/clients know that the session will be happening in “real time”
  • Discuss security, and address any concerns about who else can hear or see them. Additional information regarding technological specifications should be available if requested. Some patients appreciate being reassured that the session is not “on the internet” in the sense that it can neither be openly viewed nor will it be placed online.
  • It is important to inform patients if a session is being recorded. If you want to record a session, then you must obtain explicit consent from the patient/client.
  • If your original consent for treatment did not include telepsychology (including communication by text message or email), it is important to talk with your patient/client about what telepsychology entails and to collect and document their consent for these services.
  • Some patients/clients may choose to consent to only some services (e.g., email and phone therapy, but not video).
  • You should create a new consent form or update your existing form and go over it with your patient/client over the phone. You can then email them a copy to sign and return to you. If it is not possible for them to print/sign the document, you can consider an online signing service, such as DocuSign or DocHub. Examples of consent for telepsychology can be found here and here.

Technology[edit]

Email[edit]

Email is a convenient, but not necessarily secure, method of communication. Some organizations provide encrypted email for their employees, which enables for the safe transmission of protected health information. Even when the message is encrypted, there are some risks to using email and other things of which to be aware. It is wise to have a conversation with your patient/client about how the two of you will use email. Some use email only for scheduling and other logistical things, whereas others will engage in coaching and other services by email. Many professionals include an agreement about email as part of their consent form. If this was not done initially, you may want to have a conversation with your patient/client and then send an email indicating your agreement. They can respond affirming the agreement and this exchange becomes part of their record. Email is not secure. Even when encrypted, it can be forwarded or compromised in other ways. It can be helpful to include a message after the signature to remind patients of this.

Phone[edit]

Most practitioners are comfortable communicating with patients/clients through the phone to set appointments and occasionally check-in. Conducting therapy over the phone can be more complicated. A few things to keep in mind:

  • Make a plan with your patient/client ahead of time, so that they are prepared for the call and are situated in a quiet, private place.
  • Set expectations, so that your patient/client knows how long the call will last and whether it will be a “typical” therapy session over the phone or something else (e.g., a short check-in).
  • If you are using a cell phone, make sure you have adequate reception to limit call disruptions.
  • Consider using a hands-free headset, so that you can take notes.
  • Find a quiet, private place to conduct the call, so you are not distracted and there is no background noise.
  • Prepare materials you might need ahead of time. For example, make sure you have your notepad and a pen. If you use worksheets or other materials, make sure your patient/client has a copy ahead of time, so you can review it together.

Video Conferencing[edit]

Videoconferencing is a nice alternative to phone for communicating with patients/clients and particularly for conducting therapy or assessment. It also presents some extra challenges for people who are not familiar with the technology. Although recent circumstances have led to the relaxation of HIPAA for the provision of teletherapy. In order to assure HIPAA-compliance of a software tool, it is important to have a Business Associate Agreement with the service provider. A business associate is someone who performs functions or provides services on behalf of a covered entity which requires them to have access to protected health information. HIPAA Rules typically require business associates and covered entities to enter into Business Associate Agreements. This contract establishes the permissible uses and disclosures of protected health information and ensures that the business associate will uphold these rules and take appropriate measures to safeguard protected health information from any non-permitted uses or disclosures. The first step is choosing a platform to use. There are several options (e.g., Skype for Business / Microsoft Teams, Updox, VSee, Zoom for Healthcare, Doxy.me, Google G Suite Hangouts, Meet, Cisco Webex Meetings / Webex Teams, Amazon Chime, GoToMeeting, Spruce Health Care Messenger), a few popular ones are described below.

Doxy.me

  • Both free and premium versions are available and easy-to-use on all devices.
  • All versions are fully functional, HIPAA compliant, and include a Business Associate Agreement at no cost.
  • The premium options give providers the freedom to customize features including the waiting room, logo, text and videos.
  • Other benefits to the premium options include real-time support, file transfer, payment processing and text and email notifications. Premium costs $35 per month for individual providers and $50 for clinics per provider.
  • Doxy.me operates using any web-browser; there is no installment or download necessary for provider or patient
  • It may not be best for those with average to weak internet connections, but for those with higher speed connections, it will provide high-quality audio and video.

thera-LINK

  • A HIPAA compliant option that provides a Business Associate Agreement
  • It can be used on all devices.
  • There are three packages: Basic plan, at $30, per month offers five sessions a month for one provider and a scheduler. The Plus plan and Ultimate plan, at $45 and $60 per month offer unlimited monthly sessions, secure file sharing, advanced payment and scheduling options, and office manager accounts; the Ultimate plan also includes client notes, secure messaging and a branded portal.
  • theraLINK requires both providers and patients to have their own login.
  • theraLINK is relatively easy to navigate and offers the ability to customize aesthetic features such as imagery and music options for the waiting room.
  • theraLINK can only be used on WiFi and on devices that are well-charged or can be plugged into a power source and may be harder to master than other options.

Zoom

  • A video conferencing platform that is not tailored specifically for mental health, but s popular for business and education, so many people are familiar with it
  • Its Healthcare business plan is HIPAA compliant and includes a business Associate Agreement. Plan costs start at $200 per month.
  • Zoom is customizable and works on all devices, though it may not be suited for low bandwidths.
  • Due to the cost, Zoom may be best for those who have midsize to large practices which require the tool to have multiple functions (i.e. training, recording, seminars, etc).
  • Zoom’s popularity has also made it a target for mischief. It is important to take steps to ensure that your video call is secure and accessible only by you and your client, this includes keeping the link private and setting a password.

Prepare your space and practice

  • Make an effort to minimize potential distractions in your environment. This means things that will be visible in the background to your patient/client and things that may distract you during the session
  • Pick a spot that is quiet and private. Try to use the same space week-to-week to facilitate familiarity and an office-like experience
  • Make sure you are comfortable and have everything you need (water, notes, etc) before you start
  • Turn off all email and messaging notifications on your computer and cell phone and encourage your patient/client to do the same
  • Many videoconferencing programs have a "Virtual Background" option where you can use an image to block out the background
    Example of setting up a virtual background in videoconferencing software
  • Ensure your video is sufficiently “zoomed in” for the patient to see your facial expressions.
    Be close enough to the camera that it is easy to see facial expressions
  • Try to maintain a constant gaze into the camera, rather than frequently looking away at your computer or notes. It can be tough to maintain a constant gaze while on a video call, but there are ways you can simulate eye contact with your patients with just a few tricks.
  1. Try to focus on a point behind the camera lens, this will focus your eyes and make it clearer where you are looking. Much of perceived eye contact through video calling is related to the rotation of your eyes. The further back you sit, the less your eyes need to rotate, so sit further from the screen and zoom in closer to your face if you need to.
  2. Center the video of your patient/client under your webcam, so when you look at their eyes, you are looking directly into the camera
  • If possible, use picture-in-picture feature (e.g., where you can see both yourself and the patient) to see how you are being viewed by the patient, or if there is something distracting in the background (e.g., your cat!)
  • Ask a friend or colleague to do a practice session with you before you attempt a video session with a patient/client - there will be early snafus and it is good to figure them out before you are in a real session
  • Wear office-appropriate clothing
  • If possible, give yourself a break between sessions to stretch or take a brief walk

Prepare your patient/client

  • As with phone calls, encourage your patient/client to find a quiet and private space for the session
  • Using a laptop or desktop computer is likely to be more comfortable, but a smartphone can also be used
  • Set the client’s expectations for the session and send any materials (e.g., worksheets, mood rating scales) ahead of time
  • Make a contingency plan, in case the technology doesn’t work
  • At the beginning of the session, ask patients if they would like to see your office. Using the camera’s zoom and pan features or manually moving your device, you can give patients a virtual tour of your workspace to assure them that no one else is present and to provide context to the clinical setting.
  • Discuss any technical difficulties noticed immediately as they arise during the introduction. For instance, if there is a slight lag in audio that makes it seem as if you and patient are talking over each other, you can suggest adding a small pause after each statement.

Get ready for your telepsychology session[edit]

  • Some clinicians make the mistake of not preparing for a telepsychology session because it may feel more informal than an in-person session. However, it can be more challenging to keep a client engaged in telepsychology and it is especially important to set an agenda and to have your goals for the session planned ahead.
  • As noted above, you may want to use worksheets or other materials in your session. These can be emailed to the patient/client ahead of time. You may also want to use the “share screen” feature that most video conferencing services provide. Other features might include a “white board” or chat functions that can help you to share materials with your patient/client.
  • If you want to use some of the special features, be sure to pilot them beforehand, so you know how everything works.
  • These guidelines may be helpful for people interested in cognitive therapy.

Appropriate clients[edit]

Meeting virtually may not be appropriate for all patients/clients. Some may not be comfortable with the technology or may have privacy concerns. Other patients/clients may be high risk, which can lead to safety and liability issues when communicating with them through email, phone, or video. It is important to consider these issues and to discuss other options with your patient/client.

Patients/Clients who are not comfortable with technology

Many patients/clients may be unfamiliar with videoconferencing and hesitant to use this technology for mental health services. Plan to spend some time answering questions and helping them to get set-up prior to your appointment.

  • Ask if there is a software they already use to communicate with family or other providers, try to use the same one, if possible
  • YouTube is a good source for how-to videos about setting up a video conference
  • Your patient/client may also have friends/family who can help them get set-up, encourage them to seek help

Patients/Clients who have privacy concerns

  • Some patients/clients may not have access to a private space in their home. Help them brainstorm other options. For example, can they sit in their car? Or go to a quiet place in a local park?
  • Others may be concerned about the possibility that the communication (whether email, phone, video) will be breached in some way. You can help with these concerns by making sure to use HIPAA-compliant services and encrypted email. However, if the patient/client is not comfortable with telepsychology, it is important to have alternative options for them; this may mean referring them to another provider who is offering in-person services.

High risk patients/clients

Patients at high risk for suicide present special concerns for telelpsychology. Taking the steps below will help ensure that you are able to adequately manage risk.

  • Update emergency contact information before providing any telepsychology services.
  • Make sure you know the patient/client location (address, apartment number) at the start of the session in case you need to contact emergency services.
  • Make a plan for how you will stay on the phone with the client while arranging emergency rescue, if needed. It may be helpful to recruit a colleague who can support you during this process (i.e., call 911 on your behalf). Do not hang-up on the patient/client if there is imminent risk.
  • The circumstances that make telepsychology necessary (e.g., illness, injury) may also increase suicide risk, it is important to continue to assess suicidal thoughts and behaviors on a regular basis.
  • Risk may also increase if the patient/client has access to lethal means while house-bound. Reviewing and updating existing safety plans to account for current circumstances is wise.
  • As part of safety planning, work with the patient/client to identify the closest emergency facility and how they could get there if necessary.
  • Consider making a plan for more frequent check-ins until risk abates.
  • Provide crisis hotline numbers (1-800-273-8255) and crisis text (Text “Got5 to 741741) information.
  • More information can be found here.
  • Special considerations for working with high risk youth are here.

Working with children[edit]

Adolescents are likely to be comfortable with phone or video, but it may be a challenge to get them to focus on you and limit distractions. Younger children may also be distracted by their environment or may struggle to stay engaged. It may be necessary to modify your typical approach to work effectively with youth.

Setting the scene

  • Encourage caregivers to minimize distractions in the room where the patient/client will be completing the session
  • Young patients prefer a “less formal” room set-up, so you may wish to avoid having a table between the patient and the video-recording device (or you and the video-recording device)
  • Consider the best seating arrangement. Young children can sit next to a caregiver, between the caregivers, on a caregiver’s lap, or in front of the caregiver in either their own chair or on the floor.
  • If possible, larger rooms tend to work best with younger patients, so they can move around. In addition, if a child's motor skills, play, exploration, and movements are being assessed, the room should be large enough for this activity to fit within the camera frame.
  • Adolescents may prefer to be seen without a caregiver present
  • Establish that you are seeing the patient/client in real time. Young children may enjoy seeing you mimic their gestures, or comment on what they are wearing.
  • Socialize youth to the videoconferencing system, and highlight that it might take time to acclimate to the technology and ‘‘not talk over each other.’’
  • Give patients an opportunity to ask questions before starting the session
  • Ask children or caregivers to prepare some toys, drawing materials or other supplies that you may want to work with during the session. Try to recreate your office as much as possible

Maintaining engagement

  • If you are using or creating worksheets or other visual activities, consider allowing the patient to choose the colors/fonts/pictures in order to provide them with some control.
  • Use exaggerated expressions and gestures if needed to engage the youth (virtual high 5s, thumbs up, etc.).
  • Children may enjoy drawing pictures that they can then share through the camera while telling a story. These drawings may help you assess children’s attention, fine motor skills and creativity. Children may also use play figures (e.g., dolls, action figures) to demonstrate their ability for symbolic play and reveal their thought content.
  • For younger kids, ask them to share their favorite things about home — toys, books, blankets, etc. insofar as these can be related to clinical activities and are not disruptive.
  • For older kids, ask if they have any art, journalling, music, or anything else to share with you. Consider engaging adolescents by exploring an online site, such as YouTube or Facebook through screen sharing
  • Children and teens may appreciate getting to know clinicians as well. Consider using a brief question and answer game to share some facts about you and gathering information about your patient. For example, your patient and you can take turns answering: “What is your favorite TV show?”, “What is your favorite color?”, “What is your favorite food?”, “How many siblings do you have?”
  • Mirror the language patterns of the youth and handle any threats to rapport with genuineness (including using informal language).
  • Arts-based therapeutic methods may help engage younger patients. You can have the patient show you their work on the camera or use screen share options to create art together (based on your platform’s capabilities).
  • Consider sharing handouts and working through them in session if your platform has the functionality (e.g., Zoom screen share with editable documents or PowerPoints).
  • Try utilizing different functions to increase engagement (e.g., Zoom has a “whiteboard” feature where a patient and clinician can draw together or play tic-tac-toe). Check with technology services at your site for specific trainings and tips on functionality for your platform.
  • A hyperactive or autistic child may have difficulty remaining in the camera frame. Consider keeping the caregivers in frame and call the child back to the camera when they need to answer a question.
  • If anxious or defiant youth refuse to sit within the camera frame, try to use typical behavior management strategies first. Then, prior to the next session, ask the caregiver to turn off the self-monitor image and seat the youth farther away from the camera so as to remain in the frame. Another strategy is to allow the youth to have more privacy for part or all of the session.
  • Especially with younger patients, recognize that staying engaged via telehealth is challenging! Adjust your expectations of how long sessions may last if you are having a hard time keeping your patient engaged.
  • Consider incorporating games or other activities as appropriate. There are online games available that can be helpful for maintaining interest such as Board Game Arena or PlayingCards.io
  • Research shows that youth’s satisfaction with telehealth will likely increase with repeated use; youth who were initially anxious about telehealth showed decreased distress in about 10-15 minutes.
  • It is important to continue conversations related to technical difficulties, unique challenges, or positives that come from using telehealth throughout the treatment course. Keep asking!

Conducting assessment[edit]

Conducting assessment through telepsychology may seem challenging, but with some exceptions, it is possible to continue to incorporate assessment in your practice. In some cases, it may be necessary to split an appointment to conduct some assessments via telepsychology and save others for when an in-person meeting is possible. APA has issued guidance on the topic.

Self report

Many practitioners administer self-report rating scales to assess patients over time. These are relatively easy to continue:

  • Self reports can be emailed to patient/clients to be completed and sent back
  • Self reports can be administered through HIPAA-compliant survey tools
  • Self reports can be read to the patient and they can respond orally

Interview-based

  • Diagnostic interviews and clinical rating scales are often feasible to administer via telepsychology
  • Behavior ratings may be more difficult to ascertain though, so it is important to consider the information you need to collect and plan accordingly. If a certain interview relies on behavior observations, consider whether there is an alternative that may be more appropriate

Cognitive/Achievement and Neuropsychology

  • Tests of cognition are likely to be the most difficult to administer via telepsychology.
  • Given the importance of administering these tests under circumstances similar to those under which the norms were established, it is important to look into data supporting the administration of specific tests with telepsychology.
  • Some tests have online versions. Although there would likely be additional costs associated with this approach, it is likely to be easier and more valid than adapting tests intended to be administered in person

Legal considerations[edit]

As noted above, it is important that your patient/client understand the potential risks of telepsychology (e.g., confidentiality, safety) and that they consent to the provision of services using telepsychology. In addition to patient consent, it is incumbent upon the provider to follow rules related to HIPAA and other legal and professional guidelines. Although some of these rules have been relaxed due to the COVID19 crisis, it is best to confirm the current rules before engaging in telepsychology.


It is important to keep in mind that the rules about telepsychology are typically governed by states, so you should be familiar with the rules in the state where you are licensed and practice as well as the state(s) where your patient/client may be at the time of the service.

Reimbursement and fee collection[edit]

Services delivered via phone or video are billed under a separate code and, under typical circumstances, may be reimbursed at a different rate than in-person services. Medicare has modified its rules and will cover a wider range of telepsychology services, including testing and group therapy, during the COVID19 crisis. Private health insurance providers may follow the government, but in order to ensure reimbursement, practitioners should check with individual payors prior to providing services and submitting bills.

Practitioners in private practice may be used to collecting fees by cash or check. Alternative methods for payment may be preferable for telepsychology. Patients/clients can mail a check, but the practitioner should consider where the check is sent and whether they are comfortable receiving payment at their home address. Electronic payment methods avoid this complication, but not all patients/clients will be comfortable transferring funds. Providing some education about the pros/cons of electronic payment and coaching on how to implement it will be helpful. A few options include:

  • Zelle is a payment method that moves funds between bank accounts. It works across different banks and is integrated into many banking apps
  • PayPal is a more flexible option that can link with both credit cards and bank accounts. It also includes accounts for both businesses and individuals, which may be appealing for some who plan to collect fees electronically on an ongoing basis.
  • Venmo is a popular payment tool that allows users to send funds from their bank account or from their Venmo account (if they have been paid by others through Venmo). An important consideration with Venmo is that payments are not necessarily private. You can set your preferences to be private, but if this is not done, others on the app can see payment exchanges

Information for Trainees[edit]

Trainees should follow the guidelines set by their institution and rely on their supervisors to provide instruction and support. Additionally, the Council of Chairs of Training Councils published guidelines related to training during the COVID19 crisis.

Supervision[edit]

Supervision can be especially valuable when initiating a new approach to mental health services - including telepsychology. Trainees should be sure to maintain a consistent supervision schedule with their clinical supervisor, and even licensed practitioners may want to seek supervision from someone experienced in telepsychology until they feel comfortable with it. Although some aspects of supervision can be conducted without modification (e.g., session planning, self-report about a previous session), other aspects require some change, similar to modifications that are necessary for providing services. Seek guidance from your program to ensure supervision continues to meet APA or other professional requirements.

Observation

  • Many programs are set-up to video or audio record assessment and therapy sessions, so that supervisors can watch/listen to them later and provide feedback. Some video conferencing programs allow for recording of sessions, which is helpful, but before using this option, make sure that:
  1. The video service is HIPAA-compliant and that the recording is stored in a HIPAA-compliant fashion
  2. The video is shared with the supervisor in a HIPAA-compliant way (e.g., secured file sharing program)
  • Sessions can also be audio recorded, particularly if done through speaker phone, but the way the audio file is shared with the supervisor must be HIPAA-compliant

Progress Notes

  • Many organizations use an electronic medical record (EMR) to store notes. If you have access to this from outside the office, no change in your typical approach may be necessary.
  • Other organizations have paper records or EMR that is not accessible outside. In these cases, it is still important to document what occurred in your sessions.
  • Be sure you have a HIPAA-compliant way of storing these notes until you have access again to the EMR and can store them properly. This could be an encrypted digital folder or in a paper file.

References[edit]

Boydell, K. M., Volpe, T., & Pignatiello, A. (2010). A qualitative study of young people’s perspectives on receiving

psychiatric services via televideo. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal

De l’Academie Canadienne De Psychiatrie De L’enfant Et De L’adolescent, 19(1), 5–11.

Gloff, N. E., LeNoue, S. R., Novins, D. K., & Myers, K. (2015). Telemental health for children and adolescents.

International Review of Psychiatry, 27(6), 513–524. https://doi.org/10.3109/09540261.2015.1086322[2]

Glueck, D., Myers, K., & Turvey, C. (2013). Establishing therapeutic rapport in telemental health. In Telemental health:

Clinical, technical and administrative foundations for evidence-based practice (pp. 29–46). Elsevier. https://doi.org/10.1016/B978-0-12-416048-4.00003-8[3]

Goldstein, F., & Glueck, D. (2016). Developing Rapport and Therapeutic Alliance During Telemental Health Sessions with

Children and Adolescents. Journal of Child and Adolescent Psychopharmacology, 26(3), 204–211.

https://doi.org/10.1089/cap.2015.0022[4]

Myers, K. M., Valentine, J. M., & Melzer, S. M. (2008). Child and Adolescent Telepsychiatry: Utilization and Satisfaction.

Telemedicine and E-Health, 14(2), 131–137. https://doi.org/10.1089/tmj.2007.0035[5]

Myers, K., Nelson, E.-L., Rabinowitz, T., Hilty, D., Baker, D., Barnwell, S. S., Boyce, G., Bufka, L. F., Cain, S., Chui, L.,

Comer, J. S., Cradock, C., Goldstein, F., Johnston, B., Krupinski, E., Lo, K., Luxton, D. D., McSwain, S. D.,

McWilliams, J., … Bernard, J. (2017). American Telemedicine Association Practice Guidelines for Telemental

Health with Children and Adolescents. Telemedicine and E-Health, 23(10), 779–804.

https://doi.org/10.1089/tmj.2017.0177[6]

Nelson, E.-L., & Patton, S. (2016). Using Videoconferencing to Deliver Individual Therapy and Pediatric Psychology

Interventions with Children and Adolescents. Journal of Child and Adolescent Psychopharmacology, 26(3), 212–

220. https://doi.org/10.1089/cap.2015.0021[7]

Rockhill, C., & Goldstein, F. (n.d.). Child & Adolescent Telepsychiatry: Developing a Virtual Therapeutic Space. American

Psychiatric Association. Retrieved March 17, 2020, from

https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/child-adolescent/developing-a-virtualtherapeutic-

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Roth, D. (n.d.). Child & Adolescent Telepsychiatry: Participant Arrangement. American Psychiatric Association. Retrieved

March 17, 2020, from https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/childadolescent/

participant-arrangement

Timm, M. (2011). Crisis counselling online: Building rapport with suicidal youth. https://doi.org/10.14288/1.0054473[8]

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  7. Nelson, Eve-Lynn; Patton, Susana (2016-04). "Using Videoconferencing to Deliver Individual Therapy and Pediatric Psychology Interventions with Children and Adolescents" (in en). Journal of Child and Adolescent Psychopharmacology 26 (3): 212–220. doi:10.1089/cap.2015.0021. ISSN 1044-5463. PMID 26745607. PMC PMC5220559. http://www.liebertpub.com/doi/10.1089/cap.2015.0021. 
  8. Timm, Maria (2011) (in en). Crisis counselling online : building rapport with suicidal youth. doi:10.14288/1.0054473. https://doi.library.ubc.ca/10.14288/1.0054473.