Introduction
The COVID-19 pandemic triggered a massive shift from in-person clinical practice to telehealth. Telehealth broadly encompasses the utilization of “telecommunications and information technology to provide access to health assessment, diagnosis, intervention, and information across a distance, rather than face to face” (American Psychological Association, n.d.).   The use of telehealth reached its peak in April of 2020 but has since stabilized to a rate 38 times higher than the pre-COVID-19 baseline, with psychiatry surpassing all other healthcare disciplines (Bestsennyy et al., 2021). In 2021, the American Psychological Association (APA) distributed a national survey to doctoral-level licensed clinical psychologists and found that 96% utilized telehealth in their clinical practice throughout the pandemic, and 93% plan to continue using telehealth post-pandemic. Given the flexibility, accessibility, and comfort that telehealth affords patients and providers, it is no surprise that telehealth is here to stay. 

Despite the clear benefits of telehealth, potential limitations include work-life boundary diffusion, limited professional oversight and collaboration, and challenges with managing patient risk and safety (Mosley et al., 2021). In 2013, APA established a list of recommendations and guidelines for addressing risks of telehealth practice (APA, 2013); however, these guidelines do not fully address present-day context. More recent guidelines (Cooper et al., 2019; Smith et al., 2020) are limited in their ability to account for the long-term implications and risks of telehealth practice, as they are still largely unknown. As the field of clinical psychology adapts to reliance on technology in practice, future uses of telehealth are likely to evolve (Kuziemsky et al., 2019; Smith et al., 2020). Telehealth guidelines need to be adapted to modern contexts and project out future risks and solutions. This article aims to clarify future directions for ethical practice guidelines and considerations. 

One consideration is that use of telehealth may place psychologists at higher risk of burnout. Since the widespread implementation of telehealth, a new phenomenon of “Zoom fatigue” has emerged, which suggests that telecommunications require additional or different sources of social energy than in-person communication (Sasangohar et al., 2020). Throughout the COVID-19 pandemic, mental health providers are in greater demand than before. Many providers have reported longer waitlists and more referrals compared to pre-pandemic practice (APA, 2021). Zoom fatigue, paired with increased clinical demands, is not a sustainable situation for mental health providers. Long-term use of telehealth for mental health treatment increases provider vulnerability for compassion fatigue and vicarious trauma (Botaitis & Southern, 2020). In 2021, 46% of psychologists reported feeling burned out (APA, 2021). Principal A of the APA Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as APA Ethics Code) states, “Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work” (APA, 2017). Research suggests that mental health provider burnout can also impact client care (Rupert et al., 2015). Guideline 3.04 (a) Avoiding Harm states, “Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable” (APA, 2017). Increased engagement in self-care, whether it be providers seeing their own therapist, scheduling in breaks, and/or leaning on social and work supports, are recommended strategies for mitigating the effects of burnout and compassion fatigue on patient care and well-being (Miu et al., 2022; Sasangohar et al., 2020), and might be of particular importance among those practicing via telehealth. 

Prior to the widespread use of telehealth, providers who worked in group practices or shared clinical offices benefited from impromptu consultation with colleagues and supervisors (Sasangohar et al., 2020). Being in a shared physical office space naturally offers the reality and perception of oversight in a way that is not afforded with remote work. Despite the fact that telehealth communication channels are just as accessible for most, teleconsultation appears to be underutilized (Miu et al., 2022; Ramli & Ali, 2018). With the transition to a new treatment delivery model increasing caseloads and the ongoing collective stress and hardships associated with the pandemic, providers arguably need more consultation and peer support. 

Principle B: Fidelity and Responsibility of the APA Ethics Code states, “psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work” (APA, 2017). For many, knowing one should consult does not translate into consulting or provide any solutions, and does not overcome the previously mentioned barriers and contextual factors that make consultation difficult. To improve the likelihood that providers regularly engage in consultation, Miu and colleagues (2022) recommended that providers shift their model to one that is non-judgmental, positive, and supportive rather than one that feels surveilling or punitive. An additional recommendation for overcoming consultation barriers and resistance includes setting up static and protected supervision/consultation time within work hours (Mosley et al., 2021; Rothwell et al., 2021). Implementing a system that allows for intentional, meaningful, and consistent engagement in supervision/consultation may reduce predictable and unforeseeable ethical risks long term. 

Telehealth may not be suitable for all patient populations and there is a lack of treatment manuals to address needed adaptations for specific populations (Smith et al., 2020). The development of manuals and guidelines typically lags behind the necessitating clinical contexts (Alqahtani et al., 2021). Although specific adaptations for the use of telehealth across a variety of populations may not yet be available, APA’s Guidelines for the Practice of Telepsychology recommends that mental health providers “evaluate and assess the appropriateness of utilizing these technologies prior to engaging in, and throughout the duration of, telepsychology practice to determine if the modality of service is appropriate, efficacious and safe” (APA, 2013). Careful examination of telehealth fitness for a patient should incorporate cultural considerations related to a family’s comfort with telehealth, client technological competence and resources, ability status, and treatment needs (APA, 2013; Pollard et al., 2017). It is also worth noting how these risks may compromise fidelity to Principle E: Respect for People's Rights and Dignity, which states, “Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these factors when working with members of such groups” (APA, 2017). Proper consideration of clients’ identity factors includes a thorough assessment at the onset of treatment, incorporation of necessary adaptations, and care coordination, or referring out if clients’ needs are not within one’s bounds of competence (Chenneville & Schwartz-Mette, 2020). 

New technology platforms, applications, and services are being implemented in clinical practice despite having limited tools and understanding for continued data maintenance and security. These discrepancies pose ethical risks pertaining to privacy and confidentiality issues. With the use of video conferencing technology, patients could potentially record therapists without therapists' consent, third parties may interrupt sessions, and Personal Health Information (PHI) could be compromised (Chenneville & Schwartz-Mette, 2020; Mosley et al., 2021). Guideline 4.01 Maintaining Confidentiality of the APA Ethics Code states, “Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium” (APA, 2017).  Recommendations for improved security include the use of a secure trusted platform, headphones, a wired network connection instead of Wi-Fi, as well as adherence to Health Insurance Portability and Accountability (HIPAA) data security policies and procedures (Smith et al., 2020). However, when considering the trajectory of technology advancement and accessibility within clinical practice (e.g., artificial intelligence, virtual reality, incorporation of symptom trackers and health apps) the digital risks are unpredictable and solutions to mitigating risks may not be readily available or feasible to implement. Considering these issues, perhaps future ethical guidelines for telehealth practice should urge mental health providers to refrain from incorporating new technology into their practice until there is an abundant source of risk protection procedures available. 

Conclusions and Recommendations
The challenges associated with telehealth are only accumulating as mental health providers continue to rely on a telehealth model. However, there are a number of safeguards psychologists can implement to help ensure they protect against unethical practice while striving for excellence in professionalism and competence. Maintaining improved connection and consultation is necessary to uphold ethical and professional competence and can be done through establishing peer consultation groups and regular supervision in a way that feels supportive and nonjudgmental (Miu et al., 2022; Mosley et al., 2021; Sasangohar et al., 2020). To comply with ethical standards associated with practicing telehealth and respecting clients’ rights and dignity, providers should assess client fit for telehealth, adapt treatment to meet clients’ needs, and establish safety and technology failure plans (Chenneville & Schwartz-Mette, 2020; Pollard et al., 2017; Sasangohar et al., 2020). To minimize risks associated with the contributors of burnout, mental health providers could prioritize their own mental health (e.g., seeking and maintaining personal counseling services, reducing caseloads, and/or incorporating breaks to account for Zoom fatigue and burnout; Chenneville & Schwartz-Mette, 2020; Sasangohar et al., 2020). Lastly, providers should refrain from implementing new technology in their clinical practice until clear policies and procedures around data security become available. In an ever-evolving world, psychologists must actively evaluate the applicability of available standards and guidelines and adapt clinical practice appropriately. 

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