Are You Legally & Ethically Compliant? Telehealth Cultural Competence & Diversity

Therapists working through telehealth have an ethical and, in some states, legal duty to address cultural competence in healthcare. Awareness and accommodations must be made to address multicultural and diverse telehealth issues. Clinicians who lack the training to work with specific groups of people are required by law to obtain such training in many US states and Canadian provinces. Although not legally required in all states, provinces, or other international locales, having adequate proficiency at working with people from the group being served is ethically required in all cases. 

The need for such sensitivity is so great that some state licensing Boards require a minimum of four hours of training dedicated to cultural competence in healthcare. That need is heightened in telehealth, where clinicians can suddenly find themselves in unknown territory with differing religious or cultural norms. Most telehealth providers may want to consider detailed sensitivity training to understand and be appropriately responsive to relevant issues, including the following: 

1. Language Barriers
2. Health Literacy
3. Access to Technology
4. Digital Literacy
5. Trust in Healthcare
6. Religious Beliefs
7. Socioeconomic Factors
8. Privacy Concerns
9. Cultural Perceptions of Health and Illness
10. Stigma Associated with Certain Conditions
11. Beliefs About Medicine
12. Time Perception
13. Generational Differences
14. Gender Roles
15. Regional Differences
16. Racial Disparities
17. Immigration Status
18. Patient-Provider Relationship
19. Cross-Border Regulations
20. Interpretation of Symptoms
21. Norms around Disclosure
22. Cultural Views on Technology
23. Role of Community
24. Healthcare Access and Utilization
25. Bias and Prejudice
26. Internet Connectivity
27. Cultural Interpretations of Non-Verbal Cues
28. Access to Quiet, Private Spaces
29. Traditional Healing Practices
30. Availability of Culturally Relevant Resources
31. Discrimination and Systemic Inequities
32. Telehealth Interface Design
33. Family Involvement in Care
34. Perceptions of Professionalism

To elaborate on only one of the above issues, perceptions of professionalism within telehealth can be critically influenced by cultural norms, expectations, and values. These cultural perceptions can shape how clients evaluate their interactions with their therapists, affecting the effectiveness of therapeutic interventions, the level of trust established, and overall client satisfaction. 

Misalignments between a client’s expectations and a therapist’s conduct can result in perceived unprofessionalism, even when the therapist believes they adhere to professional standards. Below, we examine this issue through six examples.

Examples of Perceptions of Professionalism

1. Punctuality. In many Western cultures, punctuality is a key element of professionalism. Arriving late to an appointment can be perceived as disrespectful, unprofessional, and a lack of interest. However, in other cultures, time may be perceived more fluidly, and strict punctuality is only sometimes seen as crucial. A therapist who rigidly adheres to exact timing may be perceived as impersonal or uncaring by a client from such a culture. On the flip side, a client might perceive a therapist’s slight delay as a lack of professionalism when the therapist, according to their cultural norms, doesn’t view this tardiness as a significant issue
2. Formality of communication. In some cultures, a high degree of formality is considered respectful and professional. This could include using formal titles, maintaining a serious demeanor, and refraining from personal or ‘off-topic’ conversations. Conversely, other cultures could perceive such formality as distant or impersonal. A more casual, warm, and personable communication style, including some personal conversation, might be seen as a sign of caring and, thus, professionalism. Misalignment in these expectations could make clients perceive their therapists as too distant or unprofessional
3. Attire. Formal attire is a sign of professionalism in many Western professional settings. However, expectations could vary in telehealth, where the sessions might occur in the therapist’s or the client’s home. Some clients might expect the therapist to maintain formal attire, viewing this as a sign of respect and professionalism. Other clients might find formal attire in a home setting off-putting or intimidating, preferring a more casual, relatable appearance
4. Choice of technology. Some clients may associate professionalism with the help of high-end technology. They may expect their therapists to use professional-grade video conferencing software with superior audio and video quality. If a therapist uses a less sophisticated platform or experiences technical difficulties, these clients may perceive the therapist as unprofessional. Conversely, other clients, especially those less technologically literate or from lower socioeconomic backgrounds, may feel intimidated by sophisticated technology and prefer more straightforward communication methods
5. Physical setting. While therapists conducting sessions from a dedicated, tidy office space may be seen as professional by some clients, others might find this too impersonal or clinical. For instance, clients from cultures with a high emphasis on personal relationships might find a glimpse into the therapist’s personal life (such as family photos in the background) as a positive, relatable aspect that adds to the perception of the therapist as a caring, authentic individual, thus adding to their perceived professionalism
6. Eye contact. In some Western cultures, direct eye contact is often associated with honesty, attentiveness, and, thus, professionalism. However, in some Asian, African, or Indigenous cultures, direct eye contact can be seen as disrespectful or aggressive. In telehealth, misunderstandings may occur due to the difficulty of maintaining natural eye contact over video calls, affecting perceptions of professionalism.

Summary

Differing cultural perceptions of professionalism can significantly influence how telehealth psychotherapy services are received and evaluated. Therapists need to be aware of these cultural nuances and be adaptable in their professional conduct. This does not mean compromising on essential professional standards but rather being culturally sensitive and flexible in areas where cultural expectations diverge. By doing so, therapists can create a more inclusive and effective therapeutic environment that respects and values cultural diversity ranging from serving BIPOC to LGBTQIA+ communities, addressing health disparities, or managing digital literacy that can limit how individuals experience telehealth.

Conclusion for Cultural Competence in Healthcare via Telehealth

Therapists must be mindful of cultural and diversity nuances to build effective therapeutic relationships. Especially when working across distances, practitioners must be aware of the added demands for telehealth cultural competence. Some state licensing Boards require a minimum of four hours of training dedicated to cultural competence in healthcare. Practitioners wishing to develop telehealth cultural competence now have the tools at their fingertips to develop their skillsets through additional training to focus on the specifics of each of the 34 areas identified above.

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