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Technology Assisted Therapy and Tools Back to Course Index

 

 

 

When my first born was old enough to learn how to ride a bike my husband and I, video camera in hand, went out front and did the traditional running along side the bike while holding on until all three of us were exhausted. Was he ever going to get it? My husband looked at me and said, “Let’s take a break! This is not working. I’m going to Google how to teach someone how to ride a bike.” About 20 minutes later he had learned online to take the pedals off of the bike and have the child shuffle the bike along with his feet, lifting their feet off the ground after each push of their feet, while sitting on the seat. This teaches them how to balance the bike and once that is mastered the rest is easy. No lie, five minutes into this approach, our son, pedals back on the bike, was on his own riding up and down the sidewalk!  Parenting by Google, don’t underestimate it.

The World Wide Web, smart phones, computers and the like are a vast resource of information. Some good, some bad, some true and some not. Roughly 70 percent of American adults who use the Internet believe it’s mostly good for society, down from 76 percent in 2014. Yet, it is still our go to source now for directions, company research, social interaction, business communication and so much more. I’m preaching to the choir…. you’re on here now.

Digital media and resources, such as email, smart phones, tablet applications (apps), online forums, Web sites, blogs, computer software, online social networks, telephone and tele-video communication, and mobile devices are becoming universal in our culture.  

The use of electronic media and information technologies in behavioral health treatment, recovery support, and prevention programs is rapidly gaining acceptance.

Technology-based assessments and interventions are important therapeutic tools that clinicians can integrate into their work with clients. Additionally, technology allows alternative models of care to be offered to clients with specific needs that limit their ability to participate or interest in participating in more conventional interventions targeting behavioral health. Technology-assisted care can transcend geographic boundaries to reach many people otherwise unable to access services and is useful in a wide variety of settings, including Web-based interventions offered in the home, community organizations, schools, emergency rooms, and healthcare providers’ offices, as well as via mobile devices and online social networks. Furthermore, Technology assisted care is often accessible on demand at the user’s convenience, thus reducing barriers to accessing care.

According to the Washington Post, 47 percent of the world’s population now uses the Internet. About 76.2 percent of the U.S. population accessed the Internet as of 2017. Moreover, 90 percent of individual’s in the U.S. have a mobile phone, 97 percent for people under the age of 44. Of those with a smart phone, 62 percent reported having used it to acquire some type of health-related information.

As a result of these considerable increases in overall online access, technology assisted care could potentially have a significant impact on public health. Major strides have already been made in the promotion and use of telemedicine, including telebehavioral health.

The rapid growth of these resources requires a carefully planned response by treatment and prevention programs targeting behavioral health. In addition to relevant staff development and training, this response needs to address the specific electronic resources applicable to each program, the contexts in which those resources will be most useful, the benefits and risks of using them, the methods for preparing clients to accept and use these resources, and an organizational commitment to evaluating the effectiveness and utility of specific technologies. New technologies represent new means of communication; messages must be tailored to the technology and the issues at hand.

Use of advanced technologies also requires consideration of a number of legal and ethical issues, such as confidentiality, scope of practice, state licensure regulations, privacy, data security, consent management, and the potential for misuse.

This topic is vast and this course is intended as an introduction to ideas and concepts. This course will explore:

  • Potential Use of Technology Based Tools
  • Overview of Behavioral Health Online Tools
    Online Assessments
  • Online Counseling
  • Applications
  • Legal, Confidentiality, Security and Privacy
  • Areas of Concerns
  • Pros and Cons of Online Therapeutic Tools

 

Potential Use of Technology Based Tools

Technology is now being used from beginning to end in the therapeutic continuum from training and evaluating therapists through client assessments and clinical work. It can be a means of primary education, continuing education, supervision, group think activities, resources for therapeutic techniques and tools, how counselor’s advertise, set appointments, send reminders and give homework and even complete a session. Hospitals, Employee Assistance Programs and individual providers are all incorporating these tools.

I would have considered myself on the conservative side of this conversation until sitting here writing the course recognizing that I use Psychology Today.com to advertise my practice, a website for clients to download initial paperwork, email to confirm appointments (after a communication release), online continuing education for license renewal, Pinterest to collect new therapeutic articles and tools, and so forth. The potential use for the Internet in therapeutic activities is vast.

These new applications and avenues have primarily been seen as supplementing, not replacing, face-to-face therapy.  This too is changing though. The anonymity offered by some of these mechanisms make the Internet a gateway for people who might not otherwise seek help.  This anonymity is also fuel for those who think face-to-face is so much more effective because of body language and rapport.

Technology-based assessments and interventions are of use in a variety of ways, and they may also be clinically meaningful along an entire spectrum of behavioral health services, including screening, assessment, prevention, treatment, recovery management, and continuing care. The use of technology, such as a computer or a mobile device, in screening for and assessing individuals’ behavioral health needs may allow for the efficient, standardized, and cost-effective collection of clinically relevant client information in diverse settings. This can be particularly important in healthcare settings where clinicians trained in behavioral health assessment procedures are not readily available and where opportunities to identify individuals who may benefit from behavioral health interventions are missed.

Technology assisted care gives clients access to screening, intervention, and oversight by trained behavioral health care professionals. Brief computerized screenings can identify individuals with varying levels and types of behavioral health needs and can identify the differing resources and services that may be helpful to them. These brief screenings may also be useful as a less intensive therapeutic option for individuals not willing to seek professional care actively at a given point in time.

 

Overview of Behavioral Health Online Tools

This section provides an overview of some of the specific technologies and their potential applications in behavioral health.

Although this overview discusses technology and the many ways in which it can be used it is not meant as an endorsement of the tool. Clinicians must be careful to determine the ethical and legal use of the tool and to not to let the technology itself determine how it is integrated into clinical care. Technologies evolve rapidly, and new technologies are emerging all the time; clinicians should consider how a given tool would enhance clinical services and select only those technologies that are likely to be most beneficial to their clinical work and that they and their clients can use competently.

Some e-therapeutic tools are more effective than others; among these are tools that integrate evidence-based content and evidence-based approaches for technology-dependent delivery.

Although technology assisted care can mimic aspects of traditionally delivered, in-person behavioral health services, it differs in a number of ways. For example, self-directed, technology-based interventions, such as online skills training programs, cannot optimally engage clients in role-play; however, they can help ensure that clients are active participants in the learning process and can document what content clients have or have not mastered in a given program. As a result, technology-based approaches to behavioral health assessment and intervention should not be held to the same standards as traditional models of care; rather, consider what technology can do well and what it can do less well when embracing technology-based approach.

The use of technology warrants the same types of considerations as traditional care, such as being sure the client is benefiting from its in­ corporation into treatment, considering how and when to terminate its use in the context of the client’s best interests, and monitoring the treatment process to note whether any modifications to the technology will be necessary.

 

Types of Technology Assisted Care:

  • Online Assessment Tools
  • Telephone Counseling
  • Video/Web Counseling
  • Self-Directed Therapeutic Tools
  • Smart Phone Applications

The decision about which modality is safe and which to use should be made on a case-by-case basis, taking into account such variables as the disorder being treated, the technology available to participants, their ease and facility with that technology, and security and privacy issues.  Remote modes of therapy or training can be synchronous (as in chat, videoconferencing, or virtual reality sessions, where feedback is immediate) or asynchronous (as in e-mails and forums, where responses are delayed).  The former creates a “being with” experience where participants address issues as they arise, while the latter offers therapists more time to reflect on their responses and allows for more quality control in training.  Individual virtual reality programs and games provide a low-intensity service with minimal supervision, while allowing for monitoring by the therapist.  Patients can work at their own pace in areas that include overcoming phobias and managing depression.

Let’s explore some of these in more detail.

 


Online Assessments

Psychological tests are part of the field of psychology known as psychometrics. Psychometrics measures behavior, personality, and aptitude using surveys. After a person has completed the survey, their answers are scaled to provide a general overview of their personal characteristics.

People often have a difficult time accurately assessing their own behavior and understanding how their behavior causes other people to perceive them. Psychological testing allows people the opportunity to get a glimpse of how they appear to the outside world based on answers to very specific questions about behavior, attitudes, history, and preferences. Test questions often ask people to think about specific types of interactions, which can make it easier to assess behavior.

Online psychological tests rely on self-reports, and this is an inherent limitation of the tests. Many people have a positive bias when examining their own behavior and tend to see their own behaviors in the best possible light.

It is important to note that the field of psychometrics remains controversial and not all psychologists agree about its validity or relevance. Because there are only a limited number of answers available for each question, there might not be an answer that perfectly matches an individual’s response to a particular question. Test results change over time based on new experiences, additional education, and other factors. These online self-report tests should not be used to diagnose or treat mental health conditions, but as additional resources for the therapist or individual.

An example of a frequently used online assessment is the SASSI (Substance Abuse Subtle Screening). The SASSI Online is a web-based system for the administration and analysis of SASSI questionnaires. It enables the counselor to order and administer questionnaires and review questionnaire results using the Internet. The SASSI is designed to assess substance use and abuse and has an accuracy rate of 92%. The counselor must use the SASSI Online’s platform and the counselor must set up this test.

Another example of an online assessment tool is the Beck Depression Inventory-II. This 21-item, self report-rating inventory assesses the intensity of depression.

You can now administer the Minnesota Multiphasic Personality Inventory-2-Restructed Form (MMPI-2-RF) online, as well as many other historically paper/pencil tests used in the field, as well. There are even several sites that have developed online Rorschach Ink Blot tests for either the counselor to administer or the individual to perform on their own.

 

 

Online Counseling

With the click of a mouse or the tap of an application a client can have instant and inexpensive access to a therapist. This has been called E Therapy, Online Counseling, Telepsychology, Distance Therapy, or other such similar titles. Online therapy consists of the delivery of mental health services via the Internet. Therapists and online therapy networks use a variety of mediums such as applications for texting, video conferencing, voice messaging and audio messaging.

As of 2018 the largest, well-known provider networks of online therapy include:

  • betterhelp   www.betterhelp.com
  • ReGain  www.regain.com
  • My Therapist  www.mytherapist.com
  • Talk space  www.talkspace.com
  • Breakthrough  www.breakthrough.com

These platforms charge $35.00 to $140.00 a session. The reimbursement to the therapist varies among platforms. On average the therapist is reimbursed approximately $50.00 per person per month and is expected to interact with the client once or twice a week. Some platforms reimburse by word count and some have a contracted rate at approximately $17.00 per hour. There is a great deal of variation across the board. Unfortunately this lends itself to one of the downfalls to this form of help. There tends to be high turnover in the industry making it very difficult for clients and counselors to build and maintain rapport.

Many believe that online therapy should not replace in-office therapy. Rather, it should complement the traditional therapy sessions, as online therapy offers a range of benefits to users. Others however, suggest online therapy makes in-person therapy unnecessary. 

Outside of the traditional session, many are utilizing online counseling to allow a certain number of Employee Assistance Program sessions, support groups and virtual workshops.

An example of this is the adda (Attention Deficit Disorder Association) offers online support groups for adults with ADD/ADHD. They also offer online workshops…interestingly enough one topic they offer is Problematic Internet Use By Those With ADHD. Do you find the irony in that or is it just me?

Clients can “go to” an AA meeting without ever leaving their home through Lion Rock Recovery, Online Intergroup or   aaonlinemeeting.net. Some of these involve videoconference in a “live” format and some involve weekly “meetings” that the individual may read or contribute to at their convenience.

Technology can contribute to an evolution in how people receive psychotherapy or work with a mental health professional. Researchers are taking great interest in telepsychology and telehealth, evaluating how well it works, especially compared to in-person, in-office psychotherapy sessions. But much like the technology, the research is still new, and there is a lot science doesn’t yet know. There is promise and there is danger.

 


Applications

What can’t your Smartphone do? It has replaced the alarm clock, camera, calendar, radio, book, calculator, map, flashlight, level, airline ticket, credit card scanner…and the credit card, and on and on. Many professionals in the mental health field are using the applications (Apps) to both stay up to date on the latest news and research as well as with clients to aid in treatment.

 

PsycExplorer is an app used by professionals to stay up to date on the latest news in the industry. It offers blogs, videos, podcasts and more. Dragon Dictation is a voice recognition app that assists with notes in the classroom or the session.

There are a myriad of apps to use with clients, as well. These are a few of the better known:

Happify helps with relieving stress and anxiety. The objective of this app is to encourage the user to think positively. It is science-based, and users can plan their goals using this app. It also has a few activities, which can be used to empower the users thinking and to encourage their happiness. 

PTSD Coach is designed for those suffering from post-traumatic stress disorder. This app offers tools for users to track their symptoms and it also helps them with managing their illness. It can also help the user locate the nearest treatment program. It can be used to call the National Suicide Prevention Hotline quickly.

Big White Wall is an app that is designed to connect mental health patients with each other anonymously. Users can share their problems with each other and also take self-assessment tests.

Calm is an app that offers meditation. This app is designed for people that are suffering from anxiety, depression, and stress.

The Sober Grid is an app that’s geared towards recovering substance abusers and alcoholics. This has become one the most popular sobriety apps. Sober grid has a community of recovering addicts, and it allows its users to connect with each other. It offers the sobriety calculator, which helps users with keeping track of the number of days that they are sober. It offers a ”burning desire.” feature is used to alert other members when the user feel tempted to relapse.

Recovery Record is an app that’s geared towards people who are suffering and recovering from eating disorders. It offers meal plans, meal logs, and connects users with mental health professionals.

I Mood Journal is a mood tracking application. It offers a visual, simple way to track mood changes and to associate these with personal experiences. Bringing this into the traditional session can help the therapist and client work together to discover patterns and triggers and observe mood changes in perspective.

There are thousands of applications and programs to change behavior as well, with actually pretty good statistics. Txt2stop is a smoking cessation program that in a 6,000-person trail had a10.7% quit rate at six months. This was more than twice the control group. The program sends approximately five motivational and information texts such as “cravings last less than 5 minutes on. To help distract yourself try sipping a drink slowly until the craving is over” a day to users. The program also allows users to text the word “lapse” or “crave” in order to receive an instant message of support.

These are just a few of the thousands of apps geared toward mental health professionals and therapy. When they say, “there is an app for everything” they mean it.

 

Legal, Confidentiality, Security and Privacy

Ethical considerations with these Internet based tools and therapy are often extensions of (and in many cases, overlap with) ethical considerations in traditionally delivered behavioral health services. However, some unique considerations arise, as well. As clinical practices differ in various settings, it is not possible to cover every possible ethical and legal consideration relevant to the incorporation of technology into behavioral health services.

That said, this section addresses some of the most significant ethical and legal issues to consider when providing technology assisted care.

The use of technology-based therapeutic tools in behavioral health warrants a number of considerations related to confidentiality, privacy, and security. As in traditional clinical scenarios, ethical principles and procedures related to protecting clients’ privileged information (confidentiality), protecting clients’ rights to control access to their information (privacy), and protecting client data from being accessed without authorization (security) are of paramount importance. However, some unique considerations arise when collecting data and/or delivering interventions using electronic media.

Text-based communications provide a literal transcript of communication between you and your clients (e.g., email, online moderated chat forums) or among groups of clients (e.g., online support groups), but this mode of communication poses certain risks. For example, if a mobile device is used for communicating with a client via text, depending on the settings and device properties, messages stored on the mobile device as well as those sent from the device are likely unencrypted and vulnerable to security threats. Email messages are also usually unsecured and can be accessed by third parties. Even if both the sender and recipient delete emails, they may be preserved by other third parties, such as Internet service providers (ISPs). Managing security and confidentiality is the responsibility of all parties engaged in their use. Informed consent becomes very necessary with these platforms.

A thorough discussion of the broad set of security issues related to the use of mobile devices in the general healthcare environment is beyond the scope of this course. The U.S. Food and Drug Administration (FDA) has been issuing guidance as to which sorts of technologies are considered medical devices and which are considered health or medical apps that do not require approval from the FDA as medical devices. In general, apps that pose lower risk to the public will not be required to seek review as medical devices. The FDA has described some of these low-risk devices as apps that:

  • Help people maintain coping skills.
  • Alert people with asthma of environmental conditions.
  • Prompt users to check on possible drug interactions with food, herbs, or other medications.
  • Use videos to motivate patients to do their physical therapy at home.
  • Provide information or screening, counseling, and preventive recommendations from well-known and established authorities.
  • Enable a clinical conversation to be recorded for review after the visit.
  • Allow users to track behaviors related to diets, exercise, and sleep.
  • Engage in mind-challenging tests or games.

Apps that may constitute a risk to patients or others if the device fails to work properly require approval as medical devices. For example, certain devices relay heart function data to medical services that monitor a patient’s heart function; if such a device provided false in­ formation or failed to operate, it could endanger the patient.

The National Board of Certified Counselors (NBCC) was the first to adopt standards for online counseling in September 1997.

The NBCC defined E-therapy as “the practice of professional counseling and information delivery that occurs when client(s) and counselor(s) are in separate or remote locations and utilize electronic means to communicate over the Internet.” This definition would seem to include Web pages, email, and chat rooms but not telephones and faxes. The NBCC makes a statement that it does not advocate for or against Web-Counseling.

The NBCC Standards for the Ethical Practice of “Distance Professional Services” are specific, and give the impression this is an area that one does not enter lightly, without careful thought and consideration of implications and possible effects.

STANDARDS FOR DISTANCE PROFESSIONAL SERVICES

  1.  NCCs shall adhere to all NBCC policies and procedures, including the Code of Ethics.

  2. NCCs shall provide only those services for which they are qualified by education and experience. NCCs shall also consider their qualifications to offer such service via distance means.

  3. NCCs shall carefully adhere to legal regulations before providing distance services. This review shall include legal regulations from the state in which the counselor is located as well as those from the recipient’s location.

    Given that NCCs may be offering distance services to individuals in different states at any one time, the NCC shall document relevant state regulations in the respective record(s).

  4. NCCs shall ensure that any electronic means used in distance service provision are in compliance with current regulatory standards.

  5. NCCs shall use encryption security for all digital technology communications of a therapeutic type. Information regarding security should be communicated to individuals who receive distance services. Despite the use of precautions, distance service recipients shall be informed of the potential hazards of distance communications.

    Not the least of these considerations is the warning about entering private information when using a public access or computer that is on a shared network. NCCs shall caution recipients of distance services against using “auto-remember” user names and passwords. NCCs shall also inform recipients of distance services to consider employers’ policies relating to the use of work computers for personal communications.
  6. To prevent the loss of digital communications or records, NCCs who provide distance services shall maintain secure backup systems. If the backup system is also a digital mechanism, this too shall offer encryption-level security. This information shall be provided to the recipient of professional services.

  7. NCCs shall screen potential distance service recipients for appropriateness to receive services via distance methods. These considerations shall be documented in the records.

  8. During the screening or intake process, NCCs shall provide potential recipients with a detailed written description of the distance counseling process and service provision. This information shall be specific to the identified service delivery type and include considerations for that particular individual. These considerations shall include the appropriateness of distance counseling in relation to the specific goal, the format of service delivery, the associated needs (i.e., computer with certain capabilities, etc.), the limitations of confidentiality, the possibility of technological failure, anticipated response time to electronic communication, and any additional considerations necessary to assist the potential recipient in reaching a determination about the appropriateness of this service delivery format for their need(s).

  9. Because of the ease in which digital communications can inadvertently be sent to other individuals, NCCs shall adopt behaviors to prevent the distribution of confidential information to unauthorized individuals. NCCs shall discuss actions the recipient may take to reduce the possibility that they will send information to other individuals by mistake.

  10. NCCs shall provide recipients of distance professional services with information concerning their professional credentials and links to the respective credentialing organization Web sites.

  11. NCCs, either prior to or during the initial session, shall inform recipients of the purposes, goals, procedures, limitations, potential risks, and benefits of services and techniques. NCCs also shall provide information about rights and responsibilities as appropriate to the counseling setting. As a part of this type of service provision, NCCs shall discuss with recipients the associated challenges that may occur when communicating through distance means.

  12. In the event that the recipient of distance services is a minor or is unable to provide legal consent, the NCC shall obtain a legal guardian’s consent prior to the provision of distance services. Furthermore, NCCs shall retain copies of documentation indicating the legal guardian’s identity in the recipient’s file.

  13. NCCs shall avoid the use of public social media sources (e.g., tweets, blogs, etc.) to provide confidential information. To facilitate the secure provision of information, NCCs shall provide in writing the appropriate ways to contact them.

  14. NCCs shall provide recipients of distance services with specific written procedures regarding emergency situations. This information shall include emergency responders near the recipient’s home location. Given the increased dangers intrinsic to providing certain distance professional services, NCCs shall take reasonable steps to secure reasonable referrals for recipients when needed.

  15. NCCs shall develop written procedures for verifying the identity of the recipient at each instance of receiving distance services. Examples of verification means include the use of code words or phrases.

  16. NCCs shall limit use of information obtained through social media sources (e.g., Facebook, LinkedIn, Twitter, etc.) in accordance with established practice procedures provided to the recipient at the initiation of services.

  17. NCCs shall provide information concerning locations where members of the public may access the internet free of charge or provide information regarding the location of complimentary Web communication services.

  18. NCCs shall retain copies of all written communications with distance service recipients. Examples of written communications include e-mail/text messages, instant messages and histories of chat-based discussions even if they are related to housekeeping issues such as change of contact information or scheduling appointments.

  19. At a minimum, NCCs shall retain distance service records for a minimum of five years unless state laws require additional time. Due to the nature of most distance services, it may be convenient for NCCs to retain records for longer durations, and thus may be considered useful for research or other professional activities. NCCs shall limit the use of records to those permitted by law, professional standards and as specified by the agreement with the respective recipient of distance services.

  20. In recognition of the inherent ethical implications which may arise, NCCs shall develop written procedures for the use of social media and other related digital technology with current and former recipients. These written procedures shall, at a minimum, provide appropriate protections against the disclosure of confidential information and the creation of multiple relationships. These procedures shall also stipulate that personal accounts be distinct from any used for professional purposes.

The International Society of Mental Health Online (ISHMO) was established in 1997 to promote the understanding, use and development of online communication, information and technology for the international mental health community.

The American Counseling Association developed standards in 1999.

Informed consent is critical prior to starting technology assisted care. There are areas outside of the traditional concerns that should be addressed. The following are an example of items that are recommended to be included:

  • Possible misunderstandings: The client should be aware that misunderstandings are possible with telephone, text-based modalities such as messaging, and real-time Internet chat.   Even with video chat software, misunderstandings may occur due to connection problems causing image delays or less than optimal image quality.
  • Turnaround time: Using asynchronous (not in “real time”) communication such as email or messaging entails a “lag” of response. Informed consent should address the time it may take for a response and what to do if an emergency occurs.
  • Privacy of the counselor: Although the Internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. Informed consent should address how privacy is protected and what threats exist.
  • Potential risks: There are various risks related to electronic provision of counseling services related to the technology used, the distance between counselor and client, and issues related to timeliness.
  • Alternatives: Informed consent should include a statement regarding online counseling possibly not being appropriate for many types of clients including those who have numerous concerns over the risks of internet counseling, clients with active suicidal or homicidal thoughts, and clients who are experiencing active manic/psychotic symptoms. An alternative to receiving mental health services online would be receiving mental health services in person.
  • Confidentiality of the client: Informed consent should address how the counselor maintains client confidentiality. How Information about the client is released with his or her express and written permission as well as the exceptions to confidentiality.
  • Records:  How the counselor will maintain records should be included, as well as what the information these records include should be discussed.
  • Procedures: Informed consent should explore how services will be provided. What happens if there is a disruption in service? How is that billed?

 

 

Pros and Cons of Online Technology Assisted Care

As a tool for self or assisted therapy and for self-education, the Internet offers a greater sense of equality and reduces the stigma traditionally attached to mental health concerns.

The advantages of these technologies include cost and travel savings, as well as basic accessibility to therapy in remote areas lacking clinical facilities.  In one example, people living in Bangladesh use cell phones to access distant medical care; in another, a clinic on a remote island in Scotland uses videoconferencing to help treat a patient with an eating disorder. Teletherapy options are used to treat patients confined to their homes, whether as a result of physical limitations or of social anxiety disorders.  Within correctional facilities, a telepsychiatry clinic provides continuity of care to inmates experiencing institutional transfers, makes their medical records more portable, and eliminates transportation difficulties associated with using an offsite clinic.

The nature of the technology itself aids interactions.  One example given of the Internet’s “disinhibition effect” is that of an adolescent who texted her therapist in the middle of a face-to-face session in order to communicate more freely.  The use of online chats in family therapy can help defuse power struggles by making sure each member has a turn in the discussion.  Forums connect students in the field with each other, their supervisors, and their professors, while wikis foster collaboration among researchers.

Client don’t have to worry about being seen going into or out of their therapists office, they feel more comfortable in their own home to express themselves, it is easier to schedule and cancel, sessions can be made for shorter sessions or with different formats. There are many positives to consider.

While on one hand, the benefits of online counseling have been considered, online counseling has also been criticized in terms of its absence of verbal and nonverbal cues, difficulties in maintaining confidentiality and security, overall effectiveness, technological difficulties and in its limits of being able to guarantee the therapists credibility.

Verbal and nonverbal interactions are considered essential for gauging what the client is feeling and for identifying the discrepancies or incongruence between verbal and nonverbal behaviors. Online counseling has been criticized for lacking the micro skills of counseling.

Online therapy does not give an indication of characteristics such as voice tone, facial expression, body language and eye contact. This can potentially impact negatively on the counseling outcomes, as the therapist has no opportunity to observe and interpret such cues.

Mental health practitioners have an ethical responsibility to protect and maintain the confidentiality of their clients. With online therapy the security of the client’s records and information could be jeopardized and confidentiality is at greater risk of being inappropriately breached given the written nature of the medium.

Although most sites strive to have security systems to protect confidentiality, it is as good as the latest version of the security software used. Practitioners will have to continuously upgrade their technology to prevent security breaches.

Professionals and laypeople alike have continuously questioned the effectiveness of online therapeutic interventions. There is currently little research supporting the lack of effectiveness of counseling that is provided solely through such a medium. The lack of face-to-face interaction could increase the risk of misdiagnosis by the therapist.

It is not unusual for computers to fail and Internet connections to falter. For example, those who are in remote areas may have less than perfect transmission that drops out regularly or there is always the possibility of servers crashing and network connections faltering. The ability to benefit from online therapy is also partly determined by the client’s computer skills and knowledge, especially if the communication setting involves installing and learning new software and/or hardware. This may disrupt the session and can potentially be distressing for the client.

The client receiving online therapy has little or no assurance about the qualification and credentials of their therapist. There is also very little control over what a client does behind the anonymity of a video chat.

As online counseling services grow and continue to gain momentum in popularity, attention will have to be given to the construction of legal and ethical codes. Particularly because the Internet surpasses state and international borders, there are many legal and regulatory concerns. For example, is it legal for a practitioner to provide chat room services to clients in a jurisdiction that is outside their licensed or accredited practice boundary?

If no one knows who is treating whom, how is quality service ensured? If a practitioner does not know where a client is, how can they call for help in the case of an emergency, such as suicidal threats?  These are some of the questions that therapists will have to consider before they embark on providing such services.

 

Areas of Concerns

The above negative opens up to a large area of concern. Will unlicensed persons be promoting themselves as competent Internet counselors? I may be licensed to provide services in Texas, but the laws and rules of each state are different. When a counselor is unlicensed, a state has no regulatory authority, unless there is a law in that state that will allow prosecution as a criminal act for practicing counseling without a license, or gives the board regulatory authority. Unlicensed web-based counselors are almost legally untouchable, especially when a disclaimer statement is displayed stating what they are doing is not therapy.

Some of the areas of concern include:

  • Truth in advertising—does the site deliver what it promises?
  • Confidentiality and privileged communication—are the transmissions safe? Who else in the counselor’s home or workplace has access to messages?
  • Duty to warn—is the web-based counselor able to discern when a person is a threat to self or others, and what is the web-based counselor’s obligation?
  • Competence—is the web-based counselor competent and licensed? What protection exists for the counselee?
  • The anonymity of the counselee may be problematic for the web-based counselor.
  • Fee structures vary—how does a counselee determine a fair price?
  • Is the counselee actually receiving advice from the person who is on the web page? In text counseling how does one verify this?
  • Software vulnerabilities, confidentiality and security.

Many states have guest licensure provisions that allow out-of-state-licensed psychologists to provide services for a short period of time—ranging from 10 to 30 days in a calendar year—under specified conditions. In addition, the Association of State and Provincial Psychology Boards has created a credential called the Interjurisdictional Practice Certificate that facilitates temporary practice in other jurisdictions. This problem is far from being solved though.

Putting the proper safeguards in place should help to ensure that Internet technologies live up to their promise of providing care.

 

Summary

There are more questions than answers.  The use of technology warrants the same types of considerations as traditional care, such as being sure the client is benefiting from its incorporation into treatment, considering how and when to terminate its use in the context of the client’s best interests, and monitoring the treatment process to note whether any modifications to the technology will be necessary.

There are a lot of good data showing that you can form a good therapeutic alliance using technology assisted care. Now we just need to develop the formal guidelines, and hopefully the laws and regulations, to make this a successful and safe area of practice.

The test will cover the material above. We have include for your review, if interested, a few of the ethical guidelines created by several associations.

 

 

American Association of Marriage and Family Therapists AAMFT 2015 Code of Ethics:

STANDARD VI TECHNOLOGY-ASSISTED PROFESSIONAL SERVICES
Therapy, supervision, and other professional services engaged in by marriage and family therapists take place over an increasing number of technological platforms. There are great benefits and responsibilities inherent in both the traditional therapeutic and supervision contexts, as well as in the utilization of technologically-assisted professional services. This standard addresses basic ethical requirements of offering therapy, supervision, and related professional services using electronic means.

6.1 Technology Assisted Services. 
Prior to commencing therapy or supervision services through electronic means (including but not limited to phone and Internet), marriage and family therapists ensure that they are compliant with all relevant laws for the delivery of such services. Additionally, marriage and family therapists must: (a) determine that technologically-assisted services or supervision are appropriate for clients or supervisees, considering professional, intellectual, emotional, and physical needs; (b) inform clients or supervisees of the potential risks and benefits associated with technologically-assisted services; (c) ensure the security of their communication medium; and (d) only commence electronic therapy or supervision after appropriate education, training, or supervised experience using the relevant technology.

6.2 Consent to Treat or Supervise. 
Clients and supervisees, whether contracting for services as individuals, dyads, families, or groups, must be made aware of the risks and responsibilities associated with technology-assisted services. Therapists are to advise clients and supervisees in writing of these risks, and of both the therapist’s and clients’/supervisees’ responsibilities for minimizing such risks.

6.3 Confidentiality and Professional Responsibilities. 
It is the therapist’s or supervisor’s responsibility to choose technological platforms that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology.

6.4 Technology and Documentation. 
Therapists and supervisors are to ensure that all documentation containing identifying or otherwise sensitive information which is electronically stored and/or transferred is done using technology that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology.

6.5 Location of Services and Practice.
Therapists and supervisors follow all applicable laws regarding location of practice and services, and do not use technologically-assisted means for practicing outside of their allowed jurisdictions.

6.6 Training and Use of Current Technology.
Marriage and family therapists ensure that they are well trained and competent in the use of all chosen technology-assisted professional services. Careful choices of audio, video, and other options are made in order to optimize quality and security of services, and to adhere to standards of best practices for technology-assisted services. Furthermore, such choices of technology are to be suitably advanced and current so as to best serve the professional needs of clients and supervisees.

American Counseling Association ACA 2014 Code of Ethics devotes a separate section (Section H) to “Distance Counseling, Technology, and Social Media” where it is spells out guidelines regarding limitations, access, informed consent, use of the Web and more, regarding telehealth and related issues.

ACA Code of Ethics, 2014
B.3.e Transmitting Confidential Information

Counselors take precautions to ensure the confidentiality of all information transmitted through the use of any medium.

Section H. Distance Counseling, Technology, and Social Media 
Introduction
Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.

H.1. Knowledge and Legal Considerations
H.1.a. Knowledge and Competency

Counselors who engage in the use of distance counseling, technology, and/or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (e.g., special certifications, additional course work).

H.1.b. Laws and Statutes
Counselors who engage in the use of distance counseling, technology, and social media within their counseling practice understand that they may be subject to laws and regulations of both the counselor’s practicing location and the client’s place of residence. Counselors ensure that their clients are aware of pertinent legal rights and limitations governing the practice of counseling across state lines or international boundaries.

H.2. Informed Consent and Security
H.2.a. Informed Consent and Disclosure

Clients have the freedom to choose whether to use distance counseling, social media, and/or technology within the counseling process. In addition to the usual and customary protocol of informed consent between counselor and client for face-to-face counseling, the following issues, unique to the use of distance counseling, technology, and/or social media, are addressed in the informed consent process:

  • distance counseling credentials, physical location of practice, and contact information;
  • risks and benefits of engaging in the use of distance counseling, technology, and/or social media;
  • possibility of technology failure and alternate methods of service delivery;
  • anticipated response time;
  • emergency procedures to follow when the counselor is not available;
  • time zone differences;
  • cultural and/or language differences that may affect delivery of services; possible denial of insurance benefits; and
  • social media policy.

H.2.b. Confidentiality Maintained by the Counselor
Counselors acknowledge the limitations of maintaining the confidentiality of electronic records and transmissions. They inform clients that individuals might have authorized or unauthorized access to such records or transmissions (e.g., colleagues, supervisors, employees, information technologists).

H.2.c. Acknowledgment of Limitations
Counselors inform clients about the inherent limits of confidentiality when using technology. Counselors urge clients to be aware of authorized and/or unauthorized access to information disclosed using this medium in the counseling process.

H.2.d. Security
Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements. Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means.

H.3. Client Verification
Counselors who engage in the use of distance counseling, technology, and/or social media to interact with clients take steps to verify the client’s identity at the beginning and throughout the therapeutic process. Verification can include, but is not limited to, using code words, numbers, graphics, or other nondescript identifiers.

H.4. Distance Counseling Relationship
H.4.a. Benefits and Limitations

Counselors inform clients of the benefits and limitations of using technology applications in the provision of counseling services. Such technologies include, but are not limited to, computer hardware and/or software, telephones and applications, social media and Internet-based applications and other audio and/or video communication, or data storage devices or media.

H.4.b. Professional Boundaries in Distance Counseling
Counselors understand the necessity of maintaining a professional relationship with their clients. Counselors discuss and establish professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the counseling relationship (e.g., lack of confidentiality, times when not appropriate to use).

H.4.c. Technology-Assisted Services
When providing technology-assisted services, counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client. Counselors verify that clients understand the purpose and operation of technology applications and follow up with clients to correct possible misconceptions, discover appropriate use, and assess subsequent steps.

H.4.d. Effectiveness of Services
When distance counseling services are deemed ineffective by the counselor or client, counselors consider delivering services face-to-face. If the counselor is not able to provide face-to-face services (e.g., lives in another state), the counselor assists the client in identifying appropriate services.

H.4.e. Access
Counselors provide information to clients regarding reasonable access to pertinent applications when providing technology-assisted services.

H.4.f. Communication Differences in Electronic Media
Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.

H.5. Records and Web Maintenance
H.5.a. Records

Counselors maintain electronic records in accordance with relevant laws and statutes. Counselors inform clients on how records are maintained electronically. This includes, but is not limited to, the type of encryption and security assigned to the records, and if/for how long archival storage of transaction records is maintained.

H.5.b. Client Rights
Counselors who offer distance counseling services and/or maintain a professional website provide electronic links to relevant licensure and professional certification boards to protect consumer and client rights and address ethical concerns.

H.5.c. Electronic Links
Counselors regularly ensure that electronic links are working and are professionally appropriate.

H.5.d. Multicultural and Disability Considerations
Counselors who maintain websites provide accessibility to persons with disabilities. They provide translation capabilities for clients who have a different primary language, when feasible. Counselors acknowledge the imperfect nature of such translations and accessibilities.

H.6. Social Media
H.6.a. Virtual Professional Presence

In cases where counselors wish to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles are created to clearly distinguish between the two kinds of virtual presence.

H.6.b. Social Media as Part of Informed Consent
Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media.

H.6.c. Client Virtual Presence
Counselors respect the privacy of their clients’ presence on social media unless given consent to view such information.

H.6.d. Use of Public Social Media
Counselors take precautions to avoid disclosing confidential information through public social media.

[Dr. Zur’s comments: The 2014 ACA code has introduced a new and compressive Section H Distance Counseling, Technology, and Social Media. One of the major concerns of this code is Security subsection (H.2.d), which appropriately states that “Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements.” However it also adds next “Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means.” The last sentence is somewhat inconsistent with HIPAA Omnibus clarification that clients have the right to request info however they want. That means that when clients accept the risk of email, counselors are working within “applicable legal requirements,” wherever state/Board law doesn’t further limit things. However, the added line about taking precautions to “ensure the confidentiality” is confusing at best. The main problem here is that HIPAA is protecting clients’ autonomy to make choices about ways of transmitting data, but the new ACA code is potentially imposing a rigid standard that supersedes HIPAA and could reduce client autonomy by requiring therapists to use secure communications technology even where applicable laws don’t mandate it. What is actually new in the code is that counselors cannot simply inform clients that risks exist and leave it at that. Instead they have an affirmative obligation to “ensure the confidentiality of information transmitted through any electronic means.” This seems to be a unique responsibility for counselors, which does seem to be applied to other mental health practitioners. Here is important article by Roy Huggins, LPC NCC on 2014 ACA code regarding email and texting. [Informal Note: I was told (second hand) that, when the committee was asked by an expert about this concern at the 2014 annual convention of the American Counseling Association, their response was that the spirit of the code both prioritizes client autonomy and is intended to require that counselors are thoughtful about security and make sure clients fully understand its risks and benefits and where clients wish to use non-secure communication, that is their choice. A concern raised by some experts is that the code, as it is written, can drive clients away from counselors and towards social workers, psychologists or other mental health practitioners.]

The ACA 2014 code has stated a relatively new standard in regard to counselors’ right to search their clients online (i.e., Google their clients). In section H.6.c. “Client Virtual Presence,” it states “Counselors respect the privacy of their clients’ presence on social media unless given consent to view such information.” The Zur Institute’s article To Google Or Not to Google …Our Clients? provides different options for such informed consent, one of which is to include the following statement in the initial consent or Office Policies: “At times [name] may Google his/her clients before the beginning of psychotherapy or during psychotherapy. If you have concerns or questions regarding this practice, please discuss it with me.”

American Medical Association AMA 2000 Guidelines for Patient-Physician Electronic Mail

American Mental Health Counselors Association AMHCA, 2015 Code of Ethics

Principle 6: Telehealth, Distance Counseling and the Use of Social Media 
Recognizing that technology can be helpful in client’s mental health care management due to availability, expediency, and cost effectiveness, counselors engage in technology assisted, and or distance counseling.

  1. Counselors only engage in distance counseling when they are licensed in the state of the client. In the case of an emergency, counselors should first attempt to attain permission from the client’s state licensing entity and only proceed when failure to do so could result in harm to the client.
  2. Counselors only provide distance counseling when they have had training, experience, and supervision to do so.
  3. Written policies concerning the use of telehealth in a counseling relationship should include informed consent that is clearly set forth, understandable, and addresses the use of phone, online face to face counseling, electronic billing, text, and email contact with a client. This informed consent should clearly discuss the benefits and risks of entering into distance counseling.
    1. Email: Mental health counselors should advise clients about the risks of exchanging emails. It is recommended to include a disclaimer when sending emails. Refer to the most update to date HIPAA regulations. Email transmissions are part of the client record; copies should be maintained in the client file.
    2. Text messages: Text messages are not a secure form of communication therefore texting of personal information should be discouraged. Text messages are considered a part of the client record, and should be kept in the client file.
  • Online scheduling: Any online scheduling software should be encrypted and secure. If not, counselors should disclose to clients the fact that the software is not encrypted and therefore is not confidential.
  1. Chat Rooms: Counselors should not include chat rooms, because these may imply that a counselor is able to intervene in the event that a crisis is mentioned.
  1. Counselors follow carefully designed security and safety guidelines when conducting online face-to-face distance counseling.
    • . Counselors endeavor to protect clients from unwanted interruptions during online face-to-face sessions.
  1. Counselors are strongly urged to employ the use of local resources in the community of the distance client should emergency care be needed. Local resources may be law enforcement, health care or EMT services, and someone trusted by the client to be available during distance counseling sessions should it become necessary to have someone close by in the event of an emergency.
  1. The counselor will evaluate the client to determine that the client is appropriate for distance counseling services.
  2. Counselors will conduct themselves in a professional manner during distance, online counseling sessions as if the client were in the counselor’s office.
  3. Counselors will disclose to clients all procedures for documenting and storing of records of distance, online counseling sessions.
    • . Counselors will safeguard and protect all records of distance counseling sessions as they would for in person sessions in accordance with all state and federal laws and regulations.
  1. Counselors should have a written policy that prohibits both the therapist and the client from recording a treatment session without the written consent of the other. If a recording of the treatment session has been authorized, the counselor,should either erase or destroy the recording as soon as it has fulfilled its intended purpose (e.g., supervision or conclusion of counseling) in order to maintain confidentiality of the contents.
  1. Counselors do not engage in virtual relationships with clients as to do so could potentially be a violation of confidentiality.
    • . If clients follow a professional blog, the counselor will not follow them back. The counselor has a responsibility to make it clear that the blog or website does not create a therapeutic relationship, therefore, professional blogs and websites should be non-interactive in nature.
  1. Twitter, Facebook, LinkedIn, Google Plus and other social media should be professional profiles that are kept separate from personal profiles. Counselors should not establish connections or engage with clients through social media. In addition, counselors need to have appropriate privacy settings so that clients cannot contact them on these professional social media sites, or access a site in any way.
  2. Counselors shall not solicit professional reviews by clients, nor respond to reviews posted, as to do so might violate client confidentiality.
  • Counselors will only seek information about their clients through internet searches for the purpose of determining their own or their clients health and safety.
  1. Counselors endeavor to provide sensitivity to the cultural make up of all clients, as well as sensitivity to disabilities or physical condition in distance counseling as they would in a physical office.

American Psychiatric Association APA Telepsychiatry via Teleconferencing

American Psychological Association APA Code of Ethics of 2016 simply states that basically, therapy that uses telephone or Internet must abide by the same ethical guidelines as in person therapy.

Ethical Principles of Psychologists and Code of Conduct, 2010, 4.01 The preamble to the Ethical Principles of Psychologists and Code of Conduct states: This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions.

Also:

Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.

This Ethics Code applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists. Areas covered include but are not limited to the clinical, counseling, and school practice of psychology; research; teaching; supervision of trainees; public service; policy development; social intervention; development of assessment instruments; conducting assessments; educational counseling; organizational consulting; forensic activities; program design and evaluation; and administration. This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions. These activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code. (Introductory and applicability, 2nd Para.)

The use of the term guidelines within this document refers to statements that suggest or recommend specific professional behaviors, endeavors or conduct for psychologists. Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Thus, guidelines are aspirational in intent.

American Telemedicine Association – ATA Evidence-based Practice for Telemental Health Practice Guidelines for Videoconferencing Based Telemental Health

Association of Social Work Boards – ASWB Model Regulatory Standards For Technology and Social Work Practice

Australian Psychological Association – APS Guidelines for providing psychological services and products on the internet

California Association of Marriage and Family Therapists CAMFT 2011 Code of Ethics:

1.4.1 ELECTRONIC THERAPY: When patients are not physically present (e.g., therapy by telephone or Internet) during the provision of therapy, marriage and family therapists take extra precautions to meet their responsibilities to patients. Prior to utilizing electronic therapy, marriage and family therapists consider the appropriateness and suitability of this therapeutic modality to the patient’s needs. When therapy occurs by electronic means, marriage and family therapists inform patients of the potential risks, consequences, and benefits, including but not limited to, issues of confidentiality, clinical limitations, transmission difficulties, and ability to respond to emergencies. Marriage and family therapists ensure that such therapy complies with the informed consent requirements of the California Telemedicine Act.

California Board of Behavioral Sciences – CA-BBS Notice to licensees regarding psychotherapy on the Internet

Canadian Psychological Association, Committee on Ethics – CPA Cautions and guidelines for psychologists providing services by telephone or online

iHealthCoalition.org – eHealth Code of Ethics

National Association of Social Workers NASW Code of Ethics of 2017

With the growth in the use of communication technology in various aspects of social work practice, social workers need to be aware of the unique challenges that may arise in relation to the maintenance of confidentiality, informed consent, professional boundaries, professional competence, record keeping, and other ethical considerations. In general, all ethical standards in this Code of Ethics are applicable to interactions, relationships, or communications, whether they occur in person or with the use of technology. For the purposes of this Code, “technology-assisted social work services” include any social work services that involve the use of computers, mobile or landline telephones, tablets, video technology, or other electronic or digital technologies; this includes the use of various electronic or digital platforms, such as the Internet, online social media, chat rooms, text messaging, e-mail, and emerging digital applications. Technology-assisted social work services encompass all aspects of social work practice, including psychotherapy; individual, family, or group counseling; community organization; administration; advocacy; mediation; education; supervision; research; evaluation; and other social work services. Social workers should keep apprised of emerging technological developments that may be used in social work practice and how various ethical standards apply to them.

Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services. (NASW, 1999, Section 1.03, Para. E).

National Board for Certified Counselors NBCC Code of Ethics (2016) states:

  1. NCCs shall include all electronic communications exchanged with clients and supervisees, including those through digital technology and social media methods, as a part of the record, even when strictly related to clerical issues such as change of contact information or scheduling appointments. All electronic therapeutic communication methods shall use encryption and password security.
  2. NCCs shall act in a professional manner by protecting against unauthorized access to confidential information. This includes data contained in electronic formats. NCCs shall inform any subordinates who have physical or electronic access to information of the importance of maintaining privacy and confidentiality.

The NBCC Policy Regarding the Provision of Distance Professional Services states:

The NBCC Policy Regarding the Provision of Distance Professional Services identifies specific actions National Certified Counselors (NCCs) must take when providing distance services.

STANDARDS FOR DISTANCE PROFESSIONAL SERVICES

  1. NCCs shall adhere to all NBCC policies and procedures, including the Code of Ethics.
  2. NCCs shall provide only those services for which they are qualified by education and experience. NCCs shall also consider their qualifications to offer such service via distance means.
  3. NCCs shall carefully adhere to legal regulations before providing distance services. This review shall include legal regulations from the state in which the counselor is located as well as those from the recipient’s location. Given that NCCs may be offering distance services to individuals in different states at any one time, the NCC shall document relevant state regulations in the respective record(s).
  4. NCCs shall ensure that any electronic means used in distance service provision are in compliance with current regulatory standards.
  5. NCCs shall use encryption security for all digital technology communications of a therapeutic type. Information regarding security should be communicated to individuals who receive distance services. Despite the use of precautions, distance service recipients shall be informed of the potential hazards of distance communications. Not the least of these considerations is the warning about entering private information when using a public access or computer that is on a shared network. NCCs shall caution recipients of distance services against using “auto-remember” user names and passwords. NCCs shall also inform recipients of di stance services to consider employers’ policies relating to the use of work computers for personal communications.
  6. To prevent the loss of digital communications or records, NCCs who provide distance services shall maintain secure backup systems. If the backup system is also a digital mechanism, this too shall offer encryption-level security. This information shall be provided to the recipient of professional services.
  7. NCCs shall screen potential distance service recipients for appropriateness to receive services via distance methods. These considerations shall be documented in the records.
  8. During the screening or intake process, NCCs shall provide potential recipients with a detailed written description of the distance counseling process and service provision. This information shall be specific to the identified service delivery type and incl ude considerations for that particular individual. These considerations shall include the appropriateness of distance counseling in relation to the specific goal, the format of service delivery, the associated needs (i.e., computer with certain capabilities, etc.), the limitations of confidentiality, the possibility of technological failure, anticipated response time to electronic communication, and any additional considerations necessary to assist the potential recipient in reaching a determination about the appropriateness of this service delivery format for their need(s).
  9. Because of the ease in which digital communications can inadvertently be sent to other individuals, NCCs shall adopt behaviors to prevent the distribution of confidential information to unauthorized individuals. NCCs shall discuss actions the recipient may take to reduce the possibility that they will send information to other individuals by mistake.
  10. NCCs shall provide recipients of distance professional services with information concerning their professional credentials and links to the respective credentialing organization Web sites.
  11. NCCs, either prior to or during the initial session, shall inform recipients of the purposes, goals, procedures, limitations, potential risks, and benefits of services and techniques. NCCs also shall provide information about rights and responsibilities as appropriate to the counseling setting. As a part of this type of service provision, NCCs shall discuss with recipients the associated challenges that may occur when communicating through distance means.
  12. In the event that the recipient of distance services is a minor or is unable to provide legal consent, the NCC shall obtain a legal guardian’s consent prior to the provision of distance services. Furthermore, NCCs shall retain copies of documentation indicating the legal guardian’s identity in the recipient’s file.
  13. NCCs shall avoid the use of public social media sources (e.g., tweets, blogs, etc.) to provide confidential information. To facilitate the secure provision of information, NCCs shall provide in writing the appropriate ways to contact them.
  14. NCCs shall provide recipients of distance services with specific written procedures regarding emergency situations. This information shall include emergency responders near the recipient’s home location. Given the increased dangers intrinsic to providing certain distance professional services, NCCs shall take reasonable steps to secure reasonable referrals for recipients when needed.
  15. NCCs shall develop written procedures for verifying the identity of the recipient at each instance of receiving distance services. Examples of verification means include the use of code words or phrases.
  16. NCCs shall limit use of information obtained through social media sources (e.g., Facebook, LinkedIn, Twitter, etc.) in accordance with established practice procedures provided to the recipient at the initiation of services.
  17. NCCs shall provide information concerning locations where members of the public may access the internet free of charge or provide information regarding the location of complimentary Web communication services.
  18. NCCs shall retain copies of all written communications with distance service recipients. Examples of written communications include e-mail/text messages, instant mess ages and histories of chat-based discussions even if they are related to housekeeping issues such as change of contact information or scheduling appointments.
  19. At a minimum, NCCs shall retain distance service records for a minimum of five years unless state laws require additional time. Due to the nature of most distance services, it may be convenient for NCCs to retain records for longer durations, and thus may be considered useful for research or other professional activities. NCCs shall limit the use of records to those permitted by law, professional standards and as specified by the agreement with the respective recipient of distance services.
  20. In recognition of the inherent ethical implications which may arise, NCCs shall develop written procedures for the use of social media and other related digital technology with current and former recipients. These written procedures shall, at a minimum, provide appropriate protections against the disclosure of confidential information and the creation of multiple relationships. These procedures shall also stipulate that personal accounts be distinct from any used for professional purposes.

 

American Psychiatric Association APA Telepsychiatry via Teleconferencing

American Psychological Association APA Code of Ethics of 2016 simply states that basically, therapy that uses telephone or Internet must abide by the same ethical guidelines as in person therapy.

Ethical Principles of Psychologists and Code of Conduct, 2010, 4.01 The preamble to the Ethical Principles of Psychologists and Code of Conduct states: This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions.

Also:

Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.

This Ethics Code applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists. Areas covered include but are not limited to the clinical, counseling, and school practice of psychology; research; teaching; supervision of trainees; public service; policy development; social intervention; development of assessment instruments; conducting assessments; educational counseling; organizational consulting; forensic activities; program design and evaluation; and administration. This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions. These activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code. (Introductory and applicability, 2nd Para.)

The use of the term guidelines within this document refers to statements that suggest or recommend specific professional behaviors, endeavors or conduct for psychologists. Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Thus, guidelines are aspirational in intent.

 

National Association of Social Workers NASW Code of Ethics of 2017

With the growth in the use of communication technology in various aspects of social work practice, social workers need to be aware of the unique challenges that may arise in relation to the maintenance of confidentiality, informed consent, professional boundaries, professional competence, record keeping, and other ethical considerations. In general, all ethical standards in this Code of Ethics are applicable to interactions, relationships, or communications, whether they occur in person or with the use of technology. For the purposes of this Code, “technology-assisted social work services” include any social work services that involve the use of computers, mobile or landline telephones, tablets, video technology, or other electronic or digital technologies; this includes the use of various electronic or digital platforms, such as the Internet, online social media, chat rooms, text messaging, e-mail, and emerging digital applications. Technology-assisted social work services encompass all aspects of social work practice, including psychotherapy; individual, family, or group counseling; community organization; administration; advocacy; mediation; education; supervision; research; evaluation; and other social work services. Social workers should keep apprised of emerging technological developments that may be used in social work practice and how various ethical standards apply to them.

Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services. (NASW, 1999, Section 1.03, Para. E).