Ethical Framework for the Use of Technology in Mental Health
A competent practitioner working online will always adhere at least the following minimum standards and practices in order to be considered to be working in an ethical manner.
Practitioners have a sufficient understanding of technology.
Technology basics are required for practitioners who choose to deliver therapeutic services via technology. Practitioners will possess a basic understanding of technology as the technology relates to delivery of services
- Encryption: Practitioners understand how to access encrypted services to store records and deliver communication. Records storage can be hosted on a secure server with a third-party, stored on the practitioner’s hard drive utilizing encrypted folders or stored on an external drive that is safely stored.
- Backup Systems: Records and data that are stored on the practitioner’s hard drive are backed up either to an external drive or remotely via the Internet.
- Password Protection: Practitioners take further steps to ensure confidentiality of therapeutic communication and other materials by password protecting the computer, drives and stored files or communication websites.
- Firewalls: Practitioners utilize firewall protection externally or through web-based programs.
- Virus Protection: Practitioners protect work computers from viruses that can be received from or transmitted to others, including clients.
- Hardware: Practitioners understand the basic running platform of the work computer and know whether or not a client’s hardware/platform is compatible with any communication programs the practitioner uses.
- Software: Practitioners know how to download and operate software and assist clients with the same when necessary to the delivery of services.
- Third-party services: Practitioners utilize third-party services that offer an address and phone number so that contact is possible via means other than email. This offers a modicum of trust in the third-party utilized for such services as backup, storage, virus protection and communication.
Practitioners work within their Scope of Practice.
Scope of Practice indicates the specific area to which a practitioner may practice. Scope of practice in many geographic areas also defines where a practitioner may practice; whether the practitioner may practice across various geographical boundaries and within what parameters a practitioner may practice. Practitioners also follow local and regional laws and codes of ethics as applicable.
- Understanding of boundaries and limitations of one’s specific discipline: Practitioners understand which assessments and interventions are allowed within their specific discipline. For instance, career counselors who have no training in mental health issues generally do not provide psychotherapy services.
- Understanding of specific laws or ethics within one’s own discipline or geographic location: Practitioners understand the limits set forth by laws or ethics within the applicable geographic location. For instance, in the United States, Licensed Professional Counselors cannot call themselves Psychologists, and in the UK the term ‘Chartered Psychologist’ is reserved by law for use only by those with proper recognition from the appropriate authorities. Certain states dictate what a practitioner can be called due to the implementation of Title laws. Practice laws may prevent a licensed practitioner from interpreting certain personality tests in one state, yet the same practice may be accepted under Practice law in another state.
- Respect for the specific laws of a potential client’s geographic location: Practitioners understand that different geographic regions may offer additional limits to practice, particularly with regard to jurisdiction. For instance, a counsellor in the UK should be cognizant of the laws of a client who resides in a U.S. state such as California in which the law prohibits consumers residing in California from engaging in counseling from a practitioner who is not licensed in California.
Practitioners seek out training, knowledge and supervision.
Training, knowledge and supervision regarding mental health and technology is paramount to delivering a standard of care that is considered “best practice” within one’s geographic region and within a global context. Practitioners are encouraged to demonstrate proficiency and competency through formal specialist training for online work, books, peer-reviewed literature and popular media. Clinical and/or peer supervision and support are mandated for practitioners who cannot practice independently within a geographic region and is highly recommended for all practitioners.
- Formal Training: Practitioners seek out sufficient formal training whenever possible through college, university or private settings. Formal training is displayed on the practitioner’s website.
- Informal Training: Practitioners seek out continuing education and professional development and conferences, conventions and workshops.
- Books: Practitioners read books written by the general public and professionals.
- Peer-reviewed Literature: Practitioners read peer-reviewed literature that includes the latest theories and research.
- Popular Media: Practitioners are informed through popular media such as magazines, newspapers, social networking sites, websites, television and movies and understand the impact of mental health and technology on the popular culture.
- Clinical/Peer Supervision: Practitioners seek clinical supervision whenever the practitioner cannot practice independently within his or her geographic location. Clinical and/or peer supervision is sought by all practitioners who deliver services via technology. Clinical and peer supervision is delivered either face-to-face or via encrypted methods.
Example Topics of study related to Training, Knowledge and Supervision (not an exhaustive list):
- Online Therapy
- Online Clinical Supervision
- Online Peer Supervision
- Avatar Therapy
- Text-based Therapy
- Behavioral Telehealth
- Internet Addictions
- Social Media
- Mixed Reality
- Online Relationships
- Second Life
- Online Peer Support
- SMS Text Messaging
- Virtual Worlds
- Virtual Reality
- Mental Health and Technology
Practitioners display pertinent and necessary information on Websites.
Websites provide access to information for the general public, potential clients, clients and other professionals.
- Crisis Intervention Information: People may surf the internet seeking immediate help. Practitioners display crisis intervention information on the home page. Practitioners understand that people in crisis may visit the website from anywhere in the world. Offering global resources such as Befriender’s International or The Samaritans is the best course of action.
- Practitioner Contact Information: Practitioners offer contact information that includes email, post address and a telephone or VOIP number. While it is not recommended that post addresses reflect the practitioner’s home location, clients should have a post address for formal correspondence related to redress, subpoenas or other mailings requiring a signature of receipt. Practitioners state the amount of time an individual may wait for a reply to email or voice mail. Best practice indicates a maximum of two business days for therapeutic inquiries.
- Practitioner Education, License and/or Certification Information: Practitioners list degrees, licenses and/or certifications as well as corresponding numbers. If the license, certification board, or professional body offers a website that allows the general public to verify information on a particular practitioner the license and certification listings should link directly to those verifying body websites. Practitioners consider listing other formal education such as college or university courses, online continuing education and professional development courses, and conference/convention attendance directly related to mental health and technology.
- Encrypted Transmission of Therapeutic and Payment Information: Practitioners offer secure and encrypted means of therapeutic communication and payment transactions. Email and Chat programs whether embedded within the practitioner site (private practice or e-clinic) or utilizing 3rd party platforms such Hushmail or Cryptoheaven are explained on the website. Payment methods are explained as well through merchant information or information provided by the practitioner.
Practitioners conduct an initial Intake and Screening process.
The initial screening and intake process begins with the potential client’s first contact. The practitioner implements formal and informal measures for screening a client’s suitability for delivery of mental health services via technology.
- Client’s Technology Skills: Practitioners screen potential client’s use of technology through questions at the outset. Questions include but are not limited to an inquiry about the client’s experience with online culture e.g. email, chat rooms, forums, social networks, instant messaging and online purchasing, mobile texting, VOIP or telephones. Practitioners ensure that the client’s platform is compatible with the varying programs and platforms the practitioner may utilize during the course of therapy.
- Client’s Language Skills: Practitioners screen for language skills from the initial contact through the first few exchanges. Assessing for language barriers, reading and comprehension skills as well as cultural differences is part of the screening process. Text-based therapy may also involve screening for keyboarding proficiency.
- Presenting Issue, Client Identity and Clinical Concerns: Practitioners screen to ensure the presenting issue is within the scope of practice and knowledge base of the practitioner. Screening around issues of suicidality, homicidality and immediate crisis are formally addressed through an intake questionnaire or first exchange. Practitioners incorporate a mechanism for verifying identity of clients by asking for a formal identification number such as Driver’s License or other satisfactory method. The client must not be anonymous, offering at a minimum: first and last name, home address, and phone number for emergency contact. Minors must be identified through parental consent. If client identity is not required, such as is the case with crisis hotlines and triage settings, limitations of the service are stated clearly.Other concerns regarding mental stability are addressed- e.g. client currently hallucinating or delusional; actively using drugs and alcohol so that insight-oriented interventions would not be suitable; and any other medical or physical issues that might impede the intervention or require a different method of delivery, e.g. disability that impairs typing, rendering a chat exchange cost-prohibitive. Any assessment instruments that are utilized should be approved for online or computer-assisted use according to the test author/publisher.
Practitioners offer an Informed Consent process.
The informed consent process begins when the client contemplates accessing services. Therefore, clear and precise information is accessible via the practitioner’s website. The informed consent process includes a formal acknowledgement from the client to the practitioner. This acknowledgement is received via encrypted channels. Informed Consent content is revisited during the course of therapy as necessary and beneficial.
The following topics are addressed within Informed Consent:
- Possible Advantages and Disadvantages of Online Therapy: Information is disseminated about the pros and cons of online therapy including such disadvantages as lack of visual and auditory cues and the limitations of confidentiality via technology, and advantages that include easy scheduling, time management and a no need to incur transportation costs.
Confidentiality and Technology
- Encryption: An explanation about the use of encryption for therapeutic exchanges and lack of encryption if/when unencrypted methods (standard email, forum posts, mobile telephone, SMS texting, social networking) are used for issues such as appointment changes and cancellations.
- Therapist as Owner of the Record: Unless otherwise specified through law in the practitioner’s geographic location, the therapist remains the owner of the therapeutic record including all transcripts, notes and emails. The client is informed that posting direct information about the therapist or verbatim information from sessions is prohibited.
- File Storage Procedures: The client is informed about how records are stored (web-based, third party or hard-drive/external drive) and for how long the records are maintained. All procedures conform to the standards laid down in applicable law and as required by any relevant authority (such as professional body) and, at least, include encryption and password protection and a commitment to destroy all records after a given period as required by law/regulation/best practice.
Other Informed Consent Issues
- Practitioner’s Geographical Jurisdiction: The physical location of the practitioner is offered in the Informed Consent and if the practitioner is licensed within a specific jurisdiction, the Informed Consent states client understands services are rendered under the laws or jurisdiction of the relevant country, state or region.
- How to Proceed during a Technology Breakdown: The client is informed about how to proceed if a technology breakdown occurs during a session, e.g. “If we disconnect, try to reconnect within 10 minutes. If reconnection is not possible, email or call to reschedule an appointment.”
- Emergency Contact: Practitioners offer specific information about who to contact in case of an emergency and set specific rules about emergency emails that the practitioner may not be privy to e.g. (suicidal emails in the middle of the night, threatening posts on a support forum). Practitioners research local resources within the client’s geographic area as emergency backup resources.
- Cultural Specifics that May Impact Treatment: Practitioners discuss varying time zones, cultural differences and language barriers that may impact the delivery of services. Practitioners should also ensure at or prior to the start of therapy, that the client’s expectations of the service being offered (such as the meaning of the term ‘counselling’ etc) is sufficiently close to their own understanding and should take into account that different cultures around the world can have very different understandings of these matters.
- Dual Relationships: Practitioners discuss with clients the expected boundaries and expectations about forming relationships online. Practitioners inform clients that any requests for “friendship,” business contacts, direct or @replies, blog responses or requests for a blog response within social media sites will be ignored to preserve the integrity of the therapeutic relationship and protect confidentiality. If the client has not been formally informed of these boundaries prior to the practitioner receiving the request, the practitioner will ignore the request via the social media site and explain why in subsequent interaction with the client.
- Insurance, Subsidy or Reimbursement Information: If the client resides in a geographic area that generally accepts insurance or other forms of reimbursement for therapy services, the practitioner informs the client of this information. Conversely, services delivered via technologies that are not covered at all or at the same rate, the practitioner informs the client of this information also.
©2009 DeeAnna Merz Nagel & Kate Anthony, Online Therapy Institute, Inc.
This framework published in full:
Anthony, K. & Nagel, D.M. (2009). Therapy online: A practical guide. Sage Publishing: London.
This work by Online Therapy Institute, Inc. is licensed under a Creative Commons Attribution 3.0 Unported License.