Professional Association Codes of Ethics and Guidelines On TeleMental Health, E-Therapy, Digital Ethics, & Social Media
By Ofer Zur, Ph.D.
This article is also part of two online courses:
Telehealth, The New Standard:
Ethical, Legal, Clinical, Technological & Practice Considerations
Telehealth & Psychology of the Web
Table Of Contents
American Association of Marriage and Family Therapists
American Counseling Association Code of Ethics
American Medical Association
American Mental Health Counselors Association
American Psychiatric Association
American Psychological Association
American Telemedicine Association
Australian Psychological Society
California Association of Marriage and Family Therapists
California Board of Behavioral Sciences
Canadian Psychological Association
National Association of Social Workers
National Board for Certified Counselors
Ohio Psychological Association
Online Therapy Institute
Generally, telehealth practices are subject to exactly the same federal and state regulations, codes of ethics, and professional guidelines that define the fiduciary relationship in face-to-face and office-based therapy. It falls within the same standard of care.
Following are Ethics codes of different professional associations that have attended to the telehealth concerns differently:
American Association of Marriage and Family Therapists Code of Ethics (AAMFT, 2012):
AAMFT Code of Ethics, 2012
2.7 Protection of Electronic Information. When using electronic methods for communication, billing, recordkeeping, or other elements of client care, marriage and family therapists ensure that their electronic data storage and communications are privacy protected consistent with all applicable law.
American Counseling Association Code of Ethics (ACA, 2014):
http://www.counseling.org/Resources/aca-code-of-ethics.pdf 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
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
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.
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).
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.
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
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
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 donvention 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, 2010) Code of Ethics:
Principle 6: Technology-Assisted Counseling
Technology-assisted counseling includes but is not limited to computer, telephone, internet and other communication devices. Mental health counselors take reasonable steps to protect patients, clients, students, research participants and others from harm. Mental health counselors performing technology-assisted counseling comply with all other provisions of this Ethics Code. Mental health counselors:
a) establish methods to ascertain the client's identity and obtain alternative methods of contacting the client in an electronic emergency.
b) electronically transfer client confidential information to authorized third-party recipients only when both the mental health counselor and the authorized recipient have secure transfer and acceptance capabilities as state and federal laws regulate.
c) ensure that clients are intellectually, emotionally, and physically capable of using technology-assisted counseling services, and of understanding the potential risks and/or limitations of such services.
d) provide technology-assisted counseling services only in practice areas within their expertise. Mental health counselors do not provide services to clients in states where doing so would violate local licensure laws or regulations.
e) confirm that the provision of technology-assisted counseling services are not prohibited by or otherwise violate any applicable state or local statutes, rules, regulations or ordinances, codes of professional membership organizations and certifying boards, and/or codes of state licensing boards.
American Psychiatric Association Telepsychiatry via Teleconferencing:
http://www.psychiatry.org/File Library/Practice/Ethics Documents/principles2013--final.pdf
American Psychological Association (APA) Code of Ethics of 2010:
http://www.apa.org/ethics/code/principles.pdf 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.
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.)
American Psychological Association. (2013) Guidelines for the Practice of Telepsychology:
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 - Evidence-based Practice for Telemental Health Practice Guidelines for Videoconferencing Based Telemental Health:
Australian Psychological Association 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 - Notice to licensees regarding psychotherapy on the Internet.
Canadian Psychological Association, Committee on Ethics. 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 2008
http://www.socialworkers.org/pubs/code/code.asp mentions briefly under Informed Consent:
NASW Code of Ethics, 1996, Revised 2008, 1.07.m Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible.
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 (amended 2013)
http://www.nbcc.org/Assets/Ethics/nbcc-codeofethics.pdf states in section B.12:
Counselors using electronic means in which counselor and client are not in immediate proximity must present clients with local sources of care before establishing a continued short or long-term relationship. Counselors who communicate with clients via Internet are governed by NBCC standards for Web Counseling.
The NBCC Policy Regarding the Provision of Distance Professional Services at http://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf. states:
The NBCC Policy Regarding the Provision of Distance Professional Services identifies specific actions National
Certified Counselors (NCCs) must take when providing
STANDARDS FOR DISTANCE PROFESSIONAL SERVICES
- NCCs shall adhere to all NBCC policies and procedures, including the Code of Ethics.
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.
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).
NCCs shall ensure that any electronic means used in distance service provision are in compliance with current regulatory standards.
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.
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.
NCCs shall screen potential distance service recipients for appropriateness to receive services via distance methods. These considerations shall be documented in the records.
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).
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.
- NCCs shall provide recipients of distance professional services with information concerning their professional credentials and links to the respective credentialing organization Web sites.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
Ohio Psychological Association Telepsychology Guidelines:
http://www.ohpsych.org/resources/1/files/Comm Tech Committee/OPATelepsychologyGuidelines41710.pdf
Online Therapy Institute (OTI) 2011 Ethical Framework for the Use of Social Media by Mental Health Professionals:
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