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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
iHealth Coalition
International Society for Mental Health Online
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):
http://www.aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx

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
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. [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:
http://hosted.ap.org/specials/interactives/_documents/patient_physician_email.pdf

American Mental Health Counselors Association (AMHCA, 2010) Code of Ethics:
http://www.amhca.org/assets/content/AMHCA_Code_of_Ethics_11_30_09b1.pdf

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.psych.org/lib_archives/archives/199821.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.

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.)

American Psychological Association. (1997) APA statement on services by telephone, teleconferencing, and Internet:
http://www.apa.org/ethics/education/telephone-statement.aspx

The Ethics Committee can only address the relevance of and enforce the "Ethical Principles of Psychologists and Code of Conduct" and cannot say whether there may be other APA Guidelines that might provide guidance. The Ethics Code is not specific with regard to telephone therapy or teleconferencing or any electronically provided services as such and has no rules prohibiting such services. Complaints regarding such matters would be addressed on a case by case basis.

American Telemedicine Association - Evidence-based Practice for Telemental Health Practice Guidelines for Videoconferencing Based Telemental Health:
http://virtualservices.kansasworks.com/About/ Documents/Telemental%20Health2.pdf

Australian Psychological Association Guidelines for providing psychological services and products on the internet:
http://www.psychology.org.au/publications/inpsych/online/

California Association of Marriage and Family Therapists (CAMFT) 2011 Code of Ethics:
http://www.camft.org/AM/Template.cfm?Section=Code_of_Ethics_Part_I&Template=/CM/ContentDisplay.cfm&ContentID=8108

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.
http://www.psychboard.ca.gov/consumers/internet-thrpy.shtml

Canadian Psychological Association, Committee on Ethics. Cautions and guidelines for psychologists providing services by telephone or online.
http://www.cpa.ca/aboutcpa/committees/ethics/psychserviceselectronically/

iHealthCoalition.org - eHealth Code of Ethics:
http://www.ihealthcoalition.org/ehealth-code

International Society for Mental Health Online (2000).
https://www.ismho.org/suggestions.asp Suggested principles for the online provision of mental health services.

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.

NBCC Practice of Internet Counseling at http://www.nbcc.org/Assets/Ethics/internetCounseling.pdf. states:

Standards for the Ethical Practice of Internet Counseling

These standards govern the practice of Internet counseling and are intended for use by counselors, clients, the public, counselor educators, and organizations that examine and deliver Internet counseling. These standards are intended to address practices that are unique to Internet counseling and Internet counselors and do not duplicate principles found in traditional codes of ethics.

These Internet counseling standards of practice are based upon the principles of ethical practice embodied in the NBCC Code of Ethics. Therefore, these standards should be used in conjunction with the most recent version of the NBCC ethical code. Related content in the NBCC Code are indicated in parentheses after each standard.

Recognizing that significant new technology emerges continuously, these standards should be reviewed frequently. It is also recognized that Internet counseling ethics cases should be reviewed in light of delivery systems existing at the moment rather than at the time the standards were adopted.

In addition to following the NBCC Code of Ethics pertaining to the practice of professional counseling, Internet counselors shall observe the following standards of practice:

  1. In situations where it is difficult to verify the identity of the Internet client, steps are taken to address impostor concerns, such as by using code words or numbers.
  2. Internet counselors determine if a client is a minor and therefore in need of parental/guardian consent. When parent/guardian consent is required to provide Internet counseling to minors, the identity of the consenting person is verified.
  3. As part of the counseling orientation process, the Internet counselor explains to clients the procedures for contacting the Internet counselor when he or she is off-line and, in the case of asynchronous counseling, how often email messages will be checked by the Internet counselor.
  4. As part of the counseling orientation process, the Internet counselor explains to clients the possibility of technology failure and discusses alternative modes of communication, if that failure occurs.
  5. As part of the counseling orientation process, the Internet counselor explains to clients how to cope with potential misunderstandings when visual cues do not exist.
  6. As a part of the counseling orientation process, the Internet counselor collaborates with the Internet client to identify an appropriately trained professional who can provide local assistance, including crisis intervention, if needed. The Internet counselor and Internet client should also collaborate to determine the local crisis hotline telephone number and the local emergency telephone number.
  7. The Internet counselor has an obligation, when appropriate, to make clients aware of free public access points to the Internet within the community for accessing Internet counseling or Web-based assessment, information, and instructional resources.
  8. Within the limits of readily available technology, Internet counselors have an obligation to make their Web site a barrier-free environment to clients with disabilities.
  9. Internet counselors are aware that some clients may communicate in different languages, live in different time zones, and have unique cultural perspectives. Internet counselors are also aware that local conditions and events may impact the client.
  10. Confidentiality in Internet Counseling

  11. The Internet counselor informs Internet clients of encryption methods being used to help insure the security of client/counselor/supervisor communications.
     
    Encryption methods should be used whenever possible. If encryption is not made available to clients, clients must be informed of the potential hazards of unsecured communication on the Internet. Hazards may include unauthorized monitoring of transmissions and/or records of Internet counseling sessions.
  12. The Internet counselor informs Internet clients if, how, and how long session data are being preserved.
     
    Session data may include Internet counselor/Internet client email, test results, audio/video session recordings, session notes, and counselor/supervisor communications. The likelihood of electronic sessions being preserved is greater because of the ease and decreased costs involved in recording. Thus, its potential use in supervision, research, and legal proceedings increases.
  13. Internet counselors follow appropriate procedures regarding the release of information for sharing Internet client information with other electronic sources.
     
    Because of the relative ease with which email messages can be forwarded to formal and casual referral sources, Internet counselors must work to insure the confidentiality of the Internet counseling relationship.
  14. Legal Considerations, Licensure, and Certification

  15. Internet counselors review pertinent legal and ethical codes for guidance on the practice of Internet counseling and supervision.
     
    Local, state, provincial, and national statutes as well as codes of professional membership organizations, professional certifying bodies, and state or provincial licensing boards need to be reviewed. Also, as varying state rules and opinions exist on questions pertaining to whether Internet counseling takes place in the Internet counselor's location or the Internet client's location, it is important to review codes in the counselor's home jurisdiction as well as the client's. Internet counselors also consider carefully local customs regarding age of consent and child abuse reporting, and liability insurance policies need to be reviewed to determine if the practice of Internet counseling is a covered activity.
  16. The Internet counselor's Web site provides links to websites of all appropriate certification bodies and licensure boards to facilitate consumer protection.

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:
http://www.onlinetherapyinstitute.com/ethical-framework-for-the-use-of-social-media-by-mental-health-professionals/

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