By Ofer Zur, Ph.D.
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
Association of Canadian Psychology Regulatory Organizations
Association of Social Work Boards
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
Additional Mental Health Guidelines
APA 2013 Guidelines for the Practice of Telepsychology
NASW & ASWB Standards for Technology
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 AAMFT 2015 Code of Ethics:
STANDARD VITECHNOLOGY-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 ensurethe 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 attemptto protect confidentiality and meet any legal and ethical requirements for the use of such resources.
H.1. Knowledge andLegal Considerations
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 andWeb Maintenance
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 andDisability 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.
American Medical Association AMA 2000 Guidelines for Patient-Physician Electronic Mail
American Mental Health Counselors Association AMHCA, 2020 Code of Ethics
B. Counseling Process
6. The Use of Technology Supported Counseling and Communications (TSCC)
CMHCs recognize that technology has become culturally normative worldwide and may employ modern technology communications judiciously, attentive to both the benefits and risks to clients and to the therapeutic process of using technologies to arrange, deliver, or support counseling.
- a. CMHCs understand that the uses of TSCC in counseling may be considered to fall under the following categories:
- i. The use of TSCC as the medium for counseling, also called “telehealth” or “distance counseling,” which includes but is not limited to the delivery of counseling by video call (e.g., internet, video chat), by voice (e.g., telephone), by synchronous text (e.g., chat or SMS), or by asynchronous text (e.g., email)
- ii. The use of TSCC as an adjunct to counseling (i.e., for arranging, coordinating, or paying for counseling services), including the use of payment processing services that are integrated with TSCC (e.g. PayPal, Stripe, Zelle) for receipt of payment for counseling services
- iii. The use of online “cloud-based” services for the storage of counseling records
- iv. Marketing, educational forums, and other TSCC to include blogs, webpages, chatroom, etc.
- b. CMHCs recognize that federal, state, and local laws prevail and that the standard of care for TSCC is expected in the same manner as face-to-face and in-office counseling. Continuity of care is crucial and, at times, may conflict with local laws and regulations. CMHCs should employ a solid ethical decision-making model to secure continuity of care.
- c. CMHCs are not required to provide services via TSCC or may decide not to offer services based on appropriateness.
- d. CMHCs only provide telehealth or distance counseling when they have had sufficient training which can be gained through education, supervision, or other appropriate activities (see the TSCC section of AMHCA Standards for the Practice of Clinical Mental Health Counseling in Appendix B of the “Essentials of the Clinical Mental Health Counseling Profession” text or online at www.amhca.org/publications/standards).
- e. CMHCs need to be familiar with state laws and regulations in both the state in which the CMHC is licensed and the state in which the client is presently located.
- f. At the beginning of a course of distance counseling, CMHCs acquire the contact information for emergency services in the location of the client and develop a procedure to follow in the event of a psychiatric or health emergency.
- g. In states where there is a legal requirement that CMHCs must include in the client record client communications through TSCC, CMHCs inform the client of that fact.
- h. Unless email and text messages are encrypted or otherwise secured or confidential, the client should be informed of the risks and discouraged from using as a means to disclose personal information.
- i. Chat Rooms: Typically, unsecured, open chat rooms are discouraged as a platform for communicating with clients.
- j. CMHCs may maintain professional profiles that are kept separate from personal profiles. CMHCs need to be aware of their impact on clients should personal information or opinions be disclosed in a public platform. When applicable, CMHCs educate clients on confidentiality, implications for client activity on these pages, and appropriate channels for contacting CMHCs.
- k. CMHCs only seek information about their clients through internet searches for the purpose of determining their own or their client’s safety, as necessary to conduct a forensic evaluation, or at the client’s request.
A. Counselor-Client Relationship
- m. When using a computer to store confidential information, CMHCs control access to such information. As specified by state regulations, the information may be deleted from the system.
- n. CMHCs take necessary precautions to ensure client confidentiality of information transmitted electronically through the use of a computer, e-mail, fax, telephone, voice mail, answering machines, or any other electronic means as described in the Telehealth section of this document.
B. Counseling Process
2. Informed Consent
- d. CMHCs inform the client of specific limitations, potential risks, and/or potential benefits relevant to the client’s anticipated use of online counseling services.
D. Assessment and Diagnosis
2. Interpretation and Reporting
- g. CMHCs are responsible for ensuring the confidentiality and security of assessment reports, test data, and test materials regardless of how the material is maintained or transmitted.
E. Record-Keeping, Fee Arrangements, and Bartering
- a. CMHCs create, maintain, store, transfer, and dispose of client records in ways that protect confidentiality and are in accordance with applicable regulations or laws.
- d. All communication regarding mental health treatment, including emails and texts, should be kept.
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.
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 Psychological Association. (2013). – Guidelines for the practice of telepsychology.
American Telemedicine Association – ATA Evidence-based Practice for Telemental Health Practice Guidelines for Videoconferencing Based Telemental Health
Association of Canadian Psychology Regulatory Organizations. (2011). – Model standards for telepsychology service delivery. Toronto, Canada.
Association of Social Work Boards – ASWB Model Regulatory Standards For Technology and Social Work Practice
California Association of Marriage and Family Therapists CAMFT 2019 Code of Ethics:
Marriage and family therapists recognize that ongoing technological developments promote availability and access to healthcare and expand opportunities to provide their services outside of the therapy office. When utilizing Telehealth to provide services to clients/patients, marriage and family therapists consider the welfare of the client/patient, the appropriateness and suitability of the modality in meeting the client’s/patient’s needs, make appropriate disclosures to the client/patient regarding its use, exercise reasonable care when utilizing technology, and remain current with the relevant laws and regulations.
Marriage and family therapists take precautions to meet their responsibilities to clients/patients who are not physically present during the provision of therapy. Prior to utilizing Telehealth, marriage and family therapists consider the appropriateness and suitability of this therapeutic modality in meeting the client’s/patient’s needs and do so competently. The suitability and appropriateness of Telehealth includes consideration of multiple factors such as the client’s/patient’s familiarity with the modality, the issues to be addressed, the therapeutic orientation, and other pertinent factors.
6.2 COMPLIANCE WITH TELEHEALTH LAWS:
Marriage and family therapists, prior to engaging in Telehealth, are familiar with the state and federal laws governing Telehealth and ensure compliance with all relevant laws.
Marriage and family therapists inform clients/patients of the potential risks, consequences, and benefits of the Telehealth modality, including but not limited to issues of confidentiality, clinical limitations, and transmission/technical difficulties.
6.4 ELECTRONIC MEDIA:
Marriage and family therapists are aware of the possible adverse effects of technological changes with respect to the dissemination of client/patient information, and take care when disclosing such information. Marriage and family therapists are also aware of the limitations regarding confidential transmission by Internet or electronic media and take care when transmitting or receiving such information via these mediums.
2.3 MAINTENANCE OF CLIENT/PATIENT RECORDS—CONFIDENTIALITY:
Marriage and family therapists store, transfer, transmit, and/or dispose of client/patient records in ways that protect confidentiality.
3.12 DOCUMENTING TREATMENT RATIONALE/CHANGES:
Marriage and family therapists document treatment in their client/patient records, such as major changes to a treatment plan, changes in the unit being treated and/ or other significant decisions affecting treatment.
9.6 EMERGING PUBLIC POLICY:
Marriage and family therapists are encouraged to be aware of current and emerging laws and regulations pertaining to marriage and family therapy that serve the public interest, and with the revisions of such laws and regulations that are not in the public interest.
12.6 THIRD-PARTY PAYERS:
Marriage and family therapists represent facts regarding services rendered and payment for services fully and truthfully to third-party payers and/or guarantors of payment. When appropriate, marriage and family therapists make reasonable efforts to assist their clients/patients in obtaining reimbursement for services rendered.
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
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:
54. 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.
55. 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 identifies specific actions NationalCertified Counselors (NCCs) must take when providingdistance services.
STANDARDS FOR DISTANCE PROFESSIONAL SERVICES