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Clinical Ethics in a Digital World

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1 Clinical Ethics in a Digital World
Randy N. Walton, Ph.D. Sarah W. Bisconer, Ph.D. Friday March 15, 2013 9:00 am until 11:30 pm

2 Training Objectives Provide a brief overview of digital and social media platforms (e.g., Internet, Facebook, Twitter, ) that may impact clinical practice Review existing practice guidelines for use of digital and social media in clinical practice Present a model for applying existing ethical principles to digital and social media in clinical practice Review and discuss challenging clinical questions and scenarios involving digital and social media

3 Handouts in Packet Guiding Principles and Digital Media
Key Definitions and Glossary Sample Agency Policy Sample Private Practice Policy Guidelines Discussion

4 Context Questions “Psychotherapists as a group have not been known to be highly adaptive or flexible. Many new ideas, approaches, and techniques are often met with resistance and skepticism. In spite of the token commitment to individual differences and cultural diversity, [clinicians] often fail to acknowledge or say ‘This is foreign to me’, ‘I don’t understand’, or ‘I am intimidated’ but instead often say ‘It is inappropriate and unethical’”. Zur, O. (2012) TelePsychology or TeleMentalHealth in the Digital Age: The Future is Here. California Psychologist, 45/1, p. 14. In general, would you say this statement is: True False As applied to you, would you say this statement is:

5 Context Question: Better-Worse vs
Context Question: Better-Worse vs. Advantages-Disadvantages Which of these advantages and disadvantages are relevant in psychotherapy? In-person Relationships** Cyberspace Relationships* Better More real/Less superficial All five senses In-person interactive kinesthetic activities Non-verbal/pre-verbal communication More intimate More connected Limited by physical proximity Isolation/withdrawal due to fear/awkwardness in IPR Healthier Unhealthier **Invokes physical presence (IPR) Better More real/Less superficial Primarily two senses Virtual interactive physical activities Limited non-verbal/pre-verbal More intimate More connected Not limited by physical proximity CSR due to fear/awkwardness in IPR Healthier Unhealthier *Invokes place and spatial interaction (CSR)

6 Challenges in Developing and Using Ethical Guidelines
In clinical practice, the proliferation of digital media in society requires a significant shift in ethical thinking and practice to help clinicians: Identify potential ethical dilemmas and concerns Identify relevant existing ethical principles Identify applicable existing ethical guidelines Appropriately apply, extrapolate, and modify existing principles and guidelines

7 Practical Use of Ethics Codes
Ethics codes cannot do our questioning, thinking, feeling, and responding for us. Such codes can never be a substitute for the active process by which the individual therapist or counselor struggles with the sometimes bewildering, always unique constellation of questions, responsibilities, contexts, and competing demands of helping another person. Ethics must be practical. Clinicians confront an almost unimaginable diversity of situations, each with its own shifting questions, demands, and responsibilities. Every clinician is unique in important ways. Every client is unique in important ways. Ethics that are out of touch with the practical realities of clinical work, with the diversity and constantly changing nature of the Therapeutic venture, are useless. (Pope & Vasquez, 1998, xiii–xiv) Kaslow, F., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42,

8 Purposes of and Challenges to Professional Ethical Codes
Codes of ethics are designed to benefit the client, protect the client, and protect the integrity of the therapeutic process. The development of codes of ethics is generally delayed and reactive to changing social norms, practices, and the innovations brought about by emerging technologies. The use and rapidly evolving technology associated with digital media are new enough that there are currently no broadly accepted guidelines regarding how digital media can or should be used ethically in behavioral health

9 Professional Codes of Ethics
Current ethical codes offer limited or no specific guidelines for clinicians’ use of digital technology: ACA A.12 – Focuses on multiple uses of technology, but no information specifically addresses counselor’s use of social networking AAMFT, APA, NASW Discuss universal concepts such as “dual or multiple relationships” and “client’s right to privacy”, but nothing specifically on clinicians’ use of digital technology or social networking

10 Other Guidance Regarding Clinical Use of Digital Technology
Ohio Psychological Association (2010): National Association of Social Workers and Association of Social Work Boards - Standards for Technology and Social Work Practice: Canadian Psychological Association – Providing Psychological Services via Electronic Media: American Telemedicine Association - Practice Guidelines for Videoconferencing-Based Telemental Health: American Telemedicine Association – Evidence Based Practice for Telementalhealth: International Society for Mental Health Online - Suggested Principles for the Online Provision of Mental Health Services: For a more comprehensive list of available guidelines see: Pope, K. Ethical Standards & Practice Guidelines for Assessment, Therapy, Counseling, & Forensic Practice.

11 Ethical Principles Principle-based Ethics is based on a commitment to five overarching, common, basic prima facie moral principles: Beneficence: Responsibility to do good and promote others’ welfare Nonmaleficence: Obligation to do no harm or act in ways that have a high risk of harming others Autonomy: Support others’ informed, non-coerced freedom of thought and action; promote independence Fidelity: Be faithful to commitments and promises, do not deceive or exploit, be trustworthy Justice: Act fairly or justly, especially balancing rights and interests of clients and others; afford all individuals the opportunity for equal access to the same high-quality treatment

12 Vignette It’s 10:00 on a Friday night. A child psychologist sits at her home computer checking Facebook updates and thinking about upcoming weekend plans. Distracted by thoughts about a particularly intense session that afternoon with a teenage client, wherein he’d disclosed some distressing recent peer interactions, she decides on a whim to try to view his Facebook page. She finds it easily, set up without privacy restrictions, and is troubled when she reads his latest status update: “I’m going to sleep now See you all on the other side.” The psychologist continues to read back through her client’s Facebook wall and is horrified to find a series of taunting and harsh comments left by some of the client’s “friends” over the past few weeks. After viewing this disturbing content for a short while, the clinician feels uncertain about her professional obligation and worriedly wonders what she should do to help ensure her client’s safety. From: Rachel A. Tunick, Lauren Mednick, and Caitlin Conroy (2011). A Snapshot of Child Psychologists’ Social Media Activity: Professional and Ethical Practice Implications and Recommendations. Professional Psychology: Research and Practice,

13 Major Ethical Issues in a Digital World
Informed Consent Boundaries Dual/multiple relationships Therapist self-disclosure Confidentiality The following slides briefly consider these issues in a non-digital context

14 Informed Consent: Factors to consider
Assess Competence: Before engaging in the remote delivery of mental health services via electronic means, practitioners should carefully assess their competence to offer the particular services and consider the limitations of efficacy and effectiveness that may be a function of remote delivery. Check Liability Insurance: Practitioners should consult with their professional liability insurance carrier to ascertain whether the planned services will be covered. Ideally, a written confirmation from a representative of the carrier should be obtained. Seek Consultation: Practitioners are advised to seek consultation from colleagues and to provide all clients with clear written guidelines regarding planned emergency practices (e.g., suicide risk situations). Develop Written Plan: Because no uniform standards of practice exist at this time, thoughtful written plans that reflect careful consultation with colleagues may suffice to document thoughtful professionalism in the event of an adverse incident. Cite Confidentiality Limitations: A careful statement on limitations of confidentiality should be developed and provided to clients at the start of the professional relationship. The statement should inform clients of the standard limitations (e.g., child abuse reporting mandates), any state-specific requirements, and cautions about privacy problems with broadcast conversations (e.g., overheard wireless phone conversations or captured Internet transmissions). Specify Services Offered: Clinicians should thoroughly inform clients of what they can expect in terms of services offered, unavailable services (e.g., emergency or psychopharmacology coverage), access to the practitioner, emergency coverage, and similar issues. Clarify Billing for Services: If third parties are billed for services offered via electronic means, practitioners must clearly indicate that fact on billing forms. If a third-party payer who is unsupportive of electronic service delivery is wrongly led to believe that the services took place in vivo as opposed to on-line, fraud charges may ultimately be filed. Koocher, G., & Morray, E. (2000). Regulation of telepsychology: A survey of state attorneys general. Professional Psychology: Research and Practice, 31,

15 Informed Consent: Additional Factors to Consider
“Several critical issues need to be addressed: Many technologies are powerful but fragile; crucial information can be lost or intercepted; not all Web sites providing information are reliable; service providers can easily misrepresent themselves and their credentials online; confidentiality in an electronic medium can quickly evaporate; jurisdiction, liability and malpractice issues blur when state lines and national boundaries are crossed electronically; numerous digital divides can thwart access and success; and clients and social workers alike may have unrealistic expectations for what a technology can actually provide.” NASW and Association of Social Work Boards Standards for Technology and Social Work Practice. p.6 For a sample Social Media Policy available for download and use, see Handouts or: K. Kolmes - Social Media Policy:

16 Dual Relationships and Therapist Self Disclosure
Boundaries are addressed in all professional ethics codes Dual/multiple relationships and therapist self-disclosure Involve at least Boundary crossing Possibly involve Boundary violation “Boundary violations” are clearly unethical and must be avoided. “Boundary crossings” are inevitable and must be monitored, managed, and deliberate when possible. Boundary crossings can be important and appropriate to enhance therapeutic effectiveness. In some situations it may be violating ethical principle of Beneficence to not cross a boundary if it would benefit a client. Zur, O. (2009). Therapeutic boundaries and effective therapy: Exploring the relationships. In W. Donohue & S. Graybar (Eds.), Handbook of contemporary psychotherapy: Toward an improved understanding of effective psychotherapy (pp ). Thousand Oaks, CA: Sage. Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the internet age. Professional Psychology: Research and Practice, 40,

17 Dual Relationships: Boundaries
Boundaries: “a flexible set of conditions that…establish rules and role expectations that the patient may rely upon for the safety required for treatment” Glass, L. L. (2003). The gray areas of boundary crossings and violations. American Journal of Psychotherapy, 57, 429. No longer inflexible prohibitions derived from strict analytic and risk management rules, e.g., “Never touch your client”, “Never give or accept gifts” The 2005 ACA Code of Ethics regarding potentially beneficial boundary crossings: "Examples of potentially beneficial interactions include, but are not limited to, attending a formal ceremony (e.g., a wedding/commitment ceremony or graduation); purchasing a service or product provided by a client or former client (excepting unrestricted bartering); hospital visits to an ill family member; mutual membership in a professional association, organization, or community.” American Counseling Association. (2005). ACA code of ethics. Alexandria, VA: American Counseling Association.

18 Confidentiality Confidentiality issues will be discussed in relation to various digital media platforms Keely Kolmes, Psy.D. addresses limits of confidentiality in her Private Practice Social Media Policy and on her website. Issues of confidentiality in specific situations are also addressed at her website

19 Clinical Ethics in a Digital World Summary and Overview
There are no current widely accepted guidelines regarding clinical use of digital technology Therapists must combine and apply their knowledge of: Digital technology currently available/in use We will review: Digital terms and digital platforms in use Developing guidelines for clinical use of digital technology We will review: Clinical uses of these digital platforms Existing principles and accepted guidelines We will consider: Ethical issues and concerns that may arise Clinical experience We will present: Ideas and facilitate discussion to address ethical issues and concerns

20 Ethics and Cultural Competence in a Digital World
Cultural competence refers to an ability to understand, communicate with, and effectively interact with people across cultures. Cultural competence comprises four components: (a) awareness of one's own cultural worldview, (b) attitude towards cultural differences, (c) knowledge of different cultural practices and worldviews, and (d) cross-cultural or multicultural skills. Consider your responses to the Context Questions regarding therapist’s flexibility, ability to adapt, and commitment to cultural diversity. The concepts of “digital natives” and “digital immigrants” provides a helpful cultural context for ethical decision-making in a digital world.

21 Digital Natives Generation X - Born in the early 1960's through the early 1980's, Gen X encompasses 44 to 50 million Americans. Members of Generation X are largely in their 30’s and 40’s. On the whole, they are more ethnically diverse and better educated than Baby Boomers. The first generation to grow up with computers, technology is woven into their lives. They adapt well to change, are tolerant of alternative lifestyles, and often "work to live rather than live to work". They appreciate fun in the workplace and espouse a work hard/play hard mentality. Generation Y - Born in the early 1980's through early 2000's, Generation Y (or the Millennial Generation or Eco-boomers) encompasses 70 to 80 million Americans, and is often sub-divided by age (adults, teens, tweens). Generation Y grew up with technology and takes it for granted. They are typically tech-savvy and often connected via smart phones, tablets, laptops, and other digital media platforms 24/7. Many in this generation prefer to communicate through social media, , text messaging, and digital media platforms rather than face-to-face contact. Post Gen Y

22 Digital Immigrants Baby Boomers - Born during the post WWII baby boom between the years 1943 and the early 1960's, Baby Boomers number around 80 million in the U.S. Baby Boomers are often associated with a rejection or redefinition of traditional values, with a general cynicism and distrust of government. Baby boomers found that their music, most notably rock and roll, was another expression of their generational identity. Baby boomers comprised the first generation to grow up with television, telephones, and portable (transistor) radios, and technologically sophisticated analog (as opposed to digital) devices. Pre-Baby Boomer

23 Terms to Facilitate Cultural Competence
What is digital technology? Technology used by devices such as computers, cell phones, TV, etc. Information represented digitally (i.e., using digits) instead of analogically, which allows much higher data volume and accuracy. What is the Internet? A global network of interconnected computer networks. “Net for Beginners” Wikipedia Internet entry What is the Web or World Wide Web (www)? A system of interlinked hypertext documents accessed via the Internet. With a web browser, one can view web pages that may contain text, images, videos, and other multimedia, and navigate between them via hyperlinks. Wikipedia World Wide Web entry What is a web browser? A software program for retrieving and presenting information resources on the Web. Internet Explorer (default browser with Microsoft Windows OS), Firefox (open source alternative to IE). What is a Search Engine? A program that searches Web documents for specified keywords and returns a list of the documents where the keywords were found. Google, Bing,,, DuckDuckGo, Dogpile

24 Terms to Facilitate Cultural Competence
What is social media? A broad term covering diverse types of digital media websites which do not just provide information. A common link between these websites is the ability to interact with the website and interact with other visitors, hence , “social” media. What is a blog? A personal journal posted on the Web for public viewing. Includes text, can include multimedia, and often links to other blogs or websites. May be primarily informational, may involve discussion (at which point it is a social media site) and sometimes called a weblog. What is TeleMentalHealth? The use of digital technology, usually interactive, 2-way audio and video, to provide mental health services between individuals who are not physically located in the same place. In addition to direct mental health care/psychotherapy, may include continuing education and consultation. Sometimes called telehealth, telepsychiatry, telemedicine, telepsychology, or e-health What is texting? Typing and sending a brief, electronic message between two or more cell phones or other digital devices over a network. Sometimes called text messaging. What is ? A method of exchanging text-based messages from an author to one or more recipients via digital devices (e.g., computers or cell phones).

25 Digital Technology Platforms and Issues Relevant to Clinicians
Focus on five types of digital technology platforms Internet Social Media (including blogs) TeleMentalHealth Texting For each platform Potential uses Advantages and concerns/disadvantages Potential therapist-client interactions/relationships and associated clinical and ethical considerations

26 The Internet: Potential Clinical Uses
Source of education/information Adjunct resource for in-person therapy Therapist seeks/discovers client information Client seeks/discovers therapist information Alternatives to in-person therapy, e.g., Online-Therapy, FearFighter

27 Therapist Accessing Client Internet Data
Digital Immigrants and Natives have typically heard that “nothing on the Internet is private.” Undisclosed or unauthorized Internet searches may not be illegal or violate specific ethical guidelines. However, if therapist assumes the right to seek such information, may violate principles of Autonomy, Justice, Fidelity. May also violate Principles of Beneficence and Non-maleficence if client feels trust has been violated and drops out of treatment, etc. Digital Immigrants may not have concerns about a therapist seeking information about them without explicit consent. However, it is the therapist’s responsibility to understand and uphold ethical practices, not the client’s.

28 Therapist Accessing Client Internet Data Client Privacy
Clients have the right to control information sharing with the therapist Awareness of information therapist possesses – Facilitates safe, trusting relationship Types of information - Demonstrating perceptions of the relevance of the shared information with presenting problems and treatment goals Amount of information - Testing the therapist’s ability to receive and process information; monitoring therapist reaction to information Timing of sharing - Perceived trust of the therapeutic relationship; reflection of client readiness to change Kaslow, F., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42,

29 Therapist Accessing Client Internet Data Informed Consent
Obtaining client Informed Consent about therapist practices regarding Internet searches for client information is strongly recommended (Principle of Autonomy). Internet searches without informed consent sometimes appropriate under duty to protect statutes/regulations, client incapacity, etc. (Principles of Non-maleficence and Justice trump Autonomy). With client’s prior informed consent, therapist on more solid ethical ground in either situation.

30 Informed Consent: Reflects Therapist Practice and Perspectives
Within sound clinical and ethical boundaries there can be different approaches to a therapist accessing client information: “At times I may Google my clients before the beginning of psychotherapy or during psychotherapy. If you have concerns or questions about this practice, please discuss them with me.” “I neither search for clients on Internet search engines such as Google, nor search my clients' social networking profiles such as Facebook, unless there is an acute crisis which involves safety issues.” “While my present or potential clients might conduct online searches regarding my practice and/or me, I do not search my clients via search engines or social networking sites such as Google, YouTube, or Facebook. If clients ask me to conduct searches or review their websites or profiles, and I assess that it might be helpful, I will consider it.” Zur, O. Digital Ethics 101: To Google or not to Google Our Clients? Retrieved from

31 Therapist Accessing Client Internet Data Intentional vs. Accidental
Digital scenario: Therapist inadvertently discovers troubling client behavior on social networking site, blog, sex offender registry, police blotter, etc. Non-digital analog: Therapist sees inebriated client at a public gathering by happenstance; client has claimed abstinence Therapist reading client’s blog entry during session with client, at client’s request, discovers troubling information about another client Spouse in couple’s therapy reveals secret about a client without client’s consent

32 Therapist Accessing Client Internet Data Intentional vs. Accidental
Discussion No inherent ethical issues in these situations. Therapist did not intentionally seek information without client consent. In first digital and non-digital scenarios, no reasonable expectation of privacy (although people often demonstrate poor judgment about this). However, clear clinical issues in these situations that can raise ethical issues. It is essential for therapist to determine how to handle such information consistent with Principles of Beneficence and Fidelity.

33 Client Access to Information About Therapist
Therapist Self-Disclosure: Revelation of personal rather than professional information Deliberate – Information a therapist chooses to share Example: Verbal disclosure of personal information, nonverbal disclosure ( e.g., displaying personal photos or affective reactions to client information) Self-revealing (therapist information) and self-involving (therapist personal reactions) Designed to enhance effectiveness of treatment, benefit client Unavoidable – therapist “disclosure that is neither deliberate nor avoidable … [information shared that is] part of everyday life” (p. 23) Example: Gender, age, personal appearance, office location and décor, time off Accidental/Inadvertent – Information therapist inadvertently shares when inadvertently overlooking or ignoring safeguards Example: Unplanned encounters in a public venue, spontaneous verbal or non-verbal responses to client information Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the internet age. Professional Psychology: Research and Practice, 40,

34 Client Access to Therapist Internet Data
Digital Technology: More difficult for therapist to control information sharing (i.e., to deliberately share information): Clients “Google” therapist Online evaluations and complaints (,,, Social network (Facebook, MySpace, LinkedIn) Licensing Board information Therapists cannot control all information available about them Accept, manage, embrace, take advantage of the digital technology that makes the information available

35 Client Accessing Therapist Internet Data
Curiosity APPROPRIATE Simple Internet search (e.g., Google, Bing) Done by most people before going to therapist Due Diligence More thorough: Search engines plus social media, licensing boards, ratings sites Not unusual, healthy, often encouraged Intrusive “Lurking” in professional sites, chatrooms, listserv without therapist knowledge Deceitful Client using false identity to interact in social media sites, chatrooms, etc. Illegal and Cyber-stalking Pay to obtain extensive personal information (typically $15 - $60) Type name in search engines and ads often appear on right side of page INAPPROPRIATE Zur, O. “Digital Ethics and online boundaries”.

36 Client Accessing Therapist Internet Data: Managing Therapist Internet Disclosures
Expect and encourage informed consumers to do “simple” or “more thorough” searches Be careful about anything you post on websites, social media, blogs, chatrooms, etc. - Remember: everything posted online remains indefinitely and anything posted online is potentially available for anyone to view Separate professional and personal information (privacy settings, passwords, etc.) Search yourself regularly using various name combinations Sign up for Google alerts ( Carefully evaluate your response to negative postings Zur, O. “Digital Ethics and online boundaries”.

37 Managing Therapist Internet Disclosures Negative Postings About You
Do not panic or react impulsively Carefully evaluate your options (some options listed below) Consult with colleagues and/or experts ORM (Online Reputation Management) (e.g., Ask site to remove the negative posting (some will, some will not) Ask colleagues to write honest positive information on the site Do not post a rebuttal or criticism (confidentiality, inflammatory) Establish a positive web presence (preponderance of Internet information about you is accurate and deliberate)

38 Description and Examples of Social Media
For helpful descriptions of various social media platforms (and the source of the graphic above), see “The Immense Guide to Social Media Sites 2013” : Select slide information obtained from Macchi, C. R., & Ingram, J. (2011). Ethical issues of therapists’ involvement in social networking. Retrieved from

39 Description of Social Media
A broad term covering diverse types of digital media websites which do not just provide information. A common link between these websites is the ability to interact with the website and interact with other visitors Facilitates connecting and communicating among diverse groups, or individuals with common interests

40 Social Media: Categories
Networking Facebook: maintain personal connection with friends and family Twitter: follow relevant people within your area of interest, more relaxed than LinkedIn LinkedIn: primary professional network, online CV Google+: newest of social networking platforms, tries to combine best of Twitter and Facebook MySpace: Discover, share and connect to music from the world's largest streaming library.

41 Social Media: Categories
Support and Health Information Sharing Use search engine, type “[problem or disorder] support group online” Depression: – Depression, Anxiety:, PsychCentral – Anxiety Sexual Abuse: Pandora’s Project, sexual abuse support groups PTSD: PTSD support groups, National Center for PTSD

42 Social Media: Categories
Discovery Pinterest: online pin board, “pin” visual content StumbleUpon: go to random website, blog, image or video aligned with your chosen interests Delicious: catalog and organize online bookmarks/hyperlinks, resources 

43 Social Media: Categories
Showcase YouTube: most popular (4B hits/day) video sharing site, entertainment and education (similar: Vimeo, Metacafe) MySpace: entertainers and fans, especially music, connect and showcase (similar: Soundcloud, Mixcloud) Pinterest: exhibit work/products visually (similar: Piccsy) Blogs: Tumblr, WordPress Webinars

44 Social Media: Categories
Q & A Sites Quora: contribute answers/questions, can establish expertise, “best” answers, not all answers StackExchange: network of specialist Q&A sites, profile page allows posting your Q’s and A’s Yahoo! Answers: widespread use, lacks social dimensions/community controls Webinars

45 Social Media: Categories
Social News Digg: keep abreast of breaking news across the internet, submit interesting content Reddit: news submitted and recommended by users, can start topic with a question Technorati: a leading search engine for blogs Buzzfeed, Alltop, Fark

46 Clients’ Use of Social Media
Clients are increasingly using social media to access health-related resources and become better-informed consumers Types of social media most often used involve support groups: Blogs Chat rooms Message boards Online communities Patient testimonials “New technology is empowering patients and enabling them to be much more assertive and health-care professionals have to spend more time helping them to sift through what might or might not be helpful online.” (Neil Coulson, a chartered psychologist at the University of Nottingham, UK, p. 1142) Devi, S. (2011). Facebook friend request from a patient? Lancet Medical Journal, 33, Retrieved from

47 General Ethical Issues Associated with Social Media
Client confidentiality – privacy of information client controls the timing, types, amounts, and ways personal information is shared with the therapist clinicians use reasonable safeguards to protect PHI from unintended or unauthorized disclosures or uses (HIPAA Privacy Rule) Client confidentiality – security of information Clinicians prevent unintended or malicious disclosure, alteration, or loss of PHI Therapist self-disclosure and transparency Therapist manages personal information shared or available to client Dual relationships Therapist enters into relationship with client outside of therapy relationship Taylor, L., McMinn, M., Bufford, R., & Chang, K. (2010). Psychologists attitudes and ethical concerns regarding the use of social networking web sites. Professional Psychology: Research and Practice, 41, Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the internet age. Professional Psychology: Research and Practice, 40,

48 Specific Issues: Ethical Principles - Therapist Accessing Client Information Via Social Networking Sites Autonomy, Fidelity: Disrupts the client’s control of personal information and the pacing of treatment Therapist views information on FB page that appears to be relevant to the therapeutic work that the client has not yet revealed Autonomy, Fidelity, Justice: Therapist becomes a “secret-holder” Client working on extra-marital affair is pictured with the paramour on his FB page while his partner remains unaware Autonomy, Fidelity: Therapist becomes an investigator verifying client information Client reports about having written books and attending certain schools while the internet reveals no information Autonomy, Fidelity: Therapist must manage conflicting or contradictory information Client describes she has been sober for three months. A picture on FB shows her holding a drink at a recent party Kaslow, F., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42,

49 Specific Issues: Ethical Problems - Facebook “Friend” Request from a Client
Dual Relationship: Altering client’s perception of the therapeutic relationship Client learns about therapist’s political and social views/activities, family and friends, listed on profile Client interacts with therapist like other Facebook “friends Blurred Boundaries: Client develops an expectation that contacting the therapist outside of therapy is acceptable and even invited Client is “invited” into clinician's personal life Client posts questions that should be addressed in therapy on the therapist’s wall Confidentiality: Client sees list of therapist’s “friends”, wonders which others may be clients Kaslow, F., Patterson, T., & Gottlieb, M. (2011). Ethical dilemmas in psychologists accessing internet data: Is it justified? Professional Psychology: Research and Practice, 42, Devi, S. (2011). Facebook friend request from a patient? Lancet Medical Journal, 33, Retrieved from Therapist’s approach to “friend” requests should be explicitly covered in Informed Consent

50 Specific Issues: Potential Problems Related to Subtleties of Digital Technology
If account used to create Twitter account is used to a client (e.g., to change an appointment time), when client looks for "friends" on the Twitter site you are likely to be on the list and vice versa.; however, therapists should be mindful of unavoidable and accidental forms of self-disclosure that may affect others’ perceptions and the therapy process Relatives or friends of clients may follow our professional social media postings and express strong reactions to client. Client may feel protective, defensive, or uncomfortable If clients become “Fans” or “like” clinician's professional Facebook page, this may raise confidentiality concerns, e.g., which other Fans may also be clients If clients become “Fans” or “like” clinician's professional Facebook page, this may be considered a passive request for a client testimonial, which is forbidden in ethics codes If family members and friends become “Fans” or “like” the page, clients will have access to this information If clinician posts at 2:00 AM, is this indirectly revealing information about clinician’s personal schedule and habits and how might it affect clients who notice? Friends or colleagues may post well-meaning comments on clinician's Facebook wall which might be too personal for clinician's comfort You are meeting with a client addressing a certain issue. Later that day, the client views your Facebook page where you have provided a link to information related to their issue; client believes the post is about him/her

51 Initial Considerations of Using Social Networking
Determine if social networking is right for your personal use, for your practice, or both Decide if your professional involvement in social networking is an added benefit to your therapeutic work Consider the potential risks and challenges that your involvement in social networking may present to your therapeutic relationships and work Informed Consent is necessary to provide guidelines for the therapeutic relationship and to make your policy of social networking explicit Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the internet age. Professional Psychology: Research and Practice, 40,

52 Practical Guidelines for Social Networking
Maintain separate accounts for professional and personal involvement in social networking A professional account can be established to promote practice and disseminate therapeutic resources A professional social media presence becomes part of a clinician's professional space, with associated legal and ethical responsibilities Carefully consider site affiliations and access to affiliated professions – “identity by association” Provide clear guidelines for participant postings All clinical activities, including social media presence, should consider potential effects on clients: Beneficence, Non-maleficence, Fidelity Set personal accounts to the highest privacy setting in order to control the amount and types of information that are available to the general public, and thus to your clients

53 TeleMentalHealth Our Focus
Sometimes called telehealth, telemedicine, telepsychology, telepsychiatry, e-health Limited consistency in defining what it is, how it should be conducted, when, where, and with whom it is appropriate, who can provide it, types of technology involved However, addressed more completely than clinical use of most other digital media Specific service directed toward specific individual (as opposed to broad audience of Internet and Social Media) Ethical issues similar to in-person Our Focus Direct counseling/psychotherapy via real-time, audio/visual teleconferencing between therapist and client

54 TeleMentalHealth: Issues to Consider
Who why, what, and where Informed Consent Confidentiality Privacy Security Effectiveness Reimbursement Therapist technological competence

55 TeleMentalHealth : Issues to Consider
Who and why Individuals who have trouble attending in-person Physical disability, geography, transportation, psychological disability, cost What Primary mode of treatment Adjunct or intermittent treatment along with in-person Where Jurisdiction of therapist’s license Appropriate, secure, private site (not home)

56 TeleMentalHealth: Informed Consent
Verbal and in writing, signed copy in client record (recommend arrangement with site) Unique TeleMentalHealth Factors in addition to usual Informed Consent Possibility of technology failure and contingency plans Procedure for contacting clinician when offline Use of encryption methods to ensure security Potential risks to confidentiality when communication unsecured What info. included in record, how stored and accessed Outline emergency procedures, safety protocols, local professional Clinician response to routine communications, including time Fees and reimbursement/billing procedures Where and how to make complaints Sample Social Media Policy available for download and use: K. Kolmes - Social Media Policy:

57 TeleMentalHealth: Advantages
Client satisfaction comparable to in-person Outcomes comparable to in-person Accessible, not limited by proximity Improved client choice for best treatment Less costly

58 TeleMentalHealth: Concerns
Inconsistencies in definitions, regulations Clients for whom it is contraindicated Client and therapist acceptance (better than anticipated) Less environmental control (addressed through planning/coordination with site) Clinician competence req. by Ethics Codes (education, consultation, supervision) Acceptable technologies (HIPAA compliant) Encrypted Secure Transmission quality Provide audit trail, breach notification, Business Associate Agreement Inconsistencies re. reimbursement Medicare – Federal rate comparable to in-person, conditions include HPSA and MSA, at approved sites, live A/V communication (not phone or ) Medicaid – Varies by state, reimbursed in Virginia, verify specific conditions Private Payers – Vary by payer, typically follow BC/BS reimbursement for TeleMentalHealth, rates vary by payer and state, verify with payer.

59 TeleMentalHealth: HIPAA Regulations
Several alternatives to Skype which are/may be HIPAA compliant: Secure Telehealth VIA3 TelemedicineIM Vsee eTherapi

60 TeleMentalHealth: HIPAA Regulations
Confidentiality involves: HIPAA Privacy Rule: Focus on rules governing intentional disclosures of PHI Requires clinicians to use reasonable safeguards to protect PHI from unintended or unauthorized disclosures or uses HIPAA Security Rule: Focus on preventing unintended or malicious disclosure, alteration, or loss of PHI

61 Text and E-mail Communication - Considerations
Absence of face to face cues Synchronous vs. asynchronous interaction Disinhibition Recordable Technology problems/disruptions Reduced environmental control Confidentiality Where and how documented

62 Guidelines for use of Texting and Email
If you discuss clinical issues with clients/potential clients via text or , this can be considered a clinical service and clinical relationship Such communication should be documented as part of the clinical record Such interactions should comply with all legal and clinical requirements/guidelines, including HIPAA, state laws, etc., including confidentiality, privacy, security, boundaries. Informed Consent should be reviewed as soon as reasonably possible

63 Guidelines for use of Texting and Email
Clarify to yourself your thoughts and feelings regarding text and communication with clients. What are your preferences for appropriate use, your limits, etc.? Discuss the issue of text and communications with clients, when relevant, in the first session or first contact (brief verbal description of Informed Consent). Learn from them about their expectations and clarify your expectations and boundaries, potential limitations of confidentiality. Continue the dialogue as clinically and ethically necessary throughout the course of therapy. Make sure that your office policies include a section on the use of text and ( along with use/not use of Internet, Social Media, etc.) For text and (or other digital communication) make sure your computer, cell phone or other digital device has a password, virus protection, firewall, and back up system (see HIPAA Privacy and Security Rules). Encryption is recommended. Consider secure, encrypted, user verified services such as Hushmail Make sure that each includes an electronic signature that covers issues such as confidentiality and security. Zur, O. (2011). I Love These s, or Do I? The Use of s in Psychotherapy and Counseling. Retrieved from

64 Discussion: Online Treatment Recommendations

65 Principle-based Ethics
ADDENDUM Principle-based Ethics

66 Principle-based Ethics
Principle-Based Ethics is based on a commitment to five overarching, common, basic prima facie moral principles: Beneficence Nonmaleficence Autonomy Justice Fidelity

67 Principle-based Ethics: Beneficence
Benefit others, promote others’ welfare Accept responsibility to do good Beneficence is one of the primary reasons for existence of helping professions Others seek services with expectation that they will profit/benefit from out services

68 Principle-based Ethics: Nonmaleficence
Do no harm, physical or psychological Do not engage in activities that have high risk of harming others Nonmaleficence is fundamental to any helping profession dedicated to promoting others’ welfare Engaging in harmful activities contradicts core concept of profession

69 Principle-based Ethics: Autonomy
Informed, non-coerced freedom of thought Informed, non-coerced freedom of action (as long as it does not interfere with others’ freedom of action) Moral independence Clinician does not have the right to interfere in others’ lives just because their decisions seem wrong, except in very circumscribed conditions Assumes individual has: Ability to think and act rationally Ability to act with understanding of the consequences of the action Implies reciprocal relationship with others Each respecting the other’s choices, even if not in agreement

70 Principle-based Ethics: Justice
Act fairly or justly Concern for the equality and rights of all Fair treatment of an individual when his/her interests must be balanced against the rights and interests of others. Justice is fundamental for clinicians because of professions’ concern for welfare of others Fairness is necessary for trust that clinician will act in client’s best interest

71 Principle-Based Ethics: Fidelity
Being faithful to commitments and promises Do not deceive or exploit Fidelity is at the core of relationships between helping professionals and clients Promise-keeping Trustworthiness Loyalty

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