Practicing Psychotherapy on the Internet
by Marlene M. Maheu, Ph.D.
Learning Objectives
- Learn the risks associated with reporting confidential information via internet.
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Learn how to effectively employ risk management when offering psychotherapy through the internet.
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Learn the legal and ethical ramifications that come with providing services via internet and the important diagnostic cues that are absent.
RISK MANAGEMENT CHALLENGES
AND OPPORTUNITIES
Imagine a dot.com referral
service that allows consumers to select a psychotherapist in their state
of residence. You register, and eagerly await referrals. Within a month,
you receive an email referral from someone at the far end of your state.
The email describes the
details of how a prospective patient "had to punish" her elderly grandmother
for not eating and not bathing last night. The consumer is requesting
your professional services for managing her anger toward her grandmother.
The note describes the punishment in enough detail that you have reason
to report her for elder abuse. You have her name, street address and
telephone number, as well as that of her grandmother. The consumer awaits
your response. You look at the website documentation, and they suggest
you "follow your state protocols" or "dial 911" for all emergencies.
What do you do?
The unwitting clinician
in the above scenario is in a difficult position. Depending on state
laws, reporting the patient could be mandatory. However, such a report
is fraught with complications, and risk of losing or alienating the
patient is high. Duty-to-warn situations, such as the one above, can
leave the untrained and uninformed practitioner at increased risk for
malpractice when operating
in email with unknown, unscreened, unseen and unheard prospective patients.
Yet, the assimilation of
technology is a requirement for almost any industry seeking to maintain
a viable position in today's global marketplace. Psychotherapy is no
exception. Practicing psychotherapy online is inevitable. Technology
will increasingly enhance our ability to offer services to patients
who are unable or unwilling to use existing faceto- face services because
of geography, disability, finances, work schedules, and a variety of
other life circumstances. Yet, as we can see with the above vignette,
barriers to such practice are becoming more salient.
While technology has leapt
ahead of our ability to develop a body of research and clear legal,
regulatory or ethical guidelines for the remote practice of psychotherapy,
many earnest clinicians are seeking guidance to expand their practices
without incurring additional risk. Making sense of often-conflicting
informational sources is time consuming and anxiety provoking. Therefore,
this article will give a brief outline of barriers to using telecommunication
technologies, and suggest a risk-management model that takes advantage
of the telehealth literature to carve a path through those barriers.
BARRIERS TO USING THE
INTERNET FOR PSYCHOTHERAPY
Barriers to the immediate
practice on the Internet include a variety of factors. Only those of
direct relevance to the practitioner are discussed in the following
section.
Utility. Many technology
developers have not yet developed helpful products and services for
psychotherapists. Existing technologies often require more time and
energy than traditional service delivery.
Confidentiality.
Computer and Internet security and confidentiality are easily compromised.
Breaches of privacy are rampant. For example, many practitioners do
not know how to completely remove patient files from their own computer
hard drive, how to secure email transmissions to protect patient confidentiality,
or how easily a patient can install a "Trojan Horse" program into the
practitioner's computer to download its contents onto a remote computer.
Legal protections for patients
and practitioners are still in flux. While federal standards to protect
the transmission and privacy of medical information are currently being
developed, compliance is not yet mandatory for many such standards.
A number of Internet businesses are using the current, relatively unregulated
interval to gain a foothold on "market share," while testing various
business models with naïve practitioners.
Ecomonic Drivers.
Service delivery models suggested by many dot.com mental health websites
put the practitioner at risk. Many such websites are developed with
more of an eye toward making a profit than delivering services that
would benefit both the patient and practitioner. For example:
- Some web-based businesses require
that a practitioner sign a service agreement that not only holds the
practitioner responsible for any and all malpractice liability, but
explicitly indemnifies the dot.com.
- Some web-based businesses encourage
practitioners to work with anonymous patients.
- Some web-based businesses encourage
practitioners to ask the patient to dial "911" for all emergencies,
including suicide or homicide.
- Some web-based businesses offer consent
agreements and disclaimers, but the effectiveness of such agreements
on web pages is questionable.
- Some web-based businesses verify the
practitioner's credentials and state of licensure, they do not verify
the consumer's state of residence. The practitioner, then, does not
have evidence of a consumer's location when delivering services. Yet,
the professional may be responsible for practicing out of state, even
if consumers misrepresent themselves.
Training. Most practitioners
are not trained to use advanced telecommunications equipment, and therefore
do not fully understand the legal, ethical or practical ramifications
of using such technologies. Text-based environments, such as email and
chat rooms, are the only current types of communication supported by
web services offering any form of confidentiality. Most practitioners
have not had graduate training regarding psychotherapeutic contact in
text-based environments (email or chat). Practitioners are generally
taught to conduct assessment and treatment using auditory (voice amplitude,
rate of speech, stuttering or hesitation) and visual (eye contact, blushing,
fidgeting) cues, not textual cues. Practitioners are also not typically
aware of the numerous ways in which their own computer privacy can be
compromised by computer savvy patients.
Attentiveness, Distraction
and Privacy. From the clinician's perspective, it is more difficult
to determine if a person is fully attentive or distracted during the
therapeutic interaction when using technology. Practitioners therefore
need to be trained or otherwise experienced in the various possibilities
for misinterpretation when working with each specific technology before
offering services to the public.
Duty to Warn Situations.
While many practitioners are trained in crisis management through the
telephone, they are not trained in crisis management through email or
chat rooms. Training with one technology does not automatically amount
to training in another. Furthermore, conclusive research into the efficacy
of any treatment mediated by email or chat room has not yet been conducted.
While the lure of existing technology may be strong, the duty to protect
patients must be stronger.
Many dot.com developers
also conveniently encourage practitioners to "follow state law" when
dealing with duty to warn situations, but state laws are not yet developed
in most states. Moreover, some dot.coms encourage practitioners to "refer
suicidal or homicidal patients to 911." Many practitioners are not comfortable
with such arrangements because they know that these patients are typically
reluctant to engage law enforcement officials to stop them from their
intended actions.
Linguistic and Cultural
Competence. With worldwide connectivity brought by the Internet,
consumers from remote areas of the planet can easily make contact with
a clinician. The clinician's familiarity with colloquial expressions,
idioms, and local variations of word usage can be crucial when working
with mentally ill, suicidal or homicidal patients.
Similarly, cultural norms,
local traditions, and religious rituals can all play important roles
in the lives of clients and patients. To offer behavioral and mental
health care in the absence of such information is questionable practice.
Local Events and Emergency
Backup. A related issue is that of the clinician needing to have
awareness of local area events that might influence the emotional state
of consumers of Internet services. Similarly, it is the responsibility
of the professional to have adequate emergency backup systems in
place before offering services to consumers, even if patients do not
think such backup relevant or important.
Reliability of the Connection.
Reliability of contact is lessened significantly when delivering services
through telecommunication
technologies. Backup must be developed.
Research. By 1998,
behavioral health care via videoconferencing accounted for nearly one
fifth of all telemedicine consultations in the United States. Other
studies of current telehealth programs nationwide show that nearly one
half involve some type of mental health service. This high utilization
rate makes behavioral telehealth the fastestgrowing area of telehealth.
Such studies have been reported in the behavioral healthcare literature
for approximately 40 years. Much of these findings are related to videoconferencing
and/or computer mediated self-directed programs that augment traditional
psychotherapy.
Pilot programs investigating
two-way, interactive videoconferencing generally use a model based on
local evaluation of a patient by a clinician, with consultation or referral
to a remote specialist who is accessed through videoconferencing. These
studies are most often conducted in controlled settings with small and
often relatively homogeneous patient subgroups (not global population,
such as found on the Internet).
Computer medicated self-directed
programs have also been shown remarkably effective for treating a variety
of disorders. Successful programs tend to regularly involve the intervention
of a psychotherapist, rather than being exclusively patient-driven.
Of particular note is that
only a few studies have examined the clinical utility of using email
or chat rooms with patients. These reports typically are anecdotal and
inconclusive. Furthermore, research has not shown the efficacy of any
assessment instrument to rule out serious mental illness in the worldwide
population accessible through an Internet website.
RISK MANAGEMENT SUGGESTIONS
The dubious practice of
offering psychotherapy to unknown consumers worldwide without the proper
research to establish the utility, efficacy and reliability of email
and chat rooms with any clinical population is fraught with pitfalls.
However, the risk management procedures outlined below may also be considered
potential solutions for practitioners seeking to deliver services to
remote patients using videoconferencing.
These protocols have been
used as the basis for delivering psychotherapeutic services via videoconferencing
technologies for several decades. Suggestions include:
Obtain Training.
Before proceeding to deliver services through technology, be sure to
obtain training from recognized training organizations or specialists
in proper use of specific technologies to conduct psychotherapy with
behavioral health patients.
Referrals. Be cautious
about accepting referrals exclusively in email. Accept referrals and
conduct early assessment with patients by using the telephone. Verify
state of residence of all remote patients by asking for proof.
Initial Assessment &
Consultation. It is wise to follow the precedent set in telehealth
and telemedicine programs when seeking to deliver remote services. Require
face-to-face contact for assessment and diagnosis before using technology
of any kind to deliver psychotherapy. Obtain a fully detailed consent
agreement. Use videophones or dedicated videoconferencing equipment.
When using the Internet, only use technologies that are encrypted (encrypted
video technology is not yet developed for the Internet).
If face-to-face assessment
by a specialist is not possible, conduct full assessment with the assistance
and presence of a local, non specialist practitioner during videoconferenced
evaluation of the patient. Obtain agreement from the local practitioner
to act as backup
in the case of emergency.
Email Exchange. If
public Internet-based email is used, these suggestions may be helpful
for licensed psychotherapists:
- Have an existing professional relationship
with the patient;
- Provide the patient with informed
consent about the use of email. Have your consent form indicate that:
- contact in email has not been
proven to be a validated approach to conducting psychotherapy;
- if you engage in communication
with the patient in email, you may be acting outside the existing
standard of care for your profession; and
- confidentiality problems exist,
and that acceptable cures for those problems involve encryption.
- If the patient does not want to use
encryption or work through a website offering encryption, do not ask
patients to sign away their basic rights of privacy and confidentiality.
- Specify the type of inquiry you will
address in email, (i.e., setting or rescheduling appointments, giving
titles of books or webpages, giving referrals to other professionals).
- Explain the ease with which email
can be in tercepted not only on the public Internet, but by family
members and friends of the patient.
- Inform patients of whom else might
be seeing their email communications to you, and who might be responding
to their requests in your place (supervisor, office manager, office
assistant).
- Let the patient know when you typically
will respond to email, and what to do if they do not get the response
they anticipate. Make backup plan for when email is not received as
expected, i.e., have the patient telephone you if upset or worried.
- Print all copies of email sent to
and received from a patient. Place these hard copies in the patient's
paper file.
- Choose patients wisely when experimenting
with new procedures. Email may not be a particularly good medium for
highly reactive and potential dangerous patients such as those with
borderline personality disorder, paranoia or dissociative disorders.
- Because state licensing laws differ
from state to state, do not assume that sending email to a patient
in another state is acceptable under practice regulations for that
state. Inform yourself of the legal requirements for each state involved
when sending email to patients. If you choose to work in email with
patients you have never met face-to-face, require them to verify their
state of residence. Ask your attorney to approve your verification
procedure.
- Do not refer to colleagues who do
not use your level of precaution when communicating with patients
in email.
Economic Drivers.
Do not assume that a well-funded dot.com company or webmaster has your
best interest in mind. Given recent market pressures, economic survival
is questionable for most of these companies, and your protection is
not necessarily their highest priority. It therefore is suggested that
you thoroughly examine the service agreements offered by behavioral
and mental health care dot.coms. If you plan to develop your own website,
be sure to get a written contract with your website developer regarding
security
and confidentiality of the files that will be kept.
Manage Your Risk.
Regardless of the vendors you hire to mediate contact through technology
with your patients, describe your intended treatment protocols and their
rationale in writing. Send copies of all agreements, disclaimers, consent
forms, and treatment protocols to your attorney. Seek the advice of
your peers, and send a copy of these documents to your local, state
and national ethics
boards, malpractice carriers and licensing boards. Ask them all to respond
to you in writing about the legitimacy of the professional services
you intend to deliver to the public. While you may not obtain direct
approval for the services you plan to deliver, you will have documented
that you sought the advice of your peers in developing your innovative
services.
A series of lawsuits will
undoubtedly clarify legal and ethical matters for our professions. Be
prepared. The above activities will take you a few hours, and can prevent
years of litigation.
TECHNOLOGICAL CONSIDERATIONS
It is likely that a blend
of videoconferencing and other telecommunication and informational technologies
(email, voice over the Internet, videomail) will be used in conjunction
with face-to-face sessions to form the standard of practice for most
psychotherapists within the next decade. Meanwhile, types of two-way,
exisiting interactive videoconferencing equipment for the solo or small
group practice include videophones and specialized videoconferencing
software.
Videophones. Videophones
are products that allow interactive videoconferencing through the telephone
and television, without a computer. The videophone is an ‘easy to install’
camera unit that is smaller than a VCR. Images are presented either
on television, a monitor screen, or to a screen on the telephone itself.
Telephone charges are the same as any outgoing telephone call. They
can typically be purchased from electronics stores, such CompUSA or
Frye's Electronics, or online for between $300 - $2,400 retail. Manufactures
of reputable units include InnoMedia < http://www.innomedia.com/> and
Starview .
Specialized Videoconferencing
Software. Videoconferencing is also possible through the Internet
with software such as Microsoft's Net Meeting and White Pine Software's
CU-SEE-ME. Existing videoconferencing transmission using dial-up modems
is also not fast enough to be HIPAA compliant (secure and confidential),
rendering such transmission inadequate for immediate psychotherapeutic
application.
It has been estimated that
HIPAA compliant, reliable Internet videoconferencing will be available
in the next few years. Meanwhile, psychotherapists are able to use videophones.
Such capabilities will ultimately free the practitioner and patient
from needing to meet in the brick-and mortar office setting.
CONCLUSION
There are innumerable growth
opportunities for psychological practice through telecommunication technologies.
However, email and chat rooms remove the diagnostic and clinical (auditory
and visual) cues relied upon by traditional practice. They have not
been shown effective by well-designed research, and are accessible by
people from around the globe, with widely differing cultural and linguistic
characteristics. Practitioners have not been trained to use these technologies
to serve such a varied population. Until these services are adapted
to meet the legal and ethical requirements of mental health professionals
in these unprecedented circumstances, it
is imprudent to use email and chat rooms to establish or maintain psychotherapeutic
relationships with unscreened, undiagnosed, unseen, unheard and unknown
consumers through the Internet.
However, it is not only
reasonable but also exciting to consider the possibilities for psychotherapy
afforded by technology. A successful model has been developed for the
remote delivery of mental and behavioral services in healthcare using
two-way, interactive videoconferencing. Numerous pilot projects in behavioral
telehealth have set a precedent that requires an initial face-to-face
assessment, diagnosis, backup procedures, and a patient consent agreement
in conjunction with videoconferencing to conduct
a wide range of traditional psychotherapeutic functions with patients,
their families, and their other healthcare practitioners. Research has
also shown the efficacy of computerized, self-directed programs when
used in conjunction with traditional clinical care. The use of these
technologies have been documented and shown effective in numerous situations
with various types of patients.
Yet, the need for continued
research is obvious. We need better international screening tools for
determining who will benefit from remote treatment, especially on the
Internet. We need to identify which clinicians will be bestsuited and
most comfortable delivering services through these technologies. We
need legislation to support our work and protect practitioners as well
as patients. We need clear practice and treatment guidelines for use
with various technologies and patient populations.
At the individual level,
and as with all other new areas of practice, it is wise to seek consultation,
obtain specialized training, and familiarize ourselves with the literature.
It is reasonable to follow a behavioral telehealth model that has been
shown effective through credible research. It is prudent to document
that we have sought the advice of our peers.
The most important risk
is that if we do not become active in shaping and developing new technology
for our professions, others will. Propelling us to quicken our step
rather than wait, our competition in the healthcare arena poses yet
another and perhaps more daunting threat. Rather than leaving our fate
to be determined by business minds or inexperienced clinicians, the
future of our professional rests upon the traditional, seasoned psychotherapist/researcher
who can lead the march of identifying the salient aspects of the therapeutic
relationship for mediation through technology. The challenge is great,
and so it the opportunity.
AUTHOR
Dr. Maheu is developing
a post-doctoral certificate program in telehealth at Alliant University.
She has served as Chair of the California Psychological Association's
Presidential Telehealth Task Force, the American Psychological Association's
Committee on Professional Practice Standards (COPPS), and is Co-chair
for APA Division 46, Task Force for Media & Telehealth.
She is also a national consultant,
trainer and speaker for professionals interested in developing technology-based
healthcare services. Her award winning www.Selfhelp-Magazine.com, an
online electronic magazine, has over 7,000 daily readers. She is lead
author of E-health, Telemedicine and Telehealth: A Practical Guide to
Startup & Success, currently available through .
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