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
Training Objectives
• Provide a brief overview of digital and social media platforms (e.g.,
Internet, Facebook, Twitter, e-mail) 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
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Handouts in Packet
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Guiding Principles and Digital Media
Key Definitions and Glossary
Sample Agency Policy
Sample Private Practice Policy
Email Guidelines
Email Discussion
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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:
 True
 False
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Context Question:
Better-Worse vs. Advantages-Disadvantages
In-person Relationships**
Cyberspace Relationships*
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



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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)
Which of these advantages and disadvantages are relevant in psychotherapy?
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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
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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, 105-112.
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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
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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
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Other Guidance Regarding
Clinical Use of Digital Technology
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Ohio Psychological Association (2010):
http://www.ohpsych.org/psychologists/files/2011/06/OPATelepsychologyGuidelines41710.pdf
National Association of Social Workers and Association of Social Work Boards - Standards for
Technology and Social Work Practice: http://www.aswb.org/pdfs/TechnologySWPractice.pdf
Canadian Psychological Association – Providing Psychological Services via Electronic Media:
http://www.cpa.ca/aboutcpa/committees/ethics/psychserviceselectronically/
American Telemedicine Association - Practice Guidelines for Videoconferencing-Based Telemental
Health: http://www.americantelemed.org/docs/default-source/standards/practice-guidelines-forvideoconferencing-based-telemental-health.pdf?sfvrsn=6
American Telemedicine Association – Evidence Based Practice for Telementalhealth:
http://www.americantelemed.org/docs/default-source/standards/evidence-based-practice-fortelemental-health.pdf?sfvrsn=4
International Society for Mental Health Online - Suggested Principles for the Online Provision of Mental
Health Services: http://www.ismho.org/suggestions.asp
For a more comprehensive list of available guidelines see: Pope, K. Ethical Standards & Practice Guidelines for
Assessment, Therapy, Counseling, & Forensic Practice. http://kspope.com/ethcodes/index.php
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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
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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, 42. 440.
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Major Ethical Issues in a Digital World
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Informed Consent
Boundaries
Dual/multiple relationships
Therapist self-disclosure
Confidentiality
The following slides briefly consider these issues in a
non-digital context
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Informed Consent: Factors to consider
1.
2.
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7.
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, 503-508.
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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.
http://www.aswb.org/pdfs/TechnologySWPractice.pdf p.6
For a sample Social Media Policy available for download and use, see Handouts or:
K. Kolmes - Social Media Policy: http://drkkolmes.com/for-clinicians/social-mediapolicy/
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Dual Relationships and Therapist Self Disclosure
Boundaries are addressed in all professional ethics codes
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Dual/multiple relationships and therapist self-disclosure
– Involve at least Boundary crossing
– Possibly involve Boundary violation
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“Boundary violations” are clearly unethical and must be avoided.
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“Boundary crossings” are inevitable and must be monitored, managed, and deliberate when possible.
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Boundary crossings can be important and appropriate to enhance therapeutic effectiveness.
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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. 341-357).
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, 22-30.
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Dual Relationships: Boundaries
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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.
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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.
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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
• http://drkkolmes.com/for-clinicians/articles/
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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
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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) crosscultural 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.
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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, email, text messaging, and
digital media platforms rather than face-to-face contact.
• Post Gen Y
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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
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Terms to Facilitate Cultural Competence
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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, Yahoo.com, Ask.com, DuckDuckGo, Dogpile
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Terms to Facilitate Cultural Competence
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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 e-mail?
– A method of exchanging text-based messages from an author to one or more recipients
via digital devices (e.g., computers or cell phones).
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Digital Technology Platforms and Issues
Relevant to Clinicians
Focus on five types of digital technology platforms
•Internet
•Social Media (including blogs)
•TeleMentalHealth
•Texting
•E-mail
For each platform
•Potential uses
•Advantages and concerns/disadvantages
•Potential therapist-client interactions/relationships and associated clinical
and ethical considerations
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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
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Therapist Accessing Client Internet Data
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Digital Immigrants and Natives have typically heard that “nothing on the Internet
is private.”
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Undisclosed or unauthorized Internet searches may not be illegal or violate
specific ethical guidelines.
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However, if therapist assumes the right to seek such information, may violate
principles of Autonomy, Justice, Fidelity.
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May also violate Principles of Beneficence and Non-maleficence if client feels trust
has been violated and drops out of treatment, etc.
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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.
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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, 105-112.
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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.
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Informed Consent: Reflects Therapist Practice and
Perspectives
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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
http://www.zurinstitute.com/digital_ethics_clinicalupdate.html/
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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
• Digital scenario:
– Therapist reading client’s blog entry during session with client, at
client’s request, discovers troubling information about another client
• Non-digital analog:
– Spouse in couple’s therapy reveals secret about a client without
client’s consent
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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.
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Client Access to Information About Therapist
Therapist Self-Disclosure: Revelation of personal rather than
professional information
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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, 22-30.
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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 (yelp.com, healthgrades.com,
manta.com, complaintsboard.com)
– 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
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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”. http://zurinstitute.com/videos/zur_evms.html
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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 (www.google.com/alerts)
• Carefully evaluate your response to negative postings
Zur, O. “Digital Ethics and online boundaries”. http://zurinstitute.com/videos/zur_evms.html
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Managing Therapist Internet Disclosures
Negative Postings About You
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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., www.reputation.com)
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)
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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” :
http://www.ideasbynet.com/blog/the-immense-guide-to-social-media-sites/
Select slide information obtained from
Macchi, C. R., & Ingram, J. (2011). Ethical issues of therapists’ involvement in social networking. Retrieved from
http://www.slideshare.net/crmacchi/ethical-issues-of-social-networking-10-11-11-10542241.
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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
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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.
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Social Media: Categories
• Support and Health Information Sharing
– Use search engine, type “[problem or disorder] support
group online”
– Depression: About.com – Depression,
DepressionTribe.com
– Anxiety: findthelight.com, PsychCentral – Anxiety
– Sexual Abuse: Pandora’s Project, sexual abuse support
groups
– PTSD: PTSD support groups, National Center for PTSD
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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
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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
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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
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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
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Clients’ Use of Social Media
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Clients are increasingly using social media to access health-related resources and
become better-informed consumers
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Types of social media most often used involve support groups:
– Blogs
– Chat rooms
– Message boards
– Online communities
– Patient testimonials
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“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, 1141-1142. Retrieved
from http://www.facebook.com/TheLancetMedicalJournal.
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General Ethical Issues Associated with Social Media
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Client confidentiality – privacy of information
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Client confidentiality – security of information
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Clinicians prevent unintended or malicious disclosure, alteration, or loss of PHI
Therapist self-disclosure and transparency
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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)
Therapist manages personal information shared or available to client
Dual relationships
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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, 153-159.
Zur, O., Williams, M., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the internet age. Professional Psychology: Research and Practice,
40, 22-30.
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Specific Issues: Ethical Principles - Therapist Accessing Client
Information Via Social Networking Sites
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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, 105-112.
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Specific Issues: Ethical Problems - Facebook “Friend”
Request from a Client
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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
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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
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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, 105-112.
Devi, S. (2011). Facebook friend request from a patient? Lancet Medical Journal, 33, 1141-1142. Retrieved from
http://www.facebook.com/TheLancetMedicalJournal.
Therapist’s approach to “friend” requests should be explicitly covered in
Informed Consent
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Specific Issues: Potential Problems Related to Subtleties of
Digital Technology
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If e-mail account used to create Twitter account is used to e-mail 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
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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
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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
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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
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If family members and friends become “Fans” or “like” the page, clients will have access to this information
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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?
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Friends or colleagues may post well-meaning comments on clinician's Facebook wall which might be too personal for
clinician's comfort
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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
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Initial Considerations of Using Social Networking
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Determine if social networking is right for your personal use, for your practice, or
both
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Decide if your professional involvement in social networking is an added benefit to
your therapeutic work
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Consider the potential risks and challenges that your involvement in social
networking may present to your therapeutic relationships and work
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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, 22-30.
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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
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TeleMentalHealth
• 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
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TeleMentalHealth: Issues to Consider
• Who why, what, and where
• Informed Consent
• Confidentiality
– Privacy
– Security
• Effectiveness
• Reimbursement
• Therapist technological competence
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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)
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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
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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: http://drkkolmes.com/for-clinicians/social-media-policy/
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TeleMentalHealth: Advantages
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Client satisfaction comparable to in-person
Outcomes comparable to in-person
Accessible, not limited by proximity
Improved client choice for best treatment
Less costly
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TeleMentalHealth: Concerns
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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)
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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 e-mail)
– 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.
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TeleMentalHealth: HIPAA Regulations
• Several alternatives to Skype which are/may be HIPAA
compliant:
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Secure Telehealth
VIA3
TelemedicineIM
Vsee
eTherapi
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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
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Text and E-mail Communication - Considerations
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Absence of face to face cues
Synchronous vs. asynchronous interaction
Disinhibition
Recordable
Technology problems/disruptions
Reduced environmental control
Confidentiality
Where and how documented
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Guidelines for use of Texting and Email
• If you discuss clinical issues with clients/potential clients via text or e-mail,
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
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Guidelines for use of Texting and Email
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Clarify to yourself your thoughts and feelings regarding text and email communication with
clients. What are your preferences for appropriate use, your limits, etc.?
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Discuss the issue of text and email 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.
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Make sure that your office policies include a section on the use of text and email ( along with
use/not use of Internet, Social Media, etc.)
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For text and e-mail (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
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Make sure that each email includes an electronic signature that covers issues such as
confidentiality and security.
–
Zur, O. (2011). I Love These E-Mails, or Do I? The Use of E-Mails in Psychotherapy and Counseling. Retrieved from
http://www.zurinstitute.com/email_in_therapy.html.
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Discussion: Online Treatment Recommendations
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http://www.justanswer.com/mental-health/7ktik-hello-why-stress-whensurround-lot.html
http://www.justanswer.com/mental-health/7kqag-bipolar-ii-disorder-rapidcycling-anxiety.html
http://www.justanswer.com/mental-health/7kokk-hello-i-anxiety-ocd-episodesearly-childhood-in.html
http://www.pearl.com/question/guest/1e2df2e3598d400e8c7e896608fc22ec
http://www.pearl.com/question/guest/a70886c9327c4eb79445c27ae8cdcd18
http://www.insightpsychological.ca/ask-a-therapist.html
http://psychcentral.com/ask-the-therapist/2013/02/18/life-lacks-meaning/
http://psychcentral.com/ask-the-therapist/2013/02/02/are-all-my-problems-inmy-head/
http://psychcentral.com/ask-the-therapist/
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ADDENDUM
Principle-based Ethics
Principle-based Ethics
• Principle-Based Ethics is based on a commitment to
five overarching, common, basic prima facie moral
principles:
1. Beneficence
2. Nonmaleficence
3. Autonomy
4. Justice
5. Fidelity
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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
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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
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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
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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
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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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