Ethics in the “i" world: Internet, telehealth, social media, texting, and e-mail PATRICK B. MCGRATH, PH.D. MODERATOR Mary Karapetian Alvord, Ph.D. President-Elect, APA Division 46, Media Psychology Alvord, Baker & Associates, LLC 11161 New Hampshire Ave. Suite 307 Silver Spring, MD 20904 301-593-6554 X14 April 13, 2012 3200 Tower Oaks Blvd. Suite 200 Rockville, MD 20852 301-593-6554 X14 malvord@alvordbaker.com www.alvordbaker.com Disclaimer I have no conflicts of interest to disclose. I have not received any funding from any commercial entities that may be mentioned or discussed in this presentation. All information and opinions shared are mine alone. We are living technolgy history An example – prior to 1973, cell phones were limited to those installed in vehicles. In 1983, Motorola introduced the 16-ounce "DynaTAC" phone which cost $3,500. Fir st Cel l Ph one (19 73) : 2012 – there are more cell phone users across the world, than land line users. Mot orol a Dyn a- Tac Siz e: 9 x 5 x 1.7 5 inch es We igh t: 2.5 pou nds Dis pla y: Non e Nu mb er of Cir cui t Boa rds : 30 Tal k tim e: 35 min ute s Rec har ge Tim e: 10 hou rs Fea tur es: Tal k, liste n, dial What is Telehealth? Audio Technology (land line & cell phones; MP3’s; i-tunes; digital Video conferencing technology/internet/print (social media platforms) Mental Health Services (APA Ethics codes & state licenses) www.alvordbaker.com company will focus solely on its digital encyclopedia and education tools. . HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule – now standard of care Business associate agreements!! Security Rule – Adminstrative procedures to safeguard confidentiality and access Physical safeguards Technical security Telecommunication system Programmable! T-1 lines or VPN . Voice over IP phones, etc. HAPPY 21ST BIRTHDAY Facilitating gamesmanship and generalizing behaviors through real-life play activities Clinical Applications Exposures - Endless Loops, sounds, DVD’s, you tube http://www.youtube.com/watch?v=F5na4nE21-c Relaxation Executive –MP3’s function skills (scheduling, timers, phone alerts, alarms) Technology: Clinical applications Interactive “screen” systems → face recognition, social skills prompts. Technology in the Practice Sending assignments for group and other therapies via encrypted email Testing scoring software Research online – APA research , Google, etc. Tele-health http://www.youtube.com/watch?v=4DkezwHawXY Tele = technology Health = psychological services (tx, testing, etc.) Internet speed and bandwidth Encrypted doesn’t mean HIPAA compliant HIPAA compliant → HIPAAA Certified Secure Platforms PC’s vs. MAC’s Computer Memory HD Cameras Thank you! References: HIPAA regulations DeAngelis, T. (2012) Practicing distance therapy, legally and ethically Monitor on Psychology; 43(3). Highmark launches telehealth service. (2012). Health & Beauty Close - Up, , Retrieved from: http://search.proquest.com/docview/957428259?accountid=11243 Wolper, L. (2011) The E-Healthcare Movement: Virtual Communities, Web Services, and Other Enterprisewide, Interoperable HCITs for US Healthcare Reform . Health Care Administration . Retrieved from: http://www.r2library.com.proxygw.wrlc.org/contents/content_resource_frame.aspx?isb n=0763757918&Offset=2&SectionId=ch0008s0350&ChapterId=ch0008&library=Medic ine&Cache=true Disclaimer I have no conflicts of interest to disclose, and have not received any funding from any commercial entities that may be mentioned or discussed in this presentation. All information and opinions shared are those of the presenter. Ethics in the “i" world: Internet, telehealth, social media, texting, and e-mail TELEHEALTH IN THE TREATMENT OF ANXIETY: EFFECTIVE TECHNOLOGICAL INTERVENTIONS FOR ANXIETY DISORDERS NIKKI GODINE Disclaimer I have no conflicts of interest to disclose, and have not received any funding from any commercial entities that may be mentioned or discussed in this presentation All information and opinions shared are those of the presenter Technologies Administrative Telephone Computer Fax machine Clinical Telephone Computer Cell phone (talking, texting, apps) IATV Internet (chat, forums, message boards) Virtual reality Panic Disorder Treatment via the Internet: an effective way to reduce panic symptoms (Bergstrom et al., 2009; Wims, Titov, Andrews, & Choi, 2010) Types of treatment: Clinician-assisted CBT Settings in which this type of treatment can be used Clinical outcomes Post-Traumatic Stress Disorder Treatment via videoconferencing and the Internet can improve symptoms of PTSD (Germain, Marchand, Bouchard, Drouin, & Guay, 2009; Lange, Rietdjik, Hudcovicova, van de Ven, Schrieken, & Emmelkamp, 2003) Internet treatment Cognitive-behavioral writing assignments Videoconferencing treatment CBT Clinical outcomes Generalized Anxiety Disorder Symptoms of GAD can be successfully treated through the Internet, virtual reality, and the use of biofeedback and mobile phones (Gorini et al., 2010; Pallavicini, Algeri, Repetto, Gorini, & Riva, 2009; Titov et al., 2009). Types of treatment Clinician-assisted CBT Virtual reality with biofeedback Stress management and relaxation techniques Settings in which this type of treatment can be used Clinical outcomes Social Phobia Internet-based treatment for social phobia reduces symptoms of social phobia and other comorbid disorders (Berger, Hohl, & Caspar, 2009; Titov, Gibson, Andrews, & McEvoy, 2009) Types of treatment: Clinician-assisted CBT CBT without clinician guidance Clinical outcomes Child and Adolescent Anxiety Treatment delivered primarily via the Internet can be effective for a number of child and adolescent anxiety disorders (Spence, Holmes, March, & Lipp, 2006) Type of treatment Clinician-assisted CBT Clinical outcomes How effective is it compared to in-person CBT? References Andersson, G., Carlbring, P., Holmstrom, A., Sparthan, E., Furmark, T., Nilsson-Ihrfelt, E. … Ekselius, L. (2006). Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 677-686. doi:10.1037/0022-006X.74.4.677 Berger, T., Hohl, E., & Caspar, F. (2009). Internet-based treatment for social phobia: A randomized controlled trial. Journal of Clinical Psychology, 65, 1021-1035. doi:10.1002/jclp.20603 Bergstrom, J., Andersson, G., Karlsson, A., Andreewitch, S., Ruck, C., … Lindefors, N. (2009). An open study of the effectiveness of Internet treatment for panic disorder delivered in a psychiatric setting. Nordic Journal of Psychiatry, 63, 44-50. doi:10.1080/08039480802191132 References cont’d Botella, C., Gallego, M. J., Garcia-Palacios, A., Banos, R. M., Quero, S., & Alcaniz, M. (2009). The acceptability of an Internet-based self-help treatment for fear of public speaking. British Journal of Guidance and Counseling, 37, 297-311. doi:10.1080/03069880902957023 Carlbring, P., Nordgren, L. B., Furmark, T., & Andersson, G. (2009). Long-term outcome of Internet-delivered cognitivebehavioral therapy for social phobia: A 30-month follow-up. Behavior Research and Therapy, 47, 848-850. doi:10.1016/j.brat.2009.06.012 Germain, V., Marchand, A., Bouchard, S., Drouin, M., & Guay, S. (2009). Effectiveness of cognitive-behavioral therapy administered by videoconference for posttraumatic stress disorder. Cognitive Behaviour Therapy, 38, 42-53. doi:10.1080/16506070802473494 Gorini, A., Pallavicini, F., Algeri, D., Repetto, C., Gaggioli, A., & Riva, G. (2010). Virtual reality in the treatment of generalized anxiety disorders. Studies in Health Technology and Informatics, 154, 39 – 43. References cont’d Klein, B., Austin, D., Pier, C., Kiropoulos, L., Shandley, K., Mitchell, J., … Ciechomski, L. (2009). Internet-based treatment for panic disorder: Does frequency of therapist contact make a difference? Cognitive Behavior Therapy, 38, 100-113. doi:10.1080/16506070802561132 Klein, B., Mitchell, J., Abbott, J., Shandley, K., Austin, D., Gilson, K., … Redman, T. (2010). A therapist-assisted cognitive behavior therapy Internet intervention for posttraumatic stress disorder: Pre-, post- and 3-month follow-up results from an open trial. Journal of Anxiety Disorders, 24, 635-644. doi:10.1016/j.janxdis.2010.04.005 Klein, B., & Richards, J. C. (2001). A brief Internet-based treatment for panic disorder. Behavioural and Cognitive Psychotherapy, 29, 113-117. References cont’d Knaevelsrud, C., & Maercker, A. (2007). Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: A randomized controlled clinical trial. BioMed Central Psychiatry. Retrieved from http://www.biomedcentral.com/1471-244X/7/13 Knaevelsrud, C., & Maercker, A. (2010). Long-term effects of an Internet-based treatment for posttraumatic stress. Cognitive Behavior Therapy, 39, 72-77. doi:10.1080/16506070902999935 Lange, A., Rietdijk, D., Hudcovicova, M., van de Ven, J., Schrieken, B., & Emmelkamp, P. M. G. (2003). Interapy: A controlled randomized trial of the standardized treatment of posttraumatic stress through the Internet. Journal of Consulting and Clinical Psychology, 71, 901-909. doi:10.1037/0022-006X.71.5.901 Pallavicini, F., Algeri, D., Gorini, A., & Riva, G. (2009). Biofeedback, virtual reality and mobile phones in the treatment of generalized anxiety disorder (GAD): A phase-2 controlled clinical trial. Journal of Cybertherapy and Rehabilitation, 2, 315 – 327. References cont’d Ruwaard, J., Broeksteeg, J., Schrieken, B., Emmelkamp, P., & Lange, A. (2010). Web-based therapist-assisted cognitive behavioral treatment of panic symptoms: A randomized controlled trial with a 3-year follow-up. Journal of Anxiety Disorders, 24, 387-396. doi:10.1016/j.janxdis.2010.01.010 Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R., Prosser, S., … Kenardy, J. (2008). Online CBT in the treatment of child and adolescent anxiety disorders: Issues in the development of BRAVE-ONLINE and two case illustrations. Behavioral and Cognitive Psychotherapy, 36, 411-430. doi:10.1017/S135246580800444X Spence, S. H., Holmes, J. M., March, S., & Lipp, O. V. (2006). The feasibility and outcome of clinic plus Internet delivery of cognitive-behavioral therapy for childhood anxiety. Journal of Consulting and Clinical Psychology, 74, 614-621. doi:10.1037/0022-006X.74.3.614 References cont’d Titov, N., Andrews, G., Choi, I., Schwenke, G., & Johnston, L. (2009). Randomized controlled trial of web-based treatment of social phobia without clinician guidance. Australian and New Zealand Journal of Psychiatry, 43, 913-919. doi:10.1080/00048670903179160 Titov, N., Andrews, G., Robinson, E., Schwenke, G., Johnson, L., Solley, K., & Choi, I. (2009). Clinician-assisted Internet-based treatment is effective for generalized anxiety disorder: Randomized controlled trial. Australian and New Zealand Journal of Psychiatry, 43, 905-912. doi:10.1080/00048670903179269 References cont’d Titov, N., Gibson, M., Andrews, G., & McEvoy, P. (2009). Internet treatment for social phobia reduces comorbidity. Australian and New Zealand Journal of Psychiatry, 43, 754-759. doi:10.1080/00048670903001992 Villani, D., Riva, F., & Riva, G. (2007). New technologies for relaxation: The role of presence. International Journal of Stress Management, 14, 260 – 274. doi: 10.1037/1072-5245.14.3.260 Wims, E., Titov, N., Andrews, G., & Choi, I. (2010). Clinical-assisted Internet-based treatment is effective for panic: A randomized controlled trial. Australian and New Zealand Journal of Psychiatry, 44, 599-607. doi:10.3109/00048671003614171 Thank you! Ethics in the “i” World: Social Media Ethics © 2012 K. Kolmes. All rights reserved ADAA APRIL, 13, 2012 KEELY KOLMES, PSY.D., PRIVATE PRACTICE, SF, CA HTTP://DRKKOLMES. COM DRKKOLMES@GMAIL. COM I have no conflicts of interest to disclose. I have not received any funding from any commercial entities that may be mentioned or discussed in this presentation. © 2012 Keely Kolmes, Psy.D. All rights reserved Search Engines & Social Media: Who is looking for you? Clients Colleagues Students/Supervisees & Professors/Supervisors Training programs & employers © 2012 Keely Kolmes, Psy.D. All rights reserved Setting Up a Google Alert http://www.google.com/alerts © 2012 Keely Kolmes, Psy.D. All rights reserved Clinical & Ethical Issues for Clinicians © 2012 Keely Kolmes, Psy.D. All rights reserved Clients seeking psychotherapist information on the Internet (Kolmes & Taube, 2011) In a survey of 332 clients, 70% reported finding personal information about their therapist on the Internet. 87% of these individuals found it intentionally while 13% found it accidentally. 78% found the information via Google, 42% found it via Facebook, 17% found information on LinkedIn. 10% found it on a blog. © 2012 Keely Kolmes, Psy.D. All rights reserved Clinical & Ethical Issues for Clinicians © 2012 Keely Kolmes, Psy.D. All rights reserved Tips for Taking Control of Your Web Visibility Carefully choose which email address you use to join sites. Understand the privacy settings on your own (and family members’) profiles. Correct misinformation. Google’s URL Removal Tool for URLs that urgently need to be removed. (URLs that accidentally expose confidential data) https://www.google.com/webmasters/tools/removals © 2012 Keely Kolmes, Psy.D. All rights reserved Social Media And Your Practice Consider your intent when you join a social networking site: personal or professional? Implement a Social Media Policy http://www.drkkolmes.com/docs/socmed.pdf © 2012 Keely Kolmes, Psy.D. All rights reserved Digital Ethics? Applying existing Ethical Standards to online activity. Ethical Standards offer a guide for ethical behavior. Development of standards is ongoing. Ethical dilemmas on the Internet mirror ethical dilemmas that also occur offline. Ethics Codes refer only to our professional activities, not personal ones. Distinction between professional and personal is getting blurred online. Clinical & Ethical Issues for Clinicians © 2012 Keely Kolmes, Psy.D. All rights reserved Relevant Ethical Standards Ethical Standard 3.10 Informed Consent Ethical Standard 3.05 Multiple Relationships Ethical Standard 4.01 Maintaining Confidentiality Ethical Standard: 4.04 (b): Psychologists discuss confidential information obtained in their work only for appropriate scientific or professional purposes and only with persons clearly concerned with such matters. © 2012 Keely Kolmes, Psy.D. All rights reserved Relevant Ethical Standards (cont.) Ethical Principle 5.05: Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence. Ethical Principle 4.06 Consultations: When consulting with colleagues, (1) psychologists…. disclose information only to the extent necessary to achieve the purposes of the consultation. (See also Standard 4.01, Maintaining Confidentiality.) Clinical & Ethical Issues for Clinicians © 2012 Keely Kolmes, Psy.D. All rights reserved Beware Online Pseudonyms Invitations from people you do not know. Caution when replying to “strangers” in public. Online impersonation is fairly easy. © 2012 Keely Kolmes, Psy.D. All rights reserved Closing Remarks Know what's out there about you. Take responsibility for your web presence. Be proactive about cleaning it up or correcting inaccuracies. Consider whether access to posted information could damage a client, another professional relationship, or you. Distinguish between personal and professional use on social networking sites. Understand and use privacy settings. Be prepared to manage it clinically when internet activity comes into the room. Develop a social media policy for your practice. Include it as a part of informed consent and discuss it. Clinical & Ethical Issues for Clinicians © 2012 Keely Kolmes, Psy.D. All rights reserved References American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from: http://www.apa.org/ethics. Donner, M., The Ethical Use of the Listserv: Privacy and Professional Conduct, The California Psychologist, November/December 2007, 22. Retrieved from http://bit.ly/vsKFAW , Florence W.; Patterson, Terence; Gottlieb, Michael. Ethical dilemmas in psychologists accessing Internet data: Is it justified? Professional Psychology: Research and Practice, Vol 42(2), Apr 2011, 105-112. Kolmes, K. (2010, April). Private practice social media policy. [PDF file]. Retrieved May, 2010, from © 2012 Keely Kolmes, Psy.D. All http://www.drkkolmes.com/docs/socmed.pdf rights reserved References (cont.) Kolmes, K. & Taube, D.O. (2011) Summary of client- therapist encounters on the web: The client experience. [PPT file]. Retrieved June 2011, from http://drkkolmes.com/research/ Lehavot, K., Barnett, J., & Powers, D. (2010). Psychotherapy, professional relationships, and ethical considerations in the MySpace generation. Professional Psychology: Research and Practice. Vol 41(2), Apr 2010, 160-166. Martin, S. (2010, August 13). More than one-fifth of grad students have Googled their clients. [Web log posting]. Retrieved from http://bit.ly/ajRjWX. (2011, March 20). © 2012 Keely Kolmes, Psy.D. All rights reserved Contact Me Keely Kolmes, Psy.D. drkkolmes@gmail.com 415-501-9098 http://www.drkkolmes.com Twitter: @drkkolmes © 2012 Keely Kolmes, Psy.D. All rights reserved Ethics in the “i" world: Internet, telehealth, social media, texting, and e-mail ETHICS AND LEGAL ISSUES JEFFREY E. BARNETT, PSY.D., ABPP LOYOLA UNIVERSITY MARYLAND Disclaimer I have no conflicts of interest to disclose and have not received any funding from any commercial entities that may be mentioned or discussed in this presentation. All information and opinions shared are those of the presenter only. What is Telehealth? “The use of telecommunications and information technology to provide access to health assessment, intervention, consultation, supervision, education, and information across distance” (Nickelson, 1998, p. 527). The use of the telephone, e-mail, chat rooms, and other Internet and satellite-based technologies to provide direct clinical services (e.g. texting, IATV, etc.). Teleconferencing and Interactive Televideo Communications Interactive Televideo Communications (IATV) Consultation and treatment to remote locales other settings lacking specialized treatment professionals and for when clients can not access the professional in-person. Efficiency of service delivery/cost effective Increased access to treatment Superior to telephone and e-mail Treatment across great distances Back to the Future? Areas of Concern with IATV Technological limitations impacting audio/visual acuity and clarity – interpersonal cues Inadvertent breaches of confidentiality Technology failures Difficulty responding to emergencies Licensure issues Knowledge of local laws Behavioral telehealth may not be the most appropriate medium for all treatment needs Legal and Ethical Issues 75% provide services across state lines 60% inquired about the patient’s state of residence 74% uncertain or incorrect about states’ telemedicine or telehealth laws 50% made advanced arrangements for responding to emergencies or crises 48% used a formal informed consent procedure prior to providing online services (Maheu & Gordon, 2000) Recommendations Use a comprehensive informed consent procedure Learn relevant telehealth and telemedicine laws for all jurisdictions in which you will be providing services Do not practice outside the scope of your license Follow your profession’s ethics code regardless of the therapeutic medium used Utilize all existing technology to protect each individual’s confidentiality Recommendations (Cont.) Attend to issues of dangerousness, duty to warn and protect situations, and mandatory reporting requirements Make arrangements in consumers’ local areas for emergency and crisis situations. Be knowledgeable of local resources Maintain appropriate liability coverage and be sure malpractice insurance covers these services Remain aware of the limitations of both the online services provided and the technology used to offer them Recommendations (Cont.) Evaluate the effectiveness of all telehealth services provided and modify them as needed Assess each individual’s appropriateness for this modality of treatment. Make referrals when needed and appropriate Practice within your scope of practice and areas of competence Attend to cultural, ethnic, language, and other differences that may impact effective communication Recommendations (Cont.) Utilize effective documentation, adherence to termination and abandonment guidelines, and appropriate practices for fees and financial arrangements Ensure both clinical and technological competence needed to provide these services online Consult with knowledgeable colleagues, relevant statutes, applicable ethics codes, available professional standards, and legal counsel Participate in telehealth policy, standards, guidelines, and technology development Social Networking Counseling, Psychotherapy, and Social Networking Many clients participate in social networking sites in their lives and use them as a prime means of communicating , relating, and managing relationships. Clients may send their counselors or psychotherapists “friend” requests. Challenges to clinician transparency, selfdisclosure, privacy, and the nature of the treatment relationship. Counseling, Psychotherapy, and Social Networking (cont.) Potential impact of declining on the treatment relationship. Potential impact of accepting on the treatment relationship. Losing the ability to have “real” relationships? What is considered “real” may be different for digital natives. Transitioning from the digital world to the “inperson” world. Implications for Counseling and Psychotherapy Have a Social Networking Policy. See for example: http://drkkolmes.com Address this as part of the informed consent process with every client. Responding to “friend” requests from current and former clients - to respond or not; implications for the counseling and psychotherapy process and relationship. Boundary/multiple relationship issues. Implications for Counseling and Psychotherapy (cont.) Self-Disclosure issues and the blurred line between your professional life and your personal life The fallacy of security settings Searching for client information online Using a client’s social networking site therapeutically What to do with information obtained via the Internet Ethical Issues and Dilemmas Boundaries and Multiple Relationships Self-Disclosure and Psychotherapist Transparency Fidelity, informed consent, and integrity Clinician searches for information about a client online Graduate student activities: A faculty member discovers a student’s blog. Trainees: A client discovers a student clinician’s personal website. Seeking Ethical Guidance In general contacts with clients and former clients online should be viewed like any other multiple relationship. “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (APA, 2010, p. 6). With regard to boundaries and self-disclosure the APA Ethics Code “applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists… Those activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code” (p. 1). See also standards on Informed Consent, Confidentiality, Avoiding Harm, Exploitative Relationships, Student Disclosures of Personal Information. Questions to ask when considering online disclosures (Lehavot, 2007): What are the costs and benefits of posting the information? Is there a high probability that clients will be significantly and negatively affected? How will the disclosure affect my relationship with my clients? Does the disclosure threaten my credibility or undermine the public’s trust in the profession of psychology? References American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from: http://www.apa.org/ethics. Lehavot, K. (2007). “MySpace” or yours? The ethical dilemma of graduate students’ personal lives on the Internet. Presentation at the Annual Convention of the American Psychological Association, San Francisco, CA. Maheu, M. M., & Gordon, B. L. (2000). Counseling and therapy on the Internet. Professional Psychology: Research and Practice, 31, 484-489. Nickelson, D. W. (1998). Telehealth and the evolving health care system: Strategic opportunities for professional psychology. Professional Psychology: Research and Practice, 29, 527-535.