By Ofer Zur, Ph.D.
Table Of Contents
American Association of Marriage and Family Therapists
American Counseling Association Code of Ethics
American Medical Association
American Mental Health Counselors Association
American Psychiatric Association
American Psychological Association
American Telemedicine Association
Association of Canadian Psychology Regulatory Organizations
Association of Social Work Boards
California Association of Marriage and Family Therapists
California Board of Behavioral Sciences
Canadian Psychological Association
National Association of Social Workers
National Board for Certified Counselors
Additional Mental Health Guidelines
APA 2013 Guidelines for the Practice of Telepsychology
NASW & ASWB Standards for Technology
Generally, telehealth practices are subject to exactly the same federal and state regulations, codes of ethics, and professional guidelines that define the fiduciary relationship in face-to-face and office-based therapy. It falls within the same standard of care.
Following are Ethics codes of different professional associations that have attended to the telehealth concerns differently:
American Association of Marriage and Family Therapists AAMFT 2015 Code of Ethics:
STANDARD VITECHNOLOGY-ASSISTED PROFESSIONAL SERVICES
Therapy, supervision, and other professional services engaged in by marriage and family therapists take place over an increasing number of technological platforms. There are great benefits and responsibilities inherent in both the traditional therapeutic and supervision contexts, as well as in the utilization of technologically-assisted professional services. This standard addresses basic ethical requirements of offering therapy, supervision, and related professional services using electronic means.
6.1 Technology Assisted Services.
Prior to commencing therapy or supervision services through electronic means (including but not limited to phone and Internet), marriage and family therapists ensure that they are compliant with all relevant laws for the delivery of such services. Additionally, marriage and family therapists must: (a) determine that technologically-assisted services or supervision are appropriate for clients or supervisees, considering professional, intellectual, emotional, and physical needs; (b) inform clients or supervisees of the potential risks and benefits associated with technologically-assisted services; (c) ensure the security of their communication medium; and (d) only commence electronic therapy or supervision after appropriate education, training, or supervised experience using the relevant technology.
6.2 Consent to Treat or Supervise.
Clients and supervisees, whether contracting for services as individuals, dyads, families, or groups, must be made aware of the risks and responsibilities associated with technology-assisted services. Therapists are to advise clients and supervisees in writing of these risks, and of both the therapist’s and clients’/supervisees’ responsibilities for minimizing such risks.
6.3 Confidentiality and Professional Responsibilities.
It is the therapist’s or supervisor’s responsibility to choose technological platforms that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology.
6.4 Technology and Documentation.
Therapists and supervisors are to ensure that all documentation containing identifying or otherwise sensitive information which is electronically stored and/or transferred is done using technology that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology.
6.5 Location of Services and Practice.
Therapists and supervisors follow all applicable laws regarding location of practice and services, and do not use technologically-assisted means for practicing outside of their allowed jurisdictions.
6.6 Training and Use of Current Technology.
Marriage and family therapists ensure that they are well trained and competent in the use of all chosen technology-assisted professional services. Careful choices of audio, video, and other options are made in order to optimize quality and security of services, and to adhere to standards of best practices for technology-assisted services. Furthermore, such choices of technology are to be suitably advanced and current so as to best serve the professional needs of clients and supervisees.
American Counseling Association ACA 2014 Code of Ethics devotes a separate section (Section H) to “Distance Counseling,Technology, and Social Media” where it is spells out guidelines regarding limitations, access, informed consent, use of the Web and more, regarding telehealth and related issues.
ACA Code of Ethics, 2014
B.3.e Transmitting Confidential Information
Counselors take precautions to ensurethe confidentiality of all information transmitted through the use of any medium.
Section H. Distance Counseling, Technology, and Social Media
Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attemptto protect confidentiality and meet any legal and ethical requirements for the use of such resources.
H.1. Knowledge andLegal Considerations
Counselors who engage in the use of distance counseling, technology, and/or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (e.g., special certifications, additional course work).
H.1.b. Laws and Statutes
Counselors who engage in the use of distance counseling, technology, and social media within their counseling practice understand that they may be subject to laws and regulations of both the counselor’s practicing location and the client’s place of residence. Counselors ensure that their clients are aware of pertinent legal rights and limitations governing the practice of counseling across state lines or international boundaries.
H.2. Informed Consent and Security
H.2.a. Informed Consent and Disclosure
Clients have the freedom to choose whether to use distance counseling, social media, and/or technology within the counseling process. In addition to the usual and customary protocol of informed consent between counselor and client for face-to-face counseling, the following issues, unique to the use of distance counseling, technology, and/or social media, are addressed in the informed consent process:
- distance counseling credentials, physical location of practice, and contact information;
- risks and benefits of engaging in the use of distance counseling, technology, and/or social media;
- possibility of technology failure and alternate methods of service delivery;
- anticipated response time;
- emergency procedures to follow when the counselor is not available;
- time zone differences;
- cultural and/or language differences that may affect delivery of services; possible denial of insurance benefits; and
- social media policy.
H.2.b. Confidentiality Maintained by the Counselor
Counselors acknowledge the limitations of maintaining the confidentiality of electronic records and transmissions. They inform clients that individuals might have authorized or unauthorized access to such records or transmissions (e.g., colleagues, supervisors, employees, information technologists).
H.2.c. Acknowledgment of Limitations
Counselors inform clients about the inherent limits of confidentiality when using technology. Counselors urge clients to be aware of authorized and/or unauthorized access to information disclosed using this medium in the counseling process.
Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements. Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means.
H.3. Client Verification
Counselors who engage in the use of distance counseling, technology, and/or social media to interact with clients take steps to verify the client’s identity at the beginning and throughout the therapeutic process. Verification can include, but is not limited to, using code words, numbers, graphics, or other nondescript identifiers.
H.4. Distance Counseling Relationship
H.4.a. Benefits and Limitations
Counselors inform clients of the benefits and limitations of using technology applications in the provision of counseling services. Such technologies include, but are not limited to, computer hardware and/or software, telephones and applications, social media and Internet-based applications and other audio and/or video communication, or data storage devices or media.
H.4.b. Professional Boundaries in Distance Counseling
Counselors understand the necessity of maintaining a professional relationship with their clients. Counselors discuss and establish professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the counseling relationship (e.g., lack of confidentiality, times when not appropriate to use).
When providing technology-assisted services, counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client. Counselors verify that clients understand the purpose and operation of technology applications and follow up with clients to correct possible misconceptions, discover appropriate use, and assess subsequent steps.
H.4.d. Effectiveness of Services
When distance counseling services are deemed ineffective by the counselor or client, counselors consider delivering services face-to-face. If the counselor is not able to provide face-to-face services (e.g., lives in another state), the counselor assists the client in identifying appropriate services.
Counselors provide information to clients regarding reasonable access to pertinent applications when providing technology-assisted services.
H.4.f. Communication Differences in Electronic Media
Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.
H.5. Records andWeb Maintenance
Counselors maintain electronic records in accordance with relevant laws and statutes. Counselors inform clients on how records are maintained electronically. This includes, but is not limited to, the type of encryption and security assigned to the records, and if/for how long archival storage of transaction records is maintained.
H.5.b. Client Rights
Counselors who offer distance counseling services and/or maintain a professional website provide electronic links to relevant licensure and professional certification boards to protect consumer and client rights and address ethical concerns.
H.5.c. Electronic Links
Counselors regularly ensure that electronic links are working and are professionally appropriate.
H.5.d. Multicultural andDisability Considerations
Counselors who maintain websites provide accessibility to persons with disabilities. They provide translation capabilities for clients who have a different primary language, when feasible. Counselors acknowledge the imperfect nature of such translations and accessibilities.
H.6. Social Media
H.6.a. Virtual Professional Presence
In cases where counselors wish to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles are created to clearly distinguish between the two kinds of virtual presence.
H.6.b. Social Media as Part of Informed Consent
Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media.
H.6.c. Client Virtual Presence
Counselors respect the privacy of their clients’ presence on social media unless given consent to view such information.
H.6.d. Use of Public Social Media
Counselors take precautions to avoid disclosing confidential information through public social media.
American Medical Association AMA 2000 Guidelines for Patient-Physician Electronic Mail
American Mental Health Counselors Association AMHCA, 2015 Code of Ethics
Principle 6: Telehealth, Distance Counseling and the Use of Social Media
Recognizing that technology can be helpful in client’s mental health care management due to availability, expediency, and cost effectiveness, counselors engage in technology assisted, and or distance counseling.
- Counselors only engage in distance counseling when they are licensed in the state of the client. In the case of an emergency, counselors should first attempt to attain permission from the client’s state licensing entity and only proceed when failure to do so could result in harm to the client.
- Counselors only provide distance counseling when they have had training, experience, and supervision to do so.
- Written policies concerning the use of telehealth in a counseling relationship should include informed consent that is clearly set forth, understandable, and addresses the use of phone, online face to face counseling, electronic billing, text, and email contact with a client. This informed consent should clearly discuss the benefits and risks of entering into distance counseling.
- Email: Mental health counselors should advise clients about the risks of exchanging emails. It is recommended to include a disclaimer when sending emails. Refer to the most update to date HIPAA regulations. Email transmissions are part of the client record; copies should be maintained in the client file.
- Text messages: Text messages are not a secure form of communication therefore texting of personal information should be discouraged. Text messages are considered a part of the client record, and should be kept in the client file.
- Online scheduling: Any online scheduling software should be encrypted and secure. If not, counselors should disclose to clients the fact that the software is not encrypted and therefore is not confidential.
- Chat Rooms: Counselors should not include chat rooms, because these may imply that a counselor is able to intervene in the event that a crisis is mentioned.
- Counselors follow carefully designed security and safety guidelines when conducting online face-to-face distance counseling.
- Counselors endeavor to protect clients from unwanted interruptions during online face-to-face sessions.
- Counselors are strongly urged to employ the use of local resources in the community of the distance client should emergency care be needed. Local resources may be law enforcement, health care or EMT services, and someone trusted by the client to be available during distance counseling sessions should it become necessary to have someone close by in the event of an emergency.
- The counselor will evaluate the client to determine that the client is appropriate for distance counseling services.
- Counselors will conduct themselves in a professional manner during distance, online counseling sessions as if the client were in the counselor’s office.
- Counselors will disclose to clients all procedures for documenting and storing of records of distance, online counseling sessions.
- Counselors will safeguard and protect all records of distance counseling sessions as they would for in person sessions in accordance with all state and federal laws and regulations.
- Counselors should have a written policy that prohibits both the therapist and the client from recording a treatment session without the written consent of the other. If a recording of the treatment session has been authorized, the counselor,should either erase or destroy the recording as soon as it has fulfilled its intended purpose (e.g., supervision or conclusion of counseling) in order to maintain confidentiality of the contents.
- Counselors do not engage in virtual relationships with clients as to do so could potentially be a violation of confidentiality.
- If clients follow a professional blog, the counselor will not follow them back. The counselor has a responsibility to make it clear that the blog or website does not create a therapeutic relationship, therefore, professional blogs and websites should be non-interactive in nature.
- Twitter, Facebook, LinkedIn, Google Plus and other social media should be professional profiles that are kept separate from personal profiles. Counselors should not establish connections or engage with clients through social media. In addition, counselors need to have appropriate privacy settings so that clients cannot contact them on these professional social media sites, or access a site in any way.
- Counselors shall not solicit professional reviews by clients, nor respond to reviews posted, as to do so might violate client confidentiality.
- Counselors will only seek information about their clients through internet searches for the purpose of determining their own or their clients health and safety.
- Counselors endeavor to provide sensitivity to the cultural make up of all clients, as well as sensitivity to disabilities or physical condition in distance counseling as they would in a physical office.
American Psychiatric Association APA Telepsychiatry via Teleconferencing
American Psychological Association APA Code of Ethics of 2016 simply states that basically, therapy that uses telephone or Internet must abide by the same ethical guidelines as in person therapy.
Ethical Principles of Psychologists and Code of Conduct, 2010, 4.01 The preamble to the Ethical Principles of Psychologists and Code of Conduct states: This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions.
Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship.
This Ethics Code applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists. Areas covered include but are not limited to the clinical, counseling, and school practice of psychology; research; teaching; supervision of trainees; public service; policy development; social intervention; development of assessment instruments; conducting assessments; educational counseling; organizational consulting; forensic activities; program design and evaluation; and administration. This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions. These activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code. (Introductory and applicability, 2nd Para.)
The use of the term guidelines within this document refers to statements that suggest or recommend specific professional behaviors, endeavors or conduct for psychologists. Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Thus, guidelines are aspirational in intent.
American Psychological Association. (2013). – Guidelines for the practice of telepsychology.
American Telemedicine Association – ATA Evidence-based Practice for Telemental Health Practice Guidelines for Videoconferencing Based Telemental Health
Association of Canadian Psychology Regulatory Organizations. (2011). – Model standards for telepsychology service delivery. Toronto, Canada.
Association of Social Work Boards – ASWB Model Regulatory Standards For Technology and Social Work Practice
California Association of Marriage and Family Therapists CAMFT 2011 Code of Ethics:
1.4.1 ELECTRONIC THERAPY: When patientsare not physically present (e.g., therapy by telephone or Internet) during the provision of therapy, marriage and family therapists take extra precautions to meet their responsibilities to patients. Prior to utilizing electronic therapy, marriage and family therapists consider the appropriateness and suitability of this therapeutic modality to the patient’s needs. When therapy occurs by electronic means, marriage and family therapists inform patients of the potential risks, consequences, and benefits, including but not limited to, issues of confidentiality, clinical limitations, transmission difficulties, and ability to respond to emergencies. Marriage and family therapists ensure that such therapy complies with the informed consent requirements of the California Telemedicine Act.
California Board of Behavioral Sciences – CA-BBS Notice to licensees regarding psychotherapy on the Internet
Canadian Psychological Association, Committee on Ethics – CPA Cautions and guidelines for psychologists providing services by telephone or online
National Association of Social Workers NASW Code of Ethics of 2017
With the growth in the use of communication technology in various aspects of social work practice, social workers need to be aware of the unique challenges that may arise in relation to the maintenance of confidentiality, informed consent, professional boundaries, professional competence, record keeping, and other ethical considerations. In general, all ethical standards in this Code of Ethics are applicable to interactions, relationships, or communications, whether they occur in person or with the use of technology. For the purposes of this Code, “technology-assisted social work services” include any social work services that involve the use of computers, mobile or landline telephones, tablets, video technology, or other electronic or digital technologies; this includes the use of various electronic or digital platforms, such as the Internet, online social media, chat rooms, text messaging, e-mail, and emerging digital applications. Technology-assisted social work services encompass all aspects of social work practice, including psychotherapy; individual, family, or group counseling; community organization; administration; advocacy; mediation; education; supervision; research; evaluation; and other social work services. Social workers should keep apprised of emerging technological developments that may be used in social work practice and how various ethical standards apply to them.
Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services. (NASW, 1999, Section 1.03, Para. E).
National Board for Certified Counselors NBCC Code of Ethics (2016) states:
54. NCCs shall include all electronic communications exchanged with clients and supervisees, including those through digital technology and social media methods, as a part of the record, even when strictly related to clerical issues such as change of contact information or scheduling appointments. All electronic therapeutic communication methods shall use encryption and password security.
55. NCCs shall act in a professional manner by protecting against unauthorized access to confidential information. This includes data contained in electronic formats. NCCs shall inform any subordinates who have physical or electronic access to information of the importance of maintaining privacy and confidentiality.
The NBCC Policy Regarding the Provision of Distance Professional Services identifies specific actions NationalCertified Counselors (NCCs) must take when providingdistance services.
STANDARDS FOR DISTANCE PROFESSIONAL SERVICES
- NCCs shall adhere to all NBCC policies and procedures, including the Code of Ethics.
- NCCs shall provide only those services for which they are qualified by education and experience. NCCs shall also consider their qualifications to offer such service via distance means.
- NCCs shall carefully adhere to legal regulations before providing distance services. This review shall include legal regulations from the state in which the counselor is located as well as those from the recipient’s location. Given that NCCs may be offering distance services to individuals in different states at any one time, the NCC shall document relevant state regulations in the respective record(s).
- NCCs shall ensure that any electronic means used in distance service provision are in compliance with current regulatory standards.
- NCCs shall use encryption security for all digital technology communications of a therapeutic type. Information regarding security should be communicated to individuals who receive distance services. Despite the use of precautions, distance service recipients shall be informed of the potential hazards of distance communications. Not the least of these considerations is the warning about entering private information when using a public access or computer that is on a shared network. NCCs shall caution recipients of distance services against using “auto-remember” user names and passwords. NCCs shall also inform recipients of distance services to consider employers’ policies relating to the use of work computers for personal communications.
- To prevent the loss of digital communications or records, NCCs who provide distance services shall maintain secure backup systems. If the backup system is also a digital mechanism, this too shall offer encryption-level security. This information shall be providedto the recipient of professional services.
- NCCs shall screen potential distance service recipients for appropriateness to receive services via distance methods. These considerations shall be documented in the records.
- During the screening or intake process, NCCs shall provide potential recipients with a detailed written description of the distance counseling process and service provision. This information shall be specific to the identified service delivery type and include considerations for that particular individual. These considerations shall include the appropriateness of distance counseling in relation to the specific goal, the format of servicedelivery, the associated needs (i.e., computer with certain capabilities, etc.), the limitations of confidentiality, the possibility of technological failure, anticipated response time to electronic communication, and any additional considerations necessary to assist the potential recipient in reaching a determination about the appropriateness of this service delivery format for their need(s).
- Because of the ease in which digital communications can inadvertently be sent to other individuals, NCCs shall adopt behaviors to prevent the distribution of confidential information to unauthorized individuals. NCCs shall discuss actions the recipient may take to reduce the possibility that they will send information to other individuals by mistake.
- NCCs shall provide recipients of distance professional services with information concerning their professional credentials and links to the respective credentialing organization Web sites.
- NCCs, either prior to or during the initial session, shall inform recipients of the purposes, goals, procedures, limitations, potential risks, and benefits of services and techniques. NCCs also shall provide information about rights and responsibilities as appropriate to the counseling setting. As a part of this type of service provision, NCCs shall discuss with recipients the associated challenges that may occur when communicating throughdistance means.
- In the event that the recipient of distance services is a minor or is unable to provide legal consent, the NCC shall obtain a legal guardian’s consent prior to the provision of distance services. Furthermore, NCCs shall retain copies of documentation indicating the legal guardian’s identity in the recipient’s file.
- NCCs shall avoid the use of public social media sources (e.g., tweets, blogs, etc.) to provide confidential information. To facilitate the secure provision of information, NCCs shall providein writing the appropriate ways to contact them.
- NCCs shall provide recipients of distance services with specific written procedures regarding emergency situations. This information shall include emergency responders near the recipient’s home location. Given the increased dangers intrinsic to providing certain distance professional services, NCCs shall take reasonable steps to secure reasonable referrals for recipients when needed.
- NCCs shall develop written procedures for verifying the identity of the recipient at each instance of receiving distance services. Examples of verification means include the use of code words or phrases.
- NCCs shall limit use of information obtained through social media sources (e.g., Facebook, LinkedIn, Twitter, etc.) in accordance with established practice procedures provided to the recipient at the initiation of services.
- NCCs shall provide information concerning locations where members of the public may access the internet free of charge or provide information regarding the location of complimentary Web communication services.
- NCCs shall retain copies of all written communications with distance service recipients. Examples of written communications include e-mail/text messages, instant mess ages and histories of chat-based discussions even if they are related to housekeeping issues such as change of contact information or scheduling appointments.
- At a minimum, NCCs shall retain distance service records for a minimum of five years unless state laws require additional time. Due to the nature of most distance services, it may be convenient for NCCs to retain records for longer durations, and thus may be considered useful for research or other professional activities. NCCs shall limit the use of records to those permitted by law, professional standards and as specified by the agreement with the respective recipient of distance services.
- In recognition of the inherent ethical implications which may arise, NCCs shall develop written procedures for the use of social media and other related digital technology with current and former recipients. These written procedures shall, at a minimum, provide appropriate protections against the disclosure of confidential information and the creation of multiple relationships. These procedures shall also stipulate that personal accounts be distinct from any used for professional purposes.
- APA 2013 Guidelines for the Practice of Telepsychology
- NASW, ASWB, CSWE, & CSWA Standard for Technology for Social Work Practice (2017)