Ethical Guidelines for On-line Therapy
by Storm A. King & Stephan T. Poulos
(written in October, 1997, first published in February, 1999)
Cite as:
King, S. A. & Poulos, S. T. (1999). Ethical Guidelines for On-line Therapy. In Jeri Fink "How to Use Computers and Cyberspace in the Clinical Practice of Psychotherapy" page 121-132. Jason Aronson, Inc. Publishers
Abstract
The Internet currently hosts millions of on-line users throughout the world and it's use is growing at a tremendous rate. Some consumers are using their Internet connection to seek professional guidance, support, or therapy. Mental health professionals worldwide are pioneering new services that offer to establish a therapeutic relationship over the Internet, sometimes on a fee basis. Existing ethical guidelines proposed by the American Psychological Association (APA) do not specifically address what constitutes responsible ethical conduct for licensed clinical psychologists who are engaged in such activities. Although the APA has formed a task force to make recommendations for such a guideline, to date there are no precedences the professional can rely upon. We will review the current information available and discuss the APA ethical guidelines and how they might apply to the use of the Internet in establishing therapeutic relationships by email.
Ethical Guidelines for On-line Therapy
The purpose of ethical guidelines is not to set rigid codes of conduct, but to inform the professional as to the parameters of behavior that are acceptable to one's peers. "Ethical codes, which have been described as moral guides to self-regulation, attempt to insure the appropriate use of skill and techniques" (Keith-Spiegel & Koocher, 1985, p2). While this tends to create an environment whereby the consumer is theoretically assured of minimal risk, it is worthwhile to consider that an ethical guideline designed and drafted by professionals cannot help but be somewhat self-serving. Ethical guidelines and standards of conduct are limited in their scope of equity because they do not necessarily address the power differential inherent in therapeutic relationships and tend to be reactive, not anticipatory (Prilleltensky, 1997). "Any set of suggested guidelines, if taken too literally, will seem to over-simplify the nature of the problem they address" (King, 1996a, p199). In particular, when a professional field expands into new modes of delivery, the finer points of ethical consideration are yet to be clearly distinguished (King, 1996b).
Given the anarchic nature of the world wide Internet, whether or not Virtual Therapy is something which can be prohibited is already a moot point. Scenarios exist today whereby a mental health professional as far away as Australia is counseling a disturbed client in Belgium using email as the method of communication. Licensed clinical psychologists have web sites that offer expert advice and counseling for a fee (Hannon, 1996; McKeon, 1997). If we consider the payment of a fee as evidence that a professional relationship exists, then clearly some guideline for ethical behavior ought to be delineated in order to both protect the client as well as provide some sort of template by which the professional can offer services.
A recent survey of on-line professional advice and counseling efforts show that consumer satisfaction with these services is high. An initial pilot study was done by King, where recipients of on-line services answered questions relating to various aspects of their experience with an on-line professional. Of the recipients (N=30), 76% reported that they felt that the on-line therapist truly cared about them; 69% felt it was worth the expense. Only 14% had any ethical concerns about the treatment they received. These results indicate a significant degree of consumer satisfaction with on-line professional mental health treatment (King, 1997). It is clear that the use of the on-line medium for therapeutic reasons will continue to grow according to the growth of the medium itself. There is a list of cybertherapy sites at http://www.cmhc.com/guide/cyber.
Applying APA Ethical Principals to Virtual Therapy
Competency
The first and foremost ethical concern which arises out of a method of communication characteristically anonymous in nature, at least in the visual sense, is that while one professional may be quite capable of determining the educational scope and competency level of a peer, the typical on-line consumer is at a distinct disadvantage. There is currently nothing to prevent anyone from holding himself forth on-line as a competent mental health professional. It is not difficult to perceive the potential for harm to the unwary consumer of these services. Whether or not the definition and professional limitations of such roles as counselor, therapist, and psycho-educational information provider, have been determined by a professional standards board, the typical on-line consumer may perceive any of these definitions as being one and the same. Existing on-line psychological professional service providers are not currently subject to verification of their professional status, nor is there any process for review and quality control. "The ease of communications provided by the Internet allows anyone to put out information of any sort" (Huang, 1996). The consumer does not have the benefit of seeing a visual shingle hanging above the professional's door. The Web site maintained by the on-line professional is the only means by which the consumer can determine an actual, or virtual, "location" in Cyberspace. "A poorly informed consumer in crisis who has a history of mental health difficulties will be an easy target for incompetent or fraudulent Internet counseling service providers" (Sampson, 1997a).Integrity
As a means of providing self-monitoring by peers, established professionals are suggesting a service that would provide the verifying of credentials of anyone offering mental health services on-line. Recent discussions on the NetPsy on-line group have been exploring the potential for the use of an electronic signature as a foolproof method of credential verification (Maheu, 1997). This is in keeping with the APA principle concerning the need for self-regulation: psychologists "attempt to clarify for relevant parties the roles they are performing and to function appropriately in accordance with those roles" (APA, 1992).Professional and Scientific Responsibility
Professional psychologists consult with, refer to, or cooperate with other professionals and institutions to the extent necessary in order to serve the best interests of their patients, clients, or other recipients of their services (APA, 1992).
Today's on-line professional may suddenly find him/herself in an arena where the written word is determined to be evidence of the quality of one's professional expertise and finesse. Voice tonality, pitch, and timbre—all good qualities in telephone communication—no longer apply where email and on-line conferencing are increasingly commonplace, actually preferred in many circumstances. And with the advent of real-time chat groups, avatars, and two-way cameras, Virtual Therapy is already upon us" (Poulos, 1997).Respect for People's Rights and Dignity.
In a survey of APA members, the most frequently reported ethical concern had to do with issues surrounding confidentiality (Pope & Vetter, 1992). What is fundamentally different about assuring confidentiality in an on-line professional relationship is that electronic communications are inherently unsecured. In addition to this, the permanency of record creates new potentials for violation of privacy; e.g., a client's spouse might access, whether intentionally or not, a file of email communications that were intended to be confidential. In the future, methods of encryption and password protection will be readily available to the consumer and standard practice for the professional.Concern for Other's Welfare
The ability to demonstrate proper concern for someone with whom only a text-based relationship exists is dependent upon one's experience with the nuances of on-line communication. It is critical that a psychologist considering offering mental health services to the on-line community first be experienced with text-only based relationships. The potential for misunderstandings when people are communicating solely by email is considerable. In using text-based environments to facilitate therapeutic programs, some important considerations are worth bearing in mind. One especially important concern with on-line support services is the potential for clients to devalue communications appearing on their computer screen. When making initial arrangements to use the Internet for therapy, the therapist should secure the clients' agreement to contact the therapist whenever the client finds an interpretation of a note unsettling. Many people are well-equipped at communication by telephone, or even written letter. Not all, however, are adept at writing with the intent of disclosing intimacies previously unexpressed. Text that is conversational in nature, as it exists on the Internet today, is a relatively new phenomenon and these communications may appear colder and more impersonal than the author intended. Most people have the impression that written text represents the well-thought-out and carefully edited views of the writer; however, on-line communications are often the product of someone "typing off the top of his or her head". The reader may in turn interpret these messages as being far more representative of the writer's firmly held thoughts and feelings than is warranted. These kinds of misunderstandings have been documented by people experienced in the use of Internet communications of an emotionally charged nature. Some research on understanding the psychological effects of substituting written word with verbal conversation has been done (Goode & Johnson, 1991; King, 1995).
Part of being experienced in on-line communication is understanding the increased potential for projection and transference in the client/therapist relationship. Because of the lack of visual and auditory clues in electronic communications, there is a tendency to idealize the other, as the mind naturally tries to fill in the missing clues. An intensification loop can develop where a cycle of "behavioral confirmation and magnification" may occur.
It is well accepted that, Off-line, we respond to others based largely on our expectations despite what their actual behavior may present. At the same time, when disconfirming social data are less available and what does occur is selectively sent and selectively perceived, the reciprocal process of behavioral confirmation may be more likely yet. Such a process as this may explain how such surprisingly intimate, sometimes intense, and hyper-personal interactions take place" computer mediated communications (CMC). The CMC provides the intensification loop" (Walther, 1996, p.28).Social Responsibility
Psychologists "apply and make public their knowledge of psychology in order to contribute to human welfare" (APA, 1992). On-line psychologists who maintain a website advertising their services often include a wealth of information about psychological disorders and their treatment. This psycho-educational service is available to the public 24 hr. a day, can be accessed to the advantage of anyone, not necessarily a client, and is generally provided free of charge. In situations where a recipient of services is in a geographically remote location, on-line therapy may be the only psychological therapy available to them.
Current Evaluations of Ethics & Virtual Therapy
James Sampson, in a recent article titled "Counseling on the information highway: Future possibilities and potential problems" outlines many of the ethical concerns that on-line therapists must consider. Sampson addresses confidentiality problems and suggests that security of data storage, unauthorized access, and the need for therapists to be educated about appropriate security measure are central issues. Sampson states that clients who receive information by computer tend to believe that information, and therapists are obligated to ensure the validity of the information they present to the on-line community. If a therapist is working with a client that is geographically remote, then the therapist should be aware of the conditions that exist locally for the client which may impact on their relationship, such as natural disasters or political unrest. Local cultural norms vary as well, and unawareness of these differences can be problematic. "For example, a geographically remote counselor may be unaware of traumatic recent local events that are exacerbating a client's reaction to work and family stressors . . . If a counselor encounters an unanticipated reaction on the part of the client, the counselor needs to proceed slowly, clarifying the clients perceptions of their thoughts, feelings, and behavior" (Sampson, 1997, p210). Sampson further stated that credentialing concerns are unresolved at this time, and that it is not clear how any enforcement of credentialing requirements would be implemented.
The National Career Development Association Ethics Committee has a draft version of a proposed ethical standards for the delivery of career counseling services over the Internet. The draft lists the following responsibilities of the on-line counselor in his professional relationships:
To communicate to the client the member's credentials and experience; the limitations of their skills; the limits of confidentiality; the need for release of information; the length of time communications will be stored; and the potential need for making contact by telephone when appropriate.Suggestions for Applications of Ethical Virtual TherapyFinding and presenting a local referral to the client in case of the need for crisis intervention.
Proper screening to insure that on-line counseling is appropriate.
Proper follow-up of any self-help assessment measures used.
Assuring that only current valid and relevant information is posted to the website associated with the counselor's service.
Assurance of the validity and relevance of any information derived through links to their own website.
Obligation to be aware of local conditions, cultures, and events.
If the client is not benefiting from the counseling delivered over the Internet, then the counselor has a responsibility to intervene by telephone and/or make an appropriate referral.
If the member provides counseling they must have an appropriate credential for independent practice.
The client must be provided with an email address or a website of the credentialing association which provided the counselor's licensure so that unethical on-line behavior can be responsibly reported (Bloom, 15 April 1997).
In 1995, the APA Ethics Committee adopted a statement that refers to therapy conducted over the Internet. It states that there has been no research done on whether a psychologist can be licensed in one state, and provide services over the Internet to someone residing in another state. No mention of the international aspect of Internet services is made. It may be that the final analysis will result in the on-line community being classified as a "special population", similar to the ones prescribed as requiring special considerations when conducting research: i.e. ., prison populations and people unable to give full informed consent to be human subjects. If such were the case, then the logical criteria for credential requirements would be that psychologist be licensed by their local licensing board, and certified by an association that specializes in on-line therapy services. Just because a method of delivery of therapy services is new does not relieve the therapist from full considerations of all ethical guidelines (Hines, 1994).
Clients who can not, or will not, present for traditional treatment
"Computers can be valuable for counseling and conducting surveys about sensitive topics, situations in which many people are anxious and cover their true feelings and opinions" (Sproull & Kiesler, 1995 p.133). There is a well documented disinhibiting effect that occurs in text-based relationships (Walther 1996), one that can be utilized by the on-line therapists. Clients have been reported to reveal things to their helping professional by email that they were unwilling to share in person (Sellu, 1996). Some clients with certain psychopathology, such as Avoident Personality Disorder, may well benefit from email therapy used as an adjunct to traditional therapy protocols.Conclusion
The information revolution continues to bring changes to the manner in which people are able to communicate with each other. Future trends in interactive therapeutic contact will most certainly utilize real time video connections. Currently, email exchanges do offer an alternative for establishing a transformitive relationship between a client and a therapists, but the exact manner that these relationships can be ethically implemented is not well researched. Once a professional relationship has been established, the licensed clinical psychologist has a responsibility to the welfare of the client, and it is unclear how this can be executed completely by email. However, email therapy is occurring, and it behooves the profession to examine the constraints imposed by this medium, as well and the potential benefits to consumers of mental health services. The development of clear ethical guidelines that state the need for on-line therapists to be experienced in and knowledgeable about this new medium will benefit all involved. Future research on outcomes of therapy done by email is required to fully understand what the true scope of the ethical considerations. One thing is clear; of the millions of people that regularly log on to the Internet, looking for information or to socialize with others, a small percent will be currently suffering some kind of emotional disturbance, and they are likely to seek assistance from this new medium. Licensed clinical psychologists responding to this need are obligated to share information, research results, and conduct themselves in as ethical a manner possible in their email professional relationships.
References
American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologists, 47, 1597-1611.
Bloom, J. (1997). On-line self-regulatory body & proposed NCDA Internet standards. Posted to NetPsy (Discussion of psychological services on the Internet, 15 April 1997. [on-line]. Available: archives of NetPsy on LISTSERV@MAELSTROM.STJOHNS.EDU.
Goode, J. & Johnson, M. (1991). Putting out the flames: The etiquette and law of email. Online, p. 61-65.
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Hines, M. H. (1994) Using the Telephone in Family Therapy. Journal of Marital and Family Therapy, 20, 2, 175-184.
Huang, M. & Alessi, N. E. (1996). The Internet and the future of psychiatry. American Journal of Psychiatry, 153, 7, 861-869.
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King, S. A. (1997, April). Ethics of on-line psychology. Paper presented at the meeting of the California Psychological Association, San Jose, California.
Maheu, M. (1997). Credentials on-line. . Posted to NetPsy (Discussion of psychological services on the Internet, 22 April 1997. [on-line]. Available: archives of NetPsy on LISTSERV@MAELSTROM.STJOHNS.EDU.
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Poulos, S. T. (in press). Literacy and the on-line Professional. Self Help & Psychology Magazine. Available WWW: http://cybertowers.com/selfhelp.
Prilleltensky, I. (1997). Values, assumptions, and practices: Accessing the moral implications of psychological discourse and action. American Psychologist, 52, 5, 517-533.
Sampson, J. (1997a). Internet counseling. Posted to NetPsy (Discussion of psychological services on the Internet, 11 Mar 1997. [on-line]. Available: archives of NetPsy on LISTSERV@MAELSTROM.STJOHNS.EDU.
Sampson, J. (1997b). Counseling on the information highway: Future possibilities and potential problems. Journal of Counseling and Development, 75, 203-211.
Sellu, D. (1996) Clinical encounters in cyberspace. British Medical Journal, 312, p.49
Sproull, L. & Kiesler, S. (1995) Computers, networks and work. In The Computer in the 21st Century. Scientific American, a special issue, 128-139.
Walther, J. B. (1996). Computer-Mediated communication: Impersonal, interpersonal, and hyperpersonal interaction. Communication Research, 23, 1, p3-43.
Created and maintained by Storm A. King
last updated 01/2006
