Module 1: Ethics
Module Created by Anam Khokhar
Important Terminology and Definitions
- Confidentiality: the principle that data or information is not made available or disclosed to unauthorized persons or processes
- Privacy: the right of practitioners and patients to control the amount and disposition of the information they divulge about themselves
- Security and Security Measures: the administration, physical, and technical safeguards in an information system
- Information System: interconnected set of information resources within a system including hardware, software, information, data, applications, communities, and people
- Informed Consent: informing the client of specific limitations, potential risks, and/or potential benefits relevant to the client’s anticipated use of telepsychology services (American Psychological Association, 2013; American Telemedicine Association).
Ethics in Telepsychology
As a scope of psychological practice extension, telepsychology requires an understanding of current ethical standards as well as recognition of additional concepts, decisions, and actions that may impact care (Cooper et al., 2020).
Six of the eight Telepsychology Guidelines, as outlined by the American Psychology Association (2013), are also standards of the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2017a). As defined by both the American Psychological Association and evidence-based literature and research, the foundational concepts of ethics in telepsychology are:
- Competence
- Standard of Care
- Informed Consent for Services
- Data Security, Privacy, and Confidentiality
The practitioner is responsible for having a full understanding of the ethical considerations of telepsychology, including the awareness of the foundational concepts as well as legal and regulatory accountability.
Telepsychology Competence
Within all scopes of practice, in-person or online, practitioners always have the ethical obligation to provide services only within the boundaries of their competence based on their education, experience, and training. Telepsychology practitioners must always strive to maintain an equivalent standard of competence as demonstrated when providing services in person (Cooper et al., 2020).
In telepsychology, providers should assume the responsibility for assessing and evaluating their technological competences before and during their practice of telepsychology. This includes competencies in the following:
Training
- A practitioner must be competent in their ability to effectively provide treatment regardless of the mode of communication.
- A provider conducting therapy over video conferencing should be (1) trained in the treatment and (2) able to make proper adaptations to treatment based on clinical judgement.
- This includes receiving proper supervision and feedback throughout the training process (McCord, 2020).
Evaluation of Appropriateness
- Practitioners should consider evidence, technological competence, high-risk needs of the client, emergency resources, boundary concerns, language and other diversity variables, and mental health status (among others) to determine whether specific telepsychology treatments are appropriate for a client and their needs (Cooper et al., 2020).
- Available evidence should be examined to understand best practices and if an assessment or treatment is valid and reliable.
- Documentation of consideration and choices regarding the use of telecommunication technologies used in service delivery is encouraged, but privacy and confidentiality should always be considered and maintained (American Psychological Association, 2013).
Risk Management
- The knowledge of emergency situations and crisis management through a telepsychology perspective
- The same emergency situations that occur during the facilitation of in-person services can also take place during the facilitation of online services. If a client is posing a threat to themselves or others, a knowledge of telepsychology emergency management is essential.
- At the onset of the delivery of telepsychology services, psychologists should identify emergency resources in the client’s area, i.e. emergency response contacts, emergency telephone numbers, referral resources, and/or a support person in the client’s life when available (American Psychological Association, 2013).
- At the minimum, it is recommended that providers keep a record of at least one emergency center and/or one emergency contact in the area that the client is comfortable with the practitioner communicating with if needed (McCord, 2020).
- Practitioners should also ensure that they have an emergency plan in place for crisis situations as well as how to use those emergency protocols and resources.
Technology
- Understanding of available technologies and technological infrastructure, their usages, strengths, limitations, and effectiveness
- Usage and maintenance of the proper equipment, including connectivity, bandwidth, software, special equipment, etc. Providers should have connections to information technology departments in the event that outside technical support is necessary (McCord, 2020).
Maintaining Standard of Care
The same ethical and professional standards of care and practice that are met while providing in-person psychological services should also be met during the provision of telepsychology services. As noted earlier, practitioners should take care to evaluate and assess the appropriateness of the technologies they intend to use. Some technologies utilized during telepsychology services include:
- Interactive videoconferencing
- Telephones
- Text
- Web services
- Mobile applications (apps)
Before a provider engages in providing telepsychology services, they should conduct an initial assessment to determine which telepsychology services should be provided and whether they meet a high standard of care. Risks of online psychological services, such as information security, considerations for emergency management, and issues related to limited technological skills, should also be examined for decision-making on the appropriateness of certain telepsychology practices (Cooper et al. 2020).
The assessment should also include any multicultural and ethical issues that may possibly arise, as well as a review of the most appropriate medium for service delivery. (APA, 2013).
Like within the provision of in-person services, providers should also ensure they are following the best practices of service delivery and keeping up with empirical literature to do so. Multicultural considerations that are relevant to the service model should also be explored.
Throughout the practice and service delivery, practitioners should also monitor and regularly assess the progress of their patients. Some questions guided by the American Psychology Association’s standards for telepsychology (2013) that practitioners should consider are:
- Am I using the empirically supported best practices in the provision of my telepsychology services?
- Is the standard of care up to par with my in-person services?
- Is the patient showing improvement through the care I am providing?
- Is the provision of telepsychology services still appropriate and beneficial to the client/patient?
- Is there a significant change in the client/patient or in our therapeutic interactions that causes concern?
Within the considerations of these questions, practitioners should take any steps necessary to retain an ethical standard of care while also regularly adjusting and reassessing the appropriateness of their telepsychology services.
Furthermore, practitioners should obtain liability insurance and coverage for the teleservices they provide. Practitioners should verify that their provider covers telepractice. Consider contacting your insurance agency for consultation regarding legal questions and concerns.
Informed Consent for Services
Informed consent for telepsychology involves using language that is easily understood to inform the client of risks, benefits, and the services and practices they will receive.
- Practitioners should also inform the patient of clinician rights and responsibilities; establishing a patient-provider relationship; and making sure the client has the ability to provide consent (Sabin, 2017)
- A clear description of the telepsychology services should also be included as a part of the informed consent agreement
- As a whole, practitioners should always seek to obtain and document informed consent when providing any kind of professional services (APA Ethics Code, Standard 3.10).
Smucker Barnwell and Campbell’s Ethical and legal aspects of the practice of teletherapy (2017) notes eight components for establishing informed consent for telepsychology beyond in-person services and treatment:
- Screening for appropriateness with full consideration of client variables
- Limits of confidentiality and potential breaches
- Emergency procedures inclusive of area-specific resources
- Means of communication, particularly in asynchronous practice, and reasonable timeline for response
- Identification of language or cultural factors
- Clarification of storage and disposal method of sensitive information and data
- Agreement on the conditions at the remote site
- Billing
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- As part of informed consent, practitioners should be mindful of the need to discuss with their patients what billing will include prior to the onset of services.
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- Billing documentation may include the type of technology used, the type of services provided, and the fee structure for each relevant telepsychology service, including but not limited to: video chat, texting fees, telephone services, emergency scheduling, etc.
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- It may also include discussion about charges incurred for service interruptions or failures, responsibility for overage charges on data plans, fee reductions for technology failures, and/or any other costs associated with the telepsychology services provided
(American Psychological Association, 2013).
Issues related to electronic communication should also be considered. Professional language should be used over text/email, patient emails should not be forwarded without their consent, and the client should be informed of when and how you are available and what to do in an emergency.
- Special considerations should also be given to social media usage.
- Practitioners should establish boundaries from an early stage and avoid interacting with clients via social media (Sabin, 2017).
Above all, informed consent and informed consent agreements ensure that as a practitioner, you have explained the features of electronic communication while also providing education to your client on the expectations they should have for teletherapy.
Data Security, Privacy, and Confidentiality
The use of telecommunications to deliver care presents challenges with handling data security and privacy. Practitioners must take the necessary steps to protect the confidentiality of their patients and should develop an awareness of the risks to confidentiality before utilizing any telepractice technologies.
According to the American Psychological Association (2013), a few potential data security and confidentiality issues that may arise include:
- Steps should be taken to ensure confidentiality when transmitting information through online mediums.
- Practitioners and service providers should ensure they have the appropriate security methods in place.
- Current encryption standards should be utilized within websites and/or telecommunications technology that meet any legal requirements
- If there is a breach of unencrypted electronic communications or maintained data, practitioners are urged to notify their patients and other appropriate individuals/organizations as soon as possible.
- Any internet participation by practitioners has the potential of being discovered by patients and others – considerations should be taken as this may compromise the professional practitioner-patient relationship.
- Practitioners that participate in online social networking sites should educate themselves about the risks to privacy and should use all available privacy settings to reduce these risks.
- Maintenance, storage, and disposal of client records should be done in ways that protect confidentiality and are in accordance with applicable regulations or laws.
- All communication regarding mental health treatment, including emails and texts, should be kept.
Practitioners should exert reasonable effort to create a safe, secure remote/online environment in which:
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- the conditions for confidentiality are met
- HIPAA privacy requirements are in place
- systems for responding to breaching are met
- appropriate software is used (Cooper et al., 2020)
Multicultural and Diversity considerations
Practitioners are encouraged to be aware and educated of any issues that may arise with diverse populations when providing telepsychology. Appropriate arrangements should be made to address these potential issues. Some examples defined by the APA (2013) include:
Language
- Practitioners should ensure their websites and services are accessible to people with disabilities.
- Translation capabilities for clients who have a different primary language
Cultural Differences
- Practitioners should be mindful of cultural competence when framing their telepsychology services.
- Appropriate language should be used, especially in terms of obtaining informed consent. Practitioners must exert reasonable effort to ensure that individuals of diverse cultures, ethnicities, and language preferences understand the meaning and content of the informed consent form (Cooper et al., 2020).
Cognitive, physical, or sensory skills or impairments
- Transcription capabilities for clients with auditory impairments
Accessibility and socioeconomic status
- Clients of low SES may not be able to afford the cost of the equipment to participate.
- While there may be unavoidable reasons for differential quality or access to services, practitioners should make every effort to eradicate these barriers in order to exercise fairness and promote equity in access (Cooper et al., 2020).
Resources
- APA ethics guidelines for practice and for telepsychology
- APA training modules
- Technology education
- Your state’s psychological association’s guidelines for telepsychology
- State laws on confidentiality
- Your liability insurance guidelines
References
American Psychological Association (2017). Ethical principles of psychologists and code of conduct. http://www.apa.org/ethics/code/index.html
American Psychological Association (2013). Guidelines for the practice of telepsychology. http://www.apa.org/practice/guidelines/telepsychology
American Telemedicine Association (2012). Guidelines for telepathology. www.americantelemed.org/i4a/ams/amsstore/category.cfm?category_id=2
Cooper, S. E., Campbell, L. F., & Smucker Barnwell, S. (2019). Telepsychology: A Primer for Counseling Psychologists. The Counseling Psychologist, 47(8), 1074–1114. https://doi.org/10.1177/0011000019895276
McCord, C., Bernhard, P., Walsh, M., Rosner, C., & Console, K. (2020). A consolidated model for telepsychology practice. Journal of Clinical Psychology, 76(6), 1060-1082.
Sabin, J. E., & Harland, J. C. (2017). Professional ethics for digital age psychiatry: Boundaries, privacy, and communication. Current psychiatry reports, 19(9), 1-7.