The general coverage of online counseling, both in professional and general print and other media, has exploded within the past couple of years and the debate about such issues as liability, efficacy and jurisdiction is raging. Clinicians across all disciplines are bombarded with information and solicitation by online counseling companies and recent reports indicate that there are several hundred therapists across the country providing such e-therapy services. The belief of the Clinical Social Work Federation is that psychotherapy services cannot be delivered online because of the inherent nature of the service and, therefore, the Federation is opposed to the practice of Internet-based treatment. By the term Internet-based treatment, the Federation is referring specifically to, and this paper asserts a position about, psychotherapy services that are limited to text-based exchanges between therapist and client.
This position paper does not address telephone counseling or email when used as an adjunct to in-person sessions, or two-way video conferencing either as a primary means or adjunct to in-person sessions, or any other technological medium that is used as primary or adjunctive to a basically in-person treatment process. While this paper does not express a position with respect to those forms of communication when used as an adjunct to the therapeutic process, the Federation recommends that the principles detailed later in this paper be used as a means of evaluating whether those adjunctive techniques meet well-accepted professional standards. According to some sources, 90% of the e-therapy field is totally text-based; this position paper addresses that arena and, for the purposes of this paper, the terms "online counseling" and "e-therapy" are used to indicate text-based services.
This paper is intended as a working document and may be amended in the future as new forms of telehealth develop. It is recommended that the principles detailed below serve as standards with which to examine and evaluate various forms of telehealth as they emerge. The position of the Federation, as detailed in this paper, is related to professional and ethical standards and is not intended as legal advice.
It is a fact that whenever and wherever a licensed clinical social worker delivers a professional service, that clinician is working under their state license; that is, they are governed by the laws, ethics and professional standards of their profession whether they are seeing clients in a hospital, school, private practice office, employee assistance setting, prison, clinic or in cyberspace. However, it seems that the obliteration of the usual limits of time and distance in the Internet world have led somehow to a similar blurring in the minds of some clinicians, and they believe that "new rules" apply to the Internet world. Licensing boards have clarified, and the Federation wishes to emphasize, that the limits imposed by the usual standards of professional practice are unchanged by the "freedom" of the Internet world.
In 1997, The Joint Working Group on Telemedicine1 identified for its specific attention the need for clinical standards of practice in the area of telehealth. While telehealth is the broader area under which online counseling is subsumed (in other words, on-line counseling is a form of telehealth), the principles for practice are a very good fit in terms of providing a framework for our analysis. These principles are explained in a recent journal article entitled "Ten Interdisciplinary Principles for Professional Practice in Telehealth"2.
There are several reasons that interdisciplinary collaboration in this area is essential; certainly, first and foremost, is the protection of clients. In this way, our concern with establishing a position on the delivery of online therapy services and the primary mission of state licensing boards - protecting the consumer - is in absolute alignment. With this primary goal in mind, the following principles are offered as both an explanation for the Federation's position and a framework for the analysis of online services:
1. The basic standards of professional conduct governing each health care profession are not altered by the use of telehealth technologies to deliver health care, conduct research, or provide education. Developed by each profession, these standards focus in part on the practitioner's responsibility to provide ethical and high-quality care.
Discussion: As noted above, even though the Internet profoundly influences the aspects of time and distance in that it may obliterate those boundaries, this technology does not change, in any sense, the duties and responsibilities of the clinician. If we consider the most fundamental and basic ethic in our role as providers of treatment - to not harm and to help heal3 - and we review the Code of Ethics developed by the Federation4, we can immediately identify the serious gaps between the quality of in-person services vs. services that are delivered online.
2. Confidentiality of client visits, client health records, and the integrity of information in the health care information system is essential.
Discussion: The need to protect client confidentiality is a standard of professional conduct for clinical social workers and, of course, mental health records are particularly sensitive. The role of confidentiality is central in the delivery of mental health services; without that assurance, the clinician risks both the loss of the working alliance with the client and the addition of tremendous legal exposure. Confidentiality is the foundation upon which the structure of treatment is built.
One may assert with conviction that confidentiality is impossible to ensure when information is transmitted over the Internet, at least at this point in time and perhaps ever; consider that computer hackers have found their way into the Department of Defense, that family members may share a log-in password and/or the view of the computer screen, and that, generally, "the possibility that information transmitted via E-mail or the Internet may be intercepted by a third party is a constant threat."5
3. All clients directly involved in a telehealth encounter must be informed about the process, the attendant risks and benefits, and their own rights and responsibilities, and must provide adequate informed consent.
Discussion: It is unknown as to how the clinician could accomplish the above when the primary information as to even the basic identity (age, gender, location, ethnicity) of the client comes from words on a computer screen - the tremendous amount of information that is provided by sight and sound is not available. Given that the identity and location of the client is impossible to confirm, providing adequate informed consent is a moot point.
Clinicians may practice only in the state or states in which they are licensed; while client honesty about location, identity and presenting facts may be desired by the clinician, the medium of the Internet provides no way in which to confirm this information. In fact, it is possible that clients who choose to access services on-line may not be the same clients who walk into our waiting rooms. With regard to risk, online clients may be self-selected in ways that serve to significantly increase clinician exposure to liability.
4. Services provided via telehealth must adhere to the basic assurance of quality and professional health care in accordance with each health care discipline's clinical standards.
Discussion: This principle arises from the obligation to assure quality in clinical care and relates to the comparison regarding quality between in-person services and those delivered via telehealth; in this sense, this principle is more applicable to the broader area of telehealth than the narrower focus of online counseling. For our purposes, this comparison is relevant only for those clients who do not have access to in-person services; in fact, according to the 1998 Bureau of Census figures, 20% of the U.S. population lives in rural areas.
While clearly in-person services would be far preferable for this population, travel to a metropolitan area may simply not be possible and an alternative method of delivering service may be better than no service at all. If telephone communication is available, this medium would be preferable to online communication, as there is much more information available from the human voice than from a computer screen. There may be rare instances in which telephone access is not available and computer access is available; providing online services on these rare occasions, then, would be based appropriately on the client's need and not on the clinician's.
5. Each health care discipline must examine how its patterns of care delivery are affected by telehealth and is responsible for developing its own processes for assuring competence in the delivery of health care via telehealth technologies.
Discussion: Again, this principle relates to the larger area of telehealth; however, the primary message is applicable to the issue of online counseling. Clinical social work needs to take the lead in establishing its position on this topic so that government and other oversight entities do not become involved in regulating the behavior of clinicians in this arena.
The current development of telehealth technology, including online therapy, is being driven primarily by commercial forces; instead of responding to the need of potential clients, the industry around online services is being driven by the technology itself (witness the recent proliferation of "Online Therapy Certification Workshops".) The authors of this article state that "If the technology drives consumer applications and systems development, rather than the technology being responsive to the real health needs of its users, the result could be extremely costly and elaborate systems that do not deliver better - or even effective - health care." This understatement, when applied to online therapy, would suggest that the question "can we do it?" has, unfortunately, replaced the far better question "should we do it?"
6. Documentation requirements for telehealth services must be developed that assure documentation of each client encounter with recommendations and treatments, communication with other health care providers as appropriate, and adequate protections for client confidentiality.
Discussion: Documentation of each client contact is an accepted professional standard of care. However, as described earlier in this paper, electronic communications are subject to inappropriate access by third parties and it is impossible to assure confidentiality. In addition, contacts that are recorded via email contain far more information than is normally in a paper record; that fact increases the stakes in terms of the lack of privacy and confidentiality when using electronic mediums.
Even if there were some method of ensuring client confidentiality, the issue of documentation poses another subtle, yet potentially very significant, risk for both the client and the clinician. Does documentation of each client encounter, the usual standard of care, mean that the clinician maintains the record in its original form (emails) or does a paper summary meet the professional standard? Certainly the existence of a "real time" record of the client-therapist interactions provides a very useful document for attorneys to subpoena during the discovery phase of a lawsuit. Then, the "raw record", as it were, is in the hands of non-clinicians to read and interpret as they wish, placing the clinician in a uniquely vulnerable position.
7. Clinical guidelines in the area of telehealth should be based on empirical evidence, when available, and professional consensus among involved health care disciplines.
Discussion: In contrast with practice guidelines, clinical guidelines provide specific recommendations about treatments to be offered to clients; clinical guidelines are client-focused and are condition or diagnosis-dependent, e.g., major depression, adjustment disorder. As described above, there is no assurance that the presenting information delivered online is accurate; there is also no empirical evidence that providing therapy services online is effective. Methods and recommendations for treatment of various conditions, as per commonly accepted professional standards, is unchanged by the medium used to deliver services.
8. The integrity and therapeutic value of the relationship between client and health care practitioner should be maintained and not diminished by the use of telehealth technology.
Discussion: Again, this refers to the larger area of telehealth and one can imagine that there are situations in which video conferencing may serve to not only deliver services but save lives - for example, when the physician at the hospital is able to view the patient being treated by paramedics and determine the course of treatment based on visual contact as well as readings from machines. There are many other effective and "safe" applications of telehealth as a tool in the medical world; those applications find only rare analogies in the world of mental health.
Managed care has already served to diminish the commonly accepted vehicle for change in mental health - the therapeutic relationship - and online therapy, as a tool, serves to nearly eradicate it. Barbara Gutek's (1995)6 analysis of service interactions in late 20th century America makes the distinction between relationships and encounters; it is essential that clinical social workers, in their rush to embrace the Internet and its promise of ubiquitous communication, not contribute to the further erosion of quality mental health services.
9. Health care professionals do not need additional licensing to provide services via telehealth technologies. At the same time, telehealth technologies cannot be used as a vehicle for providing services that otherwise are not legally or professionally authorized.
Discussion: The scope of practice, as defined at the state, professional and individual level, is not changed by the introduction of telehealth tools as technologies for service delivery. This principle underlines again that clinicians will be held to the in-person standard of care in terms of the major aspects of service delivery. State licensing boards are very concerned about this issue and many are in the process of developing recommendations. Given the high potential for harm to the consumer such as breach of confidentiality, misdiagnosis because of limited or incorrect information and jurisdiction issues (practicing, perhaps unwittingly, in a state in which one is not licensed), it would not be a surprise to see some licensing boards, in the near future, caution against or prohibit online counseling except for specific, unusual situations.
10. The safety of clients and practitioners must be ensured. Safe hardware and software, combined with demonstrated user competence, are essential components of safe telehealth practice.
Discussion: The assurance described in this principle is possible only in theory as it relates to online therapy, as detailed above. User competence is more of an issue with certain complex telehealth technology than with online counseling; however, online counseling is only available to those individuals who have adequate written expressive capability.
Psychotherapy has at its heart a profoundly human connection; a connection that is, in itself, the major vehicle for change. Healing and restoration occur when the therapist and the client together find the bridge leading back, and forward at the same time, to the true self. It will always be the case that the best in our field, the most expert and gifted clinical social workers, blend art and science into a seamless whole in their daily work. So much human suffering has been caused by disconnection - disconnection between individuals, between thought and feeling, between body and mind - and e-therapy offers yet another form. Clients seek our services in order to improve the quality of their lives, the quality of their relationships. Alienation from others and the self will not be healed through a virtual connection in cyberspace, a "connection" that is fraught with risks and hazards for both clients and clinicians.
By: Renee B. Lonner, MSW, BCD, for the Clinical Social Work Federation;
Review Committee: Susan Trimm, MSW, BCD; David G. Phillips, DSW, BCD; Betsy Amey, LCSW-C; and Betty Jean Synar, MSW.
1 This Group was convened in 1995 by the Secretary of the Department of Health and Human Services; it is now coordinated by the federal Office for the Advancement of Telehealth, created in 1998. The JWGT is an ad hoc group of representatives from federal agencies, departments and programs who are involved in significant telehealth activities and provides recommendations regarding federal telehealth policy.
The Clinical Social Work Federation wishes to express its appreciation to authors Reed, McLaughlin and Milholland, and to publisher, the American Psychological Association, for a most articulate, comprehensive and relevant paper.
2 Reed, G.M., McLaughlin, C. J. and Milholland, K., (2000). Ten Interdisciplinary Principles for Professional Practice in Telehealth: Implications for Psychology, Professional Psychology: Research and Practice, 31, 170-178.
3 Kass, L. R., Professing Ethically (1983). Journal of the American Medical Association and the Clinical Social Work Federation Code of Ethics.
4 Clinical Social Work Federation, Code of Ethics.
6 Gutek, B. (1995). The dynamics of service: Reflections on the changing nature of customer/provider interactions, San Francisco: Josey-Bass.
© 2001 Clinical Social Work Federation. All rights reserved. May not be copied or reprinted without permission.