Introduction
The purpose of this research is to review recent literature regarding the ethics of conducting telepsychotherapy. The examination is concentrated mostly on North American papers but with some discussion of multicultural aspects of telepsychotherapy. By summarizing the recent research regarding the ethical use of technology for conducting remote psychotherapy, this paper hopes to summarize the most common situations that can create ethical dilemmas when conducting telepsychotherapy and methods to minimize them. The basic finding from this investigation is that while conducting telepsychotherapy introduces ethical dilemmas not present in face-to-face counseling, there are some ethical issues that are diminished with the use of Internet technology. These strengths are explored. Finally, this paper discusses the attitudes counselors have toward the use of telepsychotherapy. The basic conclusion drawn from this investigation is that counselors may find telepsychotherapy useful in some scenarios but lacking in others.
What is Considered Telepsychotherapy?
In simplest terms, telepsychotherapy can be defined as any communications that occur remotely using technology for the purpose of conducting psychotherapy. Amichai-Hamburger, Klomek, Friedman, Zuckerman, and Shani-Sherman (2014) define e-therapy as “a licensed mental health care professional providing mental health services via email, video conferencing, virtual reality technology, chat technology or any combination of these” (as cited in Manhal-Baugus, 2001). Koocher (2007) says that tele is Greek for from a distance. Subsequently, telepsychotherapy can also be thought of as any psychotherapy conducted from a distance. Electronic communications of all types aid in telepsychotherapy. This includes the use of smartphones, Skype, email, SMS messaging (also known as texting), and more. Independent of any particular theoretical orientation, any communications using these and other Internet-based technologies for the purpose of performing psychotherapy can be considered telepsychotherapy.
Another aspect of telepsychotherapy that is important to define is the difference between synchronous and asynchronous communication. Rummell and Joyce (2010) explain that synchronous communication exists in real-time. The examples they give include chat rooms and instant messaging. In 2018, we can also include teleconferencing, Facetime, and the use of streaming apps. Asynchronous communication happens when time elapses between the initial communication and the response, writes Rummell and Joyce (2010). The clearest example of asynchronous communication is the use of email.
The Ethics of Telepsychotherapy
The ethics of telepsychotherapy are largely identical to the ethics of face-to-face psychotherapy. A licensed counselor who practices according the American Counseling Association is held to the same ethical standards when using Internet-based technologies to conduct counseling. Nevertheless, there are nuances about telepsychotherapy that require examining scenarios in unique ways.
Proudfoot (2004) writes that organizations have emerged to specifically address the new ways services are rendered. Organizations such as the Psychiatric Society for Informatics and the International Society for Mental Health Online are available to help guide practitioners using telepsychotherapy, writes Proudfoot (2004). The organizations help in areas of informed consent, laws, and other areas of concern for the professional conducting therapy remotely.
Koocher (2007) says we should consider the 4 C’s when it comes to engaging in telepsychotherapy. The four C’s are: contracting, competence, confidentiality, and control. Koocher (2007) explains that contracting means informed consent, and contracts with clients must include descriptions and explanations of intended use of electronic communication technologies. Koocher (2007) continues by explaining that competency regarding telepsychotherapy means not using technology to hide a lack of competency. For example, when operating remotely, it’s much more difficult for the client to determine that someone is who they say they are and to determine their qualifications. When using electronics, communications may be vulnerable to unauthorized monitoring. Koocher (2007) implores practitioners to be aware of these vulnerabilities and make clients aware of these issues around confidentiality. Finally, Koocher (2007) addresses the fourth and most ambiguous of his “C’s” regarding telepsychotherapy—the issue of control. When client and practitioner operate in different states, or even countries, who is the regulatory agency that intervenes when something goes wrong? Practitioners must be aware of the issues regarding control and be prepared for acting ethically according to multiple regulatory agencies when conducting telepsychotherapy.
Drum and Littleton (2014) raise issues of boundaries and professionalism concerning the use of telepsychotherapy. They worry that therapists may conduct therapy in “less formal environments.” The concern is that this decision may lead the therapist down a slippery slope. If the therapist continues on this path toward informal atmospheres, including dressing casually, using shorthand in emails and messaging, Drum and Littleton (2014) believe that the therapeutic alliance could deteriorate as the client’s perception of the counselor as a serious professional diminishes.
According to Finn and Barak (2010), one-third of counselors conducting telepsychotherapy aren’t confident about client confidentiality. To determine whether this is significantly different from the beliefs of counselors who only perform face-to-face counseling, the same survey would need to be administered to a similar number of counselors who only see clients in-person. Perhaps one-third or more of these counselors aren’t confident about client confidentiality. Without this information, it’s certainly possible to draw the conclusion that online counselors overall feel more confident about confidentiality compared with those who only practice face-to-face. Certain issues around confidentiality are removed from Internet-based counseling. No one can see a client in a waiting room. No one in a nearby office can hear a conversation happening behind a counselor’s thinly insulated door. In rural areas, confidentiality is even more difficult to obtain when a client must leave the home to obtain counseling. It’s certainly possible that one of the most important aspects of ethical counseling practice, confidentiality, is easier to obtain when a client doesn’t have to make a physical appearance at a location outside of their home.
Ethical Dilemmas Unique to Telepsychotherapy and Techniques to Mitigate Them
Most clients who see counselors in person aren’t trying to be anonymous. However, many people on the Internet are purposefully trying to maintain anonymity. One ethical dilemma mentioned by McCrickard and Butler (2005) relates to this unique characteristic of online behavior. They say counselors need to be able to verify the identity of the person they are working with in case a safety issue, duty to warn, or legal issue arises during the course of counseling. Counselors who are receiving cash payments via a PayPal account, or even Bitcoin or other cryptocurrencies, may not have an easy time verifying who they are working with. Without medical insurance or the use of a bank checking account, a person engaging with the counselor is more difficult to identify since the client’s geographical location could be unknown and the counselor could potentially lack a clear view of a person’s physical characteristics.
Policies and procedures can mitigate the ethical dilemma of client anonymity. Counselors may require that a client provide a scan or photograph of a form of legal identification such as a state-issued driver’s license or a federal-issued passport. While some client’s may balk at this request, the counselor has an ethical obligation to verify the identity of the person they are working with in the event they must respond to issues where knowing a person’s identity and location are necessary.
McCrickard and Butler (2005) also mention another ethical dilemma that relates to the use of the Internet for conducting psychotherapy. With access to a much larger pool of clients, counselors may encounter cultures that they are completely unfamiliar with. If a counselor is asked to render services to a person from a culture the counselor knows nothing about, the counselor must decide if they are competent to work with the client. Again, policies and procedures can mitigate the problems that may arise from this situation. The counselor has a duty to inform the client that while the counselor may be trained in multicultural counseling, the therapist is unfamiliar with the culture of the client and therefore he or she may not be the best fit. If the client still wants to meet with the counselor, then the client has been informed and has consented to treatment with the full knowledge of the counselor’s limitations regarding their culture. Of course, the counselor can then use the work with the client to better understand the client’s culture.
Additional ethical dilemmas can arise with conducting therapy remotely with technology. Finn and Barak (2010) wrote that 94% of counselors surveyed in a study reported that they received no training on telepsychotherapy in their professional programs. This high percentage may have been because of the age of the respondents when they received their training and may not represent the current state of professional training programs today. Nevertheless, the ethical dilemma remains—are counselors competent to perform telepsychotherapy if they have received only informal training? Forty-four percent of the respondents in the study felt that professionals should have formal training. As an adjunct to other professional training already received, counselors can mitigate the ethical dilemma of lack of professional training in e-counseling by enrolling in a professional workshop. This formal training can also be complemented by informal learning through colleagues and self-learning.
Kotsopoulou, Melis, Koutsompou, and Karasarlidou (2015) raise the ethical dilemma of using telepsychotherapy for treating Internet addiction. Since this group is addicted to the very medium being proposed for treatment, what should a counselor do ethically? If the client is addicted to the Internet, they may be more inclined to seek treatment if they can remain online to meet with the therapist. However, by using Internet technology to treat someone with Internet addiction, is the therapist enabling the client, or encouraging the behavior the client wants to change? A way to mitigate this would be to include in the treatment an agreement about the use of Internet technologies during the course of treatment. Perhaps the counselor could establish that only a certain number of sessions can be conducted online before transitioning to face-to-face treatment. Regardless of the approach, the counselor must have a policy and procedure in place when treating this high-risk group using Internet technologies.
Another ethical dilemma presented by Rummell and Joyce (2010) is what to do when technology fails. Imagine a scenario where a client is in deep distress. The session is taking place online. During a critical time in the session, the technology fails. How should the therapist proceed? Again, if the therapist has a policy and procedure in place, this dilemma can be mitigated. For example, the therapist could have in their informed consent a section regarding backup technologies if the primary technology fails. A client could know that if the online session suddenly ends, the therapist would call the client’s phone immediately.
Rummell and Joyce (2010) also bring up the issue of treating minors. How does one receive parental consent and verify the identification of the parents when using telepsychotherapy? A policy that requests the parents’ identification as well as a bank statement that includes a current address can help mitigate the issue of confirming parental consent when working with minors online.
Strengths of Telepsychotherapy
If telepsychotherapy presents counselors with new ethical dilemmas and complications, why even use it? The reason telepsychotherapy has been adopted so quickly is that it has some strengths compared with face-to-face counseling. If telepsychotherapy didn’t have characteristics that made it preferable to in-person counseling in some scenarios, then it certainly wouldn’t be used to the extent it is. Finn and Barak (2010) say that studies have found that online therapy results in successful therapeutic alliances at the same rate as in-person counseling. They also say that studies report that consumer satisfaction with online therapy is similar to face-to-face consumer satisfaction. As a result, there is no reason to believe that telepsychotherapy suffers from a deficit of one of the most basic elements of counseling necessary for it to work.
Even in the beginning years of widespread Internet adoption, counseling professionals saw the merits of using technology in certain areas. Oravec (2000) wrote that the use of technology with families can eliminate one of the most significant barriers that prevents families from entering counseling: scheduling. Once the number of people who are required to meet at the same place and same time grows, the difficulty in scheduling can become so enormous that some families could simply give up on going. One of the strengths of telepsychotherapy is that it enables families to use remote technology to more conveniently meet online with a family therapist.
Oravec (2000) continues to explain that asynchronous online tools can also help families share experiences through narrative. Families can be provided with online journaling areas, for example. Families can find convenient times outside of the session and write about their own experience with the family. Oravec (2000) makes similar comparisons between family therapy and online group counseling regarding the strengths of telepsychotherapy.
Li, Jaladin, and Abdullah (2013) discuss the usefulness of using telepsychotherapy as a way to intervene when clients suffer from social phobia. They explain that even those who have no social phobia but have a fear of the social stigma of attending therapy could potentially benefit from telepsychotherapy since no one would see them entering a therapist’s office. Li et al. (2013) also explain that telepsychotherapy could lower costs since practitioners could more easily operate from their homes without maintaining outside office space and incurring the subsequent costs.
Rummell and Joyce (2010) say that a strength of telepsychotherapy is making practitioners who specialize in a specific area of treatment available to those in more geographic areas. For example, a client may suffer from a seldom treated diagnosis. With the use of telepsychotherapy, the client may be able to utilize the expertise of a therapist who specializes in that disorder who practices in a faraway geographic location, Rummell and Joyce (2010) say.
Attitudes toward Telepsychotherapy
Finn and Barak (2010) conducted a study (N = 93) that surveyed counselors with at least a master’s degree in order to understand their opinions regarding online therapy and if and how the counselors used online therapy. The sample consisted of 79% female therapists. Eighty percent of respondents lived in the United States. Most of the counselors offered email and chat as telepsychotherapy services. Only about 1 in 10 counselors offered videoconferencing.
The counselors were almost unanimous in believing that telepsychotherapy is a suitable mechanism for treating social issues and relational problems. The counselors’ attitudes were largely split concerning technology’s usefulness when it comes to treating severe trauma. With only 27% of counselors feeling that e-counseling is appropriate for treating suicidal thoughts, this area of treatment had the lowest level of support.
Regarding effectiveness, opinions were split among the responding counselors. Only a small percentage, 9%, found telepsychotherapy to be more effective that in-person treatment. However, the majority, 55%, found it to be equally effective. Nevertheless, more than one-third of counselors who responded to the study’s survey found that e-counseling is less effective than in-person treatment. Interestingly, most respondents said that clients are either almost always seen exclusively face-to-face or online, and rarely a mix of both. This implies that for these counselors, it’s possible that telepsychotherapy is only used out of necessity.
As previously mentioned, confidentiality is one of the ethical areas that raises flags when using telepsychotherapy. In this area, Finn and Barak (2010) found that only 14% of counselors surveyed weren’t confident about the confidentiality of their telepsychotherapy sessions. However, 57% of those same therapists felt that knowing the identity of the online client was unimportant. This response raises some questions concerning these therapists’ judgment about the ethics of online counseling as many papers have detailed the ethical importance of knowing client identity for many important reasons.
Drum and Littleton (2014) believe that even though technology makes it possible to conduct therapy at practically all hours of the day, therapy should still be conducted during normal office hours to maintain professional boundaries and help clients distinguish between therapeutic communications and other types of communications. Drum and Littleton (2014) believe this boundary should be extended to asynchronous communication as well for the same reasons. In this regard, they also recommend not using shorthand, emoticons, and other trendy forms of communication that telepsychotherapy could encourage.
Lazuras and Dokou (2016) found that female therapists found telepsychotherapy to be more positive and simpler to use than males in the same study (N = 63). The authors noted though, that in their sample, males comprised only one-third of responses and may be underrepresented. In spite of these gender differences in the attitude toward technology, Lazuras and Dokou (2016) found no gender differences concerning the intention to use technology in therapeutic settings.
A small study (N = 15) conducted by Tanrikulu (2009) found that counselors didn’t want to use telepsychotherapy as their first choice. Responses suggested that most of those surveyed would only use technology to conduct therapy if a face-to-face meeting wasn’t possible. All of those surveyed in Tanrikulu (2009) felt that technology could be effective, but not as effective as in-person treatment.
The Ethics of Telepsychotherapy Conclusion
A survey of the literature regarding the ethics of telepsychotherapy yields information that informs us that counselors are beholden to the same ethical principles as when operating face-to-face. The same ACA code applies to counselors when treating clients face-to-face or online. Nevertheless, technology presents counselors with unique scenarios that require new ways of thinking about how to ethically conduct treatment.
The anonymity of the Internet can be both a strength and a weakness of using it for therapy. While it can be a boon to those suffering from anxieties and issues that are exacerbated by being in public, such as those who suffer from agoraphobia and social anxiety, the problem of verifying a person’s identity can be an issue if circumstances require intervening at the client’s physical location. While anonymity isn’t the only characteristic of telepsychotherapy that raises ethical issues, it seems to raise many of the most serious ones.
Therapists’ attitudes toward telepsychotherapy vary across demographics. Research surveys suggest that telepsychotherapy is generally seen as useful, at least in some capacity. Most therapists must use technology to some degree in their practice. As a result, therapists seem to want to learn more about technology and how to use it in their practices. Nevertheless, telepsychotherapy doesn’t seem to be a serious alternative to meeting with clients in-person. As a result, while the ethics of using telepsychotherapy are important to learn and codify, counselors will still primarily be using in-person therapy for the foreseeable future.
The Ethics of Telepsychotherapy References
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