online ethical considerations for mental health clinicians

TheNetworkofChristianCounselors13February2017

Copyright©2017.HarryMorgan.AllRightsReservedPermissiongrantedtoreproducewithattribution&citationofwww.http://networkofchristiancounselors.com/

Part I. Fundamental Ethical Considerations for Christian Mental Health Clinicians

Part II. Online-line Ethical Considerations for Christian Mental Health Clinicians

Part III. Avoiding Common Security Breaches & HIPPA Violations

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Part IIOnline-line Ethical Considerations

AsInternettechnologiesincreasinglybecomeingrainedinourprofessionalandpersonallives,theissuesofprofessionalismandethicsshouldbeconsideredcarefully.ThegoalofthiscourseistoraiseawarenessandbuildtheknowledgebaseofChristianmentalhealthprofessionalsregardingtheimpactofInternettechnologyonprofessionalismandethics.TechnologyhasbecomeanintegralpartoftheAmericanlifestyle,anditiscrucialforpractitionerstodeterminehowitimpactstheirprofessionallives.

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• PersonalandprofessionaluseoftheInternetasdramaticallyexpandedduringthepast25years.

• Internettechnologyisapowerfultoolhavingaplethoraofusesformentalhealthprofessionalsincluding:research,education,networking,andclinicalpractice.

• Inherentdangersexistofinadvertentlyviolatingethicalandprofessionalboundarieswhenutilizingthesefunctions.

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Ø DefineInternetusagepatternsandcommonInternettechnologies.

Ø AnalyzehowvariousInternettechnologiesareutilizedinclinicalpractice.

Ø EvaluatehowtheuseofspecificInternettechnologiescanaffectprofessionalismandethics.

Ø DiscusshowtheuseofInternettechnologiescanimpactissuesofboundaries,self-disclosure,privacy/confidentiality,andprofessionalrelationships.

Ø IdentifybestpracticesforusingInternettechnologiesasaclinicalmentalhealthpractitioner.

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Internet TechnologyProfessionalismandEthics

Ethical Legal

• HIPAABusinessAssociates&Email

DEFINITIONS:

• Secure&Non-SecureHardware&Communication

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• Internet

• InternetRisks&Threats

• Encryption

“Thepracticeoftelephone-basedtherapyhasalonghistory,beginningwithitsuseinconsultationandcrisisinterventionandextendingintopsychotherapyandpsychoanalysisinprivatepractice(Leffert,2003;Lindon,2000;Saul,1951).WiththeadventoftheAffordableCareAct,fundshavebeenmadeavailabletosupportahugegrowthincommunity-basetelemedicineservicesusingthetelephoneorvideoconference.TheVeteransAdministration,ArmedForcesHealthServices,andMedicaidhavebeenintheleadbecause,beingfederalprograms,theyavoidtheproblemsofstateregulationsconstrainingserviceacrossadistance.”– JillScharff

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Ø Counselingdoneonlineviaemail,chatrooms,instantmessaging

Ø TelephoneConversationsØ VideoConferencingakaITVØ Someonlinecounselingisoneononeandsome

involvesagroupØ SomeCyber-counselingevenincorporatesart

therapybysendingpicturesbackandforth(audiographic communication).

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Ø PeopleinruralareaswhocannottraveltoaclinicØ Disabledorelderly/unabletodrivetoandfroma

clinicØ Peoplewhoaretooembarrassedtoseek

treatmentinpublicØ Peoplewhoareextremelyantisocialandspend

mostoftheirtimeonlineandarecomfortablethere

Ø PeoplewithAgoraphobiaØ MilitaryPersonalinremotelocations

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Ø Confidentiality,encryption,passwordprotectionØ Establishingclientidentity(minors,homicide,

suicide)Ø Ensuringequalityofaccess/Accessibility

(individualsmaynotbeabletoseecoloronscreenduetovisualdisability,somefamiliesmaynothaveaccesstocomputersatall)

Ø InformedconsentØ Lawsandstatutesorjurisdictionofstatesofboth

counselorandclient

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Ø ProvidingcredentialsØ ProvidingreferralsincaseofemergencyØ Dealingwithtechnicalfailure

Ø In2009itwasestimatedthat68%ofUShouseholdshadInternetaccess

Internet and Digital Technology Usage & Consumption in the US

Ø Ina2014studyconductedbythepewresearchCenterwith1006adults18yearsofageandolder,87%ofmenand86%ofwomenreportedInternetuse

Ø 57%of65yearold'sandolderarelikelytoutilizetheInternet

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Ø In2012itwasestimatedthat74.8%ofUShouseholdshadInternetaccess

Ø 97%of18- 29yearold'sarelikelytoutilizetheInternet

Ø In2010,theaverageAmericanspendssixhours&35minutesonblogsandsocialnetworkingsiteseveryday89%ofthose18- 29yearsofage

Facebook, Google +

Ø In2014,74%ofadultswereusingsocialnetworkingsites

Ø In2014,anestimated:71%ofAmericans18yearsofageandolderuseFacebook26%hadtheInstagramprofile28%reportedusingLinkedIn23%ofonlineadultsuseTwitter

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Ø ELECTRONICMAIL(E-MAIL)

Ø CHATROOMS

Ø BLOGSORMICROBLOGSBloggerGoogleTumblrWordPressBlogSpotLiveJournal

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Ø SOCIALNETWORKINGWEBSITESFacebookGoogle+LinkedInVKPinterestYik YakTwitterSecond LifeInstagramClassmatesReunion

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Ø PHOTOORVIDEOSHARING

Ø WIKIS

InstagramYouTubeVineFlickr.

Wikipedia

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1. Email– themostcommonlyutilizedweb-basedinterventionsforclinicalpracticeØ Provides asynchronous interactions

between a counselor and a client

Ø Allows the client to provide brief narratives, and the counselor can structure the communication for exploration of the described symptoms with a problem-solving focus

Ø Provides support which can help to mitigate maladaptive responses to stressors

Ø Most useful for clients who cannot easily see a practitioner due to transportation issues or residing in remote areas

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1. Email– themostcommonlyutilizedweb-basedinterventionsforclinicalpracticeØ As a supplement for supervision, and they can serve

as a journal of thoughts and questions between an intern and a supervisor to stimulate reflection

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Ø Email distribution list (LISTSERV)Particularlyhelpfulinkeepingpractitionersabreastofcurrentinformationandconnectedwithcolleagues.Thesedistributionlistsmayalsobebeneficialfortrainingandcontinuingprofessionaldevelopment


Ø As a supplement for supervision, and they can serve as a journal of thoughts and questions between an intern and a supervisor to stimulate reflection

2.Chatroomsordiscussiongroups

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3.BlogsØ A regularly updated website or web

page, typically one run by an individual or small group, that is written in an informal or conversational style.


Ø As a supplement for supervision, and they can serve as a journal of thoughts and questions between an intern and a supervisor to stimulate reflection

4.SocialNetworking

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HealthInsurancePortability&AccountabilityActof1996(HIPAA)protectsclient’sconfidentialityandsecurityforhealthinformation.

HIPAAViolationsInappropriatedisclosureofinformationcanresultinconsequencesupto$50,000

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Confidentialitymustbemaintainedthroughanytreatmentmedium– eventechnology.

AmericanPsychologicalAssociation’sCodeofEthics(2010)– ethiccodes“[apply]totheseactivitiesacrossavarietyofcontexts,suchasinperson,postal,telephone,Internet,andotherelectronictransmissions.”

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Allthemajorprofessionalethicscodescallforconfidentiality measuresintheelectronicworldinsomewayoranother: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.

AAMFT Code of Ethics, 2015, 6.3 (emphasis mine)

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Counselors take precautions to ensure the confidentiality of all information transmitted through the use of any medium.

ACA Code of Ethics, 2014, B.3.e (emphasis mine)

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.

Ethical Principles of Psychologists and Code of Conduct, 2010, 4.01 (emphasis mine)

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34. NCCs shall protect the confidentiality and security of tests or assessments, reports, data and any transmission of information in any form.

National Board for Certified Counselors Code of Ethics, 2012 (emphasis mine)

Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible.

NASW Code of Ethics, 1996, Revised 2008, 1.07.m (emphasis mine)

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Business Associates are people and organizations who, in the normal course of business, handle sensitive information on your behalf. Examples:

• Billing services• Collection agencies• Record storage companies• Practice Management Systems• Electronic Health Record systems• Email providers• Attorneys• Accountants

Regulationsvarystatebystate,howeveralltreatmentmustfollowthesetwoguidelines:1. Servicesaredeemedtoberenderedinthestate

wherethepatientislocated;accordinglyprovidersmustdeterminelicensurerequirementsinthepatient’sstate.Providersmustalsodetermineandcomplywithapplicablelawrelevanttoprovidinghealthcareservicesinthepatient’sstate

2. TheStandardofcareforremotehealthcareservicesisthesameasifbothpartiesareinthephysicalpresenceofeachother.Professionalassociation,includingtheAmericaPsychologicalAssociation,assertthisaswell.

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Ø Provideroftelemedicalservicesmusthavesometypeofregistrationinpatient’sstate.

o 58statemedicalboardsrequirefulllicensureinstateo 11statemedicalboardsrequireaspecialtelemedicinelicense

oMinnesotarequiretelemedicineregistration

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Ø Consentmustbeobtainedasstatedinstatelawsandguidelines

Ø Providersmustdevelopcontingencyplansasaprecautionfortechnologyfailures

ContingencyPlansMentalhealthcliniciansshouldmakeefforttoidentifyandlocateaccesstoappropriateemergencyresourcesinthepatient’slocalarea;suchasemergencyresponse(e.g.,telephonenumbers,hospitaladmissions,referralresources,etc.)

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Throughmeansoftechnologicalcommunications,havingappropriatepatientselectioniscrucial.TheAPAstatesthat“mostsourcesdiscouragetheuseofe-therapyforsuicidalpatients.”ConsiderationsforTelepracticialEngagements

Ø AwarenessandassessmentofbehaviorbythepatientØ Ensuringprivacyandprotectionofconfidentialinformation

throughtransmissionØ RelationalandtransferalissuesØ DistributionofcomputersandcomputerfamiliarityissuesØ Emergencyprovisions,andØ Technologicalproficienciesandculturerespects/language

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Whentreatingmilitarypatientsremotely,mentalhealthcliniciansmustfollowjurisdictionregulationsofthestateinwhichthepatientislocated.

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WhilethepatientistheServiceMember,theDoDispresentinalltreatmentconsiderationsasathirdparty.

Ø Whenjoiningthemilitarysystem,mentalhealthprofessionalsneedtofamiliarizethemselveswithamilitaryculture,andmoreimportantly,theorganizationalstructure.

Confidentialinformationregardingapatientshouldbelesssecure.

Ø TheDoDhasregulationsthatputmentalhealthprofessionalsinapositionwithlessconfidentialitybetweenapatientbecause…

Ø TheSafetyneedsofthelargermilitaryandotherservicememberstrumptheneedsofanindividualpatient.

Ø Sharedinformationincludes:diagnosis,mentalstatus,fitnessfordutyand/ordeploymentstatus,andspecificrecommendationsrequiringcommandinvolvement.

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Ø Therules ofallboardsunderwhichyouarelicensed/registered/certified

Ø Relevantlicensing/certifyingboardsinthestateornationwheretheclientislocated.

Whendeterminingthejurisdictionthataclientisin,usethephysicallocationofthepatientatthetimeofthesession,notnecessarilywherehe/sheresides.

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Steps you can take to make use of Google Apps for Workto keep your client’s PHI protected and make themHIPAA compliant.1. Downloadandreadthe “HIPAACompliance&DataProtection

withGoogleApps”bookletfromGooglehere. ItgoesintodetailabouthowtosetupGoogleAppsforWork.

2. SignupforGoogleAppsforWorkat https://apps.google.com/.Asmentionedalready,thisisapaidservicefromGooglethatcurrentlyonlycosts$5amonthperuser.(Itreallyisabargainforallthatyouget!)

3. Makesureyourpasswordisuniqueandnoteasyfigureout. DONOTuse“password”or“1234”.

Steps to Protect Your Clients

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4. Go through the set-up steps outlined in the Google HIPAA guidementioned above. Particularly the set-up on the administratorside of Google Apps for Work for Gmail.

5.OnlyusetheCoreServicesthatGoogleagreestoprotectundertheBAAforanyclientinformation.

6.Limitthenumberofdevicesthatyouaccesstheaccountfrom. Iknowweareverymobiledependent,butdonotstoreanypatientrecordsonyourphoneortablet.Inotherwords,donotusetheGoogleDriveAppwhichallowsyoutostorewhatisonyourGoogleDriveinyourdevice.Youcanstillreadandaccessfilesifyouhaveaninternetconnection.


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7.IfyouareusingaHIPAAcompliantPracticeManagementService,(TherapyAppointment,TherapyNotes,SimplePractice,etc.)youcanstillcreatedocuments,suchaswritingprogressnotesusingtheGoogleDocsapp. YousimplycutandpastethenoteintoyourPracticeManagementapplication. IwouldsuggestthatyouthendeletethenotefromGoogleDocsjustasprecaution.IfyouarenotusingaPracticeManagementServiceyoucansaveorprintyournotesandotherdocumentsinGoogleDrive. Justmakesureyouhaveallofthesharingoptionsturnedoff.Again,usetheset-uprecommendationsgivenbyGoogle.

8.Makesureyouareusinga“2-stepverification”. Thissimplymeanshavingapasswordfor yourdevicesinadditiontorequiringasecondloginsteptogetintoyourapplications.And,neverletyourbrowsersaveyourpasswordsforyou.


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9.Includeaconfidentialitystatementtoyoursignatureblockonallelectroniccorrespondence. Thisdoesnot,ofcourse,guaranteeanysortofprotectionbyitself,butitdoescommunicateyourintentionstokeepinformationfromgettingintothewronghands. HereisasampleoftheonethatIuseonmyemails:


CONFIDENTIALITY NOTICEThis message and any accompanying documents are covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521, and may be protected by the doctor-patient privileges, or may constitute non-public information, and may contain information intended only for the designated recipient(s) named above. This information is confidential. If you are not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error and that any review, dissemination, copying, or the taking of any action based on the contents of this information is not authorized and may be unlawful. If you have received this communication in error, please notify us immediately by E-mail, and delete the original message.

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http://www.onlinetrainingforcounsellors.com/

https://personcenteredtech.com/

Person-Centered Tech

Highly recommended

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Telementalhealthcomparisons.com alsooffers a list and resources of online mentalhealth providers and whether or not they areHIPAA compliant. You can click on the HIPAAcompliant video conference companies to seewhat distinguishes them from the rest.

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There are HIPAA compliance regulations that health care providers have to follow in the United States. This may be a starting point for you. You can reference some links in our resources page at http://ismho.org/resources/standards-for-online-practice/ for some of the ethics guidelines outlined by organizations in the field.

q Collie,K.,Cubranic,D.,&Long,B.(2002).Audiographic CommunicationforDistanceCounselling:AFeasibilityStudy.BritishJournalofGuidance&Counseling,30(3),269-284.

q Gregory,KimL.(2010,Jan10)CamarilloFuneralHomeUnplugsOnlineGriefCounseling.Ventura CountyStar:Ventura,California.

q Heinlen,K.,Welfel,E.,Richmond,E.,&O'Donnell,M.(2003).Thenature,scope,andethicsofpsychologists'e-therapyWebsites:WhatconsumersfindwhensurfingtheWeb.Psychotherapy:Theory,Research,Practice,Training,40(1),112-124.

q Heinlen,K.,Welfel,E.,Richmond,E.,&Rak,C.(2003).ThescopeofWeb-Counseling:AsurveyofservicesandcompliancewithNBCCStandardsfortheethicalpracticeofWebCounseling.JournalofCounseling&Development,81(1),61-69.

q “InternationalOnlineTherapy:WhatToKnowBeforeYouGo."Person-CenteredTechnology.N.p.,2016.Web.29Dec.2016.

q Kaplan,D.(2005).EthicalUseofTechnologyonCounseling.CounselingToday.AmericanCounselingAssociation:Alexandria,Virginia.

q "MilitaryPatients:RecommendationsforTreatingServiceMembers.“NationalRegister.N.p.,2016.Web.27Dec.2016.

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q NetCE.ContinuingEducationforFloridaMentalHealthProfessionals.5thed.Vol.142.Sacramento,CA:NetCE,2017.Print.ContinuingEducation.

q Ritchie,Rene."Apple'sFaceTimeIsEnd-to-endEncrypted.GoogleHangouts...Isn't.”iMore.MobileNations,13May2015.Web.27Dec.2016.

q Scharff,JillSavege.PsychoanalysisOnline2:ImpactofTechnologyonDevelopment,Training,andTherapy.London:Karnac,2015.Print.

q Shaw,H.,&Shaw,S.(2006).Criticalethicalissuesinonlinecounseling:Assessingcurrentpracticeswithanethicalintentchecklist.JournalofCounseling&Development,84(1),41-53.

q "SocialWorkersandE-Therapy."N.p.,Web.27Dec.2016.

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YoucancontactHarryat:

BiblicalCounselingCenter145059th StreetWestUnit101Bradenton,FL34209

941-729-6600

[email protected]

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online ethical considerations for mental health clinicians

Healthcare