The Vast Differences Between Telemental Health Ethics and Face to Face.
Sometimes we overlook telemental health ethics and associated impacts and consequences. We spend our professional careers studying ethics, worrying about ethics and applying ethics in our practices. Then along comes telemental health and all of the following has changed. What do you do about:
1) Client moves out of state
2) Handling client emergencies
3) Confidentiality
4) HIPAA compliance
5) Ability to effectively counsel via electronic therapy
6) Privacy
It follows that telemental health also carries additional licensing, consumer complaints and other legal issues.
Telemental Health Ethics: The Fundamental Challenge
Your Client Controls The Counseling Room
This is the number one hazard in electronic synchronous or teletherapy. Normally, we make great efforts to ensure we provide psychotherapy in a controlled environment. Examples of these efforts are:
1) Soundproofing the walls between offices. Using white noise generators when sound proofing is inadequate.
2) Creating waiting room environments that are private, calming and quiet.
3) Silencing our office phones. Instructing our clients to silence their phones.
4) Creating a safe therapy room.
5) A variety of efforts to prevent interruptions.
6) Having clients sign release of information forms for family members.
7) Implementing informed consent that include limits of confidentiality. Instances when we may be required to protect them from themselves or hospitalize them.
8) Creating and fostering connections.
All of the above become more difficult with telemental health. You are no longer delivering services in your space. You are delivering services in their space. But not to worry: I’m going to teach you in this blog post how to address these challenges.
Clients Don't Fully Understand Safety and Confidentiality
There are few healthcare and healing professions where the sanctity of privacy is the cornerstone of the treatment. Maybe psychotherapy is the only one. Most lay people or clients believe confidentiality means you won’t talk about them or their sessions to anyone without their permission. Counselors, social workers and psychologists know that is only a small portion of ensuring confidentiality and safety.
We can’t expect clients to understand the full scope of confidentiality. It requires years of ethics training and continuing education. We also make mistakes. And hopefully we learn from them.
Even if we fully explained to clients the nuance of ensuring confidentiality. It’s not that clients lack the ability to understand it, they simply lack the experience required to grasp it. Or they just don’t consider it.–because that is not their responsibility. It is yours.
Telemental Health Ethics and HIPAA
HIPPA (Health Insurance Privacy and Portability Act of 1996) is a federal law regulated by the U.S Department if Health and Human Services. The law aims to ensure that healthcare providers protect Private Health Information (PHI) from third parties.
But it does not address or obligate your client to protect their own PHI. A patient /client can do whatever they wish with their medical records. They are not breaking the law if they don’t maintain privacy of their health information.
But you are still vulnerable to ethical and legal consequences if that information falls into the wrong hands. In short, HIPAA compliance only ensures you are in compliance with federal law.
What You Can Do To Protect Yourself
Telemental Health Across State Lines
Rules of Thumb:
1) It is illegal to practice a profession in a state you are not licensed.
2)If you are exploring this, don’t use COVID-19 as a the primary mechanism for practicing in other states.
3)COVID-19 exceptions can be helpful, but they are temporary in virtually all jurisdictions.
4) Every licensee’s situation is unique. Get help with designing your practice in multiple states. The key is to be sure what you are doing is legal. Then be sure it is ethical.
Know Your Client
First, know your client. Know their identity. We aim to foster trust with clients. Telemental health requires that you can trust your client. It is wise to obtain picture identification and confirm a physical address. In the process, you will also confirm their state of residency.
Perform a Proper Phone Assessment
One of the most hazardous aspects of telemental health is intaking a client who is a high risk for self harm. If you choose to accept a client with this risk, assess risk of suicide. Questions to ask in the telephone intake include:
1) Have they been previously hospitalized.
2)Are family members involved in their care.
3)Current and prior psychiatric medication. Medication history provides important clues about diagnoses, addiction and couse of illness.
Consider your areas of expertise and develop additional screening questions accordingly. The goal is to determine if there is a hard stop to treating that client through electronic means.
Implement A Written Telemental Health Informed Consent
This is perhaps the most important step you can take to cover the telemental health ethical and legal issues related in providing psychotherapy. Be very specific in your requirements for managing their therapy space. Requirements for handling their video camera. Everything that you require of your own office you space you should require of your client in their space and environment. Reload this page, sign up for my newsletter and I’ll send you a free editable telemental health informed consent. Feel free to change/ modify it.
Telemental health is likely a permanent trend. It is important to address telemental health ethics systematically.
