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413 -E-Therapy Ethics
Dr. Dawn-Elise Snipes LMHC, LPC-MHSP
Charles Snipes, CTO
State Laws and Boards
~ State laws and Board regulations vary considerably
~ You must know the requirements for your license in the states in which you are licensed and/or certified
~ Independent practice
~ E-Therapy
~ Privacy laws and policies vary between states and entities.

Ethical Codes and Etherapy
~ Guidelines for the Practice of Telepsychology
American Psychological Association (APA)
~ The ACA 2014 Code of Ethics and Technology: New Solutions to Emerging Problems
American Counseling Association (ACA)
~ ACA 2014 Code of Ethics Section H “Distance Counseling, Technology, and Social Media”
~ NBCC Policy Regarding the Provision of Distance Professional Services
~ ISMHO/PSI Suggested Principles for the Online Provision of Mental Health Services
International Society for Mental Health Online (ISMHO)
~ NASW Standards for Technology in Social Work Practice

Other Resources
~ TIP 60: Using Technology-Based Therapeutic Tools in Behavioral Health Services
~ HIPAA FAQs from

~ Identify differences between etherapy and face-to-face counseling
~ Discuss the pros and cons of etherapy
~ Discuss issues with client confidentiality
~ Explore issues related to boundaries, dual relationships and social networking
~ Review various ethical codes as they relate to etherapy
~ Dealing with disinhibition
~ Common ethical violations in etherapy
~ Access experts on a particular problem in a greater area
~ More cost effective for the practitioner and the patient
~ More convenient
~ Wider range of available business hours
~ Provides a degree of anonymity
~ People are generally more open since they are in their comfort zone (home)
~ Many of the youth prefer etherapy
~ An adjunct to traditional therapy “Therapist Extenders”
~ Accessible with a DSL connection and a $15 webcam

Drawbacks to Etherapy
~ Set-up takes some cost and technical know-how
~ You must be thoroughly familiar with HIPAA and HiTECH Act
~ There are a lot of HIPAA and HiTECH Act violations making etherapy seem less professional
~ Can be more difficult to handle crises and identify decompensation
~ Some argue that accurate assessments cannot be done virtually
~ All modes of etherapy can be captured and redistributed
~ In cases of domestic violence there are unique challenges
~ Not as effective with cultures that use high-context communication

~ Technology/intervention usage rates
~ Demographic characteristics of clients
~ Retention and satisfaction rates
~ Staff satisfaction
~ Equipment malfunctioning rates/downtime
~ Costs of care and cost offsets
~ Rates of referral
~ Changes in symptoms
Considerations for Appropriateness
~ Clients level of comfort, preference for and access to technology
~ Cognitive capacity and maturity
~ Past and current medical and behavioral health diagnoses including psychosis
~ Communication skills
~ Client’s support system
~ History of violence or self-injurious behavior
Appropriate Clients
~ Diagnoses
~ Generalized anxiety disorder
~ Depression and postpartum depression
~ Obsessive compulsive disorder
~ Post Traumatic Stress Disorder
~ Seasonal Affective Disorder
~ Binge Eating Disorder
~ Substance Abuse
Informed Consent
~ According to ISHMO and NBCC, all of the following must be part of the informed consent
~ The possibility of misunderstandings, particularly with text-based forms of E-therapy
~ Cultural and/or language differences that may affect delivery of services
~ The increased response time involved in asynchronous forms of communication and average response time
~ Time zone differences
Informed Consent
~ According to ISHMO and NBCC cont…
~ Social media policy and the counselor’s right to privacy and the possibility of restrictions on the client’s use of any communication with the practitioner
~ Counseling credentials, physical location of practice, and contact information
~ Alternatives to receiving assistance via E-therapy
~ Internet and data security practices including how to clear their cache and cookies after the session
~ Dangers of entering private information when using a public access or computer that is on a shared network.
Informed Consent
~ According to ISHMO and NBCC cont…
~ The need to check employer’s policies relating to the use of work computers for personal communications
~ Risks and benefits of engaging in the use of distance counseling, technology, and/or social media
~ Possibility of technology failure and alternate methods of service delivery
~ Emergency procedures to follow when the counselor is not available
~ Possible denial of insurance benefits
Emergency Safety Plan
~ The number and address of the local hospital and detoxification unit
~ A description of conditions in which the client will seek emergency services instead of calling the counselor
~ Identification of a local therapist to whom the client can be referred if etherapy services are no longer appropriate
~ 3 people the client can call in the event of an emergency
~ Releases of information for emergency contacts and the client’s physician/psychiatrist and under what circumstances that would happen
Recording Sessions
~ Requires informed consent from the patient
~ Can be used by the patient to review a session and practice new skills
~ Can be used by the therapist for self-supervision
~ Cannot be used as a replacement for written documentation
Text Based Counseling
~ There are significant benefits to expressing feelings and thoughts in text format, at a distance, and outside a face-to-face encounter
~ Clients can compose thoughts, review the text, revise if so desired, and pause between writing and sending messages
~ Parts of conversations can be reviewed with the client
Text Based Counseling
~ Dangers/Considerations
~ Clients may express an imminent threat of harm which does not get responded to in a timely fashion
~ In forums in which comments are not held for moderation, someone may post something inappropriate which triggers another client
~ People can screen capture what has been typed and share it
~ It is impossible to know with reasonable certainty who typed it
Text Based Counseling
~ Dangers/Considerations
~ Even if you are in an active chat with someone, if they set down their phone that whole conversation may be readable by an unintended third party
~ Text message apps may be set up by default to provide the person “push notifications” which can be seen by anyone near the phone
~ Without clearly defined boundaries, text messaging options can be abused by some clients, possibly creating dependency issues
Forums (Asynchronous)
~ Secure, moderated on your website
~ Secure, unmoderated on your website
~ Insecure, moderated on someone else’s website
~ Insecure, unmoderated on someone else’s website
~ Linking to resources and forums from your website

HIPAA Risk Assessment
~ Identify the PHI that your organization creates, receives, stores and transmits
~ Identify the human, natural and environmental threats to the integrity of PHI
~ Assess what measures are in place to protect against threats to the integrity of PHI, and the likelihood of areas where there a breach can be reasonably anticipated.
~ Determine the potential impact of a PHI breach and assign each potential occurrence a risk level based on the average of the assigned likelihood and impact levels.
~ Document the findings and implement measures, procedures and policies where necessary to ensure HIPAA compliance and keep all documents for at least 5 years
Technical Safeguards
~ Password protection programs
~ Use numeric, nonalphanumeric, lower and uppercase characters
~ Use automatic screen savers or lock screens
~ Store your password in an online password vault, so in the event of illness a colleague can be provided with instructions on how to access the stored data
~ Network firewalls
~ Wiping software
~ Document encryption
~ Full disk encryption on the clinician's computer
Disaster Planning
~ Redundant backups of data that can be implemented rapidly
~ A back-up plan for appointments should the clinician OR the patient be unable to access a computer
~ Alternate therapist in the event the clinician is incapacitated
~ A plan for acquiring new computers should the therapist’s computer die
~ A plan for notification of clients in the event of a data breach
~ Etherapy must be done in a private office or room (not in your living room)
~ Etherapy must be conducted on a computer with full-hard-drive encryption and specially wiped when put out of services
~ Etherapy clients must have some means to verify their identity to you each session (This is easy with video chat)
~ If you are initiating communications you must use a secure format
~ Emailing clients has many caveats*
~ Even email just containing your name (i.e., could be a breech

Life on the Web
~ Boundaries
~ It is easier than ever to get your contact info and show up at your door or call your phone at all hours of the night. Set clear boundaries.
~ Be careful how much you use geolocation and checkins on your social media
~ Social Networking and Dual Relationships
~ Clients will research you
~ Make sure anything that is publicly viewable is something you are okay with them seeing
~ Do not “friend” clients on your personal social media pages
Common Violations
~ Inattention during a session
~ Boundary violations (“friending”)
~ Not following HIPAA and HiTech guidelines for email or calendar software
~ Working on a computer that does not have the whole drive encrypted
~ Engaging in etherapy without understanding the language and social norms
~ Using nonsecure (i.e. Second Life) methods
~ Unlicensed Practice
~ Failure to plan for power or internet outages

~ Failure to develop safety plan and referral sources in the person’s locale
~ Failure to learn the language of the internet
~ Treating patients who would, by common professional standards, need a higher level of face-to-face care
~ Failure to provide all normal paperwork such as intake, treatment plan, informed consent, HIPAA notifications.
~ Failure to verify identity of the consumer each time (especially for phone and IM)
Effective Techniques
~ Psychoeducational information with audio or video recordings
~ Paper-pencil workbooks or secure fillable pdfs
~ Secure group text or video chat
~ Self-directed self-help apps
~ Online journaling/blog/vlog on a HIPAA complaint site or written in Word or another word processing program on the client's personal computer that are sent using secure email
~ Use of computer games to help with anxiety. (i.e. Flying game to reduce fear of flying)
Effective Techniques
~ Online collage that can be screen printed and securely emailed to the therapist
~ Cartoon strips made using digital art programs which are downloaded
~ Collages made in a graphics program like Canva that are downloaded and shared via screen sharing during a video session
~ Art projects the client does offline that are photographed and sent via secure email
~ Data from fitness trackers or other health or mental health related apps that is screen captured and sent via secure email
Service Option Examples
~ Texting
~ TigerText
~ Zinc
~ Qliq
~ Spok
~ Video
~ Vsee
~ Zoom*
~ Skype*
Review the NASW Standards
~ NASW Standards for Technology in Social Work Practice

~ Online therapy is becoming increasingly mainstream
~ There are many advantages such as convenience, cost effectiveness and accessibility
~ Things to consider when choosing an office are your particular skill set, your target population, how tech savvy you are and how much you want to spend
~ Building an online practice is no faster than a face-to-face one, but there are things you can do to speed up the process.