American Psychological Association
Chicago, August 22-25, 2002
Ron Kraus, Jason Williams, Craig Childress (Photo by Fenichel) Symposium #4178: Integrating Online Services into Clinical Practice
This presentation was both informative and a pleasure to attend, for several reasons. First, this was the last morning of the newly-condensed APA Convention, and it was nice to see some of us in the audience who had already presented, now in cognito and able to relax as we listened to our colleagues. :-)
With both practitioners and researchers in the audience, this panel addressed some of the salient issues and trends which online mental health professionals have been focused on for the past several years. A seasoned and knowledgeable group, the symposium was chaired by John Grohol (founder of Mental Health Net, numerous 'blogs and forums, co-founder of ISMHO, and pioneering proponent of "e-therapy"). Craig Childress and Jason Williams presented perspectives from their experience in a Children's Hospital system. Finally, Dr. Ron Kraus presented an overview and discussion of online ethical issues as they are approached and described by a number of existing web-based codes of online conduct. [See Table, below.]
John Grohol opened the symposium by taking a quick poll of the audience, which revealed that a large majority were practitioners. Most in the room indicated that they use the Internet regularly to communicate. With that, Craig Childress was introduced, to present a perspective as a clinician and employee within an inpatient hospital setting, in this case for children. Dr. Childress has written extensively about ethical and practice considerations in online clinical practice, and is a past-President of the International Society for Mental Health Online (ISMHO).
As we move into the 21st Century, with the ubiquitous experience of surfing websites and routinely using e-mail, Dr. Childress observed that within the ranks of teaching, online particularly, psychologists may tend to be particularly uncomfortable as we confront issues of confidentiality, privacy, and so forth. "Why would we even want to use it?" some in high places may be asking. "Why would it be important to incorporate the Internet into our practice?". Well, he would reply, for one thing [as this writer often repeats], Internet communication is a fact of 21st Century life, and whether we have personal qualms or worries or not, "it's going to walk into our office and demand that we use it anyway". As Internet-based activities become part of daily life, consumers will continue to search for services online. For that reason alone, psychologists, like other professionals, may well want to consider having a "web presence". One precaution here: "Once you enter Cyberspace, definitions become cloudy!"
Dr. Childress went on to present another part of the equation, one which I had tried very hard to illuminate just the day before at my own presentation, namely that whether or not we spend a great deal of time online ourselves, it is very likely that our clients, friends, and colleagues do. As that part of their life is valid and real, it really makes sense for us to be comfortable and knowledgeable about 21st century communication and online relationships. As Dr. Childress noted, "patients are going to bring in Internet issues themselves. Patients will bring in issues of their children's use, issues of online-augmented relationships... for example a patient with issues of intimacy or pseudo-relationships".
Childress highlighted another great potential use of the Internet, exploring patients' websites. While this could be "tremendously helpful", it might lead also to the question of "where do we draw the line with privacy? With the therapeutic frame?".
Another powerful use of the Internet, for research in particular, is for information gathering. By using online forms on your own site, it is possible to derive useful information, ranging from general demographics about site use to implementing programs in which monitoring is facilitated by online reporting, such as in a program designed to monitor children's behavior or relapse rates in schizophrenia.
Providing information online can in and of itself provide a service or an entry point to more intensive services. Practitioners can encourage families to complete homework assignments. [In response to an audience question, it was suggested that one typical implementation might be having parents filling out charts and sending them back to the therapist.] Another online service which is commonly offered is referral to online support groups, which in the hospital setting might range from mental health supports to disability-specific sites, such as a support group oriented towards spina bifida which offers "a chance to normalize their feelings about the disability".
Childress suggested an interesting dilemma which presents itself for the online-savvy practitioner, specifically that of how involved one need be personally in the therapeutic or support communities one recommends to patients. "Do you join the community to gauge it's quality? Or does that invade one's privacy? But if you don't see it, should you recommend it?" In daily practice it seems one is on firmest ground in providing some solid resources for things like rare disorders, where one could find others with similar concerns, and find support on issues such as shame and medical news specific to that disorder, whereas locally one might not ordinarily have access to such knowledgeable support groups.
Dr. Childress underscored the many ways in which one can employ the adjunctive use of Internet-facilitated communication in therapeutic work. One can engage in structured journaling, for example, where patients write about personal history issues, family stressors, traumatic memories, etc., in effect helping to process events therapeutically. "Writing about an emotional experience allows for the mediation needed to process it cognitively. More coherent narrative facilitates healthier functioning, and writing to the therapist acts as a regulating experience, 'calling you up' as a representation."
Before closing, Childress reminded us that one of the most important aspects of online communication which we can benefit from is enhanced professional-to-professional consultation. While "people think of e-mail as simply an extension of conversation...it's more. It's a documented record." The potential for other document-sharing and a full range of daily activities ranging from making appointments to sending parents a reminder to bring in their child's Individual Education Plan (IEP) is simply immense.
This presentation enlivened a very important topic by illustrating some of the very real ways in which online life affects offline life, including within the hospital-based environment.
Next Jason Williams outlined some of the potential and challenges of utilizing online communication within a large hospital community, from both a practice and institutional perspective. Responsible for implementing policy across 13 professional disciplines, Dr. Williams identified some of the challenges and barriers which confront those who are attempting to design effective hospital-based programs which are clinically, legally, and ethically responsive to appropriate patient care.
One of the first concerns which arises in working with families, as with individuals, is confidentiality. When e-mailing reports to a family, it is important to consider, for example, who has access to the family computer, and might end up reading very personal and privileged information. We all know how computer-savvy teens are, for example, between IM'ing and chatting and e-mailing, and it may not be appropriate for them to have access to confidential material from the hospital.
Clinicians and parents need to be mindful when replying to messages and careful to note who is being replied to, for example not hitting "reply all" when intending to respond to a single individual who has posted to a list or to a group. In Dr. Williams' experience, even among IT professionals he regularly works with there is not a keen understanding of the importance of confidentiality and privacy. It can be difficult to actually implement such basic safeguards as encrypted e-mail within large institutional settings. [Hopefully, HIPAA regulations are going to force more consideration of privacy very soon, though!]
Aside from the software issue there is also another important concern in healthcare-related communication: the issue of written consents. What if we don't have written consent but receive an urgent message? Do we answer it? What if it's from a colleague? Given the nature of online communication being available 24 hours a day, perhaps mechanisms need to be built in to the overall consent procedures, it was suggested, spelling out the limits and acceptable uses of information-sharing online.
Several practical as well as clinical challenges have emerged as online communication becomes increasingly integrated into daily routines, or available as an option. Some of the issues which come up among patients include experiences of cyber-stalking, or being caught in the middle of stressful divorce proceedings, where the therapist ends us caught in the middle. ("We're easy to find!") An absence of systemic policy guidelines makes decision-making and full implementation of programs that much more difficult, while lack of precedent leads to continuing incident-by-incident response to online issues.
Dr. Williams underscored the need for graduate training to get up to speed with what is being confronted today in daily practice. Not only is there a lack of formal study and training in these areas, but for those who understand the potential and power of the Internet (for both communication and information-sharing), there also exists in many instances an unreceptive environment where some older clinicians feel they "don't need anything new". In fact, in his hospital Dr. Williams found resistance to using even such hi-tech technology as 2-way-video. And yet how many professionals now have an e-mail address on their business cards? Is that not an invitation to actually use it? Perhaps, he wondered, it might be productive to print guidelines on the back of cards with e-mail addresses outlining some guidelines for use, and specific instructions on how to confirm that one is using the correct e-mail address, or procedures for contact during vacation times.
There are additional safeguards one can implement such as password-protecting individual computers at the end-user level, and spelling out procedures to be used in the informed consent, along with a discussion of potential risks and benefits. Procedures for establishing preferred e-mail addresses, encryption preferences, and response timelines can also be addressed at the onset. Other processes can also be used to determine positive identification of e-mail senders, if encryption is not a viable option -- even such strategies as embedding an identifier of some sort (a phrase or letter combination, for example) in the message body to confirm identity with an additional degree of confidence. Additional suggestions for efficient communication can and should be shared as well, such as encouraging efficient use of the subject line, so as to prioritize communications and help discriminate between an urgent message and, say, an appointment change.
Dr. Williams, finally, shared that despite great efforts at developing a protocol and procedures to implement a comprehensive online services policy, it is no easy task to get approval, necessarily, from an institutional review board (IRB), as has been his own experience despite the increasing acceptance among families and colleagues of online communication as a part of daily life.
The next presenter was Dr. Ron Kraus, a practitioner who was active in the development of an online ethics code (ethicscode.com), founder of OnlineClinics.com, and also 2002 President-elect of ISMHO, an organization which has itself developed a set of suggested principles for online mental health practitioners. Dr. Kraus focused in on some of the ethical concerns and guidelines which are relevant to the online mental health practitioner.
Of course it was noted that of the several existing codes, there are great similarities, while there are also professional codes of ethics which are specific to members of that profession but not specific to online mental health services. With his disclaimer of "wearing two hats" in terms of his involvement with (at least) two different sets of guidelines, Dr. Kraus proceeded on to a general discussion of why in fact we need specific ethical guidelines. Or, as he put it, "Why do we need ethics, and why is this so important online?".
Here are four basic reasons why ethical practice guidelines are so vital:
Kraus underscored several basic tenets of establishing ethical treatment parameters online. To begin with, online clinicians need to be aware of the limitations inherent in this particular type of treatment and to inform clients of potential risks. He noted the argument that telephone hotlines have for many years been available for quick anonymous use, but that text-only email carries a greater potential for mis-understanding due to the absence of tone of voice. As with hotlines, however, he feels it is incumbent on the clinician to make appropriate referrals, including offline referrals in the case of high risk or apparently great pathology. For those who are in fact appropriate, potential clients/patients need to be given relevant information about applicable research, limitations, and available f2f treatments. In brief, there is more to professional practice online than announcing "I have an online website you can use, please pay me..."
- Philosophical/Religious Tenets -- We believe in treating our neighbors as we'd like to be treated ourself.
- Psychological Perspective -- Treating others in a responsible, professional way fosters a sense of trust.
- Economics -- It is good business to treat people well, with respect.
- Legal/Regulatory -- Most of us are licensed professionals and as such we need to abide by our laws and regulations.
Even after determining appropriateness for treatment [See Assessing a Person's Suitability for Online Therapy] there needs to be clarification that at some point in-person treatment might be necessary, at least when geographically feasible. Of vital importance is the establishment of a "contingency referral plan" to be utilized in the event of a crisis, emergency, or unavailability of online therapist.
A final consideration, which has been widely discussed and heatedly debated over the past few years, is that of licensure and geography. While much has been written about the need for license "portability" and the power of individual states to define one's services as being delivered locally in that state (rather than coming from a provider who is licensed in the state where they and their computer is located), suffice to say that there are clients who may be geographically or physically/socially isolated who will choose to engage the services of a mental health professional located elsewhere but considered to be a specialist who the client specifically wishes to utilize. For the (U.S.) provider who is willing to offer services across state boundaries despite some of the online practice grey areas surrounding licensure, having a signed informed consent which specifically states that one willingly and intentionally desires to work with a provider despite being in another place (and indicating informed consent about risks, generally) is a good thing to have in the event of any future claims against the provider. Other risks which can be spelled out in advance are addressed in many of the online codes, such as the limits of confidentiality with e-mail, the risks of using credit cards, etc.
What are some strategies for helping to ensure safe and appropriate online therapy relationships? For starts, one can offer security through use of password-protected chat rooms, encrypted e-mail, and so forth. From the consumer perspective, the website of a mental health professional offering online services should provide a license which can be verified, and additional links for further information on ethical practice, such as the APA website and/or one of the online-specific ethical codes.
Online Ethical Guidelines for Mental Health Professionals
American Medical Informatics Association:
Guidelines for the Clinical Use of Electronic Mail with Patients
American Psychological Association:
Statement on Services by Telephone, Teleconferencing, and Internet
HonCode (Health on the Net Foundation)
Code of Conduct for Medical and Health Web Sites
for the Online Provision of Mental Health Services
Journal of Medical Internet Research
NBCC Ethical Guidelines:
The Practice of Internet Counseling [Updated,.pdf/Adobe doc]
Looking to the future, Dr. Kraus already sees "a lot of good beginnings" and many new and exciting endeavors still coming online. He foresees a great deal of continuing debate, and sees the need for ongoing efforts to understand and adopt appropriate regulations. Clinicians need to work carefully at establishing limits, educating self and others, and promoting higher standards for e-health services through broad efforts and initiatives.
John Grohol spoke next, about a huge phenomenon in the world of online mental health services, that of online support groups. Sharing that this topic has been "near and dear to my heart since 1991", Dr. Grohol noted that support groups not only have large followings which are self-selected by web-surfers, but they are also increasingly being used adjunctively in addition to face-to-face (f2f) treatments. He defined online support groups as "groups that utilize the power and convenience of the Internet to allow simultaneous (synchronous) and time-delayed (asynchronous) communications between an individual and a group of peers".
Why do people go online for support, Grohol asked. Some of the factors are:
Dr. Grohol said he would argue that due to the well-known "disinhibition effect", clinical issues emerge "quicker and deeper", and also may result in quickly finding increased access to sources of help. Grohol reminded the audience of the well-known fact about how people in distress typically will seek out help from family and friends before presenting for treatment with a mental health professional. With the advent of the Internet's widespread popularity, he estimates that the number of online support groups has skyrocketed about 300% within the past 5 years. Aside from the peer advice and support, members can find access to treatment resources as well as relevant information.
- Geographic issues
- Lack of time
- Immediacy and flexibility
Grohol described how support groups can be an important adjunct to more traditional therapy by providing increased social and emotional support, as well as immediate response in times of need. Moreover, the experience and insight gained through that venue can help a client further clarify central issues during the f2f sessions with a therapist. The range of group members might also help an individual develop various types of interactions more confidently, ranging from having opinions accepted by others to venting feelings safely, to employing humor.
Support groups utilize various modalities, including e-mail lists, web forums, newsgroups, and chat rooms/instant messaging. Dr. Grohol spelled out some of the pros and cons of each. E-mail lists are very prevalent, and known to most of us. It is convenient, simple, and automatic. However, the negatives include how one's posts "may be around forever", how it may be easy to get lost in the unthreaded threads (as opposed to say, Message Boards), and there is a risk of accidentally hitting "reply all" when it wasn't intended. (One needs to make a point of replying to an individual off-list, if that is the intent.) Web forums are also easy to use, and may provide easy-to-follow threading of subject heads, which some people find desirable. However, they also can retain one's posts "forever", have a sense of being more public, and require users to actively go to the site rather than simply opening e-mail. Newsgroups have similar pros & cons, but are perhaps more susceptible to tangents and spam. Chat Rooms and IM'ing "can be very engaging", as they offer real-time conversational flow and a sense of "here and now", without (usually) maintaining an archive of the conversation. However, some may find the flow of activity difficult to follow or keep up with (especially if not a speed typist) and this modality may not be as convenient as e-mail or MB-based groups for many.
One of the most obvious benefits we see from the explosion of support groups online is that it is now possible to find information and support on a myriad of physical and/or mental disabilities. If it exists, one can likely find a group dedicated to those affected by it. As with emotional support groups, such disorder-specific groups offer anonymity and convenience. Plus, the price is right! ("Free is good.") Grohol predicts an increasing number of traditional therapists will be utilizing support groups as adjuncts to conventional treatment approaches.
Grohol noted that there are some risks for clients which need to be acknowledged, including the challenges of text-only communication without verbal cues. (E.g., use of wit & sarcasm may easily be mis-interpreted.) Also one needs to know that one's posts may be archived for eternity, if that's an issue. He would advise clients to consider anonymity as an option, to familiarize themselves with a community's rules and guidelines before becoming involved, to look for larger, well-established support groups, to listen before participating, and to try not to be judgmental. Some of the places where online support groups can be found include Yahoo!Groups (groups.yahoo.com), the Open Directory Project (dmoz.org) and his own site, psychcentral.com.
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