HOW ETHICALLY ARE WE PRACTICING?

1. HOW ETHICALLY ARE WE PRACTICING? An Exploration of Liability Issues in Online Mental Health Services

2. Who am I? • Kristie Halsey Holmes, MSW LCSW • Ph.D. Candidate (keeping fingers crossed for next month!) • Assistant Professor of Social Work at Union University • 323-459-5685 • kholmes@uu.edu

3. My Background • VERY CLINICAL • Used to Conference rooms, not BIG ROOMS like this! • Training MSW Interns in the field, direct services, online therapy, Depression and PTSD in children. • Now teaching undergrad and MSW courses

4. Why Study Online Ethics? • The mire of ethics presented itself when soldiers stationed in Afganistan, Iraq etc. began contacting me. • They did not feel as though they could go to base services • Not accepted (stigma) by the “guys” • Anything but confidential • But felt suicidal and desperate for help

5. Participants • International Society for Mental Health Online Members (Ethical Standards are Framework of Study) • Approximately a 60+% response rate • Minimum of a Master’s Degree in a counseling profession (Psychology, Social Work, Counseling etc.) • Licensed in their state or country as applicable

6. Awareness Increased by Survey

7. Does the Name Matter?

8. It Matters in Court • If a therapist is sued, regardless of what the services were named, it is likely that the judge will look at what was done during the service, rather than what it was named. • For instance, if an online therapist attempts to defend their actions by calling it coaching, when in all actuality they are doing psychotherapy…judgment will be made on psychotherapy even though they did not advertise as such.

9. Ethics vs. Effectiveness • How can we study effectiveness (although we already are) without agreeing what “it” (online therapy/counseling/ consulting/ coaching) is.

10. How Nervous Should Providers be? • Ethical practices in the online environment may put online mental health providers at risk for liability and need to be identified and examined, the purpose of this exploratory study.

11. Basic Liability Issues Overview • This presentation only allows for introducing liability questions that we may have not thought of before. My study will be completed by August.

12. A Few of My Favorite Things • If I am a licensed provider in California and hold only one mental health license…and a client from Tennessee contacts me for services… • Is the client “virtually” traveling to my office in California or am I making a house call to Tennessee?

13. Interstate Commerce • Liability issues to consider: 1. Interstate commerce, geography lines 2. Practicing without a license in that particular state. 3. Licensing requirement for supervision hours not met in another state. 4. Soldiers serving our country but do not want to go to base counseling services. Are we providing services in Iraq?

14. Do you Carry Liability Insurance?

15. Does your policy cover online practice?

16. Risk in Being a Lone Ranger • Online therapists may better protect themselves against local issues, or emergency situations by working with client’s doctor, psychiatrist, or even face to face therapist.

17. Being Part of a Team • Without visual cues, and without knowing a client’s local references the presence of a local multidisciplinary team member can offset risk substantially given their already established emergency protocols.

18. Age or Experience? • Who are online therapists? Who do you picture? • Newly graduated savvy technology newbie therapists (perhaps short on experience but grew up on a computer) OR well experienced therapists utilizing a new mode of service delivery?

19. Traditional Path

20. Online Training • Should it look any different? • Where do students and interns gain experience to effectively practice online? • Training helps avoid scope of practice or malpractice lawsuits

21. The Downside of Training • No Nationally approved certification for online practice • Major professional Organizations (i.e. APA, NASW) will not endorse any such training. • This, of course is a a risk unto itself. Although seeking training on an individual basis may help a case in court.

22. Therapist Website: More than a Business Card

23. Disclosed vs. Understood • The American Way is to sign legal forms (i.e. mortgage, loan agreements, or any internet click- through) without reading them. Essentially we make ourselves responsible for things impossible to read, or comprehend, especially in the time given. • How many of you actually read all of the information (fine print) when you got a mortgage? Closings take an hour or less usually- and it would probably take you two weeks to read it.

24. A Matter of Ethics • While doing one’s best to cover the legal basics and disclosures, we must ensure that we do not make the process so overwhelming and confusing to scare people away from getting the help that they need.

25. A Nearly Non- Issue Issue • Much of the literature laments the risks in therapy services online (hackers, third party risks). • However, the therapist who provides services in 2008 without the use of a computer that is connected to the internet is rare. • So, while confidentiality risk related to computer use is an issue, it is an issue for all therapists who utilize the computer for any reason related to their work, including insurance billing.