Businesses offering online psychotherapy have been growing in recent years. For clients, they promise easy connection with an array of psychotherapists, efficiency, convenience and pay-as-you-go service (e.g., through a credit card). For private practice mental health providers, these businesses offer the potential to fill open time, grow one’s practice, widen the reach of the provider’s referral base and move more fully into technology-based treatments.
The models vary (e.g., Breakthrough, Doctor on Demand, Talkspace, etc.) but many provide an online means through which clients can find, pay for and then engage in clinical interactions with psychotherapists. This article highlights some of the risks of working with these businesses and suggests some questions clinicians can consider prior to contracting with them.
The American Psychological Association’s Telepsychology Guidelines (2013) call for technical and clinical competence in providing online services. Regarding technical competence, for example, the platforms initially seem easy to grasp. But complexities can arise quickly: What do clinicians do if their connection to the Internet fails or if the site itself goes down during a session? Can clinicians work with clients through other means, such as phone or email if there is an emergency?
Such simple yet important factors may significantly impact teletherapy services and should be considered before initiating them.
Does the service allow direct contact between the client and the therapist (i.e., contact not controlled by the service)? Unless it is merely a referral service (e.g., PsychologyToday.com), these businesses typically generate revenue by insuring that treatment occurs only through the platform provided by the business. Although this limitation is understandable, it can create ethical concerns.
For example, if a therapist decides to end the contract with the online platform, does the contract permit clients to continue to receive services from that clinician? Can the clinician refer the client if needed? If not, how will client welfare and autonomy be addressed?
It is clinically and ethically important to determine at the outset what the contract permits and to base one’s decision to participate on the degree to which the contract appropriately prioritizes clients’ needs, choices and welfare.
How is informed consent to online psychotherapy obtained — and who obtains it? Usually the online sites provide basic information to clients about how the service works. When prospective clients choose to proceed, they engage in a sign-up process that includes agreeing to various conditions. Unless clinicians review these conditions, there is no way to know whether the patient has received sufficient and ethically appropriate information to allow for adequate informed consent.
In addition, some states have laws that require the use of specific informed consent procedures for teletherapy. Nationally based commercial teletherapy businesses may or may not address these state-specific informational requirements. If they do not, the responsibility falls on the clinician.
Does the contract with the provider adequately address record keeping and confidentiality matters? For example, is the platform sufficiently confidential and secure to meet HIPAA and state-specific requirements? Is it clear who the custodian of the treatment record is?
Does the business retain any records of the treatment? If so, for how long? Does the retention period satisfy the clinician’s state requirements?
Also, under what conditions do the provider and the client have access to these records? When the contract ends, will the professional continue to have access to treatment records – for example, if there is a subpoena for the records or a former client requests that treatment information be forwarded to a new provider? Does the business have access to the clinical content of the communications between client and therapist? Furthermore, the prospective provider should consider how the business might use the treatment records and what steps it takes to protect their confidentiality. There have already been allegations of breaches of confidentiality in this regard.
Are prospective patients adequately screened prior to being connected with a provider? Though online therapy platforms may attempt to screen out potentially unsuitable clients (e.g., by putting a disclaimer on the site that refers actively suicidal clients to national or local hotlines), providers still need to engage in comprehensive intake and evaluation processes — just as they do for in vivo treatment.
Further, clinicians must be familiar with and able to link their online clients to appropriate local services to address complex clinical challenges or crises, such as patient threats of harm to self or others, substance dependence and domestic violence.
*Does the business address cross-jurisdictional issues? When clients struggle with treatment relationships and become angry with the provider, licensing complaints are more likely. Thus it is useful to consider whether the business matches the client’s location to the state in which the clinician is licensed. If not, the psychologist may wish to determine his or her status in the client’s state. Some states permit a brief period during which an otherwise licensed professional can practice within its jurisdiction; others do not. The risks of providing services across state lines should carefully be considered.
Online platforms are becoming more common and more accepted across the nation. A thoughtful, prospective consideration of the ethical, legal and clinical challenges of such services can increase the likelihood that psychologists will provide good quality care to clients without undue risk.
References available from authors
Joe Scroppo, Ph.D., J.D., risk management consultant with The Trust, is a forensic psychologist and attorney in Woodmere, N.Y. His email address is: firstname.lastname@example.org. Dan Taube, J.D., Ph.D., risk management consultant with The Trust, is a psychologist and professor at the California School of Professional Psychology-San Francisco. His email address is email@example.com.