Ethics in the “i" world: Internet, telehealth, social media, texting, and e-mail

PATRICK B. MCGRATH, PH.D.MODERATOR

Ethics in the “i" world: Internet, telehealth, social media, texting,

and e-mail

The i-world:The Media Age and TechnoEthics

Mary Karapetian Alvord, Ph.D.President-Elect, APA Division 46, Media

PsychologyAlvord, Baker & Associates, LLC

11161 New Hampshire Ave.Suite 307Silver Spring, MD 20904301-593-6554 X14

3200 Tower Oaks Blvd.Suite 200Rockville, MD 20852301-593-6554 [email protected]

April 13, 2012

Disclaimer

I have no conflicts of interest to disclose.

I have not received any funding from any commercial entities that may be mentioned or discussed in this presentation.

All information and opinions shared are mine alone.

We are living technolgy history

An example – prior to 1973, cell phones were limited to those installed in vehicles.

In 1983, Motorola introduced the 16-ounce "DynaTAC" phone which cost $3,500.

2012 – there are more cell phone users across the world, than land line users.

First

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Motor

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Size:

9 x 5

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ht:

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ds

Disp

lay:

None

Num

ber

of

Circ

uit

Boar

ds:

30

Talk

time:

35

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es

Rech

arge

Time

: 10

hours

Feat

ures:

Talk,

listen

, dial

What is Telehealth?

www.alvordbaker.com

Encyclopedia Britannica to stop printing booksBy Julianne Pepitone @CNNMoneyTech March 13,

2012

0:00 / 2:37Britannica stops presses and goes digital NEW YORK (CNNMoney) -- After 244 years,

Encyclopedia Britannica will cease production of its iconic multi-volume book sets.

Britannica usually prints a new set of the tomes every two years, but 2010's 32-volume set will be its

last. Instead, the company will focus solely on its digital encyclopedia and education tools.

.

HIPAA (Health Insurance Portability and Accountability Act)

Privacy Rule – now standard of careBusiness associate agreements!!

Security Rule – Adminstrative procedures to safeguard

confidentiality and accessPhysical safeguardsTechnical security

Telecommunication system

Programmable!

T-1 lines or VPN . Voice over IP phones, etc.

HAPPY 21ST BIRTHDAY

Facilitating gamesmanship and generalizing behaviors through real-life play activities

Clinical Applications

ExposuresExposures - Endless Loops, sounds, DVD’s, you tube http://www.youtube.com/watch?v=F5na4nE21-c

Relaxation –MP3’s

Executive function skills (scheduling, timers, phone alerts, alarms)

Technology: Clinical applications

Interactive “screen” systems → face recognition, social skills prompts.

Technology in the Practice

Sending assignments for group and other therapies via encrypted email

Testing scoring softwareResearch online – APA research , Google, etc.

Tele-health

http://www.youtube.com/watch?v=4DkezwHawXY

Tele = technologyHealth = psychological services (tx, testing,

etc.)Internet speed and bandwidthEncrypted doesn’t mean HIPAA compliantHIPAA compliant → HIPAAA CertifiedSecure Platforms PC’s vs. MAC’sComputer MemoryHD Cameras

Thank you!

References:

HIPAA regulations

DeAngelis, T. (2012) Practicing distance therapy, legally and ethically Monitor on Psychology; 43(3).

Highmark launches telehealth service. (2012). Health & Beauty Close - Up, , Retrieved from: http://search.proquest.com/docview/957428259?accountid=11243

Wolper, L. (2011) The E-Healthcare Movement: Virtual Communities, Web Services, and Other Enterprisewide, Interoperable HCITs for US Healthcare Reform . Health Care Administration . Retrieved from: http://www.r2library.com.proxygw.wrlc.org/contents/content_resource_frame.aspx?isbn=0763757918&Offset=2&SectionId=ch0008s0350&ChapterId=ch0008&library=Medicine&Cache=true

Disclaimer

I have no conflicts of interest to disclose, and have not received any funding from any commercial entities that may be mentioned or discussed in this presentation.

All information and opinions shared are those of the presenter.

Ethics in the “i" world: Internet, telehealth,

social media, texting, and e-mail

TELEHEALTH IN THE TREATMENT OF

ANXIETY:EFFECTIVE TECHNOLOGICAL INTERVENTIONS FOR

ANXIETY DISORDERS

NIKKI GODINE

Disclaimer

I have no conflicts of interest to disclose, and have not received any funding from any commercial entities that may be mentioned or discussed in this presentation

All information and opinions shared are those of the presenter

Technologies

AdministrativeAdministrative

TelephoneComputerFax machine

ClinicalClinical

TelephoneComputerCell phone (talking,

texting, apps)IATVInternet (chat, forums,

message boards)Virtual reality

Panic Disorder

Treatment via the Internet: an effective way to reduce panic symptoms (Bergstrom et al., 2009; Wims, Titov, Andrews, & Choi, 2010)

Types of treatment: Clinician-assisted CBT

Settings in which this type of treatment can be used

Clinical outcomes

Post-Traumatic Stress Disorder

Treatment via videoconferencing and the Internet can improve symptoms of PTSD (Germain, Marchand, Bouchard, Drouin, & Guay, 2009; Lange, Rietdjik, Hudcovicova, van de Ven, Schrieken, & Emmelkamp, 2003)

Internet treatment Cognitive-behavioral writing assignments

Videoconferencing treatment CBT

Clinical outcomes

Generalized Anxiety Disorder

Symptoms of GAD can be successfully treated through the Internet, virtual reality, and the use of biofeedback and mobile phones (Gorini et al., 2010; Pallavicini, Algeri, Repetto, Gorini, & Riva, 2009; Titov et al., 2009).

Types of treatment Clinician-assisted CBT Virtual reality with biofeedback Stress management and relaxation techniques

Settings in which this type of treatment can be used

Clinical outcomes

Social Phobia

Internet-based treatment for social phobia reduces symptoms of social phobia and other comorbid disorders (Berger, Hohl, & Caspar, 2009; Titov, Gibson, Andrews, & McEvoy, 2009)

Types of treatment: Clinician-assisted CBT CBT without clinician guidance

Clinical outcomes

Child and Adolescent Anxiety

Treatment delivered primarily via the Internet can be effective for a number of child and adolescent anxiety disorders (Spence, Holmes, March, & Lipp, 2006)

Type of treatment Clinician-assisted CBT

Clinical outcomesHow effective is it compared to in-person

CBT?

References

Andersson, G., Carlbring, P., Holmstrom, A., Sparthan, E., Furmark, T., Nilsson-Ihrfelt, E. … Ekselius, L. (2006). Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 677-686. doi:10.1037/0022-006X.74.4.677

Berger, T., Hohl, E., & Caspar, F. (2009). Internet-based treatment for social phobia: A randomized controlled trial. Journal of Clinical Psychology, 65, 1021-1035. doi:10.1002/jclp.20603

Bergstrom, J., Andersson, G., Karlsson, A., Andreewitch, S., Ruck, C., … Lindefors, N. (2009). An open study of the effectiveness of Internet treatment for panic disorder delivered in a psychiatric setting. Nordic Journal of Psychiatry, 63, 44-50. doi:10.1080/08039480802191132

References cont’d

Botella, C., Gallego, M. J., Garcia-Palacios, A., Banos, R. M., Quero, S., & Alcaniz, M. (2009). The acceptability of an Internet-based self-help treatment for fear of public speaking. British Journal of Guidance and Counseling, 37, 297-311. doi:10.1080/03069880902957023

Carlbring, P., Nordgren, L. B., Furmark, T., & Andersson, G. (2009). Long-term outcome of Internet-delivered cognitive-behavioral therapy for social phobia: A 30-month follow-up. Behavior Research and Therapy, 47, 848-850. doi:10.1016/j.brat.2009.06.012

Germain, V., Marchand, A., Bouchard, S., Drouin, M., & Guay, S. (2009). Effectiveness of cognitive-behavioral therapy administered by videoconference for posttraumatic stress disorder. Cognitive Behaviour Therapy, 38, 42-53. doi:10.1080/16506070802473494

Gorini, A., Pallavicini, F., Algeri, D., Repetto, C., Gaggioli, A., & Riva, G. (2010). Virtual reality in the treatment of generalized anxiety disorders. Studies in Health Technology and Informatics, 154, 39 – 43.

References cont’d

Klein, B., Austin, D., Pier, C., Kiropoulos, L., Shandley, K., Mitchell, J., … Ciechomski, L. (2009). Internet-based treatment for panic disorder: Does frequency of therapist contact make a difference? Cognitive Behavior Therapy, 38, 100-113. doi:10.1080/16506070802561132

Klein, B., Mitchell, J., Abbott, J., Shandley, K., Austin, D., Gilson, K., … Redman, T. (2010). A therapist-assisted cognitive behavior therapy Internet intervention for posttraumatic stress disorder: Pre-, post- and 3-month follow-up results from an open trial. Journal of Anxiety Disorders, 24, 635-644. doi:10.1016/j.janxdis.2010.04.005

Klein, B., & Richards, J. C. (2001). A brief Internet-based treatment for panic disorder. Behavioural and Cognitive Psychotherapy, 29, 113-117.

References cont’d

Knaevelsrud, C., & Maercker, A. (2007). Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: A randomized controlled clinical trial. BioMed Central Psychiatry. Retrieved from http://www.biomedcentral.com/1471-244X/7/13

Knaevelsrud, C., & Maercker, A. (2010). Long-term effects of an Internet-based treatment for posttraumatic stress. Cognitive Behavior Therapy, 39, 72-77. doi:10.1080/16506070902999935

Lange, A., Rietdijk, D., Hudcovicova, M., van de Ven, J., Schrieken, B., & Emmelkamp, P. M. G. (2003). Interapy: A controlled randomized trial of the standardized treatment of posttraumatic stress through the Internet. Journal of Consulting and Clinical Psychology, 71, 901-909. doi:10.1037/0022-006X.71.5.901

Pallavicini, F., Algeri, D., Gorini, A., & Riva, G. (2009). Biofeedback, virtual reality and mobile phones in the treatment of generalized anxiety disorder (GAD): A phase-2 controlled clinical trial. Journal of Cybertherapy and Rehabilitation, 2, 315 – 327.

References cont’d

Ruwaard, J., Broeksteeg, J., Schrieken, B., Emmelkamp, P., & Lange, A. (2010). Web-based therapist-assisted cognitive behavioral treatment of panic symptoms: A randomized controlled trial with a 3-year follow-up. Journal of Anxiety Disorders, 24, 387-396. doi:10.1016/j.janxdis.2010.01.010

Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R., Prosser, S., … Kenardy, J. (2008). Online CBT in the treatment of child and adolescent anxiety disorders: Issues in the development of BRAVE-ONLINE and two case illustrations. Behavioral and Cognitive Psychotherapy, 36, 411-430. doi:10.1017/S135246580800444X

Spence, S. H., Holmes, J. M., March, S., & Lipp, O. V. (2006). The feasibility and outcome of clinic plus Internet delivery of cognitive-behavioral therapy for childhood anxiety. Journal of Consulting and Clinical Psychology, 74, 614-621. doi:10.1037/0022-006X.74.3.614

References cont’d

Titov, N., Andrews, G., Choi, I., Schwenke, G., & Johnston, L. (2009). Randomized controlled trial of web-based treatment of social phobia without clinician guidance. Australian and New Zealand Journal of Psychiatry, 43, 913-919. doi:10.1080/00048670903179160

Titov, N., Andrews, G., Robinson, E., Schwenke, G., Johnson, L., Solley, K., & Choi, I. (2009). Clinician-assisted Internet-based treatment is effective for generalized anxiety disorder: Randomized controlled trial. Australian and New Zealand Journal of Psychiatry, 43, 905-912. doi:10.1080/00048670903179269

References cont’d

Titov, N., Gibson, M., Andrews, G., & McEvoy, P. (2009). Internet treatment for social phobia reduces comorbidity. Australian and New Zealand Journal of Psychiatry, 43, 754-759. doi:10.1080/00048670903001992

Villani, D., Riva, F., & Riva, G. (2007). New technologies for relaxation: The role of presence. International Journal of Stress Management, 14, 260 – 274. doi: 10.1037/1072-5245.14.3.260

Wims, E., Titov, N., Andrews, G., & Choi, I. (2010). Clinical-assisted Internet-based treatment is effective for panic: A randomized controlled trial. Australian and New Zealand Journal of Psychiatry, 44, 599-607. doi:10.3109/00048671003614171

Thank you!

Ethics in the “i” World: Social Media Ethics

ADAAAPRIL, 13, 2012

KEELY KOLMES, PSY.D., PRIVATE PRACTICE, SF,

CAHTTP://

[email protected]

OM© 2012 K. Kolmes. All rights reserved

I have no conflicts of interest to disclose.I have not received any funding from any

commercial entities that may be mentioned or discussed in this presentation.

© 2012 Keely Kolmes, Psy.D. All rights reserved


Search Engines & Social Media: Who is looking for you?

Clients Colleagues Students/Supervisees & Professors/SupervisorsTraining programs & employers

Setting Up a Google Alerthttp://www.google.com/alerts



Clinical & Ethical Issues for Clinicians


Clients seeking psychotherapist information on the Internet (Kolmes &

Taube, 2011)

In a survey of 332 clients, 70% reported finding personal information about their therapist on the Internet. 87% of these individuals found it intentionally while 13% found it accidentally. 78% found the information via Google, 42% found it via Facebook, 17% found information on LinkedIn. 10% found it on a blog.




Tips for Taking Control of Your Web Visibility

Carefully choose which email address you use to join sites.

Understand the privacy settings on your own (and family members’) profiles.

Correct misinformation.Google’s URL Removal Tool for URLs that

urgently need to be removed. (URLs that accidentally expose confidential data)

https://www.google.com/webmasters/tools/removals

Social Media And Your Practice

Consider your intent when you join a social networking site: personal or professional?

Implement a Social Media Policy http://www.drkkolmes.com/docs/socmed.pdf




Digital Ethics?

Applying existing Ethical Standards to online activity.

Ethical Standards offer a guide for ethical behavior.

Development of standards is ongoing.Ethical dilemmas on the Internet mirror ethical

dilemmas that also occur offline.Ethics Codes refer only to our professional

activities, not personal ones. Distinction between professional and personal is

getting blurred online.

Relevant Ethical Standards

Ethical Standard 3.10 Informed ConsentEthical Standard 3.05 Multiple

Relationships Ethical Standard 4.01 Maintaining

ConfidentialityEthical Standard: 4.04 (b): Psychologists

discuss confidential information obtained in their work only for appropriate scientific or professional purposes and only with persons clearly concerned with such matters.


Relevant Ethical Standards (cont.)

Ethical Principle 5.05: Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence.

Ethical Principle 4.06 Consultations: When consulting with colleagues, (1) psychologists…. disclose information only to the extent necessary to achieve the purposes of the consultation. (See also Standard 4.01, Maintaining Confidentiality.)




Beware Online

Pseudonyms

Invitations from people you do not know.

Caution when replying to “strangers” in public.

Online impersonation is fairly easy.

Closing RemarksKnow what's out there about you.

Take responsibility for your web presence. Be proactive about cleaning it up or correcting inaccuracies.

Consider whether access to posted information could damage a client, another professional relationship, or you.

Distinguish between personal and professional use on social networking sites.

Understand and use privacy settings.Be prepared to manage it clinically when internet

activity comes into the room. Develop a social media policy for your practice.

Include it as a part of informed consent and discuss it.




References

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from: http://www.apa.org/ethics.

Donner, M., The Ethical Use of the Listserv: Privacy and Professional Conduct, The California Psychologist, November/December 2007, 22. Retrieved from http://bit.ly/vsKFAW

, Florence W.; Patterson, Terence; Gottlieb, Michael. Ethical dilemmas in psychologists accessing Internet data: Is it justified? Professional Psychology: Research and Practice, Vol 42(2), Apr 2011, 105-112.

Kolmes, K. (2010, April). Private practice social media policy. [PDF file]. Retrieved May, 2010, from http://www.drkkolmes.com/docs/socmed.pdf


References (cont.)

Kolmes, K. & Taube, D.O. (2011) Summary of client-therapist encounters on the web: The client experience. [PPT file]. Retrieved June 2011, from http://drkkolmes.com/research/

Lehavot, K., Barnett, J., & Powers, D. (2010). Psychotherapy, professional relationships, and ethical considerations in the MySpace generation. Professional Psychology: Research and Practice. Vol 41(2), Apr 2010, 160-166.

Martin, S. (2010, August 13). More than one-fifth of grad students have Googled their clients. [Web log posting]. Retrieved from http://bit.ly/ajRjWX. (2011, March 20).


Contact Me

Keely Kolmes, [email protected] 415-501-9098http://www.drkkolmes.comTwitter: @drkkolmes

ETHICS AND LEGAL ISSUES

JEFFREY E. BARNETT, PSY.D., ABPPLOYOLA UNIVERSITY MARYLAND

Ethics in the “i" world: Internet, telehealth, social media, texting,

and e-mail

Disclaimer

I have no conflicts of interest to disclose and have not received any funding from any commercial entities that may be mentioned or discussed in this presentation.

All information and opinions shared are those of the presenter only.

What is Telehealth?

“The use of telecommunications and information technology to provide access to health assessment, intervention, consultation, supervision, education, and information across distance” (Nickelson, 1998, p. 527).

The use of the telephone, e-mail, chat rooms, and other Internet and satellite-based technologies to provide direct clinical services (e.g. texting, IATV, etc.).

Teleconferencing and Interactive Televideo Communications

Interactive Televideo Communications (IATV) Consultation and treatment to remote

locales other settings lacking specialized treatment professionals and for when clients can not access the professional in-person.

Efficiency of service delivery/cost effective

Increased access to treatment Superior to telephone and e-mail Treatment across great distances

Back to the Future?

Areas of Concern with IATV

Technological limitations impacting audio/visual acuity and clarity – interpersonal cues

Inadvertent breaches of confidentialityTechnology failuresDifficulty responding to emergenciesLicensure issuesKnowledge of local lawsBehavioral telehealth may not be the most

appropriate medium for all treatment needs

Legal and Ethical Issues

75% provide services across state lines60% inquired about the patient’s state of residence74% uncertain or incorrect about states’

telemedicine or telehealth laws50% made advanced arrangements for responding

to emergencies or crises48% used a formal informed consent procedure

prior to providing online services (Maheu & Gordon,

2000)

Recommendations

Use a comprehensive informed consent procedure

Learn relevant telehealth and telemedicine laws for all jurisdictions in which you will be providing services

Do not practice outside the scope of your license

Follow your profession’s ethics code regardless of the therapeutic medium used

Utilize all existing technology to protect each individual’s confidentiality

Recommendations (Cont.)

Attend to issues of dangerousness, duty to warn and protect situations, and mandatory reporting requirements

Make arrangements in consumers’ local areas for emergency and crisis situations. Be knowledgeable of local resources

Maintain appropriate liability coverage and be sure malpractice insurance covers these services

Remain aware of the limitations of both the online services provided and the technology used to offer them


Evaluate the effectiveness of all telehealth services provided and modify them as needed

Assess each individual’s appropriateness for this modality of treatment. Make referrals when needed and appropriate

Practice within your scope of practice and areas of competence

Attend to cultural, ethnic, language, and other differences that may impact effective communication


Utilize effective documentation, adherence to termination and abandonment guidelines, and appropriate practices for fees and financial arrangements

Ensure both clinical and technological competence needed to provide these services online

Consult with knowledgeable colleagues, relevant statutes, applicable ethics codes, available professional standards, and legal counsel

Participate in telehealth policy, standards, guidelines, and technology development

Social Networking

Counseling, Psychotherapy, and Social Networking

Many clients participate in social networking sites in their lives and use them as a prime means of communicating , relating, and managing relationships.

Clients may send their counselors or psychotherapists “friend” requests.

Challenges to clinician transparency, self-disclosure, privacy, and the nature of the treatment relationship.

Counseling, Psychotherapy, and Social Networking (cont.)

Potential impact of declining on the treatment relationship.

Potential impact of accepting on the treatment relationship.

Losing the ability to have “real” relationships? What is considered “real” may be different for digital natives.

Transitioning from the digital world to the “in-person” world.

Implications for Counseling and Psychotherapy

Have a Social Networking Policy. See for example: http://drkkolmes.com

Address this as part of the informed consent process with every client.

Responding to “friend” requests from current and former clients - to respond or not; implications for the counseling and psychotherapy process and relationship.

Boundary/multiple relationship issues.

Implications for Counseling and Psychotherapy (cont.)

Self-Disclosure issues and the blurred line between your professional life and your personal life

The fallacy of security settingsSearching for client information onlineUsing a client’s social networking site

therapeuticallyWhat to do with information obtained via

the Internet

Ethical Issues and Dilemmas

Boundaries and Multiple RelationshipsSelf-Disclosure and Psychotherapist

Transparency Fidelity, informed consent, and integrity

Clinician searches for information about a client online

Graduate student activities: A faculty member discovers a student’s blog.

Trainees: A client discovers a student clinician’s personal website.

Seeking Ethical Guidance

In general contacts with clients and former clients online should be viewed like any other multiple relationship. “Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical” (APA, 2010, p. 6).

With regard to boundaries and self-disclosure the APA Ethics Code “applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists… Those activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code” (p. 1).

See also standards on Informed Consent, Confidentiality, Avoiding Harm, Exploitative Relationships, Student Disclosures of Personal Information.

Questions to ask when considering online disclosures (Lehavot, 2007):

What are the costs and benefits of posting the information?

Is there a high probability that clients will be significantly and negatively affected?

How will the disclosure affect my relationship with my clients?

Does the disclosure threaten my credibility or undermine the public’s trust in the profession of psychology?

References

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from: http://www.apa.org/ethics.

Lehavot, K. (2007). “MySpace” or yours? The ethical dilemma of graduate students’ personal lives on the Internet. Presentation at the Annual Convention of the American Psychological Association, San Francisco, CA.

Maheu, M. M., & Gordon, B. L. (2000). Counseling and therapy on the Internet. Professional Psychology: Research and Practice, 31, 484-489.

Nickelson, D. W. (1998). Telehealth and the evolving health care system: Strategic opportunities for professional psychology. Professional Psychology: Research and Practice, 29, 527-535.

Documents

Ethics in the “i" world: Internet, telehealth, social media, texting, and e-mail