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ISMHO/PSI Suggested Principles of Professional Ethics for the Online Provision of Mental Health Services

These principles are being developed by a joint committee, co-chaired by Martha Ainsworth and Robert Hsiung, of the International Society for Mental Health Online and the Psychiatric Society for Informatics. The hope is that these principles will guide both psychiatrists who provide and patients who receive online mental health services.

Contents

Suggested Principles of Professional Ethics for the Online Provision of Mental Health Services

 Online mental health services often accompany traditional mental health services provided in person, but sometimes they are the only means of treatment. These suggestions are meant to address only those issues of professional ethics relating directly to the online provision of mental health services. Clinical and legal and regulatory issues are beyond the scope of this work.

  1. Informed consent

    Informed consent is one of the foundations of ethical health care today. Before the patient consents to receive online mental health services, he or she should be informed about the process, the psychiatrist, the potential risks and benefits, safeguards, and alternatives.

    1. Process

      1. Possible misunderstandings

        The patient should be informed that when interacting online with the psychiatrist, less information about each may be available to the other, so misunderstandings may be more likely. With text-based modalities such as email, nonverbal cues are relatively lacking, and even with videoconferencing, bandwidth is limited.

      2. Turnaround time

        One issue specific to the provision of mental health services using asynchronous (not in "real time") communication is that of turnaround time. The patient should be informed of how soon after sending an email, for example, he or she may expect a response.

      3. Privacy of the psychiatrist

        Privacy is more of an issue online than in person. The psychiatrist has a right to his or her privacy and may wish to restrict the use of any copies or recordings the patient makes of their communications. See also the below on the confidentiality of the patient.

    2. Psychiatrist

      When the patient and the psychiatrist do not meet in person, the patient may be less able to assess the psychiatrist and to decide whether or not to enter into a treatment relationship with him or her.

      1. Name

        The patient should be informed of the name of the psychiatrist. The use of pseudonyms is common online, but is insufficient in a clinical context.

      2. Qualifications and how to confirm them

        The patient should be informed of the qualifications (for example, having a degree or being licensed, certified, or registered) of the psychiatrist. The psychiatrist may also wish to provide supplemental information such as areas of special training or experience. So that the patient can confirm the qualifications, the psychiatrist should provide the telephone numbers or web page URLs of the relevant organizations.

    3. Potential benefits

      The patient should be informed of the potential benefits of receiving mental health services online. This includes both the circumstances in which the psychiatrist considers online mental health services appropriate and the possible advantages of providing those services online. An example of the latter is that the patient might feel less inhibited.

    4. Potential risks

      The patient should be informed of the potential risks of receiving mental health services online. One in particular is that confidentiality might be breached.

    5. Safeguards

      The patient should be informed of safeguards (such as the use of encryption) that are taken by the psychiatrist and could be taken by himself or herself against the potential risks. Extra safeguards should be considered when family members, students, library patrons, etc., share a computer.

    6. Alternatives

      The patient should be informed of alternatives to receiving mental health services online.

    7. Proxies

      Some patients are not in a position to consent themselves to receive mental health services. In those cases, consent should be obtained from a parent, legal guardian, or other authorized party -- and the identity of that party should be verified.

  2. Standard operating procedure

    The mental health professions have evolved a standard service delivery framework. When the treatment is provided online, that framework need not -- indeed, should not -- be discarded.

    1. Boundaries of competence

      The psychiatrist should remain within the boundaries of his or her competence (based on his or her education or training) and, for example, not attempt to address a problem online if he or she would not attempt to do so in person.

    2. Requirements to practice

      The psychiatrist should meet any requirements (for example, have a degree or be licensed, certified, or registered) to provide mental health services where he or she is located. In fact, the requirements where the patient is located may also need to be met for it to be legal to provide services to that patient. See also the above on qualifications.

    3. Structure of the online services

      The psychiatrist and the patient should agree on the frequency and mode of communication, the method for determining the fee, the estimated total cost to the patient, the payment procedure, etc.

    4. Evaluation

      The psychiatrist should adequately evaluate the patient when providing any mental health services online. The patient should understand that that evaluation could potentially be helped or hindered by communicating online.

    5. Multiple treatment providers

      When the patient receives mental health services from others at the same time, either online or in person, the psychiatrist should carefully consider the potential effects of his or her interventions in the overall treatment context.

    6. Confidentiality of the patient

      The confidentiality of the patient should be protected. Information about the patient should be released only with his or her permission. The patient should be informed of any exceptions to this general rule.

    7. Records

      The psychiatrist should maintain records of the services provided. If those records include copies or recordings of communications with the patient, the patient should be informed.

    8. Existing guidelines

      The psychiatrist should of course follow the laws and other existing guidelines (such as those of professional organizations) that apply to him or her.

  3. Emergencies

    When mental health services are provided online, the psychiatrist can be a great distance from the patient. This may limit the ability to respond to an emergency.

    1. Procedures

      The procedures to follow in an emergency should be discussed. These procedures should address the possibility that the psychiatrist might not immediately receive an online communication (perhaps because of technical problems) and might include trying to call the psychiatrist, an answering service, or a local backup.

    2. Local backup

      When the psychiatrist and the patient are in fact geographically separated, the psychiatrist should identify and obtain the telephone number of a qualified local health care provider. A local backup who already knows the patient, such as his or her primary care physician, may be preferable.

Ethics guidelines of selected professional organizations

 The committee is aware that the following organizations of mental health professionals have made their ethics guidelines available online. No disrespect for other organizations is intended. If you have any additional links to recommend, please feel free to email us at dr-bob@uchicago.edu.

Internet-specific

General

The development of these principles

 These suggestions are being developed by a joint committee of the International Society for Mental Health Online and the Psychiatric Society for Informatics: The committee started with and is indebted to previously published online guidelines of various types:

These suggestions were presented in a very preliminary form as part of "Clinical Use of the Internet: Some Suggestions" at the 1999 American Psychiatric Association annual meeting and in a somewhat less preliminary form as part of "Electronic Communication with Clients" at the 1999 American Psychological Association annual convention.

An official ISMHO version was produced after the ISMHO membership voted unanimously for endorsement on January 9, 2000. An official PSI version was endorsed by the PSI membership on May 13, 2000.

This is a work in progress. Questions, comments, or suggestions are welcome and may be directed to dr-bob@uchicago.edu.

[ International Society for Mental Health Online | Psychiatric Society for Informatics | ABCs of Internet Therapy ]

[dr. bob] Dr. Bob is Robert Hsiung, MD, dr-bob@uchicago.edu

Revised: May 26, 2000
URL: http://www.dr-bob.org/psi/suggestions.3.13.html
May be reproduced without explicit permission as long as no charge is assessed and the source is cited.