Etherapy Ethics

Etherapy Ethics

Update: 2019-08-09


413 -E-Therapy Ethics


Dr. Dawn-Elise Snipes LMHC, LPC-MHSP

Charles Snipes, CTO

State Laws and Boards

~ State laws and Board regulations vary considerably

~ You must know the requirements for your license in the states in which you are licensed and/or certified

~ Independent practice

~ E-Therapy

~ Privacy laws and policies vary between states and entities.

Ethical Codes and Etherapy

~ Guidelines for the Practice of Telepsychology

American Psychological Association (APA)

~ The ACA 2014 Code of Ethics and Technology: New Solutions to Emerging Problems

American Counseling Association (ACA)

~ ACA 2014 Code of Ethics Section H “Distance Counseling, Technology, and Social Media”

~ NBCC Policy Regarding the Provision of Distance Professional Services

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

International Society for Mental Health Online (ISMHO)

~ NASW Standards for Technology in Social Work Practice

Other Resources

~ TIP 60: Using Technology-Based Therapeutic Tools in Behavioral Health Services

~ HIPAA FAQs from


~ Identify differences between etherapy and face-to-face counseling

~ Discuss the pros and cons of etherapy

~ Discuss issues with client confidentiality

~ Explore issues related to boundaries, dual relationships and social networking

~ Review various ethical codes as they relate to etherapy

~ Dealing with disinhibition

~ Common ethical violations in etherapy


~ Access experts on a particular problem in a greater area

~ More cost effective for the practitioner and the patient

~ More convenient

~ Wider range of available business hours

~ Provides a degree of anonymity

~ People are generally more open since they are in their comfort zone (home)

~ Many of the youth prefer etherapy

~ An adjunct to traditional therapy “Therapist Extenders”

~ Accessible with a DSL connection and a $15 webcam

Drawbacks to Etherapy

~ Set-up takes some cost and technical know-how

~ You must be thoroughly familiar with HIPAA and HiTECH Act

~ There are a lot of HIPAA and HiTECH Act violations making etherapy seem less professional

~ Can be more difficult to handle crises and identify decompensation

~ Some argue that accurate assessments cannot be done virtually

~ All modes of etherapy can be captured and redistributed

~ In cases of domestic violence there are unique challenges

~ Not as effective with cultures that use high-context communication


~ Technology/intervention usage rates

~ Demographic characteristics of clients

~ Retention and satisfaction rates

~ Staff satisfaction

~ Equipment malfunctioning rates/downtime

~ Costs of care and cost offsets

~ Rates of referral

~ Changes in symptoms

Considerations for Appropriateness

~ Clients level of comfort, preference for and access to technology

~ Cognitive capacity and maturity

~ Past and current medical and behavioral health diagnoses including psychosis

~ Communication skills

~ Client’s support system

~ History of violence or self-injurious behavior

Appropriate Clients

~ Diagnoses

~ Generalized anxiety disorder

~ Depression and postpartum depression

~ Obsessive compulsive disorder

~ Post Traumatic Stress Disorder

~ Seasonal Affective Disorder

~ Binge Eating Disorder

~ Substance Abuse

Informed Consent

~ According to ISHMO and NBCC, all of the following must be part of the informed consent

~ The possibility of misunderstandings, particularly with text-based forms of E-therapy

~ Cultural and/or language differences that may affect delivery of services

~ The increased response time involved in asynchronous forms of communication and average response time

~ Time zone differences

Informed Consent

~ According to ISHMO and NBCC cont…

~ Social media policy and the counselor’s right to privacy and the possibility of restrictions on the client’s use of any communication with the practitioner

~ Counseling credentials, physical location of practice, and contact information

~ Alternatives to receiving assistance via E-therapy

~ Internet and data security practices including how to clear their cache and cookies after the session

~ Dangers of entering private information when using a public access or computer that is on a shared network.

Informed Consent

~ According to ISHMO and NBCC cont…

~ The need to check employer’s policies relating to the use of work computers for personal communications

~ Risks and benefits of engaging in the use of distance counseling, technology, and/or social media

~ Possibility of technology failure and alternate methods of service delivery

~ Emergency procedures to follow when the counselor is not available

~ Possible denial of insurance benefits

Emergency Safety Plan

~ The number and address of the local hospital and detoxification unit

~ A description of conditions in which the client will seek emergency services instead of calling the counselor

~ Identification of a local therapist to whom the client can be referred if etherapy services are no longer appropriate

~ 3 people the client can call in the event of an emergency

~ Releases of information for emergency contacts and the client’s physician/psychiatrist and under what circumstances that would happen

Recording Sessions

~ Requires informed consent from the patient

~ Can be used by the patient to review a session and practice new skills

~ Can be used by the therapist for self-supervision

~ Cannot be used as a replacement for written documentation

Text Based Counseling

~ There are significant benefits to expressing feelings and thoughts in text format, at a distance, and outside a face-to-face encounter

~ Clients can compose thoughts, review the text, revise if so desired, and pause between writing and sending messages

~ Parts of conversations can be reviewed with the client

Text Based Counseling

~ Dangers/Considerations

~ Clients may express an imminent threat of harm which does not get responded to in a timely fashion

~ In forums in which comments are not held for moderation, someone may post something inappropriate which triggers another client

~ People can screen capture what has been typed and share it

~ It is impossible to know with reasonable certainty who typed it

Text Based Counseling

~ Dangers/Considerations

~ Even if you are in an active chat with someone, if they set down their phone that whole conversation may be readable by an unintended third party

~ Text message apps may be set up by default to provide the person “push notifications” which can be seen by anyone near the phone

~ Without clearly defined boundaries, text messaging options can be abused by some clients, possibly creating dependency issues

Forums (Asynchronous)

~ Secure, moderated on your website

~ Secure, unmoderated on your website

~ Insecure, moderated on someone else’s website

~ Insecure, unmoderated on someone else’s website

~ Linking to resources and forums from your website

HIPAA Risk Assessment

~ Identify the PHI that your organization creates, receives, stores and transmits

~ Identify the human, natural and environmental threats to the integrity of PHI

~ Assess what measures are in place to protect against threats to the integrity of PHI, and the likelihood of areas where there a breach can be reasonably anticipated.

~ Determine the potential impact of a PHI breach and assign each potential occurrence a risk level based on the average of the assigned likelihood and impact levels.

~ Document the findings and implement measures, procedures and policies where necessary to ensure HIPAA compliance and keep all documents for at least 5 years

Technical Safeguards


~ Password protection programs

~ Use numeric, nonalphanumeric, lower and uppercase characters

~ Use automatic screen savers or lock screens

~ Store your password in an online password vault, so in the event of illness a colleague can be provided with instructions on how to access the stored data

~ Network firewalls

~ Wiping software

~ Document encryption

~ Full disk encryption on the clinician's computer

Disaster Planning

~ Redundant backups of data that can be implemented rapidly

~ A back-up plan for appointments should the clinician OR the patient be unable to access a computer

~ Alternate therapist in the event the clinician is incapacitated

~ A plan for acquiring new computers should the therapist’s computer die

~ A plan for notification of clients in the event of a data breach


~ Etherapy must be done in a private office or room (not in your living room)

~ Etherapy must be conducted on a computer with full-hard-drive encryption and specially wiped when put out of services

~ Etherapy clients must have some means to verify their identity to you each session (This is easy with video chat)

~ If you are initiating communications you must use a secure format

~ Emailing clients has many caveats*

~ Even email just containing your name (i.e., could be a breech

Life on the Web

~ Boundaries

~ It is easier than ever to get your contact info and show up at your door or call your phone at all hours of the night. Set clear boundaries.

~ Be careful how much you use geolocation and checkins on your social media

~ Social Networking and Dual Relationships

~ Clients will research you

~ Make sure anything that is publicly viewable is something you are okay with them seeing

~ Do not “friend” clients on your personal social media pages

Common Violations

~ Inattention during a session

~ Boundary violations (“friending”)

~ Not following HIPAA and HiTech guidelines for email or calendar software

~ Working on a computer that does not have the whole drive encrypted

~ Engaging in etherapy without understanding the language and social norms

~ Using nonsecure (i.e. Second Life) methods

~ Unlicensed Practice

~ Failure to plan for power or internet outages


~ Failure to develop safety plan and referral sources in the person’s locale

~ Failure to learn the language of the internet

~ Treating patients who would, by common professional standards, need a higher level of face-to-face care

~ Failure to provide all normal paperwork such as intake, treatment plan, informed consent, HIPAA notifications.

~ Failure to verify identity of the consumer each time (especially for phone and IM)

Effective Techniques

~ Psychoeducational information with audio or video recordings

~ Paper-pencil workbooks or secure fillable pdfs

~ Secure group text or video chat

~ Self-directed self-help apps

~ Online journaling/blog/vlog on a HIPAA complaint site or written in Word or another word processing program on the client's personal computer that are sent using secure email

~ Use of computer games to help with anxiety. (i.e. Flying game to reduce fear of flying)

Effective Techniques

~ Online collage that can be screen printed and securely emailed to the therapist

~ Cartoon strips made using digital art programs which are downloaded

~ Collages made in a graphics program like Canva that are downloaded and shared via screen sharing during a video session

~ Art projects the client does offline that are photographed and sent via secure email

~ Data from fitness trackers or other health or mental health related apps that is screen captured and sent via secure email

Service Option Examples

~ Texting

~ TigerText

~ Zinc

~ Qliq

~ Spok

~ Video

~ Vsee


~ Zoom*

~ Skype*

Review the NASW Standards

~ NASW Standards for Technology in Social Work Practice


~ Online therapy is becoming increasingly mainstream

~ There are many advantages such as convenience, cost effectiveness and accessibility

~ Things to consider when choosing an office are your particular skill set, your target population, how tech savvy you are and how much you want to spend

~ Building an online practice is no faster than a face-to-face one, but there are things you can do to speed up the process.









Etherapy Ethics

Etherapy Ethics

Charles Snipes