Law and Ethics in your country or state

[DeeAnna Merz Nagel]

Do you know what the guidelines or restrictions are for online therapy or telehealth in your country or state? If you do, please share!! We want to add the information to the OTI Wiki!

[Dominik M. Rosenauer]

We have guidelines in Austria too.

But I have a newbie-question: I thought that I was a member of OTI and could post to the WIKI but as I understand it you have to become a member of wikispaces too?

best

Dominik M Rosenauer

[DeeAnna Merz Nagel]

Hi Dominik,

You can just create a member login at the wiki
and then add your information...

Thanks for joining OTI!

DeeAnna

Dominik M. Rosenauer said:

We have guidelines in Austria too.

But I have a newbie-question: I thought that I was a member of OTI and could post to the WIKI but as I understand it you have to become a member of wikispaces too?

best

Dominik M Rosenauer

[Dominik M. Rosenauer]

thanks for the info- i will do so!

[Kali]

Hi DeeAnna,

I tried to view the OTI Wiki and the link went to OnlineTherapy.com but I didn't see a wiki. Did I miss something?

Thanks,

Kali

[Kate Anthony]

Hi Kali,

http://onlinetherapy.wikispaces.com/ is the main link - or there's a link from the homepage of OTI (Resources then OTI Ethical and Legal Wiki from left hand side)

Kate

Kali said:

Hi DeeAnna,

I tried to view the OTI Wiki and the link went to OnlineTherapy.com but I didn't see a wiki. Did I miss something?

Thanks,

Kali

[Sarah Blake]

Did you get any information in reference to maryland?


Lynne said:

I contacted all 50 states for information on their distance counseling. I have the information in an Excel document. (I didn't hear back from all states.)

If anyone is interested I can forward the document to you.

Lynne Coon, M.S.
http://www.dontworry-behappy.com

[DeeAnna Merz Nagel]

Hi Sarah
Check the OTI wiki.

Sarah Blake said:

Did you get any information in reference to maryland?


Lynne said:

I contacted all 50 states for information on their distance counseling. I have the information in an Excel document. (I didn't hear back from all states.)

If anyone is interested I can forward the document to you.

Lynne Coon, M.S.
http://www.dontworry-behappy.com

[Leon Tan]

I think this may be the correct forum to raise the issues I have raised in Twitter.

1. Given the globalized nature of online therapy, what kind of ethical framework is required that is not simply an imposition of the ethical guidelines developed by one or two institutions in one or two countries on the rest of the world?

2. Given the recent debacle re APA and the involvement of psychoprofessionals in torture, what are we to make of concepts such as confidentiality and privacy when these are used in the service of protecting professionals rather than clients?

3. Online therapy to my mind provides the great benefit of instigating a deterritorializing of prevailing professional structures, practices and ethics, in which numerous political and economic problems have already been identified by a variety of sources. To my mind, what is required is a truly transnational ethical framework that is client centric, that accommodates global mobility and accessibility without privileging the laws of an individual nation.

4. Keen to hear thoughts from others on this issue.

[Stephen Goss]

Hi Leon
Great way (and place) to raise this. I have been thinking on this for some time - esp your first point on the need for a global ethical framework not just developed by and applicable to one or two countries or professional organisations

I have raised with some groups the idea of creating 1) an ethical framework or guideline written to applicable everywhere for all mental health professionals practicing online and then 2) creating reciprocal arrangements between the national professional associations and groupings (and international ones perhaps) to recognise and implement them .

The main difficulties put to me - I think entirely solvable - have been the politics /sheer administrative hassle in creating enforceable rules/standards and that of enforcing jurisdictional issues. So, for example, the British Association for Counselling and Psychotherapy (or ACA or whoever) might find themselves with a client in the UK complaining about a practitioner in, say, New Zealand (or anywhere). What would they do then? Moreover, a British therapist might be complained about by a client in another country (already possible, of course) and how would that be treated? Does any one national professional association have the right to claim jurisdiction over services provided to people outwith their area of jurisdiction? I think yes, and the BACP Online Counselling Guideline is framed that way - BACP members' info for clients should say how they can complain to BACP if necessary. My own answer is that reciprocal arrangements between professional groups that have adequately rigorous complaints procedures and sufficiently similar accreditation/liciencing/approval arrangements (regardless of the terminology!) would simply refer the case to the professional body of which the practitioner was a member, allowing an agreed standard to have real effect on those who fall below it.

I mention terminology because it is one the potential sticky issues - the very meaning of the word 'counselling' or 'counsellor' (or any other similar one for 'mental health related helping activities' - language already getting tortuous there!) can vary widely around the world - in some places closely defined by law and in others very loosely applied. Personally, I think that solvable in practice for an online guideline that could be framed to avoid a lot of things like that, but I know others disagree.

The other (related) problem would be in agreeing content of any such widely adopted guidelines - but I can readily imagine a working party comprising representatives of, say a half a dozen or more or the biggest and most influential professional associations around the world (or whichever ones wanted to be involved) to draft a document that would then simply need to be ratified by each body and then as many others as could be convinced. Changes or updates would need to be similarly agreed/ratified. Areas with especially restrictive rules (California may be one example, not allowing online practice either into or out of the State, I believe) would be least likely to sign up but coverage would not have to be absolutely universal to be worth while - enough to start by heading in that direction.

So far, the few professional organisation managers I have suggested this to have more or less rolled their eyes in horror at the thought of reaching international level agreements on ethical practice and enforcement and I got the impression they felt they had more nationally-focused concerns. *But* with mutual good will - and there is a lot - I see no insurmountable barriers to that kind of development. Indeed, I would love to lead it or be part of it and would put myself forward as one part of the process if there were interest in this kind of project. But would there be the will in enough organisations to make it happen?

The other solution is to have global bodies like OTI take on such a role and have enforcement powers that would have some teeth (a matter of getting a global guideline accepted in different countries - back to agreements between professional associations or govt licencing bodies etc) but there is the issue of being suficnetly widely known as well. I see none that do so very effectively as yet. The OTI ethical framework is already pretty widely applicable and in combination with other national guidelines like the BACP guidelines I wrote with Kate Anthony and any other important online-practice-related ethical codes might be a good starting point.

In short, I'd love to see an internationally accepted global online mental health practice ethical guideline. How do we make it happen?

I'll leave confidentiality/privacy for another time!

Stephen





Leon Tan said:

I think this may be the correct forum to raise the issues I have raised in Twitter.

1. Given the globalized nature of online therapy, what kind of ethical framework is required that is not simply an imposition of the ethical guidelines developed by one or two institutions in one or two countries on the rest of the world?

2. Given the recent debacle re APA and the involvement of psychoprofessionals in torture, what are we to make of concepts such as confidentiality and privacy when these are used in the service of protecting professionals rather than clients?

3. Online therapy to my mind provides the great benefit of instigating a deterritorializing of prevailing professional structures, practices and ethics, in which numerous political and economic problems have already been identified by a variety of sources. To my mind, what is required is a truly transnational ethical framework that is client centric, that accommodates global mobility and accessibility without privileging the laws of an individual nation.

4. Keen to hear thoughts from others on this issue.

[Leon Tan]

Hello Stephen,

Thanks for your lengthy and detailed response!

"I have raised with some groups the idea of creating 1) an ethical framework or guideline written to applicable everywhere for all mental health professionals practicing online and then 2) creating reciprocal arrangements between the national professional associations and groupings (and international ones perhaps) to recognise and implement them."

As you say I think there are many complexities involved but I don't see that these are insurmountable. After all, international frameworks such as the Universal Declaration of Human Rights have been ratified by all member nations of the UN.

The problem to my mind is at once political and bureaucratic and requires as you say a fair amount of goodwill... but then we are interested in this from the pov of the client/patient first and foremost are we not? And there should be sufficient goodwill in this regards. Although the recent torture debacles involving the APA raise MANY issues regarding the concept of ethics and its use by professionals and professional organisations.

"Does any one national professional association have the right to claim jurisdiction over services provided to people outwith their area of jurisdiction? I think yes, and the BACP Online Counselling Guideline is framed that way - BACP members' info for clients should say how they can complain to BACP if necessary."

I agree, but then this is with the caveat that such a framework is truly globalized in its scope, and applicable only to members providing online counselling who are registered with BACP.

"The other (related) problem would be in agreeing content of any such widely adopted guidelines - but I can readily imagine a working party comprising representatives of, say a half a dozen or more or the biggest and most influential professional associations around the world (or whichever ones wanted to be involved) to draft a document that would then simply need to be ratified by each body and then as many others as could be convinced. Changes or updates would need to be similarly agreed/ratified. Areas with especially restrictive rules (California may be one example, not allowing online practice either into or out of the State, I believe) would be least likely to sign up but coverage would not have to be absolutely universal to be worth while - enough to start by heading in that direction."

Regarding international guidelines, definitions are important as you say, 'counselling' is interpreted in different ways. Yet as we live in a globalizing world, we need to find ways of conversation where mutual understandings can be agreed upon. I like the idea you suggest in part re: working party and biggest prof orgs, but I would argue strongly for the input of mental health consumers too in the drafting of such guidelines so that it is not entirely a profession driven product.

Areas with restrictive rules such as California, well they are welcome to be left in the dust to my mind :) I have personally considered restricting all my practice to non-Americans given the problematic situation with the APA and ludicrous restrictions such as those in California. We live in a world far bigger than Cali, and the US lol!

I think that a solution may be found over time that is more bottom up, i.e. from the 'ground' of online therapists and their clients, than top down, i.e. from professional organizations and state regulations... it may take the form of an online framework that is collaboratively drafted and ratified by practicing online therapists as well as consumers, and fed back into professional organizations. This is my personal political bias to advocate for a bottom up process.

Incidentally, Sweden's e-Health strategy for the EU is something I have been looking at very closely. It applies mainly to patient/client data/info for health but there is no reason why it should not be expanded to cover health services and treatments also.

[Leon Tan]

Just reviewed OTI's ethical framework again, and I must say it seems to me to be US centric in some regards.

Also, I take issue with the requirement for verification of identity of clients.

'Practitioners incorporate a mechanism for verifying identity of clients eg Driver’s License or other satisfactory method.'

To my mind, if a client desires anonymity, and chooses to work with a pseudonymous id, is there really a major problem (forgetting about the litigious culture of the US for a moment, and insurance reimbursements etc). Programs such as Moodgym do not require such verification in order to work.

Instead, to my mind, so long as terms and conditions are made clear, it is perfectly acceptable for a client to choose not to reveal a 'real' meaning 'actual' identity. It may even be helpful in the entire therapeutic process of change. Sure emergencies may happen, but these happen 'afk' (away from keyboard) or IRL too, and we are not here as saviours or police but rather provide specific services under clear terms and conditions on an informed consent basis.

Such a stipulation is rather more professional centric than client centric to my mind.

Keen to hear thoughts Kate, DeeAnna, Stephen?


> Online therapy helping the isolated and anonymous http://bit.ly/1446fL #anonymity #privacy Helen Christensen #ANU

[DeeAnna Merz Nagel]

Actually, Leon- that is not a US-Centric ideal- to know who your client is- this is both for client and practitioner safety, and what we have provided for in the framework is the idea that if someone wants to remain anonymous then that is akin to crisis intervention or hotline work and we are fine with that provided the service is stated in that way. To conduct ongoing counselling and psychotherapy in the traditional sense, whether delivered online or in person, without knowing the identity of the patient is hugely risky and risk is not just something U.S, counsellors are concerned with.

With regard to your response about California, in fact you negate your own premise of a globalized set of ethics if you simply lop off a state in the U.S. or, as you suggest, an entire country.

The analogy to the United Nations does not really apply; after all, the United Nations IS an organization to which each nation provides a representative. So that means someone should form the equivalent of United Nations for the helping professions and in order for us to be respectful of one another, we must embrace different cultural and educational expectations as well as various legal requirements.

Anyone can choose to practice anyway he or she chooses- under his or her own jurisdiction. We just ask that the various laws of different regions be respected. And keep in mind, our framework is not a code of ethics- it is what it is stated as being- a framework to which practitioners can adapt to.

Thank you for your thought-provoking posts!

DeeAnna