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]

you can find the legislation but only in german. there is no official translation for this kind of legislation - since it is not law but only an addendum to law. it has about 18 pages - so I did not translate it too :-)

http://bmg.gv.at/cms/site/attachments/6/8/3/CH0964/CMS1144348952885...


maybe a babelfish translation will make possible at least a core understanding of it?

[Stephen Goss]

Risk of mixing two I think different topics here so I will concetrate on the possibility of an international code of ethics and leave anonymity for another response.

All this is just 'thinking aloud' so please forgive any errors or wrong turns!

Dominik, your comments on the situation in Austria are very interesting - a practitioner in any country that effectively outlaws online/email therapy clearly could not do it. (Incidentally, I would love to know the reasoning behind that position in Austria - I have a wry smile at the thought that Freud's seminal work in your country analysing via correspondence might have been banned under that ruling if he had used email? - Am I understanding the position correctly?)

An international code would have to include a statement that any practitioner is first bound by the laws of their country. I would extend that to being bound by the ethical guidelines (whether termed 'framework' or 'code' or whatever) of any professional group/association/body applicable to the practitioner's work.

I don't see that as a major problem though for creating an internationally accepted code - online(email) counselling would not be sanctioned in, say, Austria but it would be elsewhere so practitioners would need to keep within the rule where they are. Similarly many US states seek to ban working with clients in their area without license from that state as this thread shows. That simply means that the international/inter-jurisdictional rule needs to be one of knowing the rules where you and your client are is essential - ie ethical practitioners do the necessary research before taking on a client.

I could provide email counselling to an Austrian but an Austrian practitioner could not (if I understand that right?). And so, unfortunate though it is for the Austrian practitioner, the lowering of barriers between countries offered by the Internet comes to fruition with benefit to clients by allowing access to new practices. Yay for web 2.0!

Standards of provision (the purported reason for the restrictive rules that some countries/states have) could be safeguarded by that international code - an improvement on the situation where standards are not protected across jurisdictional lines. Then (and perhaps only then) countries with restrictive rules could afford to relax them without risk to clients, which they are (quite properly) taking into account at present.

I think Leon's parrallel with the UNDHR is a good one to a point - a form of words is found to cover the agreed basic rules and then countries (in this instance professional bodies responsible in each country, perhaps) sign up. (In practice, I suspect that is harder than writing down what ethical practice involves! But not insurmountable as the UNDHR demonstrates, even though it is imperfectly(!) adhered to.)

One the keys to such a process would be the research on outcomes and processes/practices-related-to-outcomes that would help generate consensus on what is and is not necessary/desirable for good work to happen and bad practices/outcomes to be avoided. I don't see enough of that yet - but that doesn't mean it cannot happen! (Anyone want to join me in setting up an international program of research on this?)

As I have said before on this list, I would love to see such a movement towards internationally agreed and enforcable standards and will work on it with anyone who wants to see such a thing happen. I don't think the content of the 'rules' is actually very far off - there are already several models available and although I find differences I find very few actual conflicts between them.

So - what would prevent an international code being established? Is it best to use the approach DeeAnna has indicated of a good, thorough, internationally applicable framework that every locality adapts to create their own code? Is it best to have one standard we could all agree not to fall below, enhanced by additional requirements/rules for some areas? (that may be almost the same thing, come to think of it).

Looking forward to more on this!
Stephen Goss

[Dominik M. Rosenauer]

the rationale behind the abandonment of email as a means of communication between psychologists/psychotherapists and their clients is the asynchronicity of the medium. per law we have to communicate with our clients directly. the use of letters or telephone is usually not possible/allowed. one of the most important rules seems to be the confidentiality. using email seems to be too insecure for confidential communication. spouses, husbands or children reading email from the wifes/mothers account thus too likely. I experienced that problem several times when I tried to help clients with installing secure email, digital signatures and the like.
When you use chat you can use passwords, webcam, voice and other ways to make sure(r) that the person on the other end of the line is the person you think you are dealing with.

Another reason why I personally prefer synchronous ways of communication is the fact that you can find out problems of understanding and communication easier and quicker then via email. the reaction of the person on what you just said is immediate and you can take another turn and reassure the client that his perception of your reaction was a misinterpretation.

I would definitely like to work on that project of yours, Stephen! construing such a program would be a very interesting thing for me.

[DeeAnna Merz Nagel]

Hi Dominick,

Thanks for sharing!

I thought I might take this opportunity to point out that even with encryption, any online communication can potentially be risky- whether syncrhonous or asynchronous. A spouse, relative, partner, coworker or employer can install a keystroke program on the computer and then have access to every keystroke made on that computer remotely. Of course this is no different than the risk of wire taps on phones or an in-person therapy session being eavesdropped on....

Also, many chat programs record or make available a transcript of the previous chats and unless the person deletes, then the verbatim chat material can be accessed. If the chat or the email program is password protected and encrypted I would think each hold equal risk. Educating our clients about keeping their communications out of the hands of others is important and should be part of the informed consent process.

[Leon Tan]

Hi Kate,

Thanks very much... you raise a good point about 'best practice' which already calls into question the need for evidence as well as a rigorous conception of evidence.

How one determines best practice online is to my mind a rather open question. However I see your concerns regarding suicidality. Here again, this raises ethical questions concerning individual rights to their bodies, and it is true, I take a rather different approach in that I am pro choice and euthanasia unlike a great many organizations.

"the anonymity of the client doesn't help when they are telling you that they have the means to go through with a suicidal intention and you wish to do something to help them"

So here you raise the pragmatics common to many offline ethics guidelines concerning suicide. Yet this to my mind is not something that is by any means necessarily 'good' or ethical, that is, the desire and will to control, and implement strategies of control. I am not saying that there are not cases where interventions are not called for, but I am saying that the very assumption that a therapist treat ALL clients as potential suicides or risks in such terms is highly problematic.

Given that many services already specify contra-indications for working with suicidal cases, I cannot see that there is a major problem such as what you raise. In fact, I think on the whole, suicidal cases are a minority in 'general' therapy practice.

However, given that all of this relates to offline ethics frameworks, there are numerous problems with such codes as it stands, which I have already touched on. How do therapists deal with these other problems or are they simply ignored?

You seem to make a clear distinction about 'crisis' services, but I have already raised the service Moodgym which is in no way a crisis service and to my knowledge does not necessarily conflict with best practice. Why don't we talk about such a service?



Kate Anthony said:

Hi Leon,

My first thought is that this (the second) is a press release - that may not be helpful to the argument but I think worth pointing out. There are loads of services that offer an anonymous service - that doesn't necessarily promote best practice, which is what the Framework sets out to do. I'm not knocking these services, but their existence doesn't mean that the strategy is best practice for a safe environment for clients.

I think I would like to restate that the Framework is about contracted counselling services. Crisis intervention of course has it's place, and a brilliant one - I constantly cite The Samaritans, naturally. But the anonymity of the client doesn't help when they are telling you that they have the means to go through with a suicidal intention and you wish to do something to help them. That many people are helped is not the point here, it is citing best practice within the profession for contracted counselling (I tried to research this further with your first link, but cannot since my computer is not in Australia).

So look at it this way - I am turning to the Internet for help to reach out to a professional, qualified and post-qualified counsellor who has a presence online. I find an organisation that is offering me a quick anonymous chat, and the disinhibition effect means I pour my heart out and by the end of the session allowed, I am suicidal, tell the counsellor so, and what will he or she do with that? This is exacerbated by lack of training in the field, but that is a different thread...

If you accept a "client" as a "client", rather than a service user of a crisis line, you should know their identity, just as in the face-to-face therapy field . This is what the Framework sets out to achieve.

Best ,

Kate

Leon Tan said:

Regarding your frameworks stipulation of ID verification, I have found 2 more services that allow anonymous treatment, so I wish to raise again my concerns and observations wrt to the framework.

http://www.counsellingonline.org.au/en/

Lookatyourdrinking.com, First Online Alcohol Treatment Programme Launches in the UK http://is.gd/5fMUy

[Leon Tan]

"So look at it this way - I am turning to the Internet for help to reach out to a professional, qualified and post-qualified counsellor who has a presence online. I find an organisation that is offering me a quick anonymous chat, and the disinhibition effect means I pour my heart out and by the end of the session allowed, I am suicidal, tell the counsellor so, and what will he or she do with that? This is exacerbated by lack of training in the field, but that is a different thread..."


OK, this is perhaps a 'worst case' scenario, and by no means one that is necessarily characteristic of a service such as the alcohol and drug service I mentioned or of Moodgym for instance.

What I agree on is that there is a lack of training in the field, but within practices run by professionals with a firm grasp of online dynamics as well as well thought out frameworks of intervention, is it really fair to raise such a worst case image?

In any case, therapists offline DO lose clients to suicide... there is a point beyond which I think it is naive to assume the ability, necessity, or 'ethical' compulsion to attempt to avert such.

[Kate Anthony]

Well yes, I think it totally fair to raise it - it is by sharing what you term as "worse case scenarios" that we learn from eachother and are able to decide best practice guidelines etc.

I in no way meant to imply that this is a characteristic of any services mentioned here of course. And I do agree that " it is naive to assume the ability, necessity, or 'ethical' compulsion to attempt to avert such" - I too advocate euthanasia and the right to end ones own life. But that is only my opinion - it is the collective knowledge we acquire through discussion and examination of cases and situations that not only may occur, but also are in my view fairly likely, such as the one I raised, and not a worst case scenario at all.

While professionals may have "a firm grasp of online dynamics as well as well thought out frameworks of intervention", that wont protect them from not having to consider the "worst case scenarios" and what they do in the event of them happening.

Kate


Leon Tan said:

"So look at it this way - I am turning to the Internet for help to reach out to a professional, qualified and post-qualified counsellor who has a presence online. I find an organisation that is offering me a quick anonymous chat, and the disinhibition effect means I pour my heart out and by the end of the session allowed, I am suicidal, tell the counsellor so, and what will he or she do with that? This is exacerbated by lack of training in the field, but that is a different thread..."


OK, this is perhaps a 'worst case' scenario, and by no means one that is necessarily characteristic of a service such as the alcohol and drug service I mentioned or of Moodgym for instance.

What I agree on is that there is a lack of training in the field, but within practices run by professionals with a firm grasp of online dynamics as well as well thought out frameworks of intervention, is it really fair to raise such a worst case image?

In any case, therapists offline DO lose clients to suicide... there is a point beyond which I think it is naive to assume the ability, necessity, or 'ethical' compulsion to attempt to avert such.

[Leon Tan]

thank you for this, and for pointing out that it is not in fact law but addendum. i wonder how it will integrate with a push within the EU for mobility and access for EU residents and citizens wrt to healthcare

Dominik M. Rosenauer said:

you can find the legislation but only in german. there is no official translation for this kind of legislation - since it is not law but only an addendum to law. it has about 18 pages - so I did not translate it too :-)

http://bmg.gv.at/cms/site/attachments/6/8/3/CH0964/CMS1144348952885...


maybe a babelfish translation will make possible at least a core understanding of it?

[Leon Tan]

I welcome your willingness to engage in conversations and think that this is important. And Stephen, I like your point re: all of this is thinking aloud...

No of course it doesn't mean professionals can simply not think about worst case scenarios!

I am especially interested to see some research on the occurences of such scenarios in various online services.

Leon

Kate Anthony said:

Well yes, I think it totally fair to raise it - it is by sharing what you term as "worse case scenarios" that we learn from eachother and are able to decide best practice guidelines etc.

I in no way meant to imply that this is a characteristic of any services mentioned here of course. And I do agree that " it is naive to assume the ability, necessity, or 'ethical' compulsion to attempt to avert such" - I too advocate euthanasia and the right to end ones own life. But that is only my opinion - it is the collective knowledge we acquire through discussion and examination of cases and situations that not only may occur, but also are in my view fairly likely, such as the one I raised, and not a worst case scenario at all.

While professionals may have "a firm grasp of online dynamics as well as well thought out frameworks of intervention", that wont protect them from not having to consider the "worst case scenarios" and what they do in the event of them happening.

Kate


Leon Tan said:

"So look at it this way - I am turning to the Internet for help to reach out to a professional, qualified and post-qualified counsellor who has a presence online. I find an organisation that is offering me a quick anonymous chat, and the disinhibition effect means I pour my heart out and by the end of the session allowed, I am suicidal, tell the counsellor so, and what will he or she do with that? This is exacerbated by lack of training in the field, but that is a different thread..."


OK, this is perhaps a 'worst case' scenario, and by no means one that is necessarily characteristic of a service such as the alcohol and drug service I mentioned or of Moodgym for instance.

What I agree on is that there is a lack of training in the field, but within practices run by professionals with a firm grasp of online dynamics as well as well thought out frameworks of intervention, is it really fair to raise such a worst case image?

In any case, therapists offline DO lose clients to suicide... there is a point beyond which I think it is naive to assume the ability, necessity, or 'ethical' compulsion to attempt to avert such.

[Dominik M. Rosenauer]

the EU has various exceptions for the mobility of citizens and their rights to work in their jobs: lawyers eg. psychotherapists can move to any country in the EU and work under the restrictions of the law in the country they move to. so a german psychotherapist can move to austria and work as a psychotherapist - when he is trained the way the austrian law says. so they have to find an organisation of their school (cbt, systemic, rogers and others) which will accept any training already done and in most cases some additional training will be necessary. if i moved to germany i could not work as a psychotherapist because german law only allows psychoanalysts and cbt-therapists to call themselves "psychotherapists". systemic family therapy is no school which is accepted by german health insurance.