Course content © Copyright 2018 - 2024 by William W. Deardorff, Ph.D, ABPP. All rights reserved.

COURSE OUTLINE

Introduction to the Course and Overview

Learning Objectives

Author Disclaimer

Special Ethical Problems in Behavioral Health Practice 

     Competency in Training and Practice

          Recognition of One’s Boundaries of Competence

          Maintenance of Current Knowledge

     Working with People of Different Backgrounds

     Psychological Assessment

     Recognition of Personal Problems

     Imposition of Values onto the Patient

     Advertising for One’s Own Services and Endorsements

     Avoiding Improper and Potentially Harmful Dual Relationships

     Providing Mental Health Services to Those Served by Others

     Professional Responsibility

          Physical health

          Interacting with the medical hospital system

          Consult, refer, cooperate

          Consult with colleagues

     Personal behavior

     Privacy and Confidentiality

     Informed Consent

     Conflicts of Interest

     Patients Who Do Not Benefit from Treatment

     E-Therapy and Internet Therapy

          Verifying patient and clinician identity

          Initial assessment of online patients

          Clinician availability

          Standard of care

          Privacy and confidentiality

          Informed consent

          Interstate practice

Understanding versus Applying the Ethical Principles

Suggested Readings

References

INTRODUCTION TO THE COURSE

Behavioral health, as a general concept, refers to the relationship between behavioral, emotional, cognitive, social and biological components of health and disease.  The term is used to describe a field of scientific study, academic proficiency and clinical healthcare practice.  The terms behavioral health and behavioral medicine are often used interchangeably.  Behavioral medicine is an interdisciplinary field of research and practice that focuses on how people's thoughts and behavior affect their health and disease. For the purposes of this course, the term behavioral health or behavioral health practitioner will be used.  It will refer to the mental health practitioner who works with medical patients (often within a medical setting but not necessarily) to help address physical conditions and psychological sequelae.  

Because of the special settings and patient populations encountered, the practice of behavioral health brings with it unique ethical issues. Even so, the ethical codes of one’s professional organization are still applicable.  If you don't have a copy of your ethical codes handy, you may wish to view the online version at links provided subsequently.  In the area of behavioral health treatment, it is just as important to be knowledgeable of the ethical principles as in any other area of practice.  Membership in a professional organization commits members to comply with the ethics code.  Lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct. 

As will be discussed, it is important for all behavioral health practitioners to be knowledgeable of their ethical principles, whether or not they are members of the professional organization, since the codes are one aspect of establishing the professional standard of care in any malpractice or licensing board action.

This course will present an overview of ethical principles and situations especially relevant to the practice of behavioral health.  The practice of behavioral health entails a number of areas such as primary care, working collaboratively with physicians to address medical problems, and working in medical settings as consultants.  The area of behavioral health is rapidly expanding as health care becomes more interdisciplinary.  The important role of psychological factors in medical conditions has now become widely accepted in the professional health care provider community.  With this increased presence of behavioral health practitioners working with medical patients, comes unique ethical situations and challenges that do not occur in the more general practice of psychotherapy.  Anyone who collaborates with physicians and provides treatment for health-related conditions must be familiar with these unique ethical situations.

LEARNING OBJECTIVES

This is an intermediate course that assumes the behavioral health practitioner has familiarity with his or her professional organization’s ethical principles.  This might include ethical principles of the following organizations: 

After completing the course, the mental health practitioner will be able to:

AUTHOR DISCLAIMER

This course provides an analysis of some ethical issues that may arise in the practice of behavioral health.  This course does not provide legal advice; nor should it substitute for the assistance of legal counsel, if a practitioner encounters ethical or legal issues in his or her practice.

This course is not a final decision on any ethical or legal subject, as all ethical and legal issues are constantly under revision and consideration.  This material is not meant as a personal or clinical consultation, nor is it meant as a substitution for contact with an ethics committee, attorney or professional consultant.  Excerpts from a variety of ethics codes are presented for illustrative purposes only.  The excerpts may not be presented in full or may be paraphrased. All ethical codes that apply to a specific issue may not be presented.  Be sure to check your actual ethical code language for precise wording or application.

The proper handling of any particular situation depends on the facts unique to that situation, as well as applicable ethical principles and laws. Those laws may differ from state to state and also may change with some frequency. Behavioral health practitioners who encounter ethical or legal issues in their practices should consult with a competent attorney familiar with the laws in their state.

SPECIAL ETHICAL PROBLEMS IN BEHAVIORAL HEALTH PRACTICE

The following discussion examines ethical principles as relevant to behavioral health practice.

Competency in Training and Practice

It is important for the behavioral health specialist to be properly trained to work with a medical patient population.  Ethical codes invariably include a Competence guideline that mandates that the practitioner obtain appropriate education, training, supervision and experience to work in a specialized area (e.g. behavioral health).  Similarly, the practitioner takes steps to obtain appropriate training and supervision when moving into a new area of practice (e.g. the generalist beginning a behavioral health practice).

There are two types of personal competencies that are necessary for high quality practice (Koocher and Keith-Spiegel, 2016; Pope and Brown, 1996):  Intellectual competence is the acquisition of empirically based knowledge and sound clinical judgment in practice with a particular patient population. Possessing intellectual competence is also being able to recognize what one does and does not know.  Emotional competence is the behavioral health specialist’s ability to emotionally manage clinical material that emerges in treatment. This includes detecting and addressing personal biases, having a capacity for self-care, and accepting that “not all therapists can work with all clients or all kinds of problems” (Koocher and Keith-Spiegel, 2016).  The concepts of intellectual and emotional competence parallel the education, training and personal characteristics necessary for competent and ethical practice in behavioral health. 

This principle of competency for behavioral health practice has been very specifically addressed for psychologists.  Since the 1983 Arden House Conference (Stone, 1983), there has been further development of guidelines for training practitioners in health psychology. As was the case even in 1983, it is well recognized that weekend workshops do not produce a clinical health psychologist (or behavioral health specialist). Core training and preparation for clinical health psychology practice should include specific graduate-level courses in the area as well as supervised practical experience. The Division of Health Psychology of the American Psychological Association (Division 38) website has extensive information about training for health psychology careers.  A psychologist should not present him- or herself as a “clinical health psychologist” unless training has been adequately satisfied.  Similarly, one should not present him- or herself as a behavioral health specialist without proper training and experience. A psychologist is not eligible for a board certification in clinical health psychology from the American Board of Professional Psychology unless certain educational requirements have been met.  The behavioral health practitioner should be familiar with evidence-based guidelines relative to behavioral health evaluation and treatment.

Recognition of one’s boundaries of competence.  Ethical principles generally mandate that practitioners practice within their boundaries of competence and this applies to the area of behavioral health.  Some example of Boundaries of Competence in various ethics codes are as follows:

A behavioral health practitioner must ensure the best interests and welfare of the patient who presents with a problem of psychological factors related to a medical problem. Consider the following example:

Dr. Smith acted appropriately and ethically in this example. Had she not received the outside supervision, she could have been acting unethically in providing treatment outside her area of competence. This is especially true in cases of psychophysiological disorders, because there are often clearly specified and empirically validated treatment approaches available for use. Another option might have been for the psychologist to refer the patient to a colleague for concurrent treatment of the headache problem.

Related to this issue, it is unlikely that a behavioral health practitioner could be proficient in all areas of practice that fall within their specific discipline. For instance, clinical health psychology includes such diverse problems as eating disorders to headaches and such diverse assessments as neuropsychological evaluations to chronic-pain patient workups. Similarly, areas of practice in social work related to health care range from substance abuse, case management, end of life, crisis intervention, and supportive counseling.  The skills necessary for these different clinical tasks are extremely varied. As in the preceding example, the behavioral health practitioner must be aware of his or her limitations even within the field of behavioral health and take steps to assure ethical professional behavior.

Maintenance of current knowledge.  Ethical principles mandate that practitioners undertake ongoing efforts to develop and maintain their competence, and this applies to the practice of behavioral health.

In a field as rapidly changing as behavioral health, it is essential to keep abreast of current literature.  Attending continuing education workshops, belonging to professional organizations, completing ongoing Internet research about specific cases, and subscribing to behavioral health journals can facilitate this continuing education process. It has been said that the half-life of a PhD in clinical psychology is about 10 years when no further postgraduate education is sought and this likely relates to other graduate degrees (Dubin, 1972). In the area of behavioral health, this estimate may be much less, because of the high level of research and clinical activity.

WORKING WITH PEOPLE OF DIFFERENT BACKGROUNDS

Psychotherapists have an ethical obligation to be aware of special issues when working with clients of different backgrounds and this also applies to the behavioral health specialist.  Most ethical codes either specifically or generally address this issue and a few examples are as follows: 

It may be that behavioral health patient populations represent more of a cross-section of society than the populations presenting to services at mental health clinics. As such, to meet this ethical guideline in the practice of behavioral health, an understanding of patients’ health belief models is essential. Furthermore, it is important to have an appreciation for cultural and other factors that influence patients’ explanatory frameworks for medical problems.  The following is an overview of a conceptual model useful in accomplishing these goals.

A conceptual distinction among disease, illness, and sickness is helpful for understanding patients presenting to behavioral health practitioners (Engel, 1977; Fabrega, 1974; Hoffman, 2002, 2016; Kleinman, Eisenberg, & Good, 1977; 2006). Disease is an abnormality in physical structure or bodily function; it is the focus of biomedicine. Illness, on the other hand, is the human experience of sickness and is influenced by interpersonal, social, and cultural variables (Hoffman, 2002, 2016; Landrine & Klonoff, 1992; Mechanic, 1972). Illness entails explanation of the disease and how one is supposed to act when ill. It is how we perceive, experience, and cope with disease. In keeping with this model, there is rarely a one-to-one relationship between disease and illness (Beecher, 1956; McMahon & Koltzenberg, 2005; Melzack & Wall, 1983). The combined influences of disease and illness yield what we ultimately observe clinically as sickness. Patients are generally much more concerned with the treatment of their illness than with simply the “cure” of the disease.

Ethical guidelines require that the behavioral health practitioner understands the model discussed above. The domain of behavioral health treatment is often illness behavior, explanatory beliefs, and sickness. When there is a significant discrepancy between the doctor’s and patient’s explanatory models, problems in treatment can occur.

Other common examples of patients’ misconceptions about medical treatments include the following: (a) If one pill is good, then two or more must be better; (b) if symptoms are not occurring, then the pills are not necessary (often seen in medication usage for hypertension and diabetes); and (c) continued use of any medication is “overdependence.” As can be seen, any of these beliefs will have serious consequences for medical treatment.

Kleinman et al. (1977) suggested that in addressing a patient’s belief model, one should attempt the following: (a) to elicit the patient’s belief model with simple, straightforward questions; (b) to formulate the physician’s model in terms the patient can understand and communicate this to the patient; (c) to openly compare models to identify contradictions; and (d) to help the physician and patient engage in a negotiation toward shared models related to treatment and outcome. Awareness of cultural and social issues related to a patient’s belief model is crucial in guiding this process. It must also be realized that subgroups other than identified minority cultures may have beliefs about illness that affect behavior (as portrayed in the above example). It may be unethical to fail to address these issues.

ASSESSMENT

The practice of behavioral health often involves assessment of the patient using some type of objective measure.  Many ethical codes specifically address the area of objective assessment (e.g. APA, ACA, NBCC) while others do not.  If the behavioral health practitioner utilizes any type of objective assessment (e.g. a scored test with normative data), then awareness of ethical testing guidelines is essential.  To illustrate this point, the assessment guidelines from the APA code of ethics will be discussed.  The ACA and NBCC ethical codes contain similar guidelines.  Being aware of your own professions ethical guidelines for assessment is important.  The APA ethical guidelines for assessment, and some of the relevant ACA and NBCC codes, are as follows: 

In assessment with medical patients, the behavioral health practitioner must be acutely aware of using the proper standardization data for medical patients when available, differences in test interpretation with a medical-surgical patient population versus a psychiatric population, increased risk of inappropriate use of test results by other health care professionals, the language of the test interpretation and risk of misinterpretation, and systemic issues hampering the patient’s right to be informed of the test results. Consider the following relatively common example:

This example illustrates several major ethical issues related to psychological assessment in behavioral health practice. First, the psychologist used the original version of the MMPI, which was officially withdrawn from use by the test publisher as of September 1999.  Even though it is now considered obsolete (Pope, Butcher & Seelan, 2006), one often finds that it is continuing to be used in practice.  In addition, the psychologist used standard normative data to derive the patient’s profile. Although this can be adequate if the use of such norms is taken into account in the interpretation, a more useful approach would be to use both the standard norms and those for medical patients (either norms generated in one’s own clinic or those published in the literature, e.g., Graham, 2005; Greene, 1980, 1991) and compare the difference.  Even the MMPI-2 must be interpreted cautiously when used with medical and pre-surgery patients, based upon research applicable to the patient population being assessed.

Other issues in this example, and more important ones since they influenced the course of the patient’s treatment, include the consultation request itself and the interpretation of the results. First, the physician requested an inappropriate use for psychological testing. Although this type of request is commonly received from medical personnel, reviews of the literature suggest that psychologists who use the MMPI/MMPI-2 to assess pain patients should “not attempt to classify patients as organic, functional, or mixed (Prokop & Bradley, 1981, p. 96; see also Bradley, McDonald-Haile, & Jaworski, 1992; Graham, 2005). Second, the psychologist used a standard interpretation developed on psychiatric patients. This included conjecture as to the etiology of the physical symptoms as well as several personality labels that might be cast as pejorative by a non-mental health professional.

Another problem with the response to this referral was that the language of the interpretation might not be in keeping with ethically guarding against the misuse of assessment results and promoting the best interests of the client. Without further explanation, the physician may well have changed his or her opinion of this patient and have tended to see the patient as somehow volitionally controlling the presentation of symptoms or consciously malingering-while there was no evidence bearing on this.

The last ethical issue related to this case is that the psychologist did not “ensure that an explanation of the results is provided using language that is reasonably understandable to the person assessed” (Ethical Standard 9.10; Explaining Assessment Results). Although Standard 9.10 does not state that the explanation must be done directly by the psychologist, he or she must ensure that an adequate and understandable explanation is given. This can be done most effectively if the explanation is done directly by the psychologist. This explanation and feedback process, however it is accomplished, is ethically mandated (Standard 9.10) unless explicitly waived as part of the informed-consent process.

Related to this issue, sometimes the consultant will discuss findings with the referring physician and not directly with the patient. This can be problematic, and it is recommended that where possible, follow-up with the patient be provided. It should at least be offered as an option if the patient would like further clarification after feedback from their physician. It is also prudent to inform the referral source of the importance of the feedback process with the patient. Various references have provided guidelines for providing psychological test feedback to patients-including feedback as process, clarification of tasks and roles, informed consent, framing the feedback, documentation, and follow-up (Pope, 1992; Curry & Hanson, 2010).

In summary, in this case, the test results were not used in the best interests of the patient. Even if the patient had not ultimately been found to have multiple sclerosis, behavioral health evaluation should rarely preclude thorough medical evaluation. Exception to this guideline might include extreme cases, such as somatic delusions or factitious disorders, in which there is a documented history of unnecessary extensive medical evaluations and procedures. Even in these cases, it is important to have an open line of communication with the physician. Remember, people with these types of psychological problems (e.g., somatization or symptom amplification) get sick just like everyone else.

Behavioral health practitioners must be aware of special assessment issues in working with medical patients, because general-practice assessment skills are not always applicable. When the behavioral health practitioner is not familiar with current literature in the area, he or she is at higher risk for unethical practice.

COMPUTERIZED PSYCHOLOGICAL TESTING

The practice of behavioral health might also include the use of some type of computerized assessment.   Again, some ethical codes specifically address the area of computerized assessment (e.g. APA, ACA, NBCC) while others do not.  If the behavioral health specialist utilizes any type of computerized assessment (e.g. scoring and interpretation of a test) then awareness of ethical guidelines for computerized assessment is essential.  To illustrate this point, the computerized assessment guidelines from the APA code of ethics will be discussed.  The ACA and NBCC ethical codes contain similar guidelines.  Being aware of your own profession’s ethical guidelines for computerized assessment is important.  Some example ethical guidelines for computerized assessment are as follows: 

Specific and practical guidelines for users have also been discussed in various published works (Bersoff & Hofer, 1995; Butcher, 2002; Hofer & Bersoff, 1983; Weiner and Greene, 2017).  Butcher (2002) has identified nine important issues when evaluating CBTI’s.  These include validity of the underlying test, expertise of the developers, availability of documentation, availability of updates and revisions, adherence to the ethical guidelines, detection of response sets, relationship to published test interpretation research, quality of technical support, and inclusion of appropriate interpretative cautions in regard to interpretation. 

There are really two major concerns relative to CBTI’s: (a) the adequacy of the scoring algorithms and the classification system used to assign statements to particular test scores and (b) the validity of the interpretations inferred from the test results. Williams and Weed (2004) empirically tested these issues by sending the same MMPI-2 raw data to six different interpretative services.  The researchers concluded, “Among the CBTI reports, interpretative differences for the sample case were striking” (Williams and Weed, 2004, p. 80).  Findings included the following: 

First, the user should be sure that the CBTI scores (raw or scaled) are in keeping with those derived through the traditional methods. Although, computer hard copy looks accurate, such is not always the case even after extensive field-testing by the company. Second, the user should have available data on the decision rules used to match test scores with interpretative statements. When this is not possible, the user should be aware of existing research on the computer programs being used. Unfortunately, this is often not available. Third, it is important to know which interpretive statements are linked to which test scores. Many CBTI’s do not provide such information stating that it is proprietary and this makes the guideline difficult to satisfy. Often one can scan the interpretative reports, comparing interpretations with test scores, to help assure validity. Once again, application to behavioral health requires use of appropriate norms in interpretation.

Fourth, it must always be kept in mind that computerized interpretive reports are tools of the qualified professional. The clinician is ultimately responsible for the report’s validity and use. This means that the clinician might need to edit or amend the computer-generated psychological report to take into account sound clinical judgment. Clinical health psychologists  (and to a lesser degree other behavioral health practitioners) are often involved in computerized psychological testing in the context of a medical center, a comprehensive treatment program (e.g., a chronic-pain program), or on an individual clinical treatment level. At a very early stage of CBTI development, Matarazzo (1986) voiced concern that “the tremendous advances during the past five years in microcomputerized psychological testing hardware and software have made it possible and economically seductive for a psychologist, a physician, another health service provider or a hospital administrator to offer such testing to unprecedented numbers of patients and clients” (p. 17). 

The prediction of Matarazzo (1986) has come true since major publishers of CBTI’s now market directly to a variety of health care providers.  Aside from being used by psychologists and behavioral health practitioners, computerized interpretive reports are being used by other health care professionals, who are often accustomed to ordering lab tests from technicians. It is difficult enough for psychologists and behavioral health practitioners to force themselves to scrutinize the “slick” computer report. Those professionals untrained in psychometric assessment and unaware of the special ethical issues related to computerized psychological assessment are even less likely to be able to make adequate judgments. It would be easy for these reports to become just another piece of data, without interpretation by any behavioral health practitioner familiar with the case. One negative effect of this might be the physician’s prematurely ascribing symptoms to emotional distress on the basis of psychological testing and doing an inadequate diagnostic workup. Cummings (1985) was able to empirically demonstrate this in showing that the number of missed diagnoses by physicians increased significantly in proportion to the amount of psychological assessment information rendered to them.

RECOGNITION OF PERSONAL PROBLEMS

Ethical guidelines dictate that a practitioner, including the behavioral health specialist, be aware of personal problems that might impede practicing in a competent manner.  Examples of a few ethical codes relevant to this issue are as follows:

As with any area of professional practice, the behavioral health practitioner must be aware of any personal problems that could impact his or her ability to perform duties adequately. The unique settings (e.g., the acute-care hospital, rehabilitation center) and environments (e.g., working with a medical practice) in which behavioral health practitioners find themselves add to the stress of the work and may result in professional burnout. The behavioral health specialist may tend to deny the impact of the work and deal with the stress in a destructive manner including emotional detachment and substance abuse.   As reviewed by Koocher & Keith-Spiegel (2016), “Burnout has generally been described as a kind of emotional exhaustion resulting from excessive demands on energy, strength, and personal resources in the work setting” (p. 69).  They go on to discuss eleven factors that can predispose a person to professional burnout and these include role ambiguity at work, conflict and tension in the workplace, lack of social support at work, chronic helplessness, and overly high expectations of oneself.  The behavioral health practitioner who works with a variety of medical practices, consults to different hospitals, and is not part of group of practitioners, may be at increased risk for burnout. 

Important research suggests that a practitioner’s beliefs about whether it is unethical to practice in a state of burnout will affect whether steps are taken, such as decreasing one’s weekly caseload, when impairment is realized (Skorupa & Agresti, 1993). In the settings where behavioral health practitioners are more likely to practice (e.g., an acute-care medical hospital), it may be easier to “get away with” practicing while impaired and providing substandard care, because of diffusion of responsibility issues, which are discussed shortly.

IMPOSITION OF VALUES ONTO THE PATIENT

Ethical guidelines prohibit the imposition of one’s values onto the patient/client and this is important in behavioral health practice.  The following are just a few examples of how this guideline is addressed in ethical codes. 

In keeping with the various ethical principles, the behavioral health practitioner is not justified in imposing rigid criteria for “healthy behaviors” onto patients. Working within the patient’s health belief model and expectations for treatment is necessary to the formulation of treatment goals. For example, the Mexican-American patient who suffers from ulcers may be willing to modify his or her spicy diet but may reject an admonition to switch to bland food. The behavioral health practitioner could be doing an injustice by holding strictly to the latter treatment goal. This course of action would be not only risking a treatment failure but also decreasing the probability that a future intervention would be successful.  The same issue might apply relative to helping a patient lose weight, stop smoking or starting a regular exercise program.

ADVERTISING FOR ONE’S OWN SERVICES AND ENDORSEMENTS

Guidelines for advertising are specifically addressed in many ethical codes.   Generally, advertisements may contain such accurately presented information as name; highest relevant academic degree earned from a regionally accredited institution; type of certification or licensure; diplomate status; professional membership status; services offered; fee information; foreign languages spoken; scientific or clinical basis for, or results or degree of success of, their services; and policy with regard to third-party payments.  A few examples of ethical guidelines are as follows:

The behavioral health practitioner might include in advertising that he or she specializes in the treatment of psychological/behavioral issues related to health problems or a particular subcategory of practice (e.g., chronic headaches, stress disorders, eating disorders, or smoking cessation). Because the FTC has loosened guidelines on professional advertising, most simple factual information about one’s services is probably reasonable (Koocher, 1983, 1994; Koocher and Keith-Spiegel, 2016). What is prohibited in advertising is exaggeration of the uniqueness of services offered. Unwarranted claims such as “hypnotherapy will end smoking and overeating in 1 day” or “10 sessions of biofeedback will eliminate your headache problem” would be considered unfounded and unethical.

Endorsements 

Beyond advertising for one’s own services, care must be taken in the endorsement of products or printed materials, and it is generally not recommended (See Koocher & Keith-Spiegel, 2016, for a detailed discussion of this issue). In behavioral health practice, there has been an explosion of technology related to practice (e.g., relaxation tapes, hypnosis tapes, self-help manuals, and biofeedback equipment). Unfounded claims related to the efficacy of these procedures might include such statements as the following:

These hypothetical statements could be considered unfounded and unethical, because they go beyond what has been validated. Furthermore, they do not specify the context within which these technologies have been tested (e.g., as used in a comprehensive psychological treatment package). The behavioral health practitioner is ethically bound to protect how his or her name is used, even when production or publication rights have been transferred to a marketing company.

AVOID IMPROPER AND POTENTIALLY HARMFUL DUAL RELATIONSHIPS

Dual relationships have been divided into sexual and nonsexual categories. Sexual relationships with patients are prohibited in ethical standards and in many laws. This area is relevant to behavioral health, as in any other area of practice. One issue that might be unique to the practice of behavioral health is the frequent interactions with other professions (e.g., physicians, dentists, and attorneys), which have different ethical codes. In some of these other professional ethical codes, there is no prohibition against sexual relationships with patients or former clients. The behavioral health specialist must beware of influences from other professionals, who could be behaving in an ethical manner for their profession but whose behavior would reflect a clear ethical violation the behavioral health specialist.  Following are some examples of ethical codes relevant to this issue:

Nonsexual dual relationships can occur in a number of ways. One area that appears particularly relevant to behavioral health is that of financial incentives provided by a third party for either hospital or outpatient services. This is specifically covered under Ethical Standard 6.07 (Referrals and Fees). There are numerous cases in which for-profit hospital and medical corporations entered into unethical and illegal “kick back” schemes in which doctors were somehow compensated for placing patients in the hospital or billing for services not actually rendered.   For instance, one news story described a psychiatrist who did what the nursing staff had termed “wave therapy” on his inpatient cases. He would literally walk through the hospital corridor either waving or saying hello to his patients. These “sessions” were billed as full sessions of psychotherapy treatment. In this same situation, the hospital corporation was paying the doctor’s overhead expenses (e.g., rent and secretarial) in exchange for the unwritten understanding that he would keep the census high in the hospital.

Other similar situations have also been common in the workers’ compensation area, in which financial arrangements had been developed among doctors, insurance adjusters, and attorneys to form lucrative referral networks. These types of arrangements would be in violation of ethical standards, constitute harmful dual relationships (one with the patient and the other with an institution) and are very likely illegal. In these situations, treatment decisions might be based on incentives other than patient needs.

Treating Clinician and Expert Testimony

Another area in which the behavioral health practitioner may be more likely to enter a dual relationship is that of being a treating provider who provides expert testimony.  An example of how this might occur is a patient being treated for back pain that was due to a motor vehicle accident.  At some point, the behavioral health practitioner might be asked by the patient’s attorney to provide expert testimony (not just a factual witness) about the psychological sequelae associated with chronic low back pain.  As discussed by Reid (1998), civil and criminal attorneys will often refer clients for treatment and, subsequently, seek expert testimony from the provider to help with the case.  Reid (1998) points out that this dual relationship can create conflict in at least four areas:

An article by Greenburg and Shuman (1997, p. 56) outlines these issues nicely.  The authors conclude that,

Not all authors are in agreement that a treating practitioner who offers expert testimony is acting unethically.  Although the extensive details of the article are beyond the scope of this discussion, Heltzel (2007) argues that, “Although it should be clear that all psychologists must be aware of the ethical challenges associated with expert testimony, it has been demonstrated that the roles of therapist and expert witness are indeed compatible” (p. 128).  The Heltzel (2007) article was in response to the State Board of Psychology of Ohio (2003) issuing a warning to psychologists who provide expert testimony about their own patients.  The Board (2003) cited the article by Greenburg and Shuman (1997) and stated that providing expert testimony about one’s own patients involved “inherent dual roles and bias” (p.2) and concluded, “Prevailing standards essentially demand that you define and remain within one role with a given client” (p.2). 

The conclusions of Heltzel (2007) were addressed by Greenberg and Shuman (2007).  In the article, Greenburg and Shuman (2007) reiterated their original 1997 position and offered further foundation for their assertion that providing expert opinions relative to one’s own patients is an ethical dual role violation.  The authors cited the work of others (See also Strasberger, Gutheil, and Brodsky, 1998) and also provided evidence that the irreconcilability of therapeutic and forensic roles had gained wide acceptance in ethical guideline interpretations and in the courts.

The details of the arguments for and against this issue are very interesting and any practitioner involved in providing expert testimony should be familiar with these articles.  As a general guideline, it appears that functioning in a therapeutic role and an expert witness role for the same patient is in most cases an ethical violation. At the very least, the practitioner must be ready to defend him or herself and answer the question of why it is not an ethical violation.  The practitioner must also keep in mind that this type of dual relationship does not go unnoticed by defense attorneys and almost always is addressed in cross-examination.  Campbell and Lorandos (2001) specifically outline how an attorney should cross-examine a clinician who has entered into a dual relationship of being treating therapist and expert witness.  Most practitioners would not want to find themselves in the position of having to answer these cross-examination questions.

PROVIDING MENTAL HEALTH SERVICES TO THOSE SERVED BY OTHERS

In the practice of behavioral health, it is not uncommon to be referred a patient who is already in psychotherapy for other issues. It would not be unethical for the behavioral health practitioner to proceed with one intervention while a different psychological intervention continues with another mental health professional. However, this can be a potentially confusing and conflictual situation if not handled correctly. Proper management includes clearly informing the patient as to the nature of the intervention and, with appropriate releases, discussing with the other professional how the treatment focuses will be kept distinct and not work at cross-purposes. The guideline of putting the patient’s welfare first is of absolute importance in making these types of clinical decisions.   Many ethical codes address this issue specifically as can be seen in the following:

PROFESSIONAL RESPONSIBILITY

The various ethical codes of those who work in the behavioral health arena (e.g. APA, NASW, ACA, AAMFT, NBCC, and others) all include the concept of professional responsibility. This tenet may be summarized in a single statement (such as in the APA Ethics Code) or formulated across a number of different principles (e.g. Commitment to Clients, Competence, Interdisciplinary Collaboration, Unethical Conduct of Colleagues).  The APA Ethical Principle of Fidelity and Responsibility is as follows:

The effective and responsible practice within the field of behavioral health includes several areas relative to the Fidelity and Responsibility Principle as well as the ethical concepts contained within other Codes.  These include: (1) increased responsibility for physical health, (2) necessary interaction with other disciplines, (3) patient-welfare responsibilities when working in institutional systems such as the medical hospital, (4) consultation with other clinical health psychologists regarding ethical issues, and (5) ones’ personal behavior.  The clinical health psychologist has increased ethical obligations in all of these areas and these this would also likely apply to other disciplines that practice behavioral health.

RESPONSIBILITY FOR PHYSICAL HEALTH

One unique aspect of behavioral health practice is an increased responsibility for physical health. More so than in traditional practice, the behavioral health practitioner deals with psychological factors associated with medical conditions. Therefore, such things as concomitant medical evaluation and management must be assured and this requires consultation and cooperation with one’s medical colleagues.

In addition, the behavioral health practitioner is more often interacting with the medical treatment, both on an individual and an institutional level. This interaction can be intimately tied to patient care (for instance, being sure a particular medical evaluation is completed or helping a patient to confront health care systems problems).

Interacting with the Medical Hospital System

The behavioral health practitioner must be aware of the risk of diffusion of responsibility when working with a patient in a medical facility or group (Seren et al., 2017; Zerubavel, 1980).  Zerubavel (1980) calls this risk the “bureaucratization of responsibility.” He held that within the hospital context, there was an ever-increasing segmentation of responsibility for patients. Hospital patients are cared for by a myriad of specialized clinicians. Thus, the responsibility for the patient does not lie with any one clinician but rather with a collective entity such as “the hospital” or “the team.” (As Zerubavel pointed out, the legal responsibility for the patient lies ultimately with the attending physician.) With such a complex organizational structure, the likelihood of diffusion of responsibility or “floating responsibility” becomes very great. Under these conditions, passivity on the part of the behavioral health practitioner can go unnoticed, because so many aspects of care are occurring simultaneously. For example, such things as treatment planning, record keeping, follow-up, communication with other professionals, and informed consent might not be responsibly completed. The behavioral health practitioner must be sure to provide responsible care to patients even when the structure of the system allows for a diffusion of responsibility or passivity.

Consult, refer and cooperate.  The ethical guideline of consulting and cooperating with other professionals is common across disciplines.  This is illustrated in the following examples from various ethical codes:

As indicated previously, in both inpatient and outpatient settings, multiple clinicians of varying specialties often provide patient care. The behavioral health practitioner usually provides only one aspect of the complete treatment package. It is imperative that regular communication occurs among professionals. This is often achieved in team meetings but many times is accomplished chiefly through chart notes. A common complaint from physicians is that they have referred a patient to a behavioral health practitioner and have received no feedback on the evaluation or course of treatment. It is helpful to maintain written as well as verbal contact with other professionals to be sure treatments are coordinated in an appropriate manner.

Having a working knowledge of what competencies are encompassed by other professions facilitates enhancement of professional relationships and good patient care. For instance, on one case there could be a surgeon, infectious disease specialist, nutritionist, physical therapist, nursing staff, and behavioral health practitioner.  Having an understanding of what each profession does will help the behavioral health practitioner communicate more effectively, gain respect, and be aware of treatment needs of the patient that are not being met adequately. As noted before, it is also important to be aware of varying ethical principles by which different professions abide.

Consult with colleagues to avoid unethical behavior.  It is important to have colleagues to consult with regarding ethical dilemmas that occur in daily practice. This type of consulting is dictated by the various ethical standards and subsumed under maintaining one’s standard of care in practice.  Although these relationships can be established with those in general practice or other specialty areas, some of the consultants and colleagues should also practice in the area of behavioral health.  Documentation of these consultations should be completed to substantiate the decision-making process if necessary. In addition, one can find assistance from local ethics boards.

Personal behavior.  The behavior health practitioner might be subject to standards of behavior beyond those inherent in general psychological practices. As an extreme example, the clinician who is a heavy smoker, very overweight, drinks an excessive amount of coffee, and consumes more than a moderate amount of alcohol, may have special problems in relationships with professional colleagues (e.g. physicians) and patients, as well as in representing his or her discipline and behavioral health to the public. Although this could appear to be an infringement on one’s personal freedom of choice, ethical codes generally state that personal behavior can come under ethical scrutiny as it impacts professional practice. The behavioral health practitioner must be aware of personal health habits and make decisions about acceptable, ethical public behavior. These behaviors cannot be rigidly defined, nor should they be, but rather a range of acceptable behaviors must be decided on individually.

PRIVACY AND CONFIDENTIALITY

Confidentiality is the sine qua non of the psychotherapeutic relationship in general practice and the same holds true in the area of behavioral health.  Under most ethical and legal statutes, confidentially must be protected and can only be breached with consent of the patient (except in special situations such as threats to oneself or others, court order, etc).  Confidentiality of records belongs to the patient and the “duty” to protect the confidentiality belongs to the provider.  This can present special challenges for the behavioral health practitioner in medical settings including seeing a patient in a multi-bed room, storing psychological information in the general medical chart (written or electronic), and multidisciplinary team meetings.  Since some of these issues are an integral part of the medical settings, informed consent and discussing limits of confidentiality with the patient become paramount.  The various ethical codes address confidentiality as follows:     

Privileged versus confidential Information

Privileged communication refers to the legal doctrine that a professional cannot disclose confidential information without a patient’s consent (Reamer, 2003, 2015, 2018).   The limits of this privilege are determined by state statutes and vary from state to state. The privilege of confidentiality lies with the patient, and except in special circumstances, the behavioral health practitioner must abide by the patient’s determination.

Confidentiality is an ethical concept, but it is influenced by legal guidelines (e.g., mandates to breach confidentiality to prevent self-harm or harm to others; see Belar & Deardorff, 2008). The behavioral health practitioner (in accordance with applicable ethical codes and laws) must maintain a confidential relationship with the patient and obtain permission before releasing information.

Special Confidentiality Problems in Behavioral Health Practice

Some of the special confidentiality problems in behavioral health include providing information to the referral source, charting treatment notes in a more circulated medical record versus a less available psychological record (either written or electronic) and releasing medical records that contain psychological treatment notes to an outside source. Other problems arise in providing services to multiple-bed hospital rooms, case discussion within the context of a multidisciplinary team approach, and discussion of the patient’s psychological status with members of the patient’s family.

Generally, the behavioral health practitioner should strive to maximize confidentiality. One should also inform the patient of the limits to confidentiality set either by law or by the institutional organization. For instance, finding a setting to conduct confidential psychological services on a medical-surgical unit can be very difficult. Patient consultation rooms are sometimes available, but these are often heavily scheduled. If the patient is non-ambulatory and is in a multiple-bed room, it may not be possible to maintain confidentiality (unless services can be scheduled when other patients are out of the room). The patient should be explicitly given the option of declining services if not comfortable with the situation; otherwise, the pressure from an “authoritative” professional may induce the patient to engage in behavior without true consent. Similarly, when a patient’s psychological status is to be discussed in the context of a treatment-team approach, the patient should be informed of what material will be discussed.

Last, pressure from family members to discuss the patient’s psychological status often arises in the case of brain dysfunction; “conversion” disorders; and compliance problems, which can be closely related to family-systems issues (e.g., eating disorders, compliance with insulin-treatment regimens, or chronic-pain management). If the patient is not able to make informed decisions, such as in brain dysfunction cases, legal and ethical guidelines may allow release of confidential information to an appointed person as necessary. Except in these instances, the process of obtaining a written release of confidential information should be followed, as in any traditional psychological case.

INFORMED CONSENT

The doctrine of informed consent was developed so that patients could weigh the risks and benefits of a treatment and determine for themselves if they wanted to participate (Barnett, Wise, Johnson-Greene, & Bucky, 2007; Barton & Sanborn, 1978; Knapp & Vande-Creek, 1981; Pizzi, Goldfarb, & Nash, 2001; Reamer, 2015, 2018; Simon, 1992). Informed consent was established as a legal standard of care based upon the principle that individuals have rights over their own bodies.  For surgical and medical procedures, the legal aspects of informed consent were well established by the turn of the century (Beahrs & Gutheil, 2001).  However, informed consent for psychological interventions has only just recently been developed.  This was likely due to the fact that psychological interventions are non-invasive, the psychotherapeutic process was seen as “sacrosanct”, patients are conscious and able to monitor the ongoing treatment for themselves, and it is difficult to demonstrate harm resulting from the treatment (Appelbaum, 1997; Beahrs & Gutheil, 2001, p.4).  However, legal and ethical cases over the past 20 years have increased the focus on informed consent for psychological treatment.

In the various ethical codes, informed consent is addressed in several different places related to the nature of informed consent required.  These different informed consent issues include such things as Third Party Request for Services, General Informed Consent, Informed Consent to Research and Recording, Informed Consent in Assessments and Informed Consent to Therapy.  One can conclude that just based upon the amount of times informed consent is addressed in the ethical codes it is an important issue.  The patient should understand the nature of the proposed treatment, the risks and likelihood of success, and available alternative treatments. Just a few examples of ethical guidelines related to informed consent are as follows:

Ideally, the procedure of informed consent is meant to force the health care professionals to make the patients “active agents” and more equal bargaining partners in treatment decisions (Beahrs & Gutheil, 2001; A. A. Stone, 1979). Interest in informed consent for medical and psychological treatments has increased with the consumerism movement among patients and judicial involvement in this area (Reamer, 2003, 2015, 2018; Widiger & Rorer, 1984).  As an example, in the APA Code of Ethics, informed consent was not specifically addressed prior to the 1992 revision but is addressed in several places in the 2002 revision. 

The legal concept of informed consent includes capacity, information, and voluntariness. Capacity means that a patient must have the ability to make rational decisions (this tenet often excludes children and the developmentally disabled from being able to give informed consent and necessitates proxy consent by a guardian). Information consists of both the substance of the material presented and the manner in which it is given. It is gauged by demonstrated understanding by the patient. Voluntariness means that the patient was able to exercise free choice, without coercion, in making the decision.

Inadequate informed consent is unethical and has been grounds for malpractice in medical and psychiatric/psychological treatments (Beahrs & Gutheil, 2001; Cohen & Mariano, 1982; Reamer, 2003, 2015, 2018). A significant problem is how much to actually disclose about treatment (Beahrs & Gutheil, 2001; Halperin, 1980; B. M. Schutz, 1982; Simon, 1992). Adequate disclosure is legally determined by the community standard of care (telling patients what other practitioners in the community would tell their patients under similar circumstances) and “the reasonable person” statute (telling the patient what a reasonable person would need to know to make an informed decision). However, these guidelines actually offer the practitioner little guidance (A. A. Stone, 1979).

Other problems are revealed by demonstrations that informed-consent procedures are often inadequate when patient understanding and retention of the material are assessed (Ley, 1982; Pizzi et al., 2001). Such problems are sometimes related to readability of consent forms. For example, Christopher, Foti, Roy-Bujnowski & Appelbaum (2007) completed a review of 154 clinical mental health research studies that utilized informed consent forms.  All forms were assessed using several standard “readability” formulas.  The overall mean readability scores for the informed consent forms ranged from grades 12 to 14.5.  In addition, the higher the risk of the study, the higher the mean readability score of the forms. 

A review of medical informed consent studies reached similar conclusions (Pizzi et al., 2001).  The results of the National Assessment of Adult Literacy most recently completed survey in 2003 are now being analyzed and published (click here).  Part of the 2003 survey included a measure of health literacy defined as, “the ability to use literacy skills to read and understand written health-related information encountered in everyday life”.  Although it is beyond the scope of this discussion to define the complex classification system used in the survey, 75 million Americans are estimated to possess Basic and Below Basic health literacy skills with 114 million at the Intermediate level and only 12 million at the Proficient level.  It is very unlikely that Americans with Basic or Below Basic health literacy (and probably a vast majority in the Intermediate group) would be able to read and comprehend most informed consent forms since they are written at a 12 to 15 years of education readability level (See Pizzi et al., 2001 for a review).   Research findings in this area present serious problems for the practitioner in obtaining informed consent. Because of legal pressures, many medical professionals have gone to what might be considered the extreme position of providing all possible risks in graphic detail to ensure completeness. Problems with this approach and suggestions for a process of informed consent are discussed later.

Behavioral health practitioners may be involved in several aspects of informed consent in the medical setting. Behavioral health practitioners are often involved in (a) helping the physician to explore the patient’s health belief model about aspects of treatment and determining the extent of the patient’s understanding or possible misconceptions; (b) working with patients to encourage behaviors that will increase the likelihood of “true” informed consent (including determining what questions the patient has about the medical treatment and teaching the patient how to obtain the information from the physician); and (c) helping patients deal with the increase in feelings of uncertainty about treatment, which often occur after explicit informed-consent procedures are carried out.

Behavioral health practitioners must also deal with the issue of informed consent in the course of service delivery of psychological services. Many practitioners view the informed consent with contempt and rarely provide information about alternate treatments. Several authors have suggested that the informed-consent process is a double-edged sword (Beahrs & Gutheil, 2001; Gutheil, Bursztajn, Hamm, and Brodsky; 1983). The positive aspect is that it clarifies options and stimulates understanding. The negative aspect is that it can increase the patient’s having to accept more uncertainty about treatment and decrease belief in the doctor’s ability to cure. As discussed by various authors, (Beahrs & Gutheil, 2001; Gutheil et al. 1983) the informed-consent procedure should be entered into as a process of mutual discovery rather than as a formality. In the informed consent process, it is prudent to include such things as the rationale for service, treatment plan, and goals in an atmosphere of open negotiation. Once a plan is formulated, it is useful to have the patient paraphrase their understanding of the treatment (or evaluation), so that misperceptions can be corrected.

The process of informed consent can often be difficult with patients referred to a behavioral health practitioner. Many times, the physician has not given the patient much information about behavioral health services, or the physician has given incorrect information. Furthermore, the patient is being expected to shift from a biomedical orientation to a biopsychosocial approach. Overwhelming the patient in the first session with details of a treatment plan and expectations can result in premature termination. The informed-consent procedure can extend over many sessions and, in fact, over the entire course of treatment. Skills in working with people of different backgrounds (Competency) facilitate the informed-consent process.

Facilitating the informed consent process is discussed by Beahrs & Gutheil (2001) and Pizzi et al. (2001), and the following summarizes their guidelines:

CLARIFICATION OF ROLES AND THIRD PARTY REQUESTS FOR SERVICES

Clarification of roles is part of informed consent and is addressed in the various ethics codes under Multiple Relationships and Third Party Requests for Services.  For instance, the APA Ethics Code (2017) states: When psychologists agree to provide services to a person or entity at the request of a third party, psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved. This clarification includes the role of the psychologist, an identification of who is the client, the probable uses of the services provided or the information obtained, and the fact that there may be limits to confidentiality (3.07). 

The principle of informed consent dictates that behavioral health practitioners clarify the roles they are performing for all relevant parties and function in accordance with those roles. In behavioral health practice, this issue usually arises in clarifying one’s role within the context of medical treatment. In the hospital setting, patients are often seen by a variety of providers, and they will often become confused about “who does what.” The patient could mistake the behavioral health practitioner for a physician or expect a similar type of care. These roles should be clearly identified for the patient. For the patient who is unfamiliar with psychological interventions, the process of explanation of roles may proceed over several sessions.

The services of a behavioral health practitioner are often requested by a physician to provide an evaluation, treatment, or both. The behavioral health practitioner must always determine the extent of the patient’s understanding as to why the consultation was requested and whether services are necessary. Many times, the physician has not told the patient a consultation had been ordered. As with any other case, informed consent must be acquired before proceeding. Furthermore, many consultation requests are found to result from projection on the part of providers, who are experiencing frustration, anger, depression, or some other emotional response to the patient. Intervention is sometimes more appropriately targeted at the staff rather than the patient. A thorny ethical problem that then arises is determining who is going to pay for the staff intervention.

Other areas in which the services of a behavioral health practitioner (usually a clinical health psychologist) are often requested by a third party include neuropsychological assessment, psychological evaluation for a specific treatment program or procedure, and evaluation as part of filing a workers’ compensation or disability claim. Patients are often not aware that in requesting these programs to pay for services, they must agree to release their psychological evaluation as a condition of reimbursement. In any of the above situations, the practitioner must fully inform the patient as to the nature of the assessment, the purpose, what the results will be used for, who requested the evaluation, and who will pay for it.

Conflicts of Interest

When one interacts with the medical system, conflicts of interest can arise.  Various ethical codes appropriate for the behavioral health practitioner’s discipline address conflicts of interest as in the following examples:

There can occur a basic, unacknowledged, antagonistic relationship between patient and hospital or employee of the institution (Bazelon, 1974; Koocher & Keith-Spiegel, 2016). As Noll (1976) stated, “whenever the mental health professional is employed by an agency or by an institution, the institution needs will almost invariably supersede those of the patient” (p. 1451). Thus, the behavioral health practitioner may have a “hidden agenda” when consulting to a medical-surgical unit depending on the needs of the staff and the reason for the consultation request.

In this example, the behavioral health practitioner might have easily been influenced by staff issues and have thus seen the patient with a goal of convincing her to have the experimental treatment. Practitioners must remember to be responsible to the patient, to take into account the needs of the patient versus those of the staff, and to clarify the nature of their loyalties and responsibilities.

PATIENTS WHO DO NOT BENEFIT FROM TREATMENT

If a patient does not benefit from psychotherapy after a reasonable trial, the therapist is ethically mandated to terminate the treatment and to help with an appropriate referral.  The same holds true in the practice of behavioral health.  Some examples of applicable codes are as follows:

The behavioral health practitioner will often receive referrals for “last-option” treatments, in that all previous traditional medical treatments have failed (e.g., chronic-pain syndromes, tinnitus, blepharospasm, or atypical facial pain). In these cases, the psychological referral is to “give it a try,” because there appear to be no other options. These cases represent clinical challenges in which the therapist must gauge carefully, in realistic negotiation with the patient, when an adequate trial of treatment has been accomplished without significant benefit. The following case illustrates such a decision:

In this example, the behavioral health practitioner had to make a decision, with the patient’s full participation, as to when an adequate trial had been attempted. The behavioral health practitioner must also provide a referral if other treatments are available. The termination process in these cases must be handled carefully to prevent iatrogenic deterioration effects (e.g., patient being left with a “failure experience”) and to capitalize on the positive effects, however small, of the treatment experience.

E-THERAPY AND INTERNET THERAPY

For a very detailed discussion of this area, please see the course, Internet Based Treatment: A Comprehensive Review and Ethical Issues.  E-Therapy is the provision of mental health treatment through the Internet. In 2004, 23% of Internet users searched for information on mental health issues and 28% for information on a doctor or hospital (Recupero & Rainey, 2005).  Those numbers are likely much higher now with the continued penetration of Internet use into American households.  In conducting a simple Google search recently, 161,000 hits for “Online Therapy” and 172,000 hits for “E-therapy” were obtained.  There are now professional organizations for online counselors including the National Directory of Online Counselors, the American Association of Online Psychotherapists, and the International Society for Mental Health Online.  These services offer treatment for virtually every DSM 5 diagnosis and, relative to the practice of behavioral health, such things as pain management and behavioral management (e.g. smoking, alcohol consumption, weight loss, insomnia, somatization, eating disorders, just to name a few).   These “treatments” are structured in several ways including private online chat (real time), instant messaging, videoconferencing, email sessions, or a combination thereof.  In one of the more interesting arrangements, the “patient” purchases a certain number of words to be placed in a “word bank”.  With each email, the number of words used by the patient is deducted from the bank.  

Although a very new area of research, Web-Based Treatment Interventions (WBTI’s) are in the initial stages of empirical testing.  Ritterband, Gonder-Frederick, Cox, Clifton, West, & Borowitz (2003) and Haberstroh et al (2008) have reviewed some of these studies.  The studies have been done in such diverse area as smoking cessation, weight loss, headaches, body image, posttraumatic stress and pathological grief, physical activity, panic disorder, depression, tinnitus, diabetes management and pediatric encopresis.  As discussed by Ritterband et al. (2003), “These studies all focus on behavioral medicine/health psychology issues, which seem to more adaptable to Internet interventions because of the highly structured treatment approaches to many problems (p. 528; See also, Childress & Asamen, 1998). 

Ritterband et al. (2003) present a detailed model for developing a WBTI including ascertaining the effectiveness of the traditional face-to-face treatment, considering the legal and ethical issues involved in developing a WBTI, transforming treatment elements into a WBTI, building individualization and feedback components into the WBTI, and then testing the WBTI effectiveness against traditional methods. The WBTI research reviewed by Ritterband et al. (2003) generally uses the Internet in a more adjunctive fashion (e.g. patients are specifically selected for the approach, the initial session may be face-to-face, etc.) rather than a patient simply doing an Internet search, finding a therapist who may not be in the same state, paying the money, and starting treatment. As such, the type of rigorous development of an Internet based treatment approach as reviewed in scientific journals is not what is generally experienced when a patient pursues E-therapy at this time.

Newer research suggests a promising future for web based interventions for various psychological disorders. For instance, Beiwinkel et al. (2017) reviewed web-based interventions for depression (“promising” and showing positive results). The authors randomized controlled study demonstrated a decrease in depression and sickness absence. See also a comprehensive review of Internet-based psychological treatments for depression (Johansson and Andersson, 2012) and anxiety (Penate and Fumero, 2016).

As discussed by Recupero and Rainey (2005), E-therapy has provoked controversy in the mental health fields.  Proponents argue that E-therapy provides many benefits such as convenience, a certain level of anonymity preferred by some clients, the ability to reach underserved populations, the ability to do less expensive treatment, etc.  However, there are several ethical and liability risks that will be discussed subsequently (See also Mallen, Vogel & Rochlen, 2005 for an in-depth review). 

Most of the ethics codes that guide behavioral health practitioners do not specifically address E-therapy however this is changing.  For instance, E-therapy has not been specifically addressed in the 2002 APA Ethics Code but there are plans to address this new intervention approach in future versions.  The is some guidance from “A Statement by the Ethics Committee of the American Psychological Association” issued on November 5, 1997 (click here) but these are considered “inactive.” Newer guidance from APA include Guidelines for the Practice of Telepsychology (Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013) and Guidelines for the Practice of Telepsychology.

In the 2002 Code of Ethics, the same guidelines still apply.  As discussed by Smith (2003), the 2002 ethical code does not specifically address E-therapy, but language throughout the code addresses Internet and electronic transmission.  Smith (2003) specifically mentions Standard 4.02c which stipulates that psychologists who offer services, products or information via electronic transmission inform their clients of the risk to privacy and limits of confidentiality. 

Some professional counseling organizations have become active in developing ethical guidelines for online counseling or E-therapy.  The NBCC developed Web counseling guidelines in 1998 and updated them in 2001 and 2007 (The Practice of Internet Counseling, NBCC, 2007) as well as 2016 (NBCC Policy Regarding the Provision of Distance Professional Services).  Similarly, the ACA developed E-therapy ethical guidelines in 1999 and included best practices for Internet counseling in the most recent update of their ethical code (ACA, 2014). The NASW has also revised their Code of Ethics including 19 changes that address ethical responsibilities when using technology (2017). 

Haberstroh et al (2008) pointed out that, at that time, there was evidence that many online counseling websites were not following accepted ethical guidelines even when they were available.  For instance, Shaw and Shaw (2006) used a 16-item ethical checklist to assess 88 online counseling websites.  The checklist was derived from the American Counseling Association’s Ethical Standards for Internet Online Counseling (1999, 2005).  Results demonstrated that less than half of the online counselors were following accepted practice on 8 of 16 items.  In another survey, Heinlen et al (2003) found that 36% of persons claiming to provide Web counseling had no credentials or formal training in professional counseling.  Heinlen et al (2003) also found that conformity to the NBCC guidelines for online counseling was often dismal with noncompliance rates ranging between 23% and 100%. 

The current status of compliance to ethical standards by online counseling practitioners and companies is unknown. Certainly, in the last 10 years, this area of practice has exploded (with the advances in technology) but the technology is clearly ahead of implementation of guidelines and safeguards. One only needs to do an Internet search on “online counseling” to get a feeling of the current state of affairs.

It is beyond the scope of this course to review in detail the ethical, state licensing board, and malpractice risks that are inherent in E-therapy.  These have been reviewed elsewhere (Haberstroh et al, 2008; Koocher and Morray, 2000; Reamer, 2013; Recupero & Rainey, 2005; Ritterband et al., 2003; Lal and Adair, 2014) and are summarized as follows:

Verifying patient and clinician identity.  Aside from videoconferencing or telephone contact, in E-therapy it can be challenging for the patient and therapist to identify each other’s identity after a treatment relationship has been established.  For instance, the therapist must be assured that emails, online chat, or instant messaging are not intercepted or responded to by someone else.  The clinician must also be sure his or her Internet access is completely secure and this should include the use of encryption.

Initial assessment of online patients.  When a patient comes strictly from the Internet for E-therapy (without any face-to-face contact or referral from another healthcare provider), the clinician does not have the benefit of an initial evaluation including face-to-face interview (with all of the non-verbal data), mental status examination, review of background medical records, discussion with collateral sources if necessary, consultation with other treating doctors, psychological testing, etc.  Due to the anonymity afforded by E-therapy, the clinician may not know the actual identity of the patient, may be given incorrect contact information, and may be subject to deception.  These factors place the clinician at risk for misdiagnosis and various treatment mistakes. If this were to occur, in the event of an emergency such as suicidality or homicidality, the outcome could be disastrous. 

Clinician availability.  There may be technical problems that either interrupt the treatment session or cause the clinician to be completely unavailable.  This situation might lead to a mis-attribution on the part of the patient if not anticipated before it occurs (e.g. feeling abandoned, etc.).  Also, if the patient needs to reach the clinician in a crisis, having only Internet contact availability may put the client at risk.

Standard of care.  The community standard of care is what the professional’s behavior will be judged against if a question of liability arises.  E-therapy is still a very new, essentially unregulated, type of treatment with only the beginnings of empirical support for its effectiveness at this time. As such, the clinician is operating in “uncharted waters” but must always remember that, “One does not cease being a psychiatrist or psychologist when one provides therapy online” (Recupero & Rainey, 2003, p.407).   Any behavioral health practitioner doing E-therapy must be aware of the rapid development in online healthcare communication.

Privacy and confidentiality.  The mental health practitioner and patient should not assume that online interactions are necessarily confidential (written or video).  Some guidelines for Internet communication between healthcare provider and patient recommend a secure network including authentication and encryption in accordance with HIPAA.  Standard email, instant messaging and online chat do not meet these guidelines.  Consider the hypothetical case in which a young woman has been in online therapy and ultimately reveals she has been date raped.  The psychologist encourages her to report the assault to the police, which she does.  The psychologist then receives a subpoena for records from the prosecuting attorney.  The psychologist refuses to release the records and the attorney asserts that E-therapy is not traditional psychotherapy and may be analogous to self-help, in which case there is no doctor-patient privilege.  In addition, the attorney subpoenas the records directly from the Internet service provider.

Informed consent.  As discussed previously, informed consent is an important aspect of healthcare practice.  In E-therapy, informed consent should be explicit and outline all the potential risks and benefits (especially the risks, as discussed in this section).  In psychological treatment, informed consent also includes reviewing situations under which confidentiality must be breached.  All states have mandatory child abuse reporting laws, some states have elder abuse reporting laws, and many states have Tarasoff (duty to warn) laws, but some do not.  If a psychologist practices in a non-Tarasoff state (e.g. Virginia) and is providing E-therapy to a patient in a Tarasoff state (e.g. California), what is his or her duty-to-warn obligation if a viable threat is made?  These issues are very unclear at this time.

Interstate practice.  There may be problems if a behavioral health practitioner licensed in one particular state provides E-therapy service to a patient in another state.  This is due to the fact that each state has their own set of professional licensing and practice laws in order to protect their citizens. To assess this issue, Koocher and Morray (2000) conducted a survey of the 50 state attorneys general and asked several questions related to telepsychology.   The researchers asked questions about laws regarding telepsychology practice, whether any charges had ever been brought related to this practice, and how the state handles those telepsychology services provided from another state. At that time, 24 states claimed regulatory authority over practitioners residing in other states that provided E-therapy services in their state.  Seven states acknowledged receiving complaints about E-therapy services and charges had been brought in E-therapy cases in at least two states.  Given the exceptional advancement and use of the Internet in the 18 years years since that publication, things have likely changed.  For instance, the California Board of Psychology has a notice to consumers regarding those who choose to seek psychological service over the Internet (click here).  The notice provides warning about the practice, the requirement for written informed consent, and the statement, “Individuals who provide psychotherapy or counseling to persons in California are required to be licensed in California”.  Although there are efforts to change these state statutes, to our knowledge, that has not occurred. Similar statutes likely exist in other states and these should be checked carefully by the E-therapy provider.

Malpractice insurance.  Although not specifically related to ethical issues, malpractice coverage may be ambiguous in the practice of E-therapy.  The issues include whether a nontraditional treatment like E-therapy is covered, and whether coverage extends from one state (e.g. where the psychologist practices) to another (where the patient resides). 

UNDERSTANDING VERSUS APPLYING THE ETHICAL PRINCIPLES

An important aspect of professional ethics is the difference between understanding and implementing ethical principles. This is the “should” versus “would” discrepancy. Most research suggests that clinicians generally have high-quality ethical decision-making capacity but that this is put into practice to a lesser degree (see Politis and Knowles, 2013; Smith, McGuire, Abbott, & Blau, 1991; Wilkins, McGuire, Abbott & Blau, 1990, for review).

For instance, Wilkins et al. (1990) conducted a survey of a random sample of American Psychological Association members. Research participants were presented with four scenarios that reflected ethical dilemmas in the areas of alcohol-related impairment, dual-role sexual abuse of a client, confidentiality, and need for referral related to competence limits. Participants were asked what they should do according to the American Psychological Association Ethical Principles and what they would do if actually faced with the situation. These were rated on a scale from do nothing (least restrictive) to report the individual to the ethics board (most restrictive). Results confirmed that respondents were generally able to recognize ethical conflicts that required action. However, significant differences were found when the “should” ratings were compared with what the respondents “would” do (the “should” results were more restrictive than the “would” results). One important finding was that when the ethical violation was more clear-cut (e.g., misconduct related to sexual abuse or impairment due to substance abuse) and there was a consensus as to what to do vis-à-vis the ethical principles, there was increased congruence between what should and would be done.

These findings are relevant to all areas of behavioral health practice. All clinicians need to be aware of the likelihood of experiencing the “should-would” difference. Especially applicable to clinical health psychology is the finding that practitioners will have increased difficulty applying the ethical principles that are defined in a more ambiguous fashion. This might include such principles as those of confidentiality, nonsexual dual relationships, and informed consent. As discussed in previous sections, the behavioral health practitioner might be presented with challenges in these areas more frequently than other areas of practice.

REFERENCES

American Educational Research Association.  (1999).  Standards for educational and psychological testing.  Washington, DC: Author.

American Psychological Association.  (1953).  Ethical standard of psychologists.  Washington, DC: author.

American Psychological Association.  (1986).  Guidelines for computer-based tests and interpretations.  Washington, DC: Author.

American Psychological Association.  (1992).  Ethical principles of psychologists and code of conduct.  American Psychologist, 47, 1597-1611.

American Psychological Association.  (2002, 2017).  Ethical principles of psychologists and code of conduct.  American Psychologist, 55, 1449-1451.

Appelbaum, P.S. (1997).  Informed consent to psychotherapy: recent developments.  Psychiatric Services, 48, 445-446.

Barnett, J.E., Wise, E.H., Johnson-Greene, D, & Bucky, S.F. (2007). Informed consent: Too much of a good thing or not enough?  Professional Psychology: Research and Practice, 38, 179-186.

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