Email, Chat Rooms or Skype for Mental Health: What about Mandated Reporting?

When exclusively using email, chat rooms or videoconferencing platforms such as Skype, we  might not  know enough about people to fulfill our responsibilities as mandated abuse reporters. Are these approaches to practice then, diluting our professional responsibilities? Is this what we really want to do? Is it what you want to do?

Can you imagine the repercussions of hundreds of thousands of us choosing to practice this way online? What would happen to the abuse victims that we now are in a position to protect?

Skype for Mental HealthThat’s not all we need to think through… let’s consider another situation. Can you imagine the repercussions of accepting to treat someone who looks like an adult when online, but who really is a minor, only to find out that they committed homicide after your last session? Now imagine how much more complicated it would be if that minor’s family could prove that the session was terminated by soon after the minor mentioned homicide intent.

If you think that’s unlikely, consider the websites such as www.liveperson.com (where practitioners licensed in their own states and not those of the client or patient, and therefore are practicing over state lines) or are rated by counseling clients on a five-star rating scale. If you’ve ever dealt with homicidal or abusive patients, they don’t typically enjoy being informed that you’re going to need to report them. The dilemma here is that if you report, they are likely to give you a negative star rating, and might even not pay, which is allowed if they aren’t satisfied.

Now lets’ say you are a single parent with 2 kids who is making $3 or $4 per minute online with liveperson.com or $1 and $2 per minute after expenses are paid in your F2F office. Let’s get real…how likely are you to act on your mandate to report, especially if the client isn’t likely to report you if you don’t turn them over to child protective services or the police?

I’ve even seen a group online professing to educate clinicians about legal ethical issues related to online counseling, but who advocate treating people without a single face-to-face meeting to screen, assess, diagnose or get an informed consent agreement both verbally and in writing prior to treatment.

One of my most burning questions for all these professionals is how they know the client hasn’t  had a few beers or martinis prior to the initial session, and isn’t simply agreeing to the consent form without fully understanding it? How do they know the patient isn’t overly medicated with psychotropic or other prescribed drugs one agreeing to treatment?

Even more importantly, aren’t these professionals referencing the literature to make an attempt to understand the many factors that could go wrong? Isn’t that a large part of what we bring to the professional relationship when we encourage potential clients to meet with us as treating professionals?

Imagine the complications when you learn from the patient’s family attorney that the client you so readily treated online was really a 15-year old who pretended to be 21. While our some of our colleagues dare to rush into these situations without bothering to get the ethically mandated professional education, training, supervision or other formal study, let me ask you a few more questions:

  • How would any medical or mental health professional feel if their online counseling client committed suicide?
  • Do they think anyone who knew of a professional’s contact with their friend or family wouldn’t try to find a written record of the professional’s exchange with that client?

What would happen to the professional if the client were involved in a Columbine-like shooting, where the client opened gunfire on a group of teenagers in a high school? What sort of defense could a professional in such a circumstance propose in a court of law?

  • Don’t they realize that if the practicing over state lines, their malpractice insurance is unlikely to cover them?
  • How would they defend themselves when the opposing attorney asks for the referrals made to the client’s local emergency resources, especially if the professional knew of none?
  • What if the opposing attorney could prove the professional never even obtained informed consent, or bothered to get  emergency telephone numbers of at least one professional or family member to use as a  resource if they lost touch with their client?
  • What if the family had a written record of the professional ignoring information that would comprise “reasonable doubt” about the patient’s suicidality or homicidal intent? elder abuse, child abuse, spouse abuse?
  • Don’t professionals practicing in email or chat rooms realize that every word they typed can be used against them in a court of law? Don’t professionals practicing online realize that patients can be taking written notes that can be readily found?
  • What if that evidence of ignoring the information obtained showed that the professional terminated the email  chat room or video contact within minutes of receiving the incriminating information?
  • Do you think a jury would have any reluctance to convict a professional for being negligent by simply hiding behind the technology and pretending their connection was “accidentally” terminated when faced with a mandated reporting situation?

We are professionals, entrusted with public safety and a host of responsibilities, not the least of which is mandated reporting for abuse, homicide and in many states, suicide potential.

Lest I leave you hanging, let me tell you that in my opinion, it most certainly is possible to conduct online treatment, but we as professionals would do well to put a number of safeguards in place, including a clear informed consent, very specific procedures for mandated reporting. Many of these procedures have been well established in the telemedicine literature, which is quite extensive, particularly for remote mental health care delivery.

In fact, these and a host of other issues are the topics discussed in continuing education courses for online counseling available at the Center for Online Counseling and Psychotherapy where you can see that I and several colleagues have spent years researching and developing these materials. Online treatment is much more complicated than many professionals or consumers would like to imagine.

If licensed mental health professionals don’t understand, and can’t document as well as have complete discussions with their patients and clients about the risks and benefits of jumping online and complying with mandated reporting laws in email, chat rooms or VoIP-based systems such as Skype, they are being irresponsible.

Those are my concerns about mandated reporting – and my opinion, what’s yours? Can you provide additional information that might change my view? Please comment below.

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