Did you see the New York Times article, “The Therapist Will See You Now, via the Web“? It’s a wonderful article advancing telemental health, except for one comment by Tania S. Malik, the CEO of Cope Today. Like many of the start-ups in this space, this company seems to be linking therapists to consumers, which is clearly a needed and worthwhile service. Here are the comments by Ms. Malik that worry me:
Ms. Malik says the average length of a consultation is 43 minutes. She declined to say what percentage of clients return for further sessions. It is hard to sell the service to individuals who must pay for therapy themselves, Ms. Malik says. But she hopes to sign up employers who will pay for the service. “I don’t think we could be a success on a strict direct-to-consumer business, operating without reimbursement from insurance companies,” she says.
Later in the NYT article, she adds:
Patients with a strong desire for anonymity might log off, however, before providing such data. Ms. Malik, of CopeToday, says the therapists she represents — 90 percent of whom have private practices in traditional offices — do not collect personal contact information from their online patients. “If you’re counseling and it escalates, we would call 911,” she says.
Perhaps Ms. Malik was misquoted, which happens (it’s certainly happened to me and many respectable professionals.) I haven’t spoken with her, although I welcome the opportunity. Many such companies take the position that they are no more responsible for the actions of its users than a phone company is for what a therapist does on a phone line. However, the problem remains that they are supporting, advertising and advocating services to mental health (therapy) consumers that might be in violation of state law, so the line blurs. Further, in granting interviews in publications like the NYT to discuss their therapy practices, where is the line between the company’s responsibility and the professionals who use it? These are new frontiers, and the boundaries are understandably blurred.
What’s the problem?
It boils back down to consumer protection. What can be reported to 911 when a call “escalates”? Any therapist knows the police won’t act on a call stating, “Our caller escalated.” Without identifying information during any “escalation” of a contact, the authorities are powerless to do anything.
However, we all know that in mental health, patients “escalate.” In fact, many escalate into emergencies involving abuse reporting, suicide and even homicide. It’s part of routine practice, and we all train for each of these events extensively offline. Having identifying information in case of an emergency is fundamental. If patients opt-out of services that require identifying info, that’s not a reason deliver professional services on their terms. What if we all opted out of giving our ID when we go to the medical doctor? Would he or she treat us anyway? Maybe in an hurricane or flood, but otherwise, treatment is not likely…
Should any health care professional simply say, “Oh, you don’t want to do that? Well, that’s ok, just step into our online office, where we’ll serve you any way you want. Swipe your credit card and we’ll give you whatever you want right away.” In mental health, if we went along with consumer demand in our real-world practices, some patients would be coming on vacation with us (remember the movie, “What about Bob?”), moving into our houses and sleeping in our beds … literally.
Why some therapists would think they can abandon their legal and ethical duties because they are online is simple — most haven’t been formally trained to think through the issues, and in their entusiasm, just aren’t stopping long enough to think about the repercussions of their actions.
But it’s Different Online
Sure, the online world is different — but just how different is it? Aren’t we arguing that we can deliver the same service online as offline? We can’t have it both ways. If we are delivering the same quality of service online and offline, it should carry the same requirements, and it does, both legally and ethically.
Without a patient record, without the informed consent, without getting emergency contact information, many of us can’t legally or ethically do our jobs. We can’t report abuse, or other emergencies, etc. Further, some state laws, (many actually) state that we are mandated to engage the patient in a formal informed consent process and have them sign such a document. Many of us are also mandated to keep a patient record. Further, in some states, all violations of the law (including practicing over state lines, failure to keep records and failure to get informed consent) need to be reported to the state licensing board by any other licensed professional who becomes aware of such illegal activity. For instance, in Oregon, it is a violation of one’s licensure as a psychologist to not report illegal activity by a colleague to the licensing board.
What are we to do?
The truth is, many professionals are well intentioned. Many simply don’t know that an online practice advocated by any company might be illegal or unethical. Bottom line, we licensed professionals know that we are responsible to consumers, regardless of what an employer or vendor tells us. How much of that is shared by the company who recruits us online is what’s to be debated. How much responsibility do these new and creative companies have to us, as the professionals they are recruiting? How much responsibility do they have to consumers to be aware of all the legal issues involved?
Might the adaption we make online as professionals be something else? Perhaps patient education is in order on these websites? Perhaps they could consider offering their clinicians post-graduate training in how to legally and ethically deliver mental health services? Surely the answer isn’t a dilution of our “professional services.”
I don’t mean to be picking on this one company or the professionals who use it to connect with consumers. I’ve seen several others doing the same thing. (See my earlier blog posts.) They probably are very dedicated professionals, but just haven’t thought through all the issues been exposed to the legalities and ethics of doing our work. This might just be a case of the technology shaping the therapist rather than us therapists shaping the technology. That’s what I have predicted for years. Those of us who want to practice online need to help shape these companies and their policies. It’s our ethical duty to do so, and not just blindly follow policies put in place by those who don’t fully understand our legal and ethical mandates.
Dr. Maheu’s response to the New York Times Article: “When Your Therapist Is Only a Click Away“
These are some of my thoughts. What are yours?