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Why Online Practice Can Be Harmful — Part I

Online Practice

When connecting with online therapists, consumers don’t expect to list the medications they take, report their current alcohol intake or provide a suicide history  before asking a question about divorce. They don’t typically want to undergo an intake process that includes informed consent or a depression inventory before they discuss how to improve their marital relationship.

Have the last 20 years of unregulated, unmitigated, improperly licensed online psychotherapy ruined it for everyone, or created a new way of serving consumers? We may never know for sure, but it is clear that traditional behavioral health care is being challenged by revolutionary online delivery models such as Google’s Helpouts. See Google Steps into Mental Health with “Helpouts.” and How Might Licensed Professionals Think about Google’s “Helpouts?”).  

This article is the first of three in which we’ll outline my views of the key issues that can lead to harmful online practice and how they can be remediated by thoughtful professionals. 

The Mandate Remains to Do No Harm

When promised an answer sold in 15-minute packages online, consumers can reasonably expect to receive professional services from licensed professionals. Yet, online clinicians don’t typically have good tools to screen or assess consumers they’ve never met in person, let alone give them answers in 15 minutes. The truth is that the unshowered, alcohol-laden or neurologically impaired, stumbling client/patient is difficult to accurately assess online. Without specialized training and local support services, online assessment via audio or video can involve more guesswork than professionalism.

Every now and again, a client/patient experiences a serious crisis or experiences a suicidal or homicidal emergency. Such patients are difficult enough to manage in a brick-and-mortar practice. They can quickly become unmanageable across a geographical distance. See a case in point: Indeed, Skype Is Found to be Unacceptable for Telepsychiatry by Oklahoma Medical Board. 

What Consumers Don’t Know Can Be Harmful

Consumers may not know or understand that the research is strong for behavioral telehealth interventions, but those interventions are not the same as what usually occurs with online therapy. Traditional behavioral telehealth usually involves a treating professional who follows well-tested, controlled and prescribed protocols. It also often includes rigorous informed consent processes, full intakes, rigorous and standardized documentation, fully trained professionals, emergency support, etc. Referrals usually come from medical offices where the patient is known to the physician, and a full record is kept.

Online therapy often involves an informal exchange between a professional for quick chats and semi-professional relationships without full intakes, history-taking, releases and in many cases, without mandated reporting. (Some such relationships are anonymous, leaving the clinician without the ability to abide by mandated reporting rules.) Regulatory boards have not been notably responsive to date, except for a few highly publicized cases. While it is clear that regulatory boards are becoming increasingly sensitized to the issues, it is also important to note that many online therapists have received significant training and do follow state as well as federal law. It is also fair to say that many others are unfamiliar with traditional models, and have not received any training in the differences between in-person care and online practice, or how to bridge the two worlds legally, ethically or clinically.

Online consumers then, may not know which type of service or practitioner they are accessing. Some may rely on professional’s licensure for an assurance of professionalism.  They deserve to be better educated about the issues. They also may not know enough to care that the professional was licensed 30 years ago, and is untrained for telephone or video-based practice.

Consumers also deserve to better understand the services they are purchasing from different types of professionals, and how training differs across disciplines. Most consumers don’t know the differences in training or services between a psychologist and a psychiatrist, or between a coach and a counselor. They deserve to have user-friendly information about any professional group they are encouraged to access.

The Professional’s Role

While consumers have the right to request any number of services from their treating professionals, the professional’s role is to make careful decisions about the types and locations of service delivery for each individual being served. Consumer protection is the professional’s number one mandate. Unprepared professionals working with unprepared consumers in telemental health is a recipe for disaster.

One of the most serious dangers for online professionals is the lack of knowledge about training for best practices to understand and incorporate professional association guidelines. They may not be cognizant of the many issues consumers may need to know prior to being treated online. 

Immediate Solutions

1.  Professionals contemplating online practice must write to their licensing boards and professional associations to request aid in clarifying their expectations for delivering care online. The lag in regulatory change leaves licensed professionals at a serious disadvantage when it comes to options for practice expansion when compared to unlicensed practitioners.

2. Professionals must make wise choices about the services with which they associate online. Just because a service is a profit-maker does not justify forgoing current standards of care. 

3.  At this point, it is wise for professionals to seek practitioner groups with which to associate online and offline to benefit from the many safeguards they can provide in the changing times ahead. Professional training is available for responsible telepractice. See the TeleMental Health Institute’s professional training options online.

The next two articles will be: Why Online Practice Can be Harmful — Part II,  where we’ll focus in more depth in ways traditional telehealth differs from many current online practices. In Part III, we focus on the role of professional associations and how they might help their members better meet consumer demand for improved access via technology.

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One comment on “Why Online Practice Can Be Harmful — Part I

  1. Hi Marlene, thanks for bringing up somewhat of a controversial subject. Online counseling practice can in fact do harm. Especially if there is no regulatory body to monitor the best care practices of the art of distance counseling. How does one know if the counselor she or he is getting is in fact competent without credentialing? That would be a crap shoot I would not want to bet on. You may mention this in parts II and III of this blog but what concerns me is the lack of security of platforms such as Skype. Say for example one was a counseling a woman who was having relationship problems with her husband. Say there was a custody battle for their child. If the man was tech savvy he could easily ‘hack’ the conversation between the counselor and his wife and potentially use confidential information against her! I would like to hear other’s opinions about this!

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