Why Online Practice Can Be Harmful — Part III

Online Practice

In Why Online Practice Can Be Harmful — Part I, we examined the role of consumer protection in online practice. In Why Online Practice Can Be Harmful — Part II, we discussed the palpable differences between traditional telemental health and online psychotherapy. In this last segment, Why Online Practice Can Be Dangerous — Part III, we’ll examine the role of regulatory boards and professional associations in assuring consumer safety with online practice.

Professionals, Their Professional Associations and Regulatory Boards

Many licensed behavioral healthcare providers and researchers are unaware of the legal and ethical codes that govern their use of technology.  In fact, a Google search for these or related terms will return more than 1.5 million websites:

  • online therapy
  • online psychotherapy
  • internet therapy
  • etherapy
  • online counseling (or online counselling) and
  • a host of other related terms

Close examination of websites found by such a search will show that many professionals whose services are available online are operating without compliance with well-published mandates of their  regulatory boards and professional associations. The current state of affairs has not improved dramatically since the year 2000, when an early study reporting such problems was published (Maheu & Gordon, 2000).

Violations  continue to include but are not limited to:

  •  practicing over state lines without a license
  • lack of an informed consent process of any type
  • using technology that does not meet HIPAA requirements
  • failing to collect identifying information needed for mandated reporting
  • failing to collaborate with other treating professionals
  • failing to arrange for emergency backup, etc.

How Can So Many Professionals Ignore the Basics?

Most behavioral health providers are clearly operating with the best of intentions. They may not have realized their online practices need to be in line with their in-person services. It also has taken time for many of the regulatory boards and professional associations to devote significant time and attention to the complex and rapidly changing issues. Even more challenges to our governing bodies are just about to unfold….

Consumer adoption of technology and their demands that professionals do the same have forced the issue. Being accessible by email is no longer a question for many professionals. The next big issue faced by many providers is whether or not it is acceptable to allow our clients/patients to reach us with their mobile device video-conferencing features, given their typical state of non-compliance with HIPAA standards for security and privacy. (See TMHI courses designed to help you understand these issues: Legal/Ethical Issues I: Rules, Regulations & Risk Management and Legal/Ethical Issues II: Best Practices & Informed Consent.)

The time has come for all professional groups to become more cognizant of the urgency with which behavioral health is becoming involved with technology, and the speed with which they must act. Many regulatory boards are quite clear that the use of technology does not represent a new service, but does pose many complex new training challenges. As we outlined in Why Online Practice Can Be Harmful — Part II, outcome data need to be carefully considered. Generalization of outcome findings to all online practice can lead to faulty conclusions, particularly when online services are delivered without controlled settings or by using established protocols. Many parties are realizing the many ways in which existing rules have been rather lax. As professionals, then, we still need to perform basic functions, but now, through technology:

  • conduct full intakes
  • contact all involved professionals
  • keep secured notes
  • protect privacy and maintain confidentiality
  • conduct a fully informed consent process with added information about the use of technology
  • keep notes
  • document our work
  • know and be able to refer to local community resources
  • plan for and handle abuse reporting, homicide, suicide threats, etc.

Regulatory Boards

Many regulatory boards are currently bringing themselves up to speed and developing policies in harmony with that of other states, both within and across disciplines. The challenge is daunting. To date, boards have operated without much interference from outsiders. With many geographic limitations being eliminated by the Internet, these same regulatory boards are facing decisions about how to handle licensees and other professionals from around the world. Anyone claiming to be any type of professional can now suddenly deliver “professional services” to a state’s citizens as they sit in the privacy of their own living rooms. 

Some professionals are being censored and disciplined. (See Indeed, Skype Is Found to be Unacceptable for Telepsychiatry by Oklahoma Medical Board  and Oklahoma Doctor Disciplined For Using Skype To Treat Patients?  For details of this case and how they might involve you, see TMHI’s upcoming webinar on January 20, entitled, Skype and Related Practices Found Unacceptable by Oklahoma Medical Board.) Indirectly related regulatory boards are taking active stances on issues such as supervision. Their involvement is also likely to me aided by the Affordable Care Act, as depicted in the recent Forbes article, entitled, Top Health Trend For 2014: Telehealth To Grow Over 50%. What Role For Regulation?

Professional Associations

Professional associations are also taking more of a stand with respect to distance services. Several associations have issued standards and guidelines that provide varying levels of direction to their memberships. Furthermore, many are making it quite clear that providers have the responsibility of finding and obtaining adequate training before offering new services, including services that involve technologies that range from telephone to video teleconferencing. Their mandates extend to the delivery of services related that reach beyond telecommunication technologies, such as self-monitoring tools, robotics, haptics, virtual reality, biometrics, the newer forms of biofeedback, such as self-help tools that measure heart rate variability (HRT), and of course, all apps. 

Leadership Possibilities

Continued leadership by ethical boards and professional associations has begun in all directions, and more now than ever. These efforts are applauded by many. Both regulatory boards and professional associations might also:

  • allocate resources to not only keep up, but set the bar for safe, high quality use of all technologies
  • encourage professionals to obtain relevant and affordable training for 21st Century practice development (i.e., email is commonly used by professionals, but most graduate or traditional training programs do not yet offer training in how to use email for therapeutic contact; many professionals already use text-messaging services to contact their clients/patients)
  • formally and regularly educate decision-makers about technology-related issues
  • become more visible centers of collaboration for technology-minded professionals
  • create entry points at all levels to acknowledge and invite change related to technology (i.e., create convention submission categories related to various types of technology, such as telepractice, mHealth, informatics, etc.
  • foster participation and leadership of graduate students and early career professionals in the adoption of technologies through speciality niches and new disciplines, such as informatics and other growing areas such as depicted in the 

Other Options

1. See the TeleMental Health Institute’s convenient, affordable professional training options available 24/7 online.

2. Join the  Society for Technology and Behavioral Health, a growing group of technology-minded professionals attempting to work toward developing a visible center of inter-professional collaboration. Their LinkedIn group is open to all interested parties.

3. If the reader knows of any other group(s) forming toward these goals, please mention them in the Comments section below. If possible, please provide links to their websites. 

4. See Why Online Practice Can Be Harmful— Part I and Why Online Practice Can Be Harmful — Part II for more thoughts about how to protect those you serve by practicing legally and ethically with a wide variety of technologies.


 Maheu, M., & Gordon, B. (2000). Psychotherapy on the Internet: Legal, ethical and practice issues. Professional Psychology: Research and Practice, 31(5), 484-489.

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