Reviewing Limits to Confidentiality in Telepsychology Practice
Reviewing Limits to Confidentiality in Telepsychology Practice
Nichole Sage, PsyD, and the OPA Ethics Committee
The COVID-19 pandemic prompted a rapid shift to telepsychology practices for psychologists. This allowed for continuity of care and flexibility in treatment services amid the crisis. Nationwide, approximately 76% of psychologists were providing telepsychology services by late spring of this year in response to stay-home orders (American Psychological Association, 2020a). Telepsychology was fairly rare as a practice mode pre-pandemic, with just 7% of psychologists reporting virtual service delivery (Pierce et al., 2020). Considering the relatively low rates of active telepsychology practices prior to the pandemic, this new practice format was perhaps unfamiliar and initially unintuitive. Resources, time, and energy were likely required to learn new software and procedures. In the chaos of this transition, important elements of clinical practice may have been overlooked or forgotten as psychologists adjusted to new routines. One such element may have been the review and discussion of the limits to confidentiality typically conducted at the outset of treatment. This article is intended as a reminder of this important step and to highlight relevant issues when discussing the limits to confidentiality in telepsychology practice.
Reviewing informed consent at the start of the therapeutic relationship is an essential action that sets the stage for the clinical relationship and reduces legal and ethical risks. This process is highlighted in the American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (hereafter referred to as the APA Ethics Code) Section 4.02 (Discussing the Limits of Confidentiality) as an ethical imperative. The code reads as follows:
(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant.
(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.(American Psychological Association, 2017, Standard 4.02)
Whereas the safeguarding of client confidentiality may be obvious to clinicians, the expectation of reviewing confidentiality with clients at the outset of therapy might be less recognized. According to the APA Ethics Code, in addition to the duty to protect client confidentiality (APA Ethics Code Section 4.01; American Psychological Association, 2017), it is the ethical obligation of each psychologist to review the limits to confidentiality at the outset of treatment (and thereafter whenever it is indicated). This must occur whether the service occurs in-person or virtually. Included below are considerations and actions clinicians may take to address limits to confidentiality in telepsychology practice.
First, it is important for psychologists to be knowledgeable about how telepsychology services are ethically unique relative to traditional office appointments. Although the majority of clinicians offering telepsychology services report feeling knowledgeable and confident (75% and 78%, respectively) about the use of telepsychology software (American Psychological Association, 2020a), the level of awareness regarding security issues affecting confidentiality and privacy is less clear. It is essential for clinicians to recognize and understand security vulnerabilities, patient data storage and maintenance issues, therapist-client electronic communication challenges, and potential differences in billing procedures or documentation (American Psychological Association, 2013). A solid understanding of any laws pertinent to telepsychology, such as limitations to service provision only within one’s state of licensure, is also necessary to reduce liability and ensure ethical practice (for more information see the Oregon’s Board of Psychology’s 2015 article on Telepsychology [Oregon Board of Psychology, 2015]). This foundational knowledge of the potential ethical issues associated with telepsychology practice will allow practitioners to thoroughly outline these considerations for clients and respond to questions that arise.
Further complicating matters is the fact that many psychologists are currently working remotely from their own homes for social distancing purposes, perhaps without having a well-planned space for telepsychology. Working from one’s home may pose challenges with boundaries as well as privacy for both client and psychologists. According to Drum and Littleton (2014), careful consideration of potential boundary issues in telepsychology is important, as clients and therapists may not have a well-developed schema for navigating virtual boundaries. Additional considerations with respect to boundary issues may manifest in unexpected or new ways relative to traditional in-person therapeutic work. Reviewing expectations for privacy and limits to confidentiality at the outset of the therapeutic relationship sets the tone for therapy, while scaffolding appropriate boundaries minimizes potential boundary crossings or violations. Moreover, highlighting these ethical considerations with clients at the initial meeting can foster a sense of trust and enhanced therapeutic sharing on the part of the client.
Aside from reviewing the traditional elements of limits to confidentiality, psychologists may address telepsychology-specific confidentiality concerns with clients. Clinicians may consider providing appropriate information to the client about the level of privacy in the therapist’s home office. For example, is the therapist working behind closed doors? Does the therapist use headphones to prevent transfer of noise through the computer, or is there a white noise machine to drown out the therapist’s comments and questions? Because clients cannot view beyond the space captured by the camera, they are unable to feel assured that the space is private. As such, the psychologist should consider describing these aspects of the therapeutic environment to reassure clients and offer the opportunity for questions about privacy and confidentiality.
Clinicians may also consider initiating a discussion about protecting a client’s privacy within the client’s home. Education about the importance of confidentiality for effective clinical work and concerns about compromised confidentiality from within the client’s personal space or elsewhere may be useful. If clients engage in sessions in multiple places (e.g., home, office, vacation house), it may be helpful to inquire about the privacy of the client’s physical location at the start of each virtual session to confirm a confidential space. A discussion about how to respond if service is disrupted, how long to wait before making a re-attempt at connection if service is interrupted, and planning for whether the psychologist or client will initiate the call, may also be prudent. Additionally, the concept of confidentiality is rooted in values of the Western world and may be regarded differently across cultures. A culturally sensitive conversation about the client’s views related to privacy may foster better understanding and ethical decision-making about creating and maintaining confidentiality in telepsychology sessions.
It is never too late to improve one’s ethicality in any facet of clinical practice, particularly for telepsychology, should rates of telehealth practices maintain. For a comprehensive guide on telepsychology practice, readers are referred to the American Psychological Association Guidelines for the Practice of Telepsychology (American Psychological Association, 2013). The American Psychological Association (2020b) has also released an informed consent checklist for telepsychology services for practitioner reference.
Finally, psychologists should develop a telepsychology-specific informed consent document and utilize this form as the blueprint for the verbal review of the limits to confidentiality in the initial appointment with new telepsychology clients (Jacobs, 2018). Consultation with a mental health attorney or other qualified professional may be necessary for ensuring that the consent form is comprehensive and legally sound. Since the start of the pandemic, the OPA Ethics Committee has received multiple calls regarding telepsychology and we are proud to serve our psychological community in these stressful and confusing times. We encourage readers to reach out for consultation about ethical dilemmas concerning telepsychology or beyond.
References
American Psychological Association. (2013). Guidelines for the practice of telepsychology.
https://www.apa.org/practice/guidelines/telepsychology
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct
(2002, amended effective June 1, 2010, and January 1, 2017).
https://www.apa.org/ethics/code/
American Psychological Association. (2020a).
Psychologists embrace telehealth to prevent the spread of COVID-19.
https://www.apaservices.org/practice/legal/technology/psychologists-embrace-telehealth
American Psychological Association. (2020b). Informed consent checklist for telepsychological services.
https://www.apa.org/practice/programs/dmhi/research-information/informed-consent-checklist
Drum, K. B., & Littleton, H. L. (2014). Unique issues and best practice recommendations.
Professional Psychology, Research, and Practice, 45 (5), 309-315.
Jacobs, J. (2018). Managing risks of telepsychology. The National Psychologist.
https://nationalpsychologist.com/2018/08/managing-risks-of-telepsychology/104807.html
Oregon Board of Psychology. (2015). Telepsychology.
https://www.oregon.gov/psychology/Documents/Newsletter_Summer_15.pdf
Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D. (2020).
The COVID-19 telepsychology revolution:
A national study of pandemic-based changes in U.S. mental health care delivery.
American Psychologist. Advance online publication. http://dx.doi.org/10.1037/amp0000722