Ask The Ethicist: The Role of Technology in Psychotherapy

Linda asks a number of very important questions about the role the use of technology in research and practice, to include the recording (audio and/or visual) psychotherapy sessions, supervision, peer consultation, research, and presentations.  Additional questions concern the role of informed consent when making such recordings, the role of HIPAA and other confidentiality and privacy issues, and ethical practices concerning the solicitation of research participants, the use of inducements or incentives to participate in research, and related issues.  There is perhaps a book or two in the responses to all these questions and I do hope that my responses will stimulate further discussion by Linda and the readers of this blog.  I will not try to respond to every aspect of this question all at once, but will respond in several pieces.  This will hopefully enable closer examination and exploration of each issue and the greater opportunity for discussion.
Once component of the questions raised involves the role of the use of various technologies in practice and research. As Linda highlights there presently is a dearth of guidance for ethical practice when integrating various technologies into our practices.  In the Introduction and Applicability section of the APA Ethics Code it mentions that the Ethics Code applies to all the roles and functions of psychologists “across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions” (p. 1061).  Thus, it is reasonable to assume that the APA Ethics Code must be considered, and its standards followed, when utilizing various technologies in our professional activities.
Some specific standards to consider include:
2.01 Competence: We should ensure that we are competent in the use of the specific technologies involved and obtain the education, training, and experience needed to maintain this competence. Further, in areas where standards do not exist psychologists “take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participant, organizational clients, and others from harm” (p. 1064).
3.04 Avoiding Harm: We should take all reasonable steps to anticipate harm that may occur from our actions or lack of action, and work to prevent or minimize harm to the best of our abilities.
3.10 Informed Consent: This may be one of the most significant standards and one that may stimulate the most discussion.  We must ensure that those we treat, assess, study, supervise, etc. are informed of all significant information that might impact their decision to participate, prior to the professional activity is provided.  This consent should be given voluntarily and not be given under duress or in response to coercion, the individual should be competent (legally and cognitively/emotionally) to give their consent, we need to actively ensure their understanding of what they are agreeing to, and the consent should be documented.  Further, important issues such as limits to confidentiality, reasonably available options and alternatives and the risks and benefits of each, the right to refuse participation and the right to withdraw from participation without penalty, each should be addressed.  Additional specifics of informed consent are provided in the APA Ethics Code as well as in one’s relevant state laws.
4.01 Maintaining Confidentiality: The use of various technologies can greatly impact confidentiality and reasonable steps to protect each participant’s confidentiality is essential.
4.02 Discussing Limits of Confidentiality: This is one of the essential aspects of the informed consent agreement and process that is discussed above.  This standard includes: “Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality” (p. 1066).
4.03 Recording: This standard states specifically that “Before recording the voices or images of individuals to whom they provide services, psychologists obtain permission from all persons or their legal representatives (See also Standards 8.03, Informed Consent for Recording Voices and Images in Research; 8.05, Dispensing With Informed Consent for Research; and 8.07, Deception in Research.)” (p. 1066).
4.07 Use of Confidential Information for Didactic or Other Purposes: This standard is of great relevance to the aspect of Linda’s question that concerns the use of information from clients, supervisees, research participants, etc. in our writings, presentations, and the like.  This standard and its implications will be discussed in much greater detail when addressing these issues.
5.01 Avoidance of False or Deceptive Statements: This standard is relevant to all public statements made such as in writing, presentations, or through various technologies.  We must ensure accuracy of the content of these statements as well as in our basis for sharing the information (e.g., fully informed consent).
6. Record Keeping and Fees: This section of the Ethics Code contains several sections relevant to record keeping.  They emphasize the need to protect and maintain the confidentiality or records and “data relating to their professional and scientific work” (p. 1067), which should be seen as including all recordings of professional interactions.  Records are not limited to session notes, assessment reports, and other written materials. All recordings, tapes, or any other media that record information about or of those we provide professional services to should be considered as falling under these standards.
9.02 Informed Consent in Assessments: Any use of recordings when conducting assessments must be carried out with all the other applicable standards of the Ethics Code that have been addressed above.
9.11 Maintaining Test Security: Should recording of assessment be done, the issue of test security must be considered.  Those tests and assessment tools with a limited domain of stimuli must have their security protected to help ensure their ongoing validity and usefulness. Additionally, there may be copyright and other legal issues to consider as well.
10.01 Informed Consent to Therapy: This standard provides additional detail to the discussion of informed consent above, and applies it specifically to psychotherapy.
With regard to the issues raised regarding research, Section 8: Research and Publication, contains several standards relevant to the questions raised.  These will be addressed in detail in a later blog posting, but include:
8.01 Institutional Approval
8.02 Informed Consent to Research
8.03 Informed Consent to Recording Voices and Images in Research
8.05 Dispensing With Informed Consent for Research
8.06 Offering Inducements for Research Participation
8.07 Deception in Research
What Linda did not ask about and what will not specifically be addressed unless raised by others for discussion is the role of using various technologies for the provision of psychological services, such as telehealth, E-health, E-therapy, and the like.  These can include telephone and E-mail communications with clients in between in-person sessions as well as providing supervision or treatment across state or national borders via the Internet to include by E-mail, social networking sites, or Interactive Tele-Video Communications (IATV) such as Skype or other similar audio-visual communication via the Internet.  These bring with them great opportunities and potential benefit as well as a number of clinical, ethical, and legal challenges and dilemmas.
In my next posting I will begin specifically addressing:
The role the use of technology in research and practice, to include the recording (audio and/or visual) psychotherapy sessions, supervision, peer consultation, research, and presentations
The role of informed consent when making such recordings, the role of HIPAA and other confidentiality and privacy issues, and ethical practices concerning the solicitation of research participants
And then the use of inducements or incentives to participate in research, and related issues.
Again, all readers’ comments, thoughts, and questions are most welcome.  Best wishes – Jeff
Here is Part II of my response:
Before getting into the specifics of how to appropriately record a client, supervisee, peer, or research participant, I think it is important to ask why you are wanting to do this.  In psychotherapy we all must appropriately document the services we provide.  Are you thinking that recording the sessions is how you will document them?  If so, will you archive and maintain each recording in compliance with the requirements of relevant state and federal (e.g., HIPAA) laws?  Or, is there some other reason for making these recordings?  Whatever your objectives, it is important to ensure that making these recordings is the best (and most appropriate) way of achieving these goals.  If there are other options available to achieve your goals and objectives, they should be considered as well.
Should making these recordings be clinically relevant and important to do, then as you mention, it is vital that this is fully discussed in the informed consent process prior to making any recordings.  The other individual(s) should fully understand the reasons for making the recordings, how they may be used, how this potential use is relevant to the reasons you are meeting with them (e.g., how is making these recordings going to contribute to or enhance their treatment, supervision, etc.?), will they have access to these recordings and if so, how, how long will the recordings be maintained and where, and when destroyed, how will this be done?
As with all informed consent agreements it is important that the other individual’s consent be given voluntarily, that she or he is competent to give this consent (cognitively/emotionally as well as legally), that you actively ensure her or his understanding of what is being agreed to, and that the informed consent agreements are documented.  Further, consistent with the APA Ethics Code reasonably available options and alternatives should be discussed along with the relative potential risks and benefits of each along with the relative potential risks and benefits of refusal.  Finally, they should understand that they may rescind their authorization or consent at any time without penalty or adverse consequences.
The use of recordings in supervision is widely known.  Trainees regularly audio or videotape sessions with clients for their clinical supervisors to review, both prior to meeting for supervision and jointly in supervision sessions.  It can easily be seen how this use of recordings of sessions with clients  can be of benefit to the clients (as well as to the trainees).  But, due to the high likelihood of benefit to the clients an argument can be made that the use of recordings in this way is ethically and clinically appropriate, and consistent with the APA Ethics Code (as long as informed consent requirements are followed as discussed above).
But, the practice of recording treatment sessions by practicing psychotherapists, the practice of recording supervision sessions by supervisees, and the practice of recording peer supervision/consultation sessions by a member of that group are each less clear.  How will these recordings be used to benefit the members involved.  In peer supervision/consultation having recordings could be of value to group members.  Additional review of group discussions and feedback provided could be quite beneficial to participants.  How the recordings would be used and what benefit or value would result from having the recordings is less clear.  This would have to be clarified before making a decision about engaging in this practice.
In research, the use of recordings is a widely accepted practice.  Often, this is an integral component of the research.  For example, in studies of mother-infant interaction, the recordings are analyzed to discern significant patterns and dynamics.  The use of recordings is integral to the ability to conduct the research.  So, again, one must determine the relevance of the use of recordings, fully address it in the informed consent process, and ensure appropriate safeguards and security protections to minimize the risk of unauthorized access to these recordings.  Participant access to their records and any recordings made should be addressed in the informed consent process as well and compliance with institutional policies and federal and state laws are important as well.
In my next posting I will address the solicitation of research participants and the use of incentives to encourage participation in research.  As always, I welcome all comments, reactions, and questions in response to what I have posted.  Best wishes – Jeff
Here is final portion of my response:
The issue of offering incentives or inducements to potential research participants is addressed specifically in Standard 8.06 of the APA Ethics Code.  This standard states:
(a) Psychologists make reasonable efforts to avoid offering excessive or inappropriate financial or other inducements for research participation when such inducements are likely to coerce participation.
(b) When offering professional services as an inducement for research participation, psychologists clarify the nature of the services, as well as the risks, obligations, and limitations. (See also Standard 6.05 Barter With Clients/Patients). (p. 1070)
Thus, this practice may be engaged in, but it must be done so with appropriate forethought and caution.  The first part of this standard is consistent with the previous discussion of informed consent, which we must ensure is given voluntarily.  If the inducements are such that there is a coercive effect, then this is inappropriate and violates the APA Ethics Code.  For example, let’s say I am doing a study with human participants that holds many risks, requires a significant time commitment, and may be of little value to the participants.  To solicit participants I stand outside of a Methadone Clinic in an inner-city setting and offer patients there $500 for their participation in the study. This could be seen as preying on their vulnerabilities and taking advantage of their circumstances.  All use of inducements must occur without coercion.  Further, all research protocols to include the recruitment of participants should be reviewed and approved by an Institutional Review Board (IRB) prior to initiating any of these activities.
As you mention, some researchers offer participants various services in return for their participation in the research study.  Examples may include a physical exam, nutritional counseling, psychotherapy, and the like.  Consistent with the part (b) of Standard 8.06 all this must be addressed fully in the informed consent.  Further, the offer of such services as an inducement for participation in the study must be consistent with part (a) of this standard as discussed above.  If psychotherapy or other treatment services are being offered in return for participation in the study it is important that all other relevant standards of the APA Ethics Code be followed to include informed consent, competence, avoiding harm, and multiple relationships. Each must be carefully considered prior to engaging in these practices.  The use of colleagues for consultation and the use of an IRB in all research planning are extremely helpful and important as well.
Best wishes – JeffQuestion

Question by Dr. Linda Moore

In Jeff Magnavita’s statement regarding his vision for the future of Div 29, he stresses the importance and use of technology in psychotherapy research and practice. As you are likely aware, more and more psychologists are using technology and audio-visual (AV) recording as part of their psychotherapy practice, supervision, presentations and research. At the same time, I have found it very difficult to find detailed and/or current technical and practical information or ethical guidelines for the use of these technologies.

In addition to specific technical, equipment and practical questions that arise in the use and implementation of audio-visual recording of psychotherapy sessions, I have a number of ethical questions as well. The following are some of the initial questions that come to mind:

1) What should be included in an appropriate informed consent for AV recoding of a therapy session? For use in written and/or live presentations? For research use? For supervision and/or peer consultation?
2) What procedures should be followed to ensure HIPPA compliance if AV recordings are used in long distance supervision/consultation? I know some ths have sent tapes of sessions by mail. What type of mail service is adequate? Do the AV therapy recording need to be encrypted? If so, how? For example, what programs will do this on a PC for a DVD, what about video tapes etc.?
3) What procedures are appropriate to attract and obtain participation of pts in research and/or training projects? For example, for institutional/formal and private/informal research projects or for use in the training of other professionals, can the researcher/therapist offer free or reduced rate treatment for a pts participation in projects that require the use of AV recording? I think something along this line is relatively common practice in much of medical research.

I would appreciate your thoughts on these concerns and input on where to find any existing guidelines.

Response by Dr. Barnett

Linda asks a number of very important questions about the role the use of technology in research and practice, to include the recording (audio and/or visual) psychotherapy sessions, supervision, peer consultation, research, and presentations.  Additional questions concern the role of informed consent when making such recordings, the role of HIPAA and other confidentiality and privacy issues, and ethical practices concerning the solicitation of research participants, the use of inducements or incentives to participate in research, and related issues.  There is perhaps a book or two in the responses to all these questions and I do hope that my responses will stimulate further discussion by Linda and the readers of this blog.  I will not try to respond to every aspect of this question all at once, but will respond in several pieces.  This will hopefully enable closer examination and exploration of each issue and the greater opportunity for discussion.

Once component of the questions raised involves the role of the use of various technologies in practice and research. As Linda highlights there presently is a dearth of guidance for ethical practice when integrating various technologies into our practices.  In the Introduction and Applicability section of the APA Ethics Code it mentions that the Ethics Code applies to all the roles and functions of psychologists “across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions” (p. 1061).  Thus, it is reasonable to assume that the APA Ethics Code must be considered, and its standards followed, when utilizing various technologies in our professional activities.

Some specific standards to consider include:

2.01 Competence: We should ensure that we are competent in the use of the specific technologies involved and obtain the education, training, and experience needed to maintain this competence. Further, in areas where standards do not exist psychologists “take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participant, organizational clients, and others from harm” (p. 1064).

3.04 Avoiding Harm: We should take all reasonable steps to anticipate harm that may occur from our actions or lack of action, and work to prevent or minimize harm to the best of our abilities.

3.10 Informed Consent: This may be one of the most significant standards and one that may stimulate the most discussion.  We must ensure that those we treat, assess, study, supervise, etc. are informed of all significant information that might impact their decision to participate, prior to the professional activity is provided.  This consent should be given voluntarily and not be given under duress or in response to coercion, the individual should be competent (legally and cognitively/emotionally) to give their consent, we need to actively ensure their understanding of what they are agreeing to, and the consent should be documented.  Further, important issues such as limits to confidentiality, reasonably available options and alternatives and the risks and benefits of each, the right to refuse participation and the right to withdraw from participation without penalty, each should be addressed.  Additional specifics of informed consent are provided in the APA Ethics Code as well as in one’s relevant state laws.

4.01 Maintaining Confidentiality: The use of various technologies can greatly impact confidentiality and reasonable steps to protect each participant’s confidentiality is essential.

4.02 Discussing Limits of Confidentiality: This is one of the essential aspects of the informed consent agreement and process that is discussed above.  This standard includes: “Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality” (p. 1066).

4.03 Recording: This standard states specifically that “Before recording the voices or images of individuals to whom they provide services, psychologists obtain permission from all persons or their legal representatives (See also Standards 8.03, Informed Consent for Recording Voices and Images in Research; 8.05, Dispensing With Informed Consent for Research; and 8.07, Deception in Research.)” (p. 1066).

4.07 Use of Confidential Information for Didactic or Other Purposes: This standard is of great relevance to the aspect of Linda’s question that concerns the use of information from clients, supervisees, research participants, etc. in our writings, presentations, and the like.  This standard and its implications will be discussed in much greater detail when addressing these issues.

5.01 Avoidance of False or Deceptive Statements: This standard is relevant to all public statements made such as in writing, presentations, or through various technologies.  We must ensure accuracy of the content of these statements as well as in our basis for sharing the information (e.g., fully informed consent).

6. Record Keeping and Fees: This section of the Ethics Code contains several sections relevant to record keeping.  They emphasize the need to protect and maintain the confidentiality or records and “data relating to their professional and scientific work” (p. 1067), which should be seen as including all recordings of professional interactions.  Records are not limited to session notes, assessment reports, and other written materials. All recordings, tapes, or any other media that record information about or of those we provide professional services to should be considered as falling under these standards.

9.02 Informed Consent in Assessments: Any use of recordings when conducting assessments must be carried out with all the other applicable standards of the Ethics Code that have been addressed above.

9.11 Maintaining Test Security: Should recording of assessment be done, the issue of test security must be considered.  Those tests and assessment tools with a limited domain of stimuli must have their security protected to help ensure their ongoing validity and usefulness. Additionally, there may be copyright and other legal issues to consider as well.

10.01 Informed Consent to Therapy: This standard provides additional detail to the discussion of informed consent above, and applies it specifically to psychotherapy.

With regard to the issues raised regarding research, Section 8: Research and Publication, contains several standards relevant to the questions raised.  These will be addressed in detail in a later blog posting, but include:

8.01 Institutional Approval

8.02 Informed Consent to Research

8.03 Informed Consent to Recording Voices and Images in Research

8.05 Dispensing With Informed Consent for Research

8.06 Offering Inducements for Research Participation

8.07 Deception in Research

What Linda did not ask about and what will not specifically be addressed unless raised by others for discussion is the role of using various technologies for the provision of psychological services, such as telehealth, E-health, E-therapy, and the like.  These can include telephone and E-mail communications with clients in between in-person sessions as well as providing supervision or treatment across state or national borders via the Internet to include by E-mail, social networking sites, or Interactive Tele-Video Communications (IATV) such as Skype or other similar audio-visual communication via the Internet.  These bring with them great opportunities and potential benefit as well as a number of clinical, ethical, and legal challenges and dilemmas.

In my next posting I will begin specifically addressing:

The role the use of technology in research and practice, to include the recording (audio and/or visual) psychotherapy sessions, supervision, peer consultation, research, and presentations

The role of informed consent when making such recordings, the role of HIPAA and other confidentiality and privacy issues, and ethical practices concerning the solicitation of research participants

And then the use of inducements or incentives to participate in research, and related issues.

Again, all readers’ comments, thoughts, and questions are most welcome.  Best wishes – Jeff

Here is Part II of my response:

Before getting into the specifics of how to appropriately record a client, supervisee, peer, or research participant, I think it is important to ask why you are wanting to do this.  In psychotherapy we all must appropriately document the services we provide.  Are you thinking that recording the sessions is how you will document them?  If so, will you archive and maintain each recording in compliance with the requirements of relevant state and federal (e.g., HIPAA) laws?  Or, is there some other reason for making these recordings?  Whatever your objectives, it is important to ensure that making these recordings is the best (and most appropriate) way of achieving these goals.  If there are other options available to achieve your goals and objectives, they should be considered as well.

Should making these recordings be clinically relevant and important to do, then as you mention, it is vital that this is fully discussed in the informed consent process prior to making any recordings.  The other individual(s) should fully understand the reasons for making the recordings, how they may be used, how this potential use is relevant to the reasons you are meeting with them (e.g., how is making these recordings going to contribute to or enhance their treatment, supervision, etc.?), will they have access to these recordings and if so, how, how long will the recordings be maintained and where, and when destroyed, how will this be done?

As with all informed consent agreements it is important that the other individual’s consent be given voluntarily, that she or he is competent to give this consent (cognitively/emotionally as well as legally), that you actively ensure her or his understanding of what is being agreed to, and that the informed consent agreements are documented.  Further, consistent with the APA Ethics Code reasonably available options and alternatives should be discussed along with the relative potential risks and benefits of each along with the relative potential risks and benefits of refusal.  Finally, they should understand that they may rescind their authorization or consent at any time without penalty or adverse consequences.

The use of recordings in supervision is widely known.  Trainees regularly audio or videotape sessions with clients for their clinical supervisors to review, both prior to meeting for supervision and jointly in supervision sessions.  It can easily be seen how this use of recordings of sessions with clients  can be of benefit to the clients (as well as to the trainees).  But, due to the high likelihood of benefit to the clients an argument can be made that the use of recordings in this way is ethically and clinically appropriate, and consistent with the APA Ethics Code (as long as informed consent requirements are followed as discussed above).

But, the practice of recording treatment sessions by practicing psychotherapists, the practice of recording supervision sessions by supervisees, and the practice of recording peer supervision/consultation sessions by a member of that group are each less clear.  How will these recordings be used to benefit the members involved.  In peer supervision/consultation having recordings could be of value to group members.  Additional review of group discussions and feedback provided could be quite beneficial to participants.  How the recordings would be used and what benefit or value would result from having the recordings is less clear.  This would have to be clarified before making a decision about engaging in this practice.

In research, the use of recordings is a widely accepted practice.  Often, this is an integral component of the research.  For example, in studies of mother-infant interaction, the recordings are analyzed to discern significant patterns and dynamics.  The use of recordings is integral to the ability to conduct the research.  So, again, one must determine the relevance of the use of recordings, fully address it in the informed consent process, and ensure appropriate safeguards and security protections to minimize the risk of unauthorized access to these recordings.  Participant access to their records and any recordings made should be addressed in the informed consent process as well and compliance with institutional policies and federal and state laws are important as well.

In my next posting I will address the solicitation of research participants and the use of incentives to encourage participation in research.  As always, I welcome all comments, reactions, and questions in response to what I have posted.  Best wishes – Jeff

Here is final portion of my response:

The issue of offering incentives or inducements to potential research participants is addressed specifically in Standard 8.06 of the APA Ethics Code.  This standard states:

(a) Psychologists make reasonable efforts to avoid offering excessive or inappropriate financial or other inducements for research participation when such inducements are likely to coerce participation.

(b) When offering professional services as an inducement for research participation, psychologists clarify the nature of the services, as well as the risks, obligations, and limitations. (See also Standard 6.05 Barter With Clients/Patients). (p. 1070)

Thus, this practice may be engaged in, but it must be done so with appropriate forethought and caution.  The first part of this standard is consistent with the previous discussion of informed consent, which we must ensure is given voluntarily.  If the inducements are such that there is a coercive effect, then this is inappropriate and violates the APA Ethics Code.  For example, let’s say I am doing a study with human participants that holds many risks, requires a significant time commitment, and may be of little value to the participants.  To solicit participants I stand outside of a Methadone Clinic in an inner-city setting and offer patients there $500 for their participation in the study. This could be seen as preying on their vulnerabilities and taking advantage of their circumstances.  All use of inducements must occur without coercion.  Further, all research protocols to include the recruitment of participants should be reviewed and approved by an Institutional Review Board (IRB) prior to initiating any of these activities.

As you mention, some researchers offer participants various services in return for their participation in the research study.  Examples may include a physical exam, nutritional counseling, psychotherapy, and the like.  Consistent with the part (b) of Standard 8.06 all this must be addressed fully in the informed consent.  Further, the offer of such services as an inducement for participation in the study must be consistent with part (a) of this standard as discussed above.  If psychotherapy or other treatment services are being offered in return for participation in the study it is important that all other relevant standards of the APA Ethics Code be followed to include informed consent, competence, avoiding harm, and multiple relationships. Each must be carefully considered prior to engaging in these practices.  The use of colleagues for consultation and the use of an IRB in all research planning are extremely helpful and important as well.

Best wishes – Jeff

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