The Ethical Requirements of Practicing Psychiatry Online

In today's world of advancing technology and the increasing trend toward using technology in medicine come the ethical questions of practicing medicine through electronic means, most specifically through the internet. E-medicine has become a popular form of medical advice and distance treatment, in which a patient corresponds with physician via e-mail, traditional chat, or voice chat. In fact, this area of medicine has become so comprehensive within the health care industry that it now encompasses the area of mental health, the field to be addressed in this paper. It is the goal of this paper to address the ethical requirements of online psychiatry practice, how these requirements compare to face-to-face interaction, the rights and privileges of the psychiatrist and patient. Each of these areas is important in the understanding of psychiatry as an online practice, and the ethical issues that surround the field.

The Ethical Requirements of Practicing Psychiatry Online

Practicing any profession online can be risky. Television news stations and newspaper articles have repeatedly reported malpractice suits against physicians and lawyers whose advice caused some form of harm to the patient or client. In order to curb the lawsuits claimed against physicians practicing online, and still deliver the best possible care for online patients, national and international organizations such as the American Psychiatric Association, the American Counseling Association, and the International Society for Mental Health Online have laid down ethical guidelines for both patient and physician. These guidelines seek to direct the physician in their interactions with patients, their disclosures of information, liabilities, prevention of violations, and other such areas that become an issue when dealing with medical information online.

One pertinent ethical issue dealing with the online practice of psychology obtaining the consent of the patient to use electronic communication; and this consent needs to be given after the patient has been informed about the process, advantages, and potential risks of online diagnosis and treatment (International Society for Mental Health Online, 2000). Additionally, Ethics Code (1999), a website put together by experts in the heath care field state that, psychiatrists also need to "educate themselves about the uses and limits of online care, they advise potential clients about them in accordance with current research and practice." It is also important to keep the turnaround time of e-mail correspondence in mind. Professionals have an ethical obligation to give a timeline for the return of counseling and query e-mails (International Society for Mental Health Online, 2000).

Additionally, qualifications dealing with location are also a huge issue and requirement that need to be dealt with and met before undertaking an individual as a client. According to both the American Counseling Association (2005), and the International Society for Mental Health Online (200), psychiatrists are obligated to know the location of the patient in order to meet legal obligations for practicing over state lines or international borders. Not only are psychiatrists who practice in a state they are not licensed in violating the ethics of their field, but also incriminating themselves with illegal practice of psychiatry. For this reason it is essential that a psychiatrist getting into the online practice of their specialty look into all legal obligations of licensure in both their location, and any obligations or potential violations that may result from taking on a client in a different location than their own. This is especially true in the case of prescribing medication. In order to do so, a psychiatrist must be registered and licensed in their state. At risk of violating medical ethics and state laws, a psychiatrist must ensure they are not prescribing medications over state lines. This concept will also be further discussed in the section on patient and psychiatrist rights and privileges.

Furthermore, a psychiatrist must practice within their boundary or specialty (International Society for Mental Health Online, 2000). This is also in accordance with the American Psychological Association's (APA) standpoint on the issue addressed in Standard 1.04c, Boundary of Competence which states that, "In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect patients, clients, students, research participants, and others from harm" (American Psychological Association. (2007). Such a practice prevents patients from potential harm from incorrect or poor practice, and provides a legal basis for a lawsuit against psychiatrists who have done harm by stepping out of their field, no matter how good the intention was. As a matter of fact, both the American Psychiatric Association and the American Psychological Association, urge professionals in both positions to follow HIPAA regulations concerning the legal guidelines of practice and privacy.

Face-to-Face Practice Versus Online Practice

Obviously, the use of online psychiatry services differ greatly from face-to-face interaction. While online psychiatry still attempts to create a comfortable, nonjudgmental environment supportive of openness and expressiveness, there are limitations to speaking online. One example is the limitation of what a psychiatrist can get from online interaction.

Although voice chat and video conferencing are often available, differences in time or computer capability may, and often does, create difficulties in determining the meaning of tones, pauses, silences, and other signs of emotion, or state of being that are often observed in face-to-face patients. This can make it difficult for psychiatrists to properly diagnose a patient. More concerning is that it may be difficult to determine the urgency of an individual's problem. While Fenichel et al (2006), state that online psychologists and psychiatrists can treat such high risk patients as suicidal individuals and those with serious metal disorders, this requires extremely high alertness to very subtle cues. It can be argued that online psychiatrists who encounter such patients should follow protocol for transferring a patient to a qualified face-to-face professional who can properly monitor the patient. However, the issue here is really being able to identify the patient as high risk, and educating psychiatrists and psychologists on the subtle cues that might be encountered in e-mails, IMs, or video chats sessions. On this same note, the American Psychiatric Association (2006) notes that e-mails can be a good way to document and track daily activities and thoughts. This is important to detect destructive or negative behaviors and correct them.

Another ethical issue that comes up in online psychiatry is the increased risk for a patient's privacy to be compromised. Since interaction is all done online and e-mails must be stored for monitoring purposes there is an increased risk for non-authorized individuals to gain access to the records. Additionally, negligence on the part of the psychiatrist in the use or non-use of firewalls and encryption technology can compromise online records, chats, chat records, and other confidential patient information. A violation would be a strict violation as it is the psychiatrists job to maintain the privacy of the patient to the extend that court orders are even required to gain information for legal proceedings. The aforementioned is supported by the American Counseling Association's code of ethics part B.1.c Respect for Confidentiality which states that "Counselors do not share confidential information without client consent or without sound legal or ethical justification" (2005).

Liability for psychiatric professionals is also significantly different from face-to-face practice as websites and e-mail inquiries made by potential patients may be misconstrued as medically binding instead of simply informative. As the American Psychiatric Association (2006) notes on their website, even answering unsolicited e-mails from those who aren't patients can place psychiatrists in a position of liability. Because of the potential for harm to individuals visiting the website and corresponding via e-mail, and the legal ramifications for the psychiatric professional and/or their organization, disclaimers should be present on any email correspondences and in a visible place on the website (American Psychiatric Association, 2006).

The Rights and Privileges of Online Psychology

Along with the ethical obligations of psychiatric practice online come the rights and privileges of both involved parties during the treatment processes. It is this aspect of online psychiatry that bears the most resemblance to face-to-face psychiatric practice. The American Counseling Society (2005) section A-12g details the patient's right to privacy and informed consent to all relevant information and procedures involved in online psychiatric sessions, a right that also holds true in face-to-face practice. In fact, it seems that despite all the differences in communication methods and means by which to diagnose the patient, online psychiatry still maintains the same level of patient rights as though it were a face-to-face practice.

However, some of the rights that patients and psychiatrists take for granted at a face-to-face practice, are critical in an online one. For example, in a face-to-face practice the client can more easily obtain information relating to the professional, the professional's qualifications, and methods of verifying all information learned. This can make a patient feel more confident about treatment and possible prescriptions, as well as ensure that they are dealing with a true medical professional. Accessing information about a psychiatrist can also help a potential patient decide whether the psychiatrist is really good for them, and whether or not they believe they can "enter into a treatment relationship with him or her" (Wooton, et al, 2003).

Likewise, the psychiatrist has the right, even the obligation, to verify all patient information (American Counseling Association, 2005). As was previously discussed, lack of proper research into a patient's information, and thus failure to uncover pertinent information such as a patient's mental and physical health, age, and location, can cause significant legal difficulties for the practice in question. As such, any psychiatrist contacting existing patients or acquiring new ones online has the right and obligation to ask questions pertinent to the legalities and ethics of psychiatric practice online.

Conclusion

Unfortunately, the lack of specific APA guidelines concerning the ethical requirements of the online practice of psychiatry and psychology leave professionals to fend for themselves in their search for ethical practice. While organizations such as the International Society for Mental Health and the American Psychiatric Organization provide ethical guidelines for professionals to follow and refer to during their online dealings, the American Psychological Association (APA) has yet to release a definitive and binding document dealing with online mental health practice. Despite this lack of definitive rules and ethics, requirements for the practice of psychiatry through the online medium and patient-doctor rights remain. However, the difficulties and possible ethical violations that can occur as a result of online mediums require a great deal more consideration. The possible leaking or hacking of confidential patient information alone posses a grand scale problem that has to be thoroughly addressed before a psychiatrist, or any medical professional, engages in online practice. Additionally, online practice raises questions of ethical initiation of a patient-psychiatrist treatment relationship that as of now generally discourages new patients from online contact.

Until definitive documents are drafted and accepted by all branches of mental health professionals, the ethics of online psychiatry will continue to be under the existing guidelines of separate organizations, and ultimately debatable.

References

American Psychiatric Association. (2006). American Psychiatric Association Council on Psychiatry and Law. Retrieved June 25, 2007, from the American Psychiatric Association Website: http://www.psych.org/psych_pract/clin_issues/etherapyfaqs.cfm

American Psychological Association. (2007). APA Statement on Services by Telephone, Teleconferencing, and Internet. Retrieved June 25, 2007, from the American Psychological Association Website: http://www.apa.org/ethics/stmnt01.html

International Society for Mental Health Online. (2000). Suggested Principles for the Online Provision of Mental Health Services. Retrieved June 25, 2007, from the International Society for Mental Health Online Website: http://www.ismho.org/suggestions.html

Ethics Code. (2006). Guidelines for Mental Health and Healthcare Practice Online. Retreived June 25, 2007, from Ethics Code Website: http://www.ethicscode.com/pages/698182/index.htm

American Counseling Association. (2005). ACA Code of Ethics. Retrieved June 25, 2007, from Illinois Institute of Technology Website: http://ethics.iit.edu/codes/coe/amer.couns.assoc.2005.html

Fenichel, M., Suler, J., Barak, A., Zelvin, E., Jones, G., Munro, K., Meunier, V., Walker-Schumucker, W. (2006). Myths and Realities of Online Clinic Work. Retrieved June 26, 2007, from Current Topics in Psychology Website: http://www.fenichel.com/myths/

Drude, K., Lichstein, M. (2005). Psychological Use of E-mail with Clients: Some Ethical Considerations. Retrieved June 25, 2007, from Ethics and Malpractice Website: http://www.kspope.com/ethics/email.php

Wells, M., Mitchell, K., Finkelhor, D., Becker-Blease, K. (2007). Online Medical Treatment: Concerns and Considerations. Retrieved June 25, 2007, from CyberPsychology and Behavior Website: http://www.liebertonline.com/doi/abs/10.1089/cpb.2006.9933

Library of Congress. (1995). Bringing Health Care Online: The Role of Information Technologies. Government Printing Office.Washington D.C.

Link: http://books.google.com/books?id=21wxVdLvywQC&pg=PT106&ots=1Z3diMHNS_&dq=online+mental+health+care&sig=xJiX13cGT4aUbr5WF_fbr6hAB4Q#PPT66,M1

Wooton, R., Yellowlees, P., McLaren, P. (2003). Telepsychiatry and E-Mental Health. Royal Society of Medicine Press Ltd. Lake Forest, IL.

Link:

http://books.google.com/books?id=EljybHTcMIAC&pg=PA77&ots=b2SOntu0U1&dq=online+mental+health+care&sig=B_iwN9rmbc7a5uLTiz189W4kHI8