Abstract
Introduction
Internet-based telecommunication technologies have evolved rapidly and provide new opportunities for the remote provision of psychological services. Telepsychology, which is the use of telecommunication technologies to provide psychological services, has the potential to increase accessibility to services and reduce the stigma of help seeking. There is an emerging research base indicating that online therapy is effective for many conditions, including depression (Cowpertwait & Clarke, 2013), anxiety (Rees & Maclaine, 2015) and substance use disorders (Gainsbury & Blaszczynski, 2011). A recent meta-analysis has even suggested a similar effect size to traditional face-to-face therapy (Barak, Hen, Boniel-Nissim, & Shapira, 2008).
Different technologies may be used in various combinations and for different purposes during the provision of telepsychology services. Services can be provided via email, text messaging, video conferencing, websites, chatrooms or forums. The communication can be synchronous, where parties communicate in real-time (e.g., video-conferencing), or asynchronous where there are delays in interactions (e.g., email), or even non-interactional (e.g., psychoeducational websites). Telepsychology can be used as an adjunct to traditional face-to-face services or it can be used on its own.
Unfortunately, the ethical standards for psychology in South Africa do not address many of the issues raised by these technological advancements and therefore there is an urgent need for guidelines to be developed. This document is an attempt to begin the process of developing guidelines for telepsychology in South Africa. These guidelines should be viewed as recommendations rather than mandatory standards and are open to discussion and development as this fast-changing field evolves. In no way are they meant to replace the Ethical Rules of Conduct for Practitioners Registered Under the Health Professions Act (1974), which governs the provision of psychological services regardless of the communication medium.
There has been some recent work on developing guidelines for telepsychology by the American Psychological Association (Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013) and the Australian Psychological Society (2011). There has also been some peer-reviewed literature in the area (Gamble, Boyle, & Morris, 2015; Sansom-Daly, Wakefield, McGill, Wilson, & Patterson, 2016), and even a local South African postgraduate research project (Chipise, 2014). This literature was consulted, and many of the recommendations were adapted in the development of these guidelines.
Guidelines
1.1. Psychologists should always consider the best interests of the client when determining whether telepsychology is an appropriate service. The possible convenience and financial advantages of online services should not unduly influence treatment decisions. 1.2. Psychologists should continually assess whether telepsychology is an appropriate service to meet a client’s current needs and, if it is not, then refer clients to alternative in-person services. Telepsychology may be contraindicated if the: Client has a high-risk status in terms of suicidality and/or homicidality. Client’s current global assessment of functioning is low. Client is not competent in using, or does not have access to, the technology required.
2.1. Psychologists should provide telepsychology within the boundaries of their professional competence derived from their training, registration and professional experience. 2.2. Psychologists should engage in ongoing professional development in telepsychology to maintain their competence in this fast-developing field and ensure that any services offered are based on current evidence. 2.3. Psychologists need to be competent in using the technology required to perform telepsychology and have the skills to manage any potential risks posed by the technology. 2.4. Psychologists need to ensure that clients are competent in using the technology required and may need to assist clients to gain the necessary skills.
3.1. Psychologists should take all reasonable, precautionary efforts to protect and maintain the confidentiality of data/information relating to their clients while using telepsychology. Precautionary efforts should include: Protecting devices (especially mobile devices) with a secure password to prevent unauthorised access. Installation and updating of antivirus software on any computer used. Only using secure, encrypted services to communicate with clients. Password protecting any confidential documents sent via email or any other communication medium. Ensuring that any communication does not reach unintended recipients. This may include verifying that email addresses are correct and recommending that clients use secure devices that are not shared for telepsychology. Ensuring that a secure platform is used for data storage of any client records. If cloud services are used, then individual files should be password protected before being synched to remote servers. Ensuring that when data and/or devices need to be disposed that no third party can access or recover the confidential data. This may require securely deleting or even destroying any data storage media. Ensuring that both the psychologist and client use a private, confidential environment when engaging in telepsychology.
4.1. Psychologists should continue to maintain appropriate professional boundaries when using telepsychology. To maintain these boundaries psychologists should: Maintain the same level of professionalism regardless of the communication medium used. Communicate the limits of their availability (e.g., working hours) Negotiate the purposes that different communication mediums can be used for (e.g., email for administrative purposes and video-conferencing for therapeutic purposes) Clarify the anticipated response times when using asynchronous communication mediums. Avoid ‘befriending’ clients on social media platforms. 4.2. Psychologists should take reasonable steps to avoid unintended self-disclosure of personal information to clients when using social media as this has the potential to bring the profession into disrepute or negatively impact the therapeutic relationship. To manage these risks, psychologists should: Be mindful about the nature of the personal information that they post on any social media, as this information can potentially enter the public domain and be viewed by clients regardless of privacy settings. Carefully manage their privacy settings on social media to control the recipients of any personal information that is posted. Consider using separate professional and personal social media accounts. 4.3. Psychologists should respect a client’s privacy and refrain from doing internet searches to find out information about a client, unless the client has consented, or it is in the best interests of the client (e.g., in an emergency situation).
5.1. If services are provided across any jurisdictional or international boundaries then psychologists are encouraged to be familiar with and comply with all relevant laws and regulations, from both the location of their practice and location of client. 5.2. Psychologists should ensure that professional insurance covers services provided via internet based telecommunication technologies. 5.3. Psychologists should enable clients to verify their professional registration by making available their name, qualifications, registration number, and an indication of where these details can be verified (e.g., contact details for the HPSCA).
6.1. Telepsychology may differ from traditional psychological services in terms of how services are structured, which has the potential to create confusion about how these services are billed. Psychologists should therefore make a special effort to explain all the charges for different services before service provision starts. 6.2. Psychologists should arrange for secure payment methods for any services provided.
7.1. When a psychological test is conducted via telepsychology, psychologists are encouraged to ensure that the integrity of the psychometric properties of the test (e.g., reliability and validity) and the conditions of administration indicated in the test manual are preserved. 7.2. Psychologists should be aware of the risks associated with unsupervised test administration, which is increasingly afforded by internet technologies, and take active steps to manage these risks which may include: Informing clients about the need for an appropriate time and space in which to complete the test to minimise distractions. Verifying that the client completed the test without assistance from a third party, and without accessing online information about the test. Ensuring the security of any test materials to prevent distribution in the public domain.
8.1. Difficulties can arise in managing emergency situations (e.g., suicidality) when using telepsychology, as clients are often not in the same location as the psychologist providing the service. Psychologists should therefore prepare for future emergency situations by: Developing a crisis support plan collaboratively with their client. Obtaining the contact details of the client’s next of kin or another preferred personal emergency contact. Determining, in collaboration with the client, local supports and local health-care providers that can be used in emergency situations. Establishing which methods of communication should be used in an emergency situation to ensure their availability.
9.1. Psychologists should obtain and document informed consent that specifically addresses the unique concerns related to the telepsychology services they provide. 9.2. Clients should be informed about the process, benefits, limitations and possible risks of telepsychology, before being asked to consent to the services. Specific information should be provided about: The increased risks to confidentiality and how these risks can be mitigated. The technology and skills required to access services. The structure and timing of services provided. The charges billed for specific services. Crisis management strategies. 9.3. Psychologists should take steps to verify the identity and age of prospective clients. If the prospective client is under 12 years, the psychologist would need to obtain the consent of a parent/guardian before services can proceed.