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Geek Ethicist: Skype Therapy

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Dear Ethicist— Which FaceTime/Skype apps are the most HIPAA compliant? I am a therapist and have had clients request these type of sessions. However, I’m worried about privacy and heard that FaceTime was recently hacked. I need to know which of these apps would be the best and safest for my therapy sessions. Sign Me— Psychotherapist Trying to Keep Up with Technology

Hi Psychotherapist— First, a disclaimer: The ethicist is NOT a lawyer. Advice given here is for informational use only and should not be considered legal advice. Opinions expressed here are of the ethicist and not necessarily those of Any advice given here is taken at your own risk. That said, your question is more complex than it sounds. I’m not an app or technology reviewer, so it’s not my place to weigh in on the best tool for remote counseling sessions. However, using ethics and reasonable judgment it is possible to answer this question for yourself. Let’s look at the real issues:

1.)   Professional Boundaries

Establishing clear, professional, therapeutic boundaries is paramount, and in fact a challenge, in any psychotherapeutic situation.  Every competent therapist recognizes the potential for counter transference, or allowing the therapist’s own personal psychiatric needs to drive the therapy rather than the patient’s needs.   So prudent, reasonable psychotherapists must keep clear boundaries in place to avoid counter transference.  Never forget: You are not your own patient in your session if you are getting paid for it.  You, as the therapist, are professionally obligated to create and maintain the boundaries that make this relationship therapeutic, otherwise you risk ethics violations and outright malpractice liability if there is foreseeable injury.  In other words, if something goes badly because you let the boundaries break down and you should have known better it could cost you plenty, including your license!

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Obviously most therapists recognize they shouldn’t have cyber sex with their patients, but giving gifts to entice patients to continue therapy,  or doing personal or professional favors for them online,  or even carrying on personal relationships external to the therapeutic environment online are also boundary infractions and potential ethics violations, as are carrying on non-therapeutic activities online within the sessions. The problem is the online environment may soften therapeutic boundaries and make the slippery slope of counter transference even slipperier and more dangerous.  So this should be the very first thing you keep in mind if you begin online therapy.  This ain’t Lamebook: keep your distance.

2.)   Venue

When meeting in an office, certain parameters are already in place: some of these may need to be re-established when meeting over the phone. For example, is the person being counseled in a private location? How long will the session last? What will you do if there are technical difficulties? Do you have a separate phone for this, as using your personal phone may violate your personal privacy and undermine your counselor/client relationship? These should all be addressed by you before beginning this type of counseling.

3.)   Will you get paid or arrested?

It’s insurance fraud if the session isn’t full length or what happens in therapy isn’t actually therapy! Many insurance companies will not cover sessions via Skype/Facetime: best to check on this before agreeing to this type of session with a client. In Academia, there is heated discussion right now about synchronous vs asynchronous online teaching because the teacher can be out fishing when the class is working away.

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Be cautious of thinking that HIPAA protects a person’s privacy to the degree that you assume. HIPAA means your neighbor doesn’t know you have chlamydia, but your doctor, the billing department, the pharmacist, possibly your employer and the government will know.  HIPAA does not promise absolute privacy and often gives an exaggerated sense of privacy to patients. If you don’t believe me, check out The Tatiana Tarasoff ruling and consider duty to warn vs. confidentiality. It’s hard enough to figure out if your patient’s words are bluster or a serious threat when you are looking at them red-faced in your office.  Now imagine having to make that determination online. Digitized/online medical records are not safe. Period. So which method of protecting a person’s privacy is safest? This is a moving target.              

Rule of thumb: What would a reasonable, prudent person accept as a safe interface? This is how legal liability is established. So the question for you is, which app/platform would you expect to most preserve your client’s privacy, assuming #1 has been addressed? Research the different apps and make an informed decision based on your research and you will have done due diligence in protecting your clients.

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5.)   Don’t worry this won’t hurt a bit.

All medical ethics begins by determining whether or not a patient has given informed consent for a medically indicated treatment. They really have to know what they agreed to including the real risk of having their privacy compromised online.   Misunderstanding or manipulation for the patient’s own good are not  informed consent.   In other words, even if a patient seems to have agreed with a treatment does not mean the patient has given informed consent.  We all know how easily misunderstanding happens online.  Catfishing anyone?  That itself should give any online therapist pause.  Maintaining a cash cow client year after year after year is also pretty clearly a COI (Conflict of Interest), and this dirty little COI is finally beginning to receive some long overdue scrutiny by the insurance companies.  So, if you have received demonstrable informed consent, the person is reasonable, there is no conflict of interest that leads to exploitation of your patient, and you have chosen the best option available to you (and there are more options than Skype and FaceTime–see list below) then you are probably ethically fine—it doesn’t matter what app/platform you use. If you think you are going to do therapy on Facebook, however, you are out of your mind.

Other encrypted alternatives for online therapy are: Secure Video, VSee, Lync, Vidyo, Secure Telehealth, VIA3, Telemedicine, eTherapi, PASS (This list is by no means exhaustive: there are many more options out there.)


Emily Cantin researched, co-authored and created original artwork for this article.


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