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

Jeffrey Barnett

Dr. Jeffrey 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.

The APA Ethics Code and Technology in Practice

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.

The APA Ethics Code and Technology in Research

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

Technology and the Provision of Psychological Services

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 articles 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.