Suggested Principles for the Online Provision
of Mental Health Services - ISMHO Version 3.11
ISMHO has endorsed these principles. This is the only
officially endorsed version.
Online mental health services often accompany traditional
mental health services provided in person, but sometimes they are the only
means of treatment. These suggestions are meant to address only those practice
issues relating directly to the online provision of mental health services.
Questions of therapeutic technique are beyond the scope of this work.
The terms "services", "client", and "counselor" are used for
the sake of inclusiveness and simplicity. No disrespect for the traditions or
the unique aspects of any therapeutic discipline is intended.
Standard operating procedure
- Informed consent
The client should be informed before he or she consents to
receive online mental health services. In particular, the client should be
informed about the process, the counselor, the potential risks and benefits
of those services, safeguards against those risks, and alternatives to those
- Possible misunderstandings
The client should be aware that misunderstandings
are possible with text-based modalities such as email (since nonverbal
cues are relatively lacking) and even with videoconferencing (since
bandwidth is always limited).
- Turnaround time
One issue specific to the provision of mental
health services using asynchronous (not in "real time") communication is
that of turnaround time. The client should be informed of how soon after
sending an email, for example, he or she may expect a response.
- Privacy of the counselor
Privacy is more of an issue online than in person. The
counselor has a right to his or her privacy and may wish to restrict the
use of any copies or recordings the client makes of their
communications. See also the below on the
confidentiality of the client.
When the client and the counselor do not meet in person,
the client may be less able to assess the counselor and to decide whether
or not to enter into a treatment relationship with him or her.
The client should be informed of the name of the
counselor. The use of pseudonyms is common online, but the client should
know the name of his or her counselor.
The client should be informed of the
qualifications of the counselor. Examples of basic qualifications are
degree, license, and certification. The counselor may also wish to
provide supplemental information such as areas of special training or
- How to confirm the above
So that the client can confirm the counselor's
qualifications, the counselor should provide the telephone numbers or
web page URLs of the relevant institutions.
- Potential benefits
The client should be informed of the potential
benefits of receiving mental health services online. This includes both
the circumstances in which the counselor considers online mental health
services appropriate and the possible advantages of providing those
services online. For example, the potential benefits of email may include:
(1) being able to send and receive messages at any time of day or night;
(2) never having to leave messages with intermediaries; (3) avoiding not
only intermediaries, but also voice mail and "telephone tag"; (4) being
able to take as long as one wants to compose, and having the opportunity
to reflect upon, one's messages; (5) automatically having a record of
communications to refer to later; and (6) feeling less inhibited than in
- Potential risks
The client should be informed of the potential risks of
receiving mental health services online. For example, the potential risks
of email may include (1) messages not being received and (2)
confidentiality being breached. Emails could fail to be received if they
are sent to the wrong address (which might also breach of confidentiality)
or if they just are not noticed by the counselor. Confidentiality could be
breached in transit by hackers or Internet service providers or at either
end by others with access to the email account or the computer. Extra
safeguards should be considered when the computer is shared by family
members, students, library patrons, etc.
The client should be informed of safeguards that are
taken by the counselor and could be taken by himself or herself against
the potential risks. For example, (1) a "return receipt" can be requested
whenever an email is sent and (2) a password can be required for access to
the computer or, more secure, but also more difficult to set up,
encryption can be used.
The client should be informed of the alternatives to
receiving mental health services online. For example, other options might
include (1) receiving mental health services in person, (2) talking to a
friend or family member, (3) exercising or meditating, or (4) not doing
anything at all.
Some clients are not in a position to consent themselves
to receive mental health services. In those cases, consent should be
obtained from a parent, legal guardian, or other authorized party -- and
the identity of that party should be verified.
In general, the counselor should follow the same
procedures when providing mental health services online as he or she would
when providing them in person. In particular:
- Boundaries of competence
The counselor should remain within his or her boundaries
of competence and not attempt to address a problem online if he or she
would not attempt to address the same problem in person.
- Requirements to practice
The counselor should meet any necessary requirements
(for example, be licensed) to provide mental health services where he or
she is located. In fact, requirements where the client is located may also
need to be met to make it legal to provide mental health services to that
client. See also the above on qualifications.
- Structure of the online services
The counselor and the client should agree on the
frequency and mode of communication, the method for determining the fee,
the estimated cost to the client, the method of payment, etc.
The counselor should adequately evaluate the client
before providing any mental health services online. The client should
understand that that evaluation could potentially be
hindered by communicating
- Confidentiality of the client
The confidentiality of the client should be
protected. Information about the client should be released only with his
or her permission. The client should be informed of any exceptions to this
The counselor should maintain records of the online
mental heatlh services. If those records include copies or recordings of
communications with the client, the client should be informed.
- Established guidelines
The counselor should of course follow the laws and other
established guidelines (such as those of
professional organizations) that apply to him or her.
The procedures to follow in an emergency should be
discussed. These procedures should address the possibility that the
counselor might not immediately receive an
online communication and might involve a local
- Local backup
Another issue specific to online mental health
services is that the counselor can be a great distance from the client.
This may limit the counselor's ability to respond to an emergency. The
counselor should therefore in these cases obtain the name and telephone
number of a qualified local (mental) health care provider (who preferably
already knows the client, such as his or her primary care physician).
Ethics guidelines of selected professional organizations
The committee is aware that the following mental health
professional organizations have made their ethics guidelines available online:
The development of these suggested principles
These suggestions are being developed by a joint committee
of the International Society for Mental Health
Online and the
The American Association for Technology in Psychiatry (AATP) formerly known as Psychiatric Society for Informatics:
- Martha Ainsworth (co-chair)
- Michael Fenichel
- Denis Franklin
- John Greist
- John Grohol
- Leonard Holmes
- Robert Hsiung (co-chair, former ISMHO member)
- Martin Kesselman
- Peggy Kirk
- Judy Kraybill
- Russell Lim
- Roger Park-Cunningham
- Richard N. Rosenthal
- Jeanne N. Rust
- Gary Stofle
- Nancy Tice
- Giovanni Torello
- Mark Vardell
- Willadene Walker-Schmucker
The committee made use of and is indebted to previously
published online guidelines of various types:
These suggestions were presented in a very preliminary form
as part of "Clinical Use of the Internet: Some Suggestions" at the 1999
American Psychiatric Association annual meeting and in a somewhat less
preliminary form as part of "Electronic Communication with Clients" at the
1999 American Psychological Association annual convention.
The Suggested Principles for the Online Provision of Mental Health Services
are Copyright © 2000 International Society for Mental Health Online &
Psychiatric Society for Informatics. All rights reserved. The document may
be freely reproduced without permission provided that the source is cited
and no fee is assessed to access the information.