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.

1. 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 services.

    

   1. Process
      1. 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).

      2. 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.

          

      3. 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.

          

   2. Counselor

      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.

       

      1. Name

         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.

      2. Qualifications

         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 experience.

          

      3. 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.

          

   3. 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 person.

       

   4. 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.

   5. Safeguards

      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.

       

   6. Alternatives

      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.

       

   7. Proxies

      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.

       

2. Standard operating procedure

   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:

    

   1. 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.

       

   2. 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.

       

   3. 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.

       

   4. Evaluation

      The counselor should adequately evaluate the client before providing any mental health services online. The client should understand that that evaluation could potentially be helped or hindered by communicating online.

   5. 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 general rule.

       

   6. Records

      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.

       

   7. 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.

       

3. Emergencies

    

   1. Procedures

      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 backup.

   2. 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:

• American Psychiatric Association
• American Psychological Association
• Australian Psychological Society
• British Psychological Society
• Canadian Psychiatric Association
• Canadian Psychological Association
• Colegio Oficial de Psicólogos
• National Association of Social Workers
• New Zealand Psychological Society

---

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:

• American Counseling Association's Ethical Standards for Internet Online Counseling
  
   
• Code of Conduct for Medical and Health Web Sites
  Health On the Net Foundation

   

• Guidelines for the Clinical Use of Electronic Mail with Patients
  Kane Beverly, Sands Daniel Z. Journal of the American Medical Informatics Association. 1998; 5: 104-111.

   

• Services by Telephone, Teleconferencing, and Internet
  Ethics Committee, American Psychological Association

   

• The Practice of Internet Counseling
  National Board for Certified Counselors, Inc.
  This document contains a statement of principles for guiding the evolving practice of Internet counseling. In order to provide a context for these principles, the following definition of Internet counseling, which is one element of technology-assisted distance counseling, is provided.

• British Association for Counselling and Psychotherapy (BACP) Ethical Framework
   
• American Counseling Association Code of Ethics

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.

Copyright Notice:
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.