2nd in a 3 part Professional Ethics Course in partial fulfillment for recertification of licensure for mental health clinicians in the State of Florida. This course addresses ethical, legal and HIPAA issues the mental health counselor must consider when using the internet for counseling, email correspondence, chat-room conferences, blogging, video-conferencing, filing, billing, etc.

1. The Network of Christian Counselors
13 February 2017
Copyright©2017. Harry Morgan. All Rights Reserved
Permission granted to reproduce with attribution & citation of www. http://networkofchristiancounselors.com/

2. Part I. Fundamental Ethical Considerations
for Christian Mental Health Clinicians
Part II. Online-line Ethical Considerations for
Christian Mental Health Clinicians
Part III. Avoiding Common Security Breaches
& HIPPA Violations
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3. 3
Part II
Online-line Ethical Considerations

4. As Internet technologies increasingly become
ingrained in our professional and personal lives,
the issues of professionalism and ethics should be
considered carefully. The goal of this course is to
raise awareness and build the knowledge base of
Christian mental health professionals regarding
the impact of Internet technology on
professionalism and ethics. Technology has
become an integral part of the American lifestyle,
and it is crucial for practitioners to determine how
it impacts their professional lives.
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5. • Personal and professional use of the Internet as
dramatically expanded during the past 25 years.
• Internet technology is a powerful tool having a plethora
of uses for mental health professionals including:
research, education, networking, and clinical practice.
• Inherent dangers exist of inadvertently violating ethical
and professional boundaries when utilizing these
functions.
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6. Ø Define Internet usage patterns and common Internet
technologies.
Ø Analyze how various Internet technologies are utilized
in clinical practice.
Ø Evaluate how the use of specific Internet technologies
can affect professionalism and ethics.
Ø Discuss how the use of Internet technologies can
impact issues of boundaries, self-disclosure,
privacy/confidentiality, and professional relationships.
Ø Identify best practices for using Internet technologies
as a clinical mental health practitioner.
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7. Internet Technology
Professionalism and Ethics
Ethical Legal

8. • HIPAA Business Associates & Email
DEFINITIONS:
• Secure & Non-Secure Hardware & Communication
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• Internet
• Internet Risks & Threats
• Encryption

9. “The practice of telephone-based therapy has a long
history, beginning with its use in consultation and
crisis intervention and extending into psychotherapy
and psychoanalysis in private practice (Leffert, 2003;
Lindon, 2000; Saul, 1951). With the advent of the
Affordable Care Act, funds have been made available
to support a huge growth in community-base
telemedicine services using the telephone or
videoconference. The Veterans Administration,
Armed Forces Health Services, and Medicaid have
been in the lead because, being federal programs,
they avoid the problems of state regulations
constraining service across a distance.” – Jill Scharff
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Ø Counseling done online via email, chat rooms,
instant messaging
Ø Telephone Conversations
Ø Video Conferencing aka ITV
Ø Some online counseling is one on one and some
involves a group
Ø Some Cyber-counseling even incorporates art
therapy by sending pictures back and forth
(audiographic communication).

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Ø People in rural areas who can not travel to a clinic
Ø Disabled or elderly / unable to drive to and from a
clinic
Ø People who are too embarrassed to seek
treatment in public
Ø People who are extremely antisocial and spend
most of their time online and are comfortable
there
Ø People with Agoraphobia
Ø Military Personal in remote locations

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Ø Confidentiality, encryption, password protection
Ø Establishing client identity (minors, homicide,
suicide)
Ø Ensuring equality of access / Accessibility
(individuals may not be able to see color on
screen due to visual disability, some families may
not have access to computers at all)
Ø Informed consent
Ø Laws and statutes or jurisdiction of states of both
counselor and client

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Ø Providing credentials
Ø Providing referrals in case of emergency
Ø Dealing with technical failure

14. Ø In 2009 it was estimated that 68% of US households
had Internet access
Internet and Digital Technology Usage &
Consumption in the US
Ø In a 2014 study conducted by the pew research Center
with 1006 adults 18 years of age and older, 87% of
men and 86% of women reported Internet use
Ø 57% of 65 year old's and older are likely to utilize the
Internet
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Ø In 2012 it was estimated that 74.8% of US households
had Internet access
Ø 97% of 18 - 29 year old's are likely to utilize the
Internet

15. Ø In 2010, the average American spends six hours &
35 minutes on blogs and social networking sites
every day 89% of those 18 - 29 years of age
Facebook, Google +
Ø In 2014, 74% of adults were using social
networking sites
Ø In 2014, an estimated :
71% of Americans 18 years of age and older use Facebook
26% had the Instagram profile
28% reported using LinkedIn
23% of online adults use Twitter
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16. Ø ELECTRONIC MAIL (E-MAIL)
Ø CHAT ROOMS
Ø BLOGS OR MICROBLOGS
Blogger
Google
Tumblr
WordPress
BlogSpot
LiveJournal
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17. Ø SOCIAL NETWORKING WEBSITES
Facebook
Google+
LinkedIn
VK
Pinterest
Yik Yak
Twitter
Second Life
Instagram
Classmates
Reunion
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18. Ø PHOTO OR VIDEO SHARING
Ø WIKIS
Instagram
YouTube
Vine
Flickr.
Wikipedia
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19. 1. Email – the most commonly utilized web-
based interventions for clinical practice
Ø Provides asynchronous interactions
between a counselor and a client
Ø Allows the client to provide brief narratives, and the
counselor can structure the communication for
exploration of the described symptoms with a
problem-solving focus
Ø Provides support which can help to mitigate
maladaptive responses to stressors
Ø Most useful for clients who cannot easily see a
practitioner due to transportation issues or residing
in remote areas
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20. 1. Email – the most commonly utilized web-
based interventions for clinical practice
Ø As a supplement for supervision, and they can serve
as a journal of thoughts and questions between an
intern and a supervisor to stimulate reflection
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Ø Email distribution list (LISTSERV)
Particularly helpful in keeping practitioners
abreast of current information and connected
with colleagues. These distribution lists may also
be beneficial for training and continuing
professional development

21. Ø Most useful for clients
who cannot easily see
a practitioner due to
transportation issues or
residing in remote
areas
Ø As a supplement for supervision, and
they can serve as a journal of
thoughts and questions between an
intern and a supervisor to stimulate
reflection
2. Chat rooms or discussion groups
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22. 3. Blogs
Ø A regularly updated website or web
page, typically one run by an
individual or small group, that is
written in an informal or
conversational style.
Ø Most useful for clients who cannot easily see a
practitioner due to transportation issues or residing
in remote areas
Ø As a supplement for supervision, and they can
serve as a journal of thoughts and questions
between an intern and a supervisor to stimulate
reflection
4. Social Networking
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23. Health Insurance Portability &
Accountability Act of 1996 (HIPAA)
protects client’s confidentiality and security for
health information.
HIPAA Violations
Inappropriate disclosure of information can
result in consequences up to $50,000
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24. Confidentiality must be maintained through any
treatment medium – even technology.
American Psychological Association’s Code of Ethics
(2010) – ethic codes “[apply] to these activities
across a variety of contexts, such as in person, postal,
telephone, Internet, and other electronic
transmissions.”
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25. 25
All the major professional ethics codes call for
confidentiality measures in the electronic world
in some way or another:
6.3 Confidentiality and Professional Responsibilities.
It is the therapist’s or supervisor’s responsibility to
choose technological platforms that adhere to
standards of best practices related
to confidentiality and quality of services, and that
meet applicable laws. Clients and supervisees are to
be made aware in writing of the limitations and
protections offered by the therapist’s or supervisor’s
technology.
AAMFT Code of Ethics, 2015, 6.3 (emphasis mine)

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Counselors take precautions to ensure
the confidentiality of all information transmitted through
the use of any medium.
ACA Code of Ethics, 2014, B.3.e (emphasis mine)
Psychologists have a primary obligation and take
reasonable precautions to protect confidential
information obtained through or stored in any medium,
recognizing that the extent and limits of confidentiality
may be regulated by law or established by institutional
rules or professional or scientific relationship.
Ethical Principles of Psychologists and Code of
Conduct, 2010, 4.01 (emphasis mine)

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34. NCCs shall protect the confidentiality and security of
tests or assessments, reports, data and any transmission of
information in any form.
National Board for Certified Counselors Code of
Ethics, 2012 (emphasis mine)
Social workers should take precautions to ensure and
maintain the confidentiality of information
transmitted to other parties through the use of computers,
electronic mail, facsimile machines, telephones and
telephone answering machines, and other electronic or
computer technology. Disclosure of identifying
information should be avoided whenever possible.
NASW Code of Ethics, 1996, Revised 2008,
1.07.m (emphasis mine)

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Business Associates are people and organizations who,
in the normal course of business, handle sensitive
information on your behalf. Examples:
• Billing services
• Collection agencies
• Record storage companies
• Practice Management Systems
• Electronic Health Record systems
• Email providers
• Attorneys
• Accountants

29. Regulations vary state by state, however all
treatment must follow these two guidelines:
1. Services are deemed to be rendered in the state
where the patient is located; accordingly
providers must determine licensure requirements
in the patient’s state. Providers must also
determine and comply with applicable law
relevant to providing healthcare services in the
patient’s state
2. The Standard of care for remote healthcare
services is the same as if both parties are in the
physical presence of each other. Professional
association, including the America Psychological
Association, assert this as well.
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30. Ø Provider of telemedical services must have some
type of registration in patient’s state.
o 58 state medical boards require full licensure in state
o 11 state medical boards require a special telemedicine
license
o Minnesota require telemedicine registration
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Ø Consent must be obtained as stated in state laws
and guidelines
Ø Providers must develop contingency plans as a
precaution for technology failures

31. Contingency Plans
Mental health clinicians should make effort to
identify and locate access to appropriate emergency
resources in the patient’s local area; such as
emergency response (e.g., telephone numbers,
hospital admissions, referral resources, etc.)
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32. Through means of technological communications, having
appropriate patient selection is crucial. The APA states that
“most sources discourage the use of e-therapy for suicidal
patients.”
Considerations for Telepracticial Engagements
Ø Awareness and assessment of behavior by the patient
Ø Ensuring privacy and protection of confidential information
through transmission
Ø Relational and transferal issues
Ø Distribution of computers and computer familiarity issues
Ø Emergency provisions, and
Ø Technological proficiencies and culture respects/language
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33. When treating military patients remotely,
mental health clinicians must follow
jurisdiction regulations of the state in which
the patient is located.
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While the patient is the Service Member, the DoD is
present in all treatment considerations as a third party.
Ø When joining the military system, mental
health professionals need to familiarize
themselves with a military culture, and more
importantly, the organizational structure.

34. Confidential information regarding a patient should
be less secure.
Ø The DoD has regulations that put mental health
professionals in a position with less confidentiality
between a patient because…
Ø The Safety needs of the larger military and other
service members trump the needs of an individual
patient.
Ø Shared information includes: diagnosis, mental status,
fitness for duty and/or deployment status, and
specific recommendations requiring command
involvement.
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35. Ø The rules of all boards under which you are
licensed/registered/certified
Ø Relevant licensing/certifying boards in the state
or nation where the client is located.
When determining the jurisdiction that a client is
in, use the physical location of the patient at the
time of the session, not necessarily where he/she
resides.
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36. 36
Steps you can take to make use of Google Apps for Work
to keep your client’s PHI protected and make them
HIPAA compliant.
1. Download and read the “HIPAA Compliance & Data Protection
with Google Apps” booklet from Google here. It goes into
detail about how to set up Google Apps for Work.
2. Sign up for Google Apps for Work at https://apps.google.com/.
As mentioned already, this is a paid service from Google that
currently only costs $5 a month per user. (It really is a bargain
for all that you get!)
3. Make sure your password is unique and not easy figure
out. DO NOT use “password” or “1234”.
Steps to Protect Your Clients

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4. Go through the set-up steps outlined in the Google HIPAA guide
mentioned above. Particularly the set-up on the administrator
side of Google Apps for Work for Gmail.
5. Only use the Core Services that Google agrees to protect under
the BAA for any client information.
6. Limit the number of devices that you access the account from. I
know we are very mobile dependent, but do not store any
patient records on your phone or tablet. In other words, do not
use the Google Drive App which allows you to store what is on
your Google Drive in your device. You can still read and access
files if you have an internet connection.
Steps to Protect Your Clients

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7. If you are using a HIPAA compliant Practice Management
Service, (TherapyAppointment, TherapyNotes, SimplePractice,
etc.) you can still create documents, such as writing progress
notes using the Google Docs app. You simply cut and paste the
note into your Practice Management application. I would
suggest that you then delete the note from Google Docs just as
precaution. If you are not using a Practice Management Service
you can save or print your notes and other documents in Google
Drive. Just make sure you have all of the sharing options turned
off. Again, use the set-up recommendations given by Google.
8. Make sure you are using a “2-step verification”. This simply
means having a password for your devices in addition to
requiring a second login step to get into your applications. And,
never let your browser save your passwords for you.
Steps to Protect Your Clients

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9. Include a confidentiality statement to your signature block on all
electronic correspondence. This does not, of course, guarantee
any sort of protection by itself, but it does communicate your
intentions to keep information from getting into the wrong
hands. Here is a sample of the one that I use on my emails:
Steps to Protect Your Clients
CONFIDENTIALITY NOTICE
This message and any accompanying documents are covered by the
Electronic Communications Privacy Act, 18 U.S.C. 2510-2521, and may
be protected by the doctor-patient privileges, or may constitute non-public
information, and may contain information intended only for the designated
recipient(s) named above. This information is confidential. If you are not
the intended recipient or an agent responsible for delivering it to the
intended recipient, you are hereby notified that you have received this
document in error and that any review, dissemination, copying, or the
taking of any action based on the contents of this information is not
authorized and may be unlawful. If you have received this communication
in error, please notify us immediately by E-mail, and delete the original
message.

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http://www.onlinetrainingforcounsellors.com/
https://personcenteredtech.com/
Person-Centered Tech
Highly recommended

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Telementalhealthcomparisons.com also
offers a list and resources of online mental
health providers and whether or not they are
HIPAA compliant. You can click on the HIPAA
compliant video conference companies to see
what distinguishes them from the rest.

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There are HIPAA compliance regulations that health care providers
have to follow in the United States. This may be a starting point
for you. You can reference some links in our resources page
at http://ismho.org/resources/standards-for-online-practice/ for some of the
ethics guidelines outlined by organizations in the field.

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44. q Collie, K., Cubranic, D., & Long, B. (2002). Audiographic Communication for Distance
Counselling: A Feasibility Study. British Journal of Guidance & Counseling, 30(3), 269-
284.
q Gregory, Kim L. (2010, Jan 10) Camarillo Funeral Home Unplugs Online Grief
Counseling. Ventura County Star: Ventura, California.
q Heinlen, K., Welfel, E., Richmond, E., & O'Donnell, M. (2003). The nature, scope, and
ethics of psychologists' e-therapy Web sites: What consumers find when surfing the
Web. Psychotherapy: Theory, Research, Practice, Training, 40(1), 112-124.
q Heinlen, K., Welfel, E., Richmond, E., & Rak, C. (2003). The scope of Web-Counseling:
A survey of services and compliance with NBCC Standards for the ethical practice of
WebCounseling. Journal of Counseling & Development, 81(1), 61-69.
q “International Online Therapy: What To Know Before You Go." Person-Centered
Technology. N.p., 2016. Web. 29 Dec. 2016.
q Kaplan, D. (2005). Ethical Use of Technology on Counseling. Counseling Today.
American Counseling Association: Alexandria, Virginia.
q "Military Patients: Recommendations for Treating Service Members.“ National
Register. N.p., 2016. Web. 27 Dec. 2016.
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45. q NetCE. Continuing Education for Florida Mental Health Professionals. 5th ed. Vol.
142. Sacramento, CA: NetCE, 2017. Print. Continuing Education.
q Ritchie, Rene. "Apple's FaceTime Is End-to-end Encrypted. Google Hangouts ...Isn't.”
iMore. Mobile Nations, 13 May 2015. Web. 27 Dec. 2016.
q Scharff, Jill Savege. Psychoanalysis Online 2: Impact of Technology on Development,
Training, and Therapy. London: Karnac, 2015. Print.
q Shaw, H., & Shaw, S. (2006). Critical ethical issues in online counseling: Assessing
current practices with an ethical intent checklist. Journal of Counseling &
Development, 84 (1), 41-53.
q "Social Workers and E-Therapy." N.p., Web. 27 Dec. 2016.
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46. You can contact
Harry at:
Biblical Counseling Center
1450 59th Street West
Unit 101
Bradenton, FL 34209
941-729-6600
Sanctitas@aol.com
www.TRUTHtransforms.com
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