Online Consultation Is A Dangerous Thing
The increasing use of Internet user groups and listservs by psychotherapists is putting our clients at risk. Psychologists, like other psychotherapists, need to be vigilant about potential client exposure and violation of ethical standards.
APA Ethical Principles and Standards relevant to this article:
Principle A: Beneficence and Nonmaleficence
Principle B: Fidelity and Responsibility
Principle E: Respect for People’s Rights and Dignity
Standard 4. Privacy And Confidentiality, Sections 4.01, 4.02, 4.04-7
True story: A husband and wife are in individual therapy with two psychologists who know each other socially. The husband gives his therapist consent to consult with this colleague. The wife explicitly refuses to give consent to her therapist. The therapists meet at a party and discuss the couple. In a subsequent session, the husband’s therapist tells the husband about the wife’s therapist’s perspective. The husband tells his wife about this. The wife confronts her psychologist who then admits to divulging the information to the other psychologist. The wife terminates therapy. The wife’s psychologist (luckily) escapes a grievance, sanction, and lawsuit. (NB: I have no professional relationship with this couple, and I have received their permission to tell this story).
It’s a small world. Loose lips sink practices. More importantly, they destroy the trust that our patients or clients place in us as their confidants. Jessica Bier, an LCSW, recently was willing to defy a (military) judge to protect the privacy of her client who accused a fellow AFA cadet of sexual assault. Her courage and passion highlight the importance of protecting our clients’ privacy. Our vigilance also protects the integrity of our profession as a sanctuary from the increasingly wired world of electronic records and online communication where hundreds (if not millions) can access private information.
Writing has become a different sort of process now that we have computers, email, blogs, and listservs. Formal communication has become more casual, and in our sped-up world, the press of the ‘Enter’ key can forward sensitive information before we take enough time to consider the ramifications of distributing that electronic message into the world. By now, most of us have sent out an email to the wrong recipient at least once, and those of us in online listservs, chat rooms, or other groups have said things that we wish we could take back but which are forever loosed upon the world in some electronic archive…or worse.
I recently accessed online transcripts from the “psycgrad” listserv in which I participated in 1998, bleary-eyed and stressed out, while on internship. Today, I can’t access the messages. Two months ago I could. I typed those messages seven years ago. Most of us who were online then didn’t really know how secure listservs were, and I assumed that since membership was required to access the listserv, membership was required to access the listserv messages. Wrong. Luckily I didn’t say anything too stupid. Remember, like the DSM diagnostic labels many of us submit to third-party payers on behalf of our patients, once it’s out there, we lose control of it forever.
Things haven’t changed. I’m currently a member of another therapist listserv that has a modest membership vetting process. Recently I was able to access full-text messages from that listserv through a search engine. The list owners worked for about a month to regain control over the leak.
So, let’s get back to basics: Don’t talk about any of your clients to anyone, whether in-person, over the phone, or online, without clear written consent from your client. If your client does not have the legal right to grant consent because s/he is a minor, or in a mandated treatment that somehow diminishes rights to privacy, you should still work passionately to protect their privacy and obtain assent and explicitly shared goals about such communication before sharing any information. If you are in a “consultation group,” you should have your clients’ written consent before you share information about them there too. Simply disguising name, age, occupation, and other obvious identifying characteristics is not enough. And if it’s a bad idea to share your clients’ private information with a few trusted colleagues in whom you have confidence about their professional discretion, it’s a terrible idea to share such information in an online forum where hundreds, thousands, or potentially millions have free access.
Now that the World Wide Web has been humming for over a decade, I would guess that every psychotherapist who has worked with 50 or more clients has been Googled by a client at least once. When your clients Google you, they are potentially searching for everything you’ve ever put online (possibly including listserv messages). A few may also attempt to join a listserv to which you belong out of curiosity or a need to get closer to you. Now that this article is online and attached to my name, it is likely that one or more of my clients will access it some day. I need to be clear that what I say or do in the online community does not harm or expose my clients in any way. Before you seek any consultation, consider what would happen if your clients were listening or later read a transcript. Would they approve? Ask them.
Think about it this way: If your client knew about your behavior, could it harm their willingness to be fully open with you? This is not a matter of putting yourself in the client’s shoes. After all, you honestly may not mind if your therapist shares your personal information with a trusted colleague, or even hundreds of people on a listserv. The issue at hand is whether a client might mind. We cannot know for sure without asking them, so ask them! If you’re not willing to ask a client before consulting about them, then that may indicate how good an idea it is to do it.
Here’s another guideline: If you are disguising the information so well that no one (including the client him/herself) could possibly identify the client, then any professional consultation may be significantly hampered by such compression or distortion of basic information. Adding specific and clear language to your client consent form about how and when you disclose any information about them with colleagues (disguised or not) is a good idea: it empowers your clients by letting them know what the boundaries are in the “container” of their therapy, and allows them the chance to make choices about those boundaries (e.g., refusing their consent to that “breach” in the container, or refusing to work with you if you require that provision in order to work with them).
Several APA ethical standards address this issue, especially Standard 4.06:
“Consultations: When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation.”
When consulting online, the probability of client/patient identification increases dramatically. . . as do the chances of ruining the respect of our profession by the loss of client confidentiality.
Bottom line: Don’t do online (or other) consultation without clear, written permission from your client about the nature of that consultation and the potential loss of privacy it entails.
© 2005. Jason A. Seidel, Psy.D. P.C. Reprinted with permission.
Jason A. Seidel, Psy.D. is a Denver psychologist in private practice, and an expert on professional and business issues for psychotherapists. His workshop for mental health professionals, “The Business of Private Practice,” is available at www.tbopp.com .