Legal, Ethical, and Practical Dimensions of Online Psychological Interventions in Crisis Situations

This is an important topic that needs to be first addressed from a legal and ethical perspective. NBCC states that “issues of licensure and jurisdiction arise with online therapy, except that counselling boards have not begun to address the problem. A client who obtains counselling services via the Internet from a counselor licensed in the same state has recourse to that state’s regulatory board for any violations against either the state code or standards of practice. However, if a client has a complaint about a counselor licensed in another state, it is unclear in which state to register the complaint. The NBCC lists eleven critical issues in online counselling:

1. Truth in advertising—does the site delivers what it promises?
2. Confidentiality and privileged communication—are your transmissions safe? Who else in the counselee’s home or workplace (use of workplace computers for cybercounseling is not advised) has access to messages?
3. Duty to warn—is the cybercounselor able to discern when a person is a threat to self or others, and what is the cybercounselor’s obligation?
4. Competence—is the cybercounselor competent and licensed? What protection exists for the counselee?
5. Dual relationships— a predator-type of cybercounselor could use the internet to take advantage of counselees, or to arrange subsequent meetings.
6. How does a counselee know that the assigned homework or specific directions are valid for the type of problem presented?
7. Some cybercounselors may do inadequate pre-screening of potential counselees.
8. There may be a lack of cybercounselor knowledge of the circumstances or culture of the client.
9. The anonymity of the counselee may be problematic for the cybercounselor.
10. Fee structures vary—how does a counselee determine a fair price?
11. Is the counselee actually receiving advice from the person who is on the web page? In text counseling how does one verify this?

In addition to informed consent, therapists have a legal duty to warn. This means that if a client poses a threat to themselves or to another identifiable individual, the counselor has the obligation to call the authorities and warn them about this individual. The legal duty to warn was established in the case of Tarasoff v. Regents of the University of California (1976). Duty to warn can be especially problematic online because people can hide their real name or geographic location. It is also difficult for therapists to evaluate a client's violence or self-harm because of the lack of body language and tone of voice in the instance of therapy conducted using audio without video.

Nevertheless, when confronting true crisis immediate assistance is of the essence. 'Crisis interventions in online psychological counselling,' n.d. suggests that “online interventions can provide instant, effective and low-cost access to treatments that is not limited to business hours, which is extremely important because crises do not choose time or place.” Technology-based approaches may be a viable way to provide solutions and therefore, it may greatly reduce people's suffering when conventional and well-accepted methods such as face-to-face counselling and therapy may be difficult to get. It is also necessary to add that online interventions are not intended to replace face-to-face treatment. Online interventions do offer alternatives to people’s needs which can help in strategies and as complementary approaches.

Although more research needs to be done on the subject of online interventions, there is a consensus that they are appropriate in crises situations. One reason why research on this subject is scarce is due to the fact that patients in crisis were typically excluded from online therapy studies. Currently, the World Health Organization (WHO) has a developed a program to provide aid to countries in situations of crisis, especially underdeveloped nations. Currently, mental health aid programs are mostly administered face-to-face.

This study states that The Centre for Research on the Epidemiology of Disasters (CRED) reports: “There were approximately 321 disasters around the world in 2008, taking the lives of 235,816 people.” The total cost in dollars was 1 billion. In 2012 in Brazil there were a total of 376 natural disasters, which took the lives of 93 individuals and affecting the lives of 16,977,614 people. The disasters were due to droughts, forest fires, landmass movements (mudslides, landslides), floods, hailstorms and tornadoes.

Online psychological treatments may bring much needed comfort to the suffering population facing crisis. These interventions may be offered by the large rescue organizations such as the Red Cross. Some examples of online treatments are: computerized therapies (usually software-based); Internet-based therapies using web tools like audio or video conferencing and forums; and text-based therapies, which are generally conducted by e-mail. These modalities are administered via chat, audio and video which contact therapists and patients simultaneously.

'Crisis interventions in online psychological counseling,' n.d. states that the Federal Psychology Council has not yet give permission to online psychotherapy to be practiced in Brazil, a country that has been hit by many disasters, but it has accepted this types of interventions for research. Other types of online treatment have been permitted such as online counselling but not to exceed 20 meetings.

Currently, the Centro de Valorização da Vida (www.cvv.org.br), is the only Brazilian online intervention service for crisis situations which provides support to individuals who are facing crises, including suicidal ideation. This service is provided via telephone, Skype and e-mail correspondence.

This studies states: “In the United States, several mental health institutes began to realize that mobile applications (popularly known as Apps) could help to solve problems in both the individual and collective spheres, including in crisis situations.” In the future this type of interventions may become an important way of reaching individuals who are familiar with technology, such as adolescents and young adults in need of help when face-to-face interventions are limited.

Studies reveal that Internet-based interventions offer many advantages over other kinds of interventions. One advantage is that it saves time and commuting for both patients and therapists. It reduces the length of waiting-lists and the stigma related to visiting a mental health clinician. The use of attractive audiovisual resources may increase the likelihood to be used by more people especially when tailored to their culture. Online interventions may be offered to a large number of people who otherwise would have limited access to psychological interventions. These include individuals suffering from severe health issues, mobility impediments, issues with self-disclosure, and many more restrictions. However, the disadvantages are that Internet-based interventions may not be adequate for people who dislike or do not know how to use the technology, those with low level education, or people who do not understand the nuances of digital communication.

This study states that in Israel online psychological interventions are used to provide help to individuals who are facing severe emotional distress, including suicidal crises. It is important to note that people with suicidal ideation often do not seek help due to fear, shame and stigma associated with this subject. Online interventions provide anonymity which facilitate these individuals to find assistance they need. It is also common for people in crisis to search for help or to seek information anonymously through search engines, at there convenience, instead of seeking face-to-face support.

'Crisis interventions in online psychological counseling,' n.d. also suggests that online interventions can be a useful model for providing early mental health support to individuals who recently are experiencing trauma, for instance, in large-scale traumatic events. In situations such as these, mental health care services might be impaired or even unavailable due to logistics or even because of economic restrictions. It is also possible that in certain situations local teams may lack the training or the necessary preparation to provide this kind of care. Furthermore, in mass casualty incidents there is a narrow window of time for mental health clinicians to provide assistance face-to-face and the Internet is an effective method for reaching victims as soon as possible.

Crises are a real problem. Crises victims may become functional impaired and cost society millions of dollars. Crisis intervention programs are limited. Online interventions may be an effective and inexpensive option for providing psychological care for people in crisis situations and for improving access to treatment for individuals who are unable to attend traditional treatments. Online crisis intervention could also provide an option for preventing severe psychological harm.

References

1. National Board for Certified Counselors (nbcc) policy regarding the provision of distance professional services. (n.d.).
2. Retrieved from https://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf
3. Crisis interventions in online psychological counseling. (n.d.). Retrieved from http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2237-60892015003400171&lng=en&tlng=en