Selling Your Soul on the Information Superhighway: Consenting to Services in Direct-to-Consumer Tele-Mental Health

Abstract

Direct-to-consumer tele-mental health services—therapy delivered by video conference, email, and text message—is a burgeoning model of service delivery. The practice of on-demand digital psychotherapy presents ethical questions, as new economic models, service delivery systems, and therapeutic models are introduced. Virtual therapy, now offered on a subscription basis by third-party providers, requires users to accept Terms of Service (ToS) agreements to access services. This article describes the results of a survey in which participants ( n = 579) were asked to compare the values of the Human Rights Framework with the language of one tele-mental health platform’s ToS user agreement. Findings suggest that those clients with prior experience with a mental health professional will find the ToS agreements to be the most ethically compromised. Similarly, employed and better educated individuals also found the ToS to be ethically suspect. The most vulnerable of the groups we surveyed, individuals who hold less education and those who are unemployed, may be at most risk for signing consent to a system they do not understand. The study provides one example of the ethical questions that emerge from the introduction of a new model of for-profit service provision in mental health. Recommendations for consumers and practitioners are suggested.

“That’s the Beauty of It”: Practitioners Describe the Affordances of Direct to Consumer Tele-Mental Health

“…Although existing codes—the National Association of Social Workers (NASW) Code of Ethics and the NASW, ASWB, CSWE, and CSWA Standards for Technology in Social Work Practice—address the principles that guide ethical practice in virtual space, TMH generates novel treatment configurations and dilemmas. Research suggests that some components of therapy, such as securing informed consent, may be rendered complex by the context of TMH (Goldkind & Wolf, 2020; Malhotra et al, 2013; Sabin & Skimming, 2015). Practitioners confirm that, across virtual modalities, many of the primary protocols of mental health treatment—from contracting to safety planning to the promise of confidentiality—require active reimagining (Goldkind & Wolf, 2020).…”

“…Research suggests that some components of therapy, such as securing informed consent, may be rendered complex by the context of TMH (Goldkind & Wolf, 2020; Malhotra et al, 2013; Sabin & Skimming, 2015). Practitioners confirm that, across virtual modalities, many of the primary protocols of mental health treatment—from contracting to safety planning to the promise of confidentiality—require active reimagining (Goldkind & Wolf, 2020). It has been noted that clinicians continue to have mixed views when asked to deliver TMH services (Payne et al, 2020; Trub & Magaldi, 2017), and that practitioners feel individually responsible to negotiate the ethics of online practice, including confidentiality and the ability to manage crisis remotely (Glueckauf et al, 2018).…”

“…Clients and therapists communicate exclusively via the platform-provided channels, and the platform’s digital infrastructure allows it to assume administrative functions: keeping records, nudging therapists to respond to clients within a designated time window, billing clients, and calculating therapist remuneration. The DTCTMH model has been used to deliver mental health services for nearly a decade (Goldkind & Wolf, 2020), allowing private sector, for-profit suppliers, including Breakthrough, BetterHelp, iTherapy and Talkspace, and others, to offer “on-demand” virtual mental health services to clients across state and even national boundaries. Most DTCTMH platforms offer a range of communication options to choose from synchronous video conference or telephone, asynchronous text messaging or emails, or a hybrid.…”

“…Most DTCTMH platforms offer a range of communication options to choose from synchronous video conference or telephone, asynchronous text messaging or emails, or a hybrid. Both practitioners and clients can elect the mechanism(s) by which they connect (Goldkind & Wolf, 2020; Payne et al, 2020).…”

“…For those seeking accessible mental health treatment, tele-mental health (TMH) offers virtual access to licensed practitioners, whereas for social workers committed to clinical practice, various TMH configurations can offer a flexible and autonomous opportunity for meaningful work outside of agency settings. Yet few master's-level social work courses teach the skills required to practice in digital spaces (Goldkind, 2020), despite the growing need for professionals to understand the ethical, relational, and practical dimensions of providing mental health services in an accelerating technological culture.…”