Recently two postings on APA listservs caught my attention. In one posting, a psychologist was requesting treatment recommendations for a minor with an unusual source of psychic distress. The condition was likely the cause of considerable shame for the child, and perhaps embarrassment for the family as well. In the listserv request, the psychologist had described the family constellation, age of a sibling, and facts about the family's recent history relevant to the child's current experience. The second posting was a response to a listserv request for a consultation regarding a child's placement. The response was highly directive, calling the current placement for a child with a particular genetic disorder "inappropriate" and recommending another specific placement, in answer to a request for consultation that was very brief and provided no data other than age, current placement and disorder. Both postings offer an opportunity to consider the ethical aspects of using listservs to obtain clinical consultations.
Ethics is a developmental process. As time goes on, new ethical challenges face psychology and as a professional association we come together and think through how our principles apply in these new situations. In the absence of significant and clear harms, it can be beneficial to allow an area of psychology to emerge and develop, and so to allow the ethical questions and challenges to crystallize, before stepping in and setting guidelines or standards. For this reason, I believe the Ethics Code Task Force (ECTF) was wise to resist calls during the previous Ethics Code revision process (1996-2002) to elaborate standards regarding the Internet. Rather, the ECTF recommended language that made clear that the Internet could be part of a psychologist's professional life:
This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions. These activities shall be distinguished from the purely private conduct of psychologists, which is not within the purview of the Ethics Code (Ethical Principles of Psychologists and Code of Conduct, 2002).
At the time the code was being revised, when use of the Internet remained quite limited for many in our field, the ECTF's statement-that the Internet falls within the purview of the Ethics Code when used as part of a psychologist's professional life-was an important first step in developing this area of our ethics. As psychologists' use of the Internet has increased dramatically, we are now in a better position as a profession to begin examining the emerging ethical issues. The two postings that caught my eye suggest fruitful areas for our attention.
First and perhaps most important are the benefits the Internet offers to psychology. Listservs, as one example, are powerful tools with the ability to create large and immediate communities of colleagues who are then able to provide support and information across a staggering range of issues and professional challenges. The most cursory glance at a psychological association or division listserv will show how much helpful information is shared among colleagues each day. Our discussion of ethics must be placed in the context of how the Internet has the capacity to change our professional lives for the better.
The question then arises regarding the proper uses of the tools the Internet offers. Put most sharply in regard to the postings describing above: What are the ethical aspects of requesting a clinical consultation over a listserv? Two points seem important to consider in thinking about this question.
First, a consultation, by its very nature, is a dynamic process. A consultation involves two or more professionals engaging around a particular matter where questions, concerns and issues emerge that are addressed and discussed as recommendations are formulated. A consultation is a professional activity that requires competence in the areas consulted upon, as well as the ability to define the boundaries of the question posed and the opinions or recommendations offered. Both the consultant and the consultee should be aware that they are engaged in a professional activity, that is, the process of obtaining and providing a consultation, with that fact explicitly acknowledged by the psychologists involved.
Second, communications made during clinical consultations are governed by confidentiality, as set forth in Ethical Standard 4.06:
- 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...
Psychologists treat the relationship between consultant and consultee as a confidential relationship, and disclose information in the consultative process "that could reasonably lead to the identification of the client/patient" only if necessary and then only to the extent required for the consultation.
What can we glean from these two points-the first, about the nature of a consultation, the second, about confidentiality in the consultation process-that may inform our thinking about the ethical aspects of obtaining clinical consultations over a listserv? Several issues arise in thinking through the degree to which listservs allow the kind of dynamic process that is central to a clinical consultation. Consider, for example, whether the psychologist requesting the consultation is aware of the competence of those listserv members who choose to respond. Generally, psychologists choose consultants for their expertise and would hesitate to act on a recommendation of a consultant whose qualifications to address the relevant issues were uncertain.
Consider as well the degree to which exchanges on a listserv lend themselves to providing and obtaining the information necessary for a clinical recommendation, while maintaining the bounds of confidentiality. A good recommendation will have a solid foundation in the facts of a case; it takes surprisingly few facts to identify an individual or a family. Obtaining a client's consent for consultation conducted on an individual basis allows the psychologist to tell the client that the consultant, like the psychologist, is bound by confidentiality. Listservs are another matter entirely. The vast majority of listservs offer no more confidentiality than one could assume if giving a talk at the local library. It seems likely that most clients, if properly informed, would not want their confidential communications disclosed in such a setting.
A third consideration is ensuring that psychologists have an adequate basis for the opinions or recommendations offered as the result of a consultative process (See Ethical Standard 9.01, Bases for Assessments). Ensuring an adequate basis for an opinion or recommendation entails examining both whether the available data support what the consultant concludes, as well as clarifying the limits of what one can say based upon the data provided. Given the limits upon the extent to which a dynamic process can unfold over a listserv, and the strictures of confidentiality about what information can be provided in such a forum, clinical consultations given over listservs will likely entail significant limitations regarding the opinions or recommendations offered. As a result of these limitations, it is highly likely that a frequent recommendation will be to obtain a clinical consultation.
These points do not, of course,detract from the substantial benefits which listservs offer that entail little ethical analysis. Listservs can be enormously helpful in seeking referrals, and in identifying professionals with specific expertise in a given area or literature relevant to a clinical question. Listservs can also be very useful in identifying important clinical considerations for a given condition or disorder and in calling attention to unique complexities and important competencies in certain treatments. When postings on listservs move the focus from more general issues to discussing details of a specific individual's clinical situation, the ethical issues become significantly more complex. Our ethical scrutiny of how we use the Internet therefore rises correspondingly.
Author's note: For a discussion of requests for forensic consultations over listservs, see Joel Dvoskin's column, "Internet Consultation," in the summer 2006 newsletter of the American Psychology-Law Society
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