Accompanying the provision of psychotherapy is an obligation to practise ethically and to maintain the safety of both therapist and client. While the profession has a comprehensive understanding of the ethical considerations for face-to-face psychotherapy, unique and evolving ethical considerations are emerging for providing video-based therapy (VBT).
Online therapy as a practice is difficult to define, since the term has been applied to different technologies over the years and used interchangeably with other terms such as cyber therapy, e-therapy, teletherapy or telehealth, depending on the decade or context. Telehealth is applicable across different health and psychotherapeutic disciplines as a comprehensive platform for delivering health services ranging from consultation and evaluation to preventative and therapeutic services (Cason, 2014). In the literature, online therapy and its synonyms refer to psychotherapy conducted both synchronously and asynchronously between a therapist and client, via all mediums of electronic communication such as phone, email, application-based, and live video.
The inclusion of VBT in the last 15 years is a notable addition to other forms of online therapy which are limited to either written or oral communication and are unable to include the visual experience of face-to-face therapy. VBT, in this sense, is the closest mimic of face-to-face therapy (Swenson et al., 2016). VBT also occurs in real time (synchronous), while other types of e-therapy can be asynchronous, for example, email or texts. The authors use the term “VBT” for synchronous therapeutic practice using video-conferencing technology. This is an important distinction since the ethical issues pertaining to synchronous therapy may differ from asynchronous methods. Early research on the ethical concerns of online therapy adopted a common approach of adapting established ethical concerns of face-to-face therapy to “fit” the delivery of online therapy rather than identifying the unique ethical challenges of delivering VBT.
Childress (2000) explored the possible ethical issues arising from email communication with clients by adapting the traditional ethical concerns of face-to-face therapy to fit the online mode of communication. His definition of online therapy concurs with that of Bloom (1998), that is, it emphasises email. The main concerns Childress (2000) raised are confidentiality and data safety, and he discussed a need to ensure encryption software is accessible to clients as well as practitioners. Stiles-Shields et al. (2014) took a similar approach, first discussing the efficacy of therapy in general and the obligation of the therapist to provide beneficial and appropriate care for the client, and then, in relation to competence and efficacy, asking whether a therapeutic relationship could be established online as strongly as it can be for traditional forms of therapy. Their research suggests that online care can, in fact, establish a strong therapeutic relationship comparable to that of face-to-face therapy and that no evidence exists to support questioning the efficacy of online care.
Hilgart et al. (2012) provided a thorough exploration of what they considered the main ethical factors in providing online care. However, these considerations pertain to all forms of web-based (defined as self-help through a structured website platform) or online therapy (therapeutic communication of any form between therapist and client via the internet). The main areas of concern mentioned by Hilgart et al. (2012) are efficacy of treatment, informed consent and documentation, identification of the client, privacy and confidentiality, communication barriers (particularly in the case of written-only communication), and appropriateness of online treatment. While this provides therapists with a broad understanding of some ethical concerns of delivering online care, it fails to offer guidance to the practitioner on the ethics of using VBT to deliver psychotherapy.
Drum and Littleton (2014) focused specifically on the ethics of boundaries in online therapy and provided suggestions on how to maintain clear boundaries, particularly when employing VBT. They suggested that VBT may allow a snapshot of access into the home, if that is where either party resides (as has become the case through a global experience of lockdowns). This sense of increased intimacy could potentially cause either the client or therapist to behave in a traditionally (and ethically) inappropriate way. Therefore, maintaining boundaries during VBT requires a fine balance for which clear guidelines and advice are necessary. Furthermore, the increased perception of accessibility to therapeutic contact (that is, plausibly, the client can contact the therapist at any time, from anywhere) means that therapists must be vigilant in setting distinct boundaries that describe what contact is appropriate to protect the therapeutic frame of the relationship. A more physical consideration of boundaries is the geographical location of the therapist and client. Given different licensing protocols across countries and regions, it is necessary to consider whether it is ethical to practise across geographical locations (Drum & Littleton, 2014).
It is evident from the research discussed above that, commonly, ethical guidelines are simply adapted from prior contexts for application to the delivery of therapy via an online platform, including self-guided web-based programs and email contact, rather than having been specifically considered for online therapy. Moreover, in relation to research that focused on online therapy, few studies specifically focused on synchronous VBT. Given the importance of VBT as a close mimic of face-to-face therapy and its rapid uptake over the last 5 to 6 years (particularly throughout the COVID-19 pandemic, during which VBT has become a necessity), it is worth reviewing emergent and unique ethical issues related to the delivery of VBT. The authors selected 2015–2021 to situate the review in a contemporary context and capture any changes in ethical considerations during this time, including during the emergence of a COVID-19-related uptake of VBT.
Method
Data Sources
This systematic review has been written in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (Liberati et al., 2009). Given the nature of the research topic, the key databases used were PsychINFO, Medline (via EBSCO host), Cinahl (via EBSCO host), and SCOPUS. We used the following search terms: Ethic* OR issue* OR “ethic* consideration*” OR boundar* OR guideline* OR “ethic* concern*” OR “ethic* dilemma*” OR “ethic* principle*” OR “ethic* challenge*” AND “online therap*” OR “e therap*” OR Etherap* OR “video therap*” OR “video conf* therap*” OR telepsychotherap* OR telepsychology. Searching was limited to the publishing data criteria of 2015–2021. An alert was set up with PsychINFO using these search terms so any new publications that met the selection criteria would be identified.
Eligibility Criteria
To define the inclusion and exclusion criteria, the parameters shown in Table 1 were set.
Study Selection
Studies were excluded at the title level if they did not mention either online therapy in general or VBT. Titles that mentioned ethical considerations but not in the context of any form of online therapy were excluded. Inclusion at the title level required mention of online therapy and some indication that ethical considerations or challenges of providing online therapy were discussed. The third author (W) screened 550 titles, 131 of which proceeded to the abstract-screening stage. Of these 131 titles, 47 duplicates were removed, leaving 84 study abstracts to be screened. At this point of the study selection, two researchers (DP and W) screened the abstracts, and subsequently the full texts, independently of each other and reached consensus for inclusion through discussion at both the abstract-screening level and the full text–screening level.
Articles were included at the abstract level if they discussed both VBT and the ethical considerations of providing therapy through this platform. In the case that they mentioned VBT along with other forms of online therapy, articles were still selected for full article screening if a consideration of ethics was also indicated. Studies were excluded if the abstracts failed to mention ethical considerations and/or VBT specifically. Through full-text screening, only articles that discussed the ethical considerations of providing therapy through VBT were included. Other forms of online therapy could also be discussed; however, VBT was required to be clearly discussed in its own context. Articles were required to be published in English, and any type of research design was eligible for inclusion. From this process, 15 articles were selected for inclusion. This process is illustrated in Figure 1.
Data Analysis
Given the qualitative nature of the studies included in this research, it was not feasible to perform a meta-analysis of the data (Denison et al., 2013). Three steps were followed in the synthesis and analysis of data. First, we performed a narrative synthesis of the key findings of each study (results are captured in Table 2). Second, we conducted thematic analysis of the key findings, as guided by Purssell and Gould (2021), which entailed generating themes that were closely linked to the studies reviewed. Third, we developed the final themes which incorporated the interpretations of the findings by the authors of the reviewed articles; this formed the basis of the focus areas for practice included in our discussion (Thomas & Harden, 2008). One author (W) wrote the synthesis and conducted the thematic analysis, and then the authorship group discussed the themes using examples from the analysed texts to support selection of the final themes.
Results
Articles were grouped based on the key ethical considerations discussed in each study. Table 2 briefly describes the main findings and characteristics of the 15 studies informing this systematic review and illustrates similarities across the main findings. Eleven studies reviewed were literature or narrative reviews and the remaining four consisted of a systematic review, a case series study, a qualitative study, and a personal account. While there was diversity of geographical locations in which each study had been based, most studies had been conducted in a Western context. Studies that focused on a specific geographical location included Alqahtani et al. (2021), specific to Saudi Arabia, De Sousa et al. (2020), specific to India, and Neven (2020) specific to Australia. Most studies were published in either 2020 or 2021, and only three were published prior to this, either in 2016 (Swenson et al., 2016) or 2015 (Gamble et al., 2015; Kotsopoulou et al., 2015).
Research Aims Across Studies
Seven of the studies shared a general aim to provide guidelines for best ethical practice in online therapy, including or specific to VBT, and focused on geographical regions (Alqahtani et al., 2021); specific client populations (e.g., neuropsychology and rehabilitative therapy; Bilder et al., 2020; Scott et al., 2021; Wells et al., 2021) or at-risk clients (Johnson & Aldea, 2021); mode of delivery (Haydon et al., 2021); or COVID-19 related uptake of telehealth (Hames et al., 2020; Scott et al., 2021). Haydon et al. (2021) produced the most general guidelines for online services, specifically focusing on video-based practice, and Johnson and Aldea (2021) directed their guide towards practitioners working with at-risk clients. Meanwhile Wells et al. (2021) produced a guide on rehabilitative psychological and neurological practices, although their findings were still generalisable to other psychotherapeutic contexts.
The remaining eight articles shared an objective to provide an overview of the main ethical considerations of VBT practice, and there was significant overlap between the studies regarding key issues. Security and privacy, particularly relating to data safety and software security, was a major consideration (De Sousa et al., 2020; Gamble et al., 2015; Kotsopoulou et al., 2015; Swenson et al., 2016). The increased risk to the limits of confidentiality, and the requirement to communicate this to the client prior to therapy beginning, was a concern shared by four of eight studies (Gamble et al., 2015; Kotsopoulou et al., 2015; Muir et al., 2020; Swenson et al., 2016). Safety issues and emergency protocols were also repeatedly addressed (De Sousa et al., 2020; Pierce et al., 2020; Sansom-Daly et al., 2020). Prior to engaging in therapeutic practice, therapists should address the suitability of VBT for clients (Sansom-Daly et al., 2020; Swenson et al., 2016) to ensure client safety. While accessibility and the potential for VBTs to reduce access inequity was highlighted as a key consideration (De Sousa et al., 2020; Muir et al., 2020; Pierce et al., 2020), concerns about the legalities and logistics of providing services across geographical and legislative boundaries remained persistent (Muir et al., 2020; Pierce et al., 2020; Swenson et al., 2016). A need for cultural competency was addressed by De Sousa et al. (2020) and Swenson et al. (2016), and the access that VBT provides to therapists with appropriate cultural experience and backgrounds was discussed by Pierce et al. (2020). Finally, concern about maintaining appropriate boundaries was also expressed, along with suggestions on how to achieve this (De Sousa et al., 2020; Neven, 2020; Swenson et al., 2016).
Themes
Four key themes (see Table 3) were identified from the narrative synthesis captured in Table 2: the application of traditional ethical concerns in video-based therapies, unique security and data safety concerns related to the use of video and streaming technologies, the establishment of clear boundaries and considerations of working online prior to therapy beginning, and the accessibility and suitability of video-based care.
Theme 1: Applying Traditional Ethical Concerns in Video-Based Therapies
Most of the studies reviewed discussed how traditional ethical considerations in therapeutic practice are also applicable to video-based service delivery. Such considerations include confidentiality, safety, security and/or privacy, competency, and processes of gaining informed consent. Some authors suggested that although these traditional ethical concerns are still relevant, they might present in a more complex way in VBT and require more thoughtful consideration by the practitioner (Bilder et al., 2020; Gamble et al., 2015). Factors that increase the complexity include the unpredictability of client conditions (e.g., having others in the room off-camera) and the use of technology posing a greater threat to security and privacy.
Consent was a particular area of interest across the findings in the studies since it was linked to the question of evidence of video-based care efficacy compared with face-to-face care. Haydon et al. (2021) highlighted the importance of therapists meeting their ethical obligations related to consent, which is amplified by the virtual and physically distanced experience. Suggested actions included obtaining written consent prior to therapy beginning and preparing the client for the process of VBT either in person, before video sessions begin, or through written documents (in the client’s language; Scott et al., 2021). Informed consent processes for VBT differed from processes for face-face therapy; for instance, in the VBT context, therapists must explain the increased risk of confidentiality and privacy violations, in addition to any potential legal limitations of VBT or test results (Bilder et al., 2020; Scott et al., 2021).
Kotsopoulou et al. (2015) explored whether efficacy was a particularly important comparison in the context of online therapy versus no therapy offered at all. Their findings highlighted the importance of client consent for VBT, which included a specific disclosure of the lack of evidence-based research to confirm the efficacy of the treatment, before engaging with the client. However, no other studies cited efficacy of VBT as a cause for concern, and it is generally understood that video-based care has high efficacy (Stiles-Shields et al., 2014). However, research into the efficacy of online therapies continues to be important as an ongoing concern since VBT is considered the best replacement for face-to-face therapy (Swenson et al., 2016).
Theme 2: Security and Data Safety Concerns Related to the Use of Video and Streaming Technologies
The complexity of using a digital technology platform to deliver psychotherapy through video-based services requires additional consideration of cyber security and data safety. This was mentioned in many of the studies reviewed, but in more detail by five of the studies. Specific concerns included ensuring safe digital data storage (De Sousa et al., 2020; Gamble et al., 2015; Hames et al., 2020), the confidentiality of video-based practice (Kotsopoulou et al., 2015), and general privacy relating to technology (Swenson et al., 2016).
Discussions mostly focused on the safe storage of digital data (Gamble et al., 2015), the importance of using encrypted software, and storing any data on a private, password-protected computer to ensure risks are mitigated (De Sousa et al., 2020). Kotsopoulou et al. (2015) also described issues of security and its relationship to confidentiality in relation to VBT. Swenson et al. (2016) extended their discussion to include the concept of online privacy in general and encouraged therapists to respect the client’s right to online privacy and understand that their virtual relationship does not extend past video consultations.
Theme 3: Prior to Beginning Therapy: The Establishment of Clear Boundaries
The significance of establishing clear boundaries between the client and therapist was emphasised by seven of the studies reviewed (Alqahtani et al., 2021; De Sousa et al., 2020; Gamble et al., 2015; Haydon et al., 2021; Neven, 2020; Pierce et al., 2020; Wells et al., 2021). While the importance of therapeutic boundaries extends to many areas of the therapeutic alliance, specific considerations were raised that are useful for understanding how this applies to VBT. These include the establishment of emergency protocols and management of the client and therapist’s physical locations in a safe and timely manner.
Establishing emergency protocols prior to therapeutic engagement with the client provides a robust frame to manage technological failure or physical intervention to ensure the client’s safety, local to where they are. Pierce et al. (2020) and De Sousa et al. (2020) argued that establishing emergency protocols is essential for upholding the ethical obligations of the therapist and provides a safety net to balance the risk of the therapist being unable to reach the client because the therapist is in a different physical location.
The management of boundaries in face-to-face therapy is easily facilitated using a physical room and location because this automatically establishes a professional environment. Neven (2020) discussed that VBT requires more consideration of the virtual space, in which boundaries, confidentiality, and privacy might potentially be compromised by the presence of other people in the client’s space. Clear boundaries are crucial, too, for managing the presentation of issues such as transference, which might be amplified in VBT because of perceived familiarity and proximity to the therapist and difficulty reading body language (Neven, 2020).
Theme 4: Accessibility and Suitability of Video-Based Care Versus Face-to-Face Care
Given the flexibility of location that VBT provides, considerations of accessibility are highly relevant, particularly in relation to the potential to increase accessibility to care. However, although it may appear possible to provide all clients with access to video-based care, therapists have a responsibility to assess the suitability of video-based care to ensure client safety and that all ethical obligations relating to the client’s treatment can be met. Five of the studies reviewed (Bilder et al., 2020; Hames et al., 2020; Kotsopoulou et al., 2015; Pierce et al., 2020; Sansom-Daly et al., 2020) explored some of the specific considerations in assessing the suitability of VBT for the client, which include working with vulnerable populations, regulatory and legal issues, and the importance of client context.
Bilder et al. (2020) and Haydon et al. (2021) raised the issue of access inequity as a main ethical concern, mentioning issues for both older people who are less technologically adaptable and lower socio-economic populations who may have limited access to the required technologies. Wells et al. (2021), too, suggested that for older and rural populations, the use of technology may create issues in the accessibility of care. Contrastingly, Pierce et al. (2020) found that for a variety of groups, including rural populations and those with different cultures and languages, VBT can indeed increase accessibility to care from most practitioners based in the client’s geographical area given that the client does not need to travel beyond their local area to seek care.
Research by Sansom-Daly et al. (2020) suggested that a broader consideration of the client’s personal context will assist the therapist to determine whether VBT is suitable and to tailor a treatment plan and safety protocols specific to the client. Hames et al. (2020) suggested the therapist must consider the needs of the client based on the client as an individual. Older clients, for example, may require more detailed instructions on how to use video technology, while young children may need assistance from parents to set up and concentrate online.
Discussion
While the adaptation and application of traditional ethical considerations of face-to-face therapy to VBT is the most common way in which therapists attempt to maintain a good level of ethical practice, unique ethical challenges in delivering VBT emerged in the findings of this review. Ethical considerations specific to VBT include paying particular attention to the technological aspects of VBT, such as safe digital data transmission and storage, online privacy, and security considerations; when to establish the therapeutic frame, boundaries, consent, and emergency protocols; and the complexity of suitability and accessibility to VBT in the specific context of each client.
The themes identified in this study provide useful focus areas for best practice and for therapists beginning or training in VBT. While there was significant overlap across the 15 studies included in terms of what each study considered to be the main ethical considerations of video-based care, no one study offered a consolidated guide to the particular focus areas of ethical practice in delivering VBT. These focus areas comprise client privacy and data security, consent and safety processes, maintaining appropriate boundaries, and accessibility and suitability.
Client Privacy and Data Security
VBT creates a unique situation for the therapist of managing two therapeutic rooms instead of one. The set-up of both rooms must be considered when ensuring confidentiality and privacy because the therapist and client are both restricted by the scope of the camera lens. In addition to considering two physical locations, the transmission of electronic data via live-streaming is also unique to video-based care and emphasises the therapist’s responsibility to use safe technology, given the increased risk to client data (Gamble et al., 2015), and to encourage the client to do likewise.
Consent and Emergency Protocols
Additional and unique consent processes are required before delivering VBT. Consent agreements must include unambiguous information about the limitations of VBT, technology failure protocols, and emergency protocols in situations of increased risk to the client given the potential barrier of geographical distance between client and therapist.
Maintaining Appropriate Boundaries
Maintaining appropriate boundaries in VBT is challenged by the unpredictability of the client’s context and location and the associated informal and social nature of online contact. Prior to online therapy, the therapist must establish a professional and therapeutic frame similar to that established for face-to-face therapy and ensure the client is aware of these boundaries and behavioural expectations. The systems and processes by which therapists meet this ethical obligation are unique, require intentional actions, are a core aspect of therapists’ competence, and in turn contribute to the efficacy of treatment.
Accessibility and Suitability
Specific consideration should be given to older clients, clients from diverse cultural backgrounds, marginalised groups, and socio-economically disadvantaged populations. While VBT might appear to be an easy solution to equitable access, suitability might be a potential hinderance to equitable access, particularly under conditions in which face-to-face therapy is unavailable but VBT is not deemed suitable for the client.
Limitations and Recommendations
The focus areas identified for best practice are particularly limited in terms of cultural safety because most of the studies reviewed were conducted in a Western context. Other than general suggestions of “ensuring cultural competence”, the literature reviewed neither presents any pragmatic ways of enacting this nor guides therapists on how to do so. While this review was open to all perspectives pertaining to the ethical considerations of providing therapy, the literature largely reflected the perspective of the therapist; therefore, research that seeks to understand the perceptions of clients on the ethical issues of receiving VBT would be a valuable contribution to the literature.
Conclusion
Ethical practice underpins safe and efficacious psychotherapy, and delivering VBT requires therapists to engage in the consideration of additional key ethical focus areas. These comprise a specific focus on maintaining and managing digital and data safety and security, engaging in consent processes designed for VBT, setting professional boundaries, establishing emergency protocols, and assessing the suitability and accessibility of video-based care for clients, with specific reference to cultural and contextual considerations. The findings of this review also offer practical suggestions of how to apply these considerations in a VBT context to mitigate any issues that could potentially arise in therapeutic practice. This contributes to maintaining the same ethical standards in delivering VBT as required in face-to-face psychotherapeutic work.