Online therapy sites grapple with legal, ethical dilemmas

Doc and computer
An online therapy site called Talkspace is grappling with ethical and legal issues.

Editor's note: This article has been updated to include a statement from Talkspace. 

Telehealth, online consultations and other forms of remote treatments have always been plagued by regulatory, credentialing and licensing issues. But here’s a new twist: What if the platform itself creates a barrier to fulfilling legal and ethical obligations?

The illustration: An online therapy site guarantees anonymity to its clients. But a therapist on the site learns that a child is in danger or that a patient is a danger to herself or others. By law, she is required to report the incident to authorities. But she doesn’t know her patient’s contact information, or even her name.

That's the issue a therapy site called Talkspace is grappling with, according to a Verge article. The site has sent its therapists guidelines on its confidentiality policy and told them they should ask patients for contact information or contact the site’s developers to see if they can find the information in such a situation.

But multiple former workers told The Verge they had reported a safety concern, and were denied access to client contact information.

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“Like many on-demand apps, Talkspace’s business model blurs the distinction between employee and contractor,” the article noted. “But because Talkspace is dealing in healthcare, it raises another set of questions as well: If an app dictates much of how clinicians talk with patients, and totally controls access to client records, is it just a platform? Or is it a medical clinic, and thus subject to stricter rules and liabilities?”

Talkspace co-founder Oren Frank declined to give Verge a comment, but he posted an online response, disputing the accusations and saying that it "does not accurately reflect Talkspace or the state of online therapy today."

There are clear rules for when a therapist has a moral or legal obligation to report a client to the authorities, according to Talkspace response. "Such cases are a tiny fraction of therapy users and of Talkspace clientele–but we have no hesitation in helping the therapists on our platform to contact the authorities when the law or the ethical codes require it."

The recently signed 21st Century Cures Act will increase access to telehealth services for Medicare beneficiaries. But expanding access puts more pressure on states and physicians to navigate licensing laws. Just this month, the Federation of State Medical Boards said telemedicine—and all the questions surrounding it—is one of the most important topics for 2017.

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The Verge article dug into some of these questions, outlined some of the therapy and other telehealth sites out there and paints a picture of yet another hurdle to telehealth that could offer patients greater access to care at lower costs.

Frank, meanwhile, explains how Talkspace tweaked its technical platform capabilities to address the anonymity issue. For example, it added a field to the digital therapist notes so that he or she can store emergency contact information in their online notes, rather than offline. 

But Frank also points out that anonymity isn't an issue unique to telehealth platforms.

"Should we eliminate crisis lines because we don’t know who is calling?" Frank asks. "For a certain percentage of therapy clients, anonymity is a prerequisite to getting care–they give a fake name at the therapist’s office and pay cash, or they look for another solution to protect their identity. It is our belief that those clients still need, and still deserve care–as long as the therapist can do so with the confidence that the clients is not going to harm themselves or others."