Ethical dilemmas in online psychotherapy – a review of selected ethical codes and recommendations of psychotherapeutic and psychological associations

Until recently, only some psychotherapists have used a remote form of contact with their patients. The COVID-19 pandemic Has changed this situation, as the experience of life and health threats has resulted in many therapists choosing to work remotely with patients. Working online for psychotherapists poses new challenges and ethical questions. Many practitioners, when looking for answers to bothering questions arising from the clinical practice of working with patients remotely, look for answers in Professional codes of ethics or in the guidelines of therapeutic associations. This article is a review of 52 codes of ethics from different countries on five continents in terms of looking for norms and principles that provide an ethical framework for online psychotherapeutic work. Additionally, the guidelines and recommendations of selected Professional psychotherapeutic associations were analyzed. These societies, in additional Communications or statements, also introduce temporary ethical criteria, guidelines and good ethical practices that remotely working therapists should take into account in their work. epidemic; COVID-19; online psychotherapy; ethics, code of ethics


1.Introduction
Until recently, most people chose the profession of psychotherapist thinking that they would help patients in direct contact rather than remotely. Before the pandemic, only few therapists used remote forms of help to their patients. From a review of research by Perle and others [1] shows that before the outbreak of the COVID-19 pandemic, less than 20% of psychotherapists chose to provide therapeutic services in a remote form. Also, most of the training programs for psychotherapists were planned in such a way, that they included teaching how to work with the patient in face-to-face contact. The situation related to the COVID-19 pandemic, due to the threat to life and health and the need to maintain the safety of therapists and patients, in many cases forced the transition to a remote form of therapeutic contact. Research conducted at the beginning of the pandemic, for example by Zielona-Jenek, Izdebska, Soroko [2], shows that the number of people conducting psychotherapy in an online form increased, despite the lack of previous experience in this area, from 6% to 75%. Then, conducting online psychotherapy was a new experience for many therapists. Along with the new practice, various ethical dilemmas have also arisen in therapists: some new, and others already known to therapists who previously worked with patients Emilia Rutkowska; University of Szczecin, Institute of Psychology Correspondence address: emiliapsycholog@gmail.com in a remote form. Among these dilemmas, there are those that are similar to face-to-face work, others constitute a separate set of challenges characteristic of contact with the patient in a remote form [3].
Stoll, Müller and Trachsel [4] reviewed the existing literature on ethical issues related to the online psychotherapy. Based on the analysis of 249 publications, they identified the 5 most important ethical dilemmas regarding conducting psychotherapy in a remote form, which, regardless of the pandemic, accompanied therapists choosing this form of work. These included concerns about: "(1) privacy, confidentiality, and security issues; (2) the therapist's competence and the need for special training; (3) communication difficulties occurring in remote communication; (4) research gaps and (5) emergency issues".
The dilemmas regarding privacy, confidentiality and security included: whether the communication tools and software used by therapists are sufficiently secure, or how to verify the patient's identity, etc. When it comes to the therapist's competence in online psychotherapy, there were dilemmas in the literature relating to: to what extent the substantive competences possessed in the field of conducting face-to-face therapy translate into the ability to conduct psychotherapy in a remote form; or questions about whether therapists conducting psychotherapy in a remote form have sufficient technical and IT competences to conduct it effectively, or whether online therapy is an effective and effective method. Among the dilemmas regarding communication difficulties, the authors mention questions about whether the lack or limitation of non-verbal messages, much more accessible to the therapist in a direct meeting, can lead to misunderstandings in the psychotherapist-patient relationship. The researchers point out that some therapists have indicated that they lack knowledge about the effectiveness of online psychotherapy compared to direct contact psychotherapy, or there is a research gap in this area. Some therapists also emphasized ethical dilemmas associated with various emergency situations: e.g. technical problems related to conducting online therapy such as: sudden interruption of contact, or doubts related to working with patients in a situation of danger, e.g. suicide [4].
Due to the widespread use of remote psychotherapy during the COVID-19 pandemic, the described problems may have been experienced by more therapists. Certainly, these dilemmas are solved differently by therapists. The aforementioned analyses carried out by Zielona-Jenek, Izdebska, Soroko [5] show that some therapists independently develop solutions to ethical issues bothering them, while some seek guidance from authorities: individual opinions of supervisors, but also norms codified in ethical codes and recommendations of professional psychotherapeutic associations. Codes of ethics contain standards whose observance is obligatory and may be accompanied by enforcement mechanisms, while the guidelines recommend some behavior to facilitate professional development and foster a high level of professional practice [6]. Hence, in search of ethical standards relating to conducting psychotherapy in a remote form, ethical codes and recommendations of selected professional psychotherapeutic and psychological associations were analyzed.
The analysis of 52 codes indicated that only 5 of tchem have detailed records and regulations relating to online psychotherapy. The others do not relate to this form of work directly. Some associations, despite the fact that there are no such provisions in the codes of ethics, have issued separate ethical recommendations relating to this form of work. These include, for example, the American Psychological Association [6], the American Counseling Association [59], the Canadian Psychological Association [60], the European Association for Psychotherapy [61,62] and many others.
The others do not refer directly to this form of work. Some associations, despite the fact that there are no such provisions in ethical codes, issued separate ethical recommendations regarding this form of work. These include, for example: American Psychological Association [6], American Counseling Association [59], Canadian Psychological Association [60], European Association for Psychotherapy [61,62] and many others.
The following codes of ethics refer directly to online psychotherapy: American Counselling Association [34],Psychotherapy and Counselling Federation of Australia [55], Canadian Counselling and Psychotherapy Association [36], All-Russian Professional Psychotherapeutic League [28], Association for Counselling and Therapy Online [9], British Association for Counselling and Psychotherapy [8].
None of the fifty-two current codes reviewed, reported that online therapy could be an unethical form of work. However, interestingly, such information was included in the no longer binding (expired in 2006) code of ethics of the Colombian Psychological Association [49, standard 13.6]. The code contained a paragraph saying that "psychotherapy may under no circumstances be carried out by telephone, post, internet or any other similar method.". This information can be treated historically. More than 20 years ago (this code came into force in 2000), the technology was not so developed, and as a result, there were no scientific studies verifying the effectiveness of this method. However, this shows us that this is a relatively new form of work that also presents an ethical challenge.
Despite the specificity of work during remote therapy, it should be remembered that all ethical principles relating to face-to-face psychotherapy also apply in online psychotherapy [51, Standard 13], which should be carried out with due diligence, not less than in the case of face-to-face therapy [28, standard 10].
In most codes of ethics, which included a detailed reference to online psychotherapy, the rules contained in them indicated what to do to make the therapy conducted in this way ethical. These principles related to two aspects: what concerns the therapist and what concerns the patient.
Among the recommendations regarding the therapist, firstly, it seems important that the psychotherapist has competence in the field of conducting online therapy. The various codes emphasise three types of competence: (1)  Technical competences are related to the ability to use software and basic IT knowledge, which is the basis for conducting online therapy.
When it comes to knowledge about the specifics of online psychotherapy, it is important for the psychotherapist to be aware that distance therapy is different from face-to-face psychotherapy and what this difference is about [28, standard 10; 34, standards H and 4Ł]. Knowledge about the specificity of online therapy is also associated with knowledge of the latest clinical research in this field, since the psychotherapist should use online psychotherapy based on solid research foundation [36, standard H4]. However, if therapists make decision to implement new technologies or solutions, that are not sufficiently researched, then the choice of these solutions should be based on a reliable clinical judgment and at the same time should be able to justify his choice [36,Standard H4].
The aforementioned codes of ethics recommend that the psychotherapist should constantly develop his knowledge and skills in the field of online therapy [34, standard H1], and this is recommended to undergo appropriate training in the field of remote therapy [36, standard H4; 8; 55]. Of course, it should be remembered that a competent therapist is a person who is aware of his own limitation and competences [9, standard B], and what is associated with this, uses supervision [9, standard B].
Knowledge of the legal regulations applicable in the field of online psychotherapy, according to the codes of ethics, includes the therapist's awareness that engaging in remote psychotherapeutic work may lead to the fact that the therapist may be subject to laws and regulation of both the therapist practicing location and the client place of residence. Therefore, the therapists hould be aware of the legal differences between these two countries. [36, standard H7; 34, standard H1, B; 9, standard O].
In addition, when it comes to the formal and organizational aspects of online psychotherapy, it is recommended that the therapist has taken out professional liability insurance covering this form of work [9, standard M].
Secondly, a very important issue raised in the codes of ethics regarding online psychotherapy is the issue of online safety. Codes of ethics point out that online psychotherapy is fraught with a higher risk of violating the confidentiality and security of patient-therapist contact and it is difficult to offer the same level of confidentiality as in face-to-face contact [28, standard 10A]. Hence, the therapist should take care of the necessary digital security to protect the privacy and confidentiality of clients.
At the same time, he/she should inform the patient about confidentiality restrictions resulting from authorized and unauthorized access to internet transmission) [34, standard H2, B, I].
Related to confidentiality is the subject of customer identity verification in order to prevent mistakes and fraud. Code of ethics of the American Counselling Association [34, standard H3] points out to psychotherapists the need to verify the identity of clients at the beginning of therapy and throughout the therapeutic process.
Among the recommendations relating to the patient, codes of ethics indicate that the patients have the right to choose the form of therapy: whether he prefers to work face to face or remotely and therapists should respect this right [28, standard 10C; 34, standard H2, A). At the same time, the therapist's duty is to check whether the patients able to work therapeuti-cally online, due not only to his technological skills, but above all to emotional and intellectual functioning [34, standard H4, B; 9, standard D1). Such an assessment should be made by the therapist not only at the beginning of the therapy, but he or she is also obliged to monitor the effectiveness of online therapy on an ongoing basis, and if such interactions are found to be ineffective, they should switch to face-to-face contact or the patient should be referred to another therapist who is able to do so [34, standard H, D4].
The provisions of the codes of ethics show that it is very important that the patient, when deciding to user emote therapy and giving his informed consent to it, is aware of the fact that: (1) such therapy is burdened with a higher risk of violating the confidentiality and safety of contact [

Some guidelines and good practices for conducting online psychotherapy included in the temporary guidelines and recommendations of selected psychotherapeutic and psychological associations
In addition to ethical codes containing standards on how to proceed and which are mandatory, professional associations also issue guidelines aimed at suggesting or recommending specific professional behaviors in order to help ensure a high level of professional practice by psychologists. [35].
The same is also true in the field of online psychotherapy. In addition to the provisions on online therapy in ethical codes, a large number of professional associations have issued various communications, statements, temporary ethical guidelines, or guides to good practices in online therapeutic work. The information they contain can be divided into three groups. The first group consists of ethical principles similar to those that are placed in ethical codes, but due to the fact that online psychotherapy is a relatively new, still developing field, this information has not yet been permanently added to the ethical codes of individual associations. The second group includes guidelines for specific problems characteristic to the use of remote psychotherapy. The third group is specific, detailed and practical advice on good practices in online psychotherapeutic work.
This article presents selected guidelines and recommendations that will in a practical way relate to the ethical standards described above, and thanks to which it is possible to obtain guidelines on how to implement these ethical standards in practice.
The first group of guidelines concerns the competences of the psychotherapist: in technical field, concerning knowledge and legal regulations.
The American Counseling Association [34], in its guide to conducting online psychotherapy, specifies in detail how a therapist should take care of technical considerations during an online session. First, the society pays attention to the therapist taking care of the Internet speed and bandwidth so that it would not be an unnecessary factor disturbing the session. In addition, this guide indicates that it is also worth taking care of a professional side of video framing during the session, as careless framing can be a distraction during the meeting. The guide suggests that the camera should be directed forward, directly at the therapist (not from below or at distorting angles) and recommends that you make sure the image is stable (e.g. by getting a tripod).
Another aspect is the issue of competence, skills and knowledge of the psychotherapist in the field of conducting online psychotherapy. Canadian Psychological Association [60, standard II.2] emphasizes that psychologist should undertake remote work only with the types of patients and reported problems with which they have previous experience in personal work. Of course, they should also expand their knowledge of the specificity and psychological aspects of online psychotherapeutic work [60, Standard II.1], which is similarly indicated by other societies [6]. Some guides try to indicate which aspects of psychological knowledge related to online psychotherapy psychotherapists should pay special attention to. For example, the European Association for Psychotherapy [61] in its guidance on online psychotherapeutic work prepared by the former president of this association Rhodes [61] indicates that any therapist who works with patients remotely should be aware of the fact that people behave differently on the internet than in reality. Rhodes [61] points out that younger people ('digital natives') who grew up in a reality in which the internet has always accompanied them, cope better and more naturally with the situation of remote therapy compared to people who had to learn to use the internet later in life. In addition, he also points out that contact with a therapist can modify the behavior of patients in such a way that they are more inhibited and behave less naturally than in the therapy room, while others are more disinhibited, open up very quickly and reveal much more information about themselves than they would do during a live session, which is referred to in the literature on the subject as "the online disinhibition effect " [63].
Similarly to ethical codes, also in the practical guidelines of therapeutic associations, one can find references to the need for a psychotherapist to take care of his / her own competence in the field of legal aspects of the services provided [60,61]. It is recommended to know the physical lo-cation of each client [59] in order to be aware of the legal order in which the client operates and the regulations that may apply to the therapist's work. As the therapist and patient may operate in different jurisdictions, the British Association for Counseling and Psychotherapy [64] suggests in its guide to good practice in online psychotherapy that the settlement of any contractual disputes will be considered in the legal system specified for the place where the psychotherapist practices.
Another important issue raised in the recommendations and guidelines of therapeutic societies is the need to ensure security and confidentiality on the internet. The British Association for Counseling and Psychotherapy [64] identifies four reasons for the most common network security problems, which include: (1) physical intrusion, (2) electronic intrusion by third parties, (3) electronic intrusion by the online communication provider and (4) electronic surveillance by national security services.
Protection against physical intrusion means caring about not being overheard during the session, as well as taking care of the proper protection of passwords to the computer or to the programs used.
Electronic intrusions usually is caused by the use of inadequate virus protection, unprotected Wi-Fi network, inadequate passwords and encryption of services provided, inadequate firewalls, which creates the risk of security systems being by passed by third parties, possibly by the use of spyware or codebreakers, that may be readily available on the internet. Some psychologists also use free online services that often lack adequate safeguards and offer low levels of privacy protection, making the mythically inappropriate for online work. Thus, good practices to prevent third party intrusion include: password protection, encryption of services provided, regular updating of firewalls, adequate antivirus protection.
Electronic intrusion of a communication service provides to some extent inevitable when using platforms or applications that enable online communication. When choosing a program, it is worth carefully reading the regulations of potential service providers, in particular their approach to privacy and security. Especially when using free versions of programs, security issues should be taken into account in a special way, because often the advantage of these programs is that they are free, but a clear disadvantage may be that you have to agree to violations of privacy, which you do not necessarily want.
The British Association for Counseling and Psychotherapy [64] points out that electronic surveillance by national security services is a feature of contemporary life, while the practice varies between countries in how they balance the protection of public safety against electronic intrusion on private communications.
When it comes to threats to privacy and confidentiality, the therapist should also be sensitive to the client's care of this issue. The American Counseling Association [59] recommends that the therapist should expect the patients to find a time and a private and safe places, that they can focus only on their session. The European Association for Psychotherapy [61,62] points out that it should not be a public place (eg a restaurant) and that no one will be able to overhearthe conversation or see the screen. It is also recommended to remind patients to remove traces of the search for a therapist from their browsers.
In addition to the actual privacy, the perceived privacy is also very important. This is pointed out by the American Counseling Association [59] in its recommendations, saying that even if the therapist has taken care of privacy, in some situations the client may be afraid that this privacy is not properly cared for, basing on the therapist's camera view. Therefore, it is worth paying attention to additional details, e.g. that the door to the room the therapist is talking in, is closed, even if there is no one else in the clinic, because it gives the patient a sense of greater comfort. For similar reasons (but not only), it is also worth using headphones during the session (to increase privacy and prevent third parties from hearing parts of the session).
A good practice when working with patients is not only to take care of perceived privacy, but also professionalism. The Polish Psychiatric Association [65] indicated in its announcement that the therapist should take care of a professional image of the place from which the therapist conducts sessions ("the therapist should not reveal details of his daily life"). Hence, The Society emphasizes that it is recommended to contact client from the office from which the therapy is carried out on a daily basis.
A large part of societies also pay attention to the stage of initiating therapy and diagnosis. At this stage, it is important to assess your own competences as well as qualify the patient to work online. As for the general principle with which patients it is ethical to undertake work online, the Polish Psychiatric Association [65] recommends working with patients in a remote form, with whom "failure to start therapy may carry a greater risk than starting therapy in a remote form. In addition, the society recommends "to accept for remote therapy rather such patients who in the future are prognosis for the transition to personal contact". If the psychologist feels that the client would benefit better from face-to-face services, then according to the Canadian Psychological Association [60, Standard II.10,] he should refrain from providing such services and refer the patient to a person who could work in direct contact with the patient [60]. It is important that: "the possible convenience of the therapist and financial benefits of providing online services never outweigh the well-understood interests of patients" [60,Standard III.2].
The European Association for Psychotherapy [61] points out that a psychotherapist qualifying for remote therapy should in particular assess the psychological profile of the patient, paying attention to the diagnosis of the personality structure, including the possibility of the patient having personality disorders), as well as other mental health problems (mood disorders, including depressive disorders, substance abuse, significant thinking disorder ssuch as delusions) and this, to what extent the patient is particularly affected by issues such as: risk of suicide and self-harm, threat of violence. It is not always possible to make such a diagnosis via the internet, which is why, according to the Canadian Psychological Association [60,standard II.4] "the therapist should carry out such a diagnosis in direct contact or refer for the diagnosis to another specialist who has the opportunity to meet the patient face to face".
The Canadian Psychological Association[60, Standard II.6 and II.7], the American Psychological Association [6] and the British Association for Counseling and Psychotherapy [64] suggest that at the stage of signing the contract with the patient, the therapist should include information on how to proceed in emergency situations. The psychotherapist should provide the patient with contact to psychologists and psychotherapists located in the immediate vicinity of the patient, the address of the hospital to which an emergency can be reported, emergency telephone numbers. It is worth for the therapist to know whom to notify in an emergency. Additionally, the APA [6] recommends that patients at risk of suicide should receive written instructions on what to do in case of suicide risk.

Summary and conclusions
The above review of ethical codes shows that although the pandemic has been going on for almost two years and quite a large group of psychotherapists use online psychotherapy, not all ethical codes have been supplemented with information on what is ethical behavior and what is not in this form of work with the patient. In some cases, work is underway to update the codes, in others, professional societies have issued separate recommendations on what is ethical in conducting online therapy.
It can be said that historically online psychotherapy has not always been treated as an ethical form of psychotherapy [49], although even today some societies believe that "only personal contact between a psychotherapist and a patient fulfills the canon of good clinical practice" [66]. Positions denying online therapy seem to be somewhat extreme nowadays, but they should not be dismissed as it is an important voice in the discussion on the importance of the face-to-face relationship with the patient. It is true that a large part of research [67] indicates that online therapy has similar effectiveness compared to faceto-face therapy, but it should be noted that the direct relationship is a unique relationship, perhaps elusive in some research measures. And the question arises that since the psychotherapeutic relationship is often compared to the guardian-child relationship, is it possible to be a "good parent" only by phone or the internet, is it possible to "be a good therapist" only via the internet? From the observation of close relationships, we know and feel that it is not entirely possible to be a good parent, but only by a remote presence. Since the parental relationship metaphor is often used to analyze the therapist-patient relationship, perhaps such a metaphor draws some attention to the difference between personal and remote therapy.
On the other hand, nowadays online therapy has become a very common phenomenon and it is not as rare as it was two years ago [5], which is why nowadays those codes that refer to online therapy do not so much question whether the therapy online is ethical in general, but they relate to what to do to make online psychotherapy conducted in an ethical and serving way for patients. It seems that such provisions in ethical codes are necessary and valuable. Many therapists have various dilemmas and questions with the practice of online therapy, and it is worthwhile for professional codes of ethics to give guidance on what aspects of online therapy should be considered. Some of this information is included in additional guidelines and information published by psychological and psychotherapeutic associations, however, its shold be noted that perhaps not every therapist knows the detailed recommendations of various therapeutic societies (especially those to which they do not belong) regarding online therapy, while the code of ethics is the basic document, that every therapist needs and must be familiar with.
At the same time, it should be emphasized that the issue of online psychotherapeutic work is also a relatively new area of psychotherapy practice and many of its aspects are still at the research stage, hence not all ethical dilemmas currently have an answer. In addition, this area is dependent on constantly changing technologies and therefore the knowledge relating to some aspects of online psychotherapeutic work is constantly changing and what was up-to-date at the moment and what appears now in the recommendations of psychotherapeutic societies may be soon out of date. It should also be noted that we live in the times of the COVID-19 pandemic, where we face a threat to life or health in the event of contracting the coronavirus, therefore, in the face of such a threat, the protection of this value becomes a more priority and for some to the fear of infection, online psychotherapy has become "a little less evil". It should also be noted that along with pandemic situation, the recommendations of psychotherapeutic societies or even state regulations are changing. For example, in Germany [68], until some time ago, psychotherapy could be conducted with the use of ICT techniques only when there was a personal contact before (for the purpose of an initial diagnosis), while treatment in anacute cris is situation or online group therapies were not allowed. Currently, these regulations have been relaxed due to the exeptional and unprecedented situation of the COVID-19 pandemic.
An additional issue, not discussed in this article, is the issue of compatibility of online therapy with therapeutic modality, which was not the subject of the analysis, but seems to be an interesting issue that requires further research.