Given the pressing need for expanding behavioral health care access and options, inclusive of the opioid use crisis, there is an understandable enthusiasm for applying digital technology, including mobile phones, apps, and wearables, for improving behavioral health care and making therapy more accessible. The ubiquity of mobile phones by Americans and the growing use digital technology allows for innovations in delivering therapy that is no longer limited by the location of the users but more so by the limits of digital connectivity. The number of behavioral health therapy apps has proliferated, and many do not involve behavioral health professionals, or even humans, for that matter, in providing therapy for consumers. However, many of the ethical obligations concerning behavioral health care must be rooted in the therapist-consumer relationship. However, what becomes of professional ethical obligations when a “therapist” is a machine or an algorithm? All the while supporting technical innovations, attention must be paid to the ways that transforming behavioral health care cannot disrupt the therapist-consumer relationship and continue the professional obligations meant to provide a foundation of trust, transparency, and safety for behavioral l health care.
My concern is for Direct-to-Consumer (DTC) digital psychotherapy services that include both apps and services not mediated or overseen by a qualified health professional, such as a licensed behavioral health therapist or a psychiatrist. The primary concern is that the ethical obligations of a professional therapist are not being applied at the foundation in many cases. The areas of concern include informed consent, privacy, confidentiality, client safety and exploitation, and protection of user data, to name a few.
There are a variety of approaches for delivering DTC psychotherapy with digital technology(DT). The DTC services primarily include three areas. First, there are DT services that connect the user to a therapy (via email, text or voice) provided by a person with limited to no training in behavioral health services or no way to verify qualifications. Second, some apps monitor symptoms and communicate with a “provider.” Third, some services provide an interactive software platform (such as a chatbot or virtual/conversational agent) to provide psychotherapy.
Digital mental health services that utilize individuals with minimal or no mental health training as therapist-substitutes could be considered merely analogous to peer counselors. “Peer counseling” can be effective, however, these types of “peer counseling” services when moved to a digital platform and then conducted without any professional oversight, there needs to be a way to ensure that the potential benefits are sufficient to outweigh potential risks to users, particularly when it comes to privacy and safety.
Behavioral health consumers, not unlike other consumers, may not always be aware of the many ways the DTC service may collect and analyze consumer data. An app may be collecting far more than the talk therapy chats (think text messaging retrievals). Therapy apps can potentially utilize computational behavioral analyses, and machine learning to analyze user information such as voice inflection, location data, or screen taps, collected passively or actively through apps or wearables, to assess and predict cognitive and behavioral states. While this is potentially beneficial, the risks due to the lack of oversight by qualified health professionals, what can prevent the data from being monetized for commercial purposes versus assisting the consumer with positive behavioral change. The lack of professional quality review and oversight of DTC services limits the accountability of the service for the consumer and increases the consumer’s liability for safety should malpractice happen.
After saying all the above, DTC technology is not likely to go away because of market forces. Clinicians must remain vigilant with the education of the public and consumers regarding the benefit of professional oversight and involvement with DTC developers. Clinicians must continue to value the consumer-therapist human relationship along with accepting the challenge that integration of technology brings into the healthcare arena.