Be sure to read the other great articles on Dr. Alban’s website, and if you’re in San Francisco, you won’t want to miss him presenting on Saturday, May 19th on Law, Ethics, and Charts: Every Therapist’s ‘Dirty Little Secret’. 9:30am – 12:30pm.

Dr. Alban’s post is below:

I’d like to preface this comment by saying that I do not have an opinion about whether promotions such as Living Social, Groupon, etc., are appropriate or constitute impermissible fee splitting when used by psychologists.  I do, however, think that it’s useful to think about these things as the marketplace changes and as psychologists such as ourselves feel the need to be more enterprising.

Here’s the text of 6.07- “Referrals and Fees: When psychologists pay, receive payment from, or divide fees with another professional, other than in an employer- employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, or other) and is not based on the referral itself.”

It seems to me that it’s important to remember the main purpose of 6.07, which is to make sure that referrals are made based upon clinical indications and not upon a fee.  This provision of the Ethics Code is in place to maintain the integrity of the treatment.  It’s also helpful, I think, to keep in mind that 6.07 does not prohibit fee sharing; its function is to ensure that any fee distribution is based upon services rendered.

Here’s how I would approach an arrangement like Living Social or Groupon:

1.) Determine who is making the referral:  Are patients self-referred based upon a mass email?  Or, is the website targeting individuals based upon other data?  Who decides whether the patients purchase the offer and/or visit the psychologist?  IMPORTANT: If patients decide to purchase a “deal,” is he/she aware that the psychologist’s participation in the deal is a promotion?

2.) Determine, to a reasonable extent, whether/how the partnering business maintains patient data.  Under many circumstances, the mere fact that a patient is seeing a psychologist is confidential.  However, patients who willingly choose to disclose that fact to a third party may do so of their own free will.  It’s not the psychologist’s dilemma if a patient breaches some elements of confidentiality.  But if the partnering business requires that the *psychologist* continues to provide patient data after the initial contact, the patients may need to be made aware of this in order to provide consent for this data transaction.  Patients can disclose private information on their own, or they can consent to the release of their private information.  (It’s certainly possible that many psychologists would reasonably believe that the potential intrusions disrupt the frame to such an extent that the treatment becomes irrevocably warped, but IMHO that is a theoretical judgment and not an ethical decision, per se.)  HIPAA Covered Entities may, under some circumstances, need to enter into Business Associate agreements with partner businesses if the information sharing is required (by contract) to continue.

3.) Something else to consider is whether partner businesses such as Groupon or Living Social are more like advertisers or more like business partners? Or, are they some altogether different form of business?   Recall that 6.07 provides examples of “clinical, consultative, administrative, or other” as services that are permissible bases for fee division. Is advertising an “other?” Are these types of promotions an “other?”

4.) A very real and practical concern (less an ethical concern) is that the response to these daily deal sites can be overwhelming. Be prepared for an avalanche of calls.

You can read more of Dr. Alban’s thoughts on this on his own blog. If you’re interested in hearing more from him, also know that he facilitates a monthly Law & Ethics discussion night for San Francisco Psychological Association.

Thanks to everyone who came and asked great questions!

Check out the audio from my segment of our presentation:

My slide:

You can also hear the full audio here, and view the Storify tweets below.

Tweets from SXSW session WARNING: Are Online Reviews Bad for Your Health?

Session moderated by Cindy Cohn, Legal Director of EFF. Panelists: Jeffrey Segal, CEO of Medical Justice, Dr. Keely Kolmes, SF Psychologist in private practice, and Vince Sollito, VP at Yelp.

Storified by Dr. Keely Kolmes · Mon, Mar 12 2012 14:21:29

They are asking both psychotherapists and LGBTQ couples who have gone to therapy to submit brief information about that experience that would help other therapists. The goal of this project is to collect and share information will help other therapists to provide better care for LGBTQ clients.

Please note that the deadline to submit this information is February 1st. You can send your responses to: gro.atselyagnull@tcejorpselpuoc

You can find out more about the project here.

Some of the information Gaylesta would like to know from clients includes:

• How important is it that your therapist be willing to disclose their sexual identity?  Does it matter to you whether they identify as LGBTQ? Why or why not?
• How have differences related to class/race/ethnicity/religion/etc. impacted your relationship?
• What was particularly helpful or not helpful in the way your therapist supported exploration regarding sexual difficulties?
• How has your therapist been able to be supportive or not during the transitioning of one member of the couple?
• If applicable, what has helped you feel that your therapist has understood and supported your alternative relationship constellation (i.e. polyamorous or nonmonogamous)?
• What do you wish your therapist knew about your identity and/or life that would (have) help(ed) in the therapy?
• What technique or insight initiated by your therapist in relation to you being LGBTQ helped the therapy?

Please note that this is not research and it’s not anonymous. Gaylesta intends to compile the responses, however your name will be removed from them.

Looking back, it seems ironic that I haven’t written much since then about mental health or mental illness in tech culture especially when I consider that a large proportion of the people who seek my help have careers in tech. It’s as if I’ve forgotten that it’s worth mentioning.

And it’s really not.

Prodded by the recent suicide of Ilya Zhitomirskiy, one of the co-founders of Diaspora (a site, I had eagerly awaited due to multiple privacy failings on the part of Facebook), Violet Blue wrote a great post about called Tech’s Relationship With Depression, Suicide and Asperger’s. I share many of Violet’s concerns and she interviewed me for this article which includes a number of my comments.

Our friends and family in tech culture may suffer and struggle in ways that we may not see or just may not know how to identify. It’s hard to get someone the help they need when you don’t know they are suffering or if their coping or personality style involves masking their pain.

It’s not that people in tech are so special or different from anyone else, but working in the digital realm does involve the pressures of internet attention, visibility, or “celebrity,” which can sometimes be unexpected and overwhelming. Others may not realize that their normal ways of coping keep them isolated and deprived of support. I hope people will check out Violet Blue’s post which provides links to APA and NIMH’s resources for depression and suicide.

And if you or someone you know needs help, find a professional who you can talk to about your stress. There are low-fee options in every city. College counseling centers and counseling, psychology, or social work training sites may be good places to look for low-fee options. Larger sites such as APA’s Psychologist Locator and Psychology Today provide listings for private practice clinicians.

But whatever you do, talk to someone and let them know that you need some support. There is no need to suffer in silence. People are there to help you, and if you are thinking of taking your life, know that you will leave behind people who will miss you and who will wish they could have reached out to help.

We’ve just completed a Youtube video on the benefits of talking to a psychologist, and I’m pleased to share it here. Please do pass it along if you think it may help someone.

• What are the obstacles currently preventing you from being able to receive or afford therapy?
• Why do you want to go to therapy and what issues are you facing or problems are you experiencing?
• How would you like to benefit from therapy and what are you hoping to achieve?

Top entries were going to be chosen and then the winners would be selected by having readers vote on the one most deserving of the prize of free therapy. While I appreciate that many people find it empowering to use Internet forums to write about the issues they struggle with, having such comments used as a way vie for the prize of “most worthy” of psychological care, as voted by readers, was objectionable in a number of ways.

A number of mental health professionals, including DeeAnna Merz Nagel and others who focus on clinical ethics,  posted comments expressing concern that this contest was exploitative of vulnerable populations and would violate many clinical ethics codes. The initial response from the website was to say that as a referral service, they were exempt from having to adhere to ethics codes. They also noted that names and emails were anonymous in the blog comments, offering participants a layer of protection.

Nevertheless, a couple more comments were posted by concerned practitioners, including myself, stating that we thought the contest was not offering appropriate protection to vulnerable people and that having readers vote on who was worthy of the grand prize was, at the very least, in poor taste.

After just a few days of commentary, Goodtherapy.org responded by removing the public comments (entries) from the blog and deciding not to allow users to vote on stories to pick the winner. Winners will now be selected by GoodTherapy.org.

I am grateful to those who spoke up and left comments expressing opposition to the format of the contest. But I especially wish to commend GoodTherapy.org for their thoughtfulness and care in reflecting upon the objections raised. They demonstrated sensitivity and flexibility in revising the competition so that it does not expose people who are in great need.

We will soon be writing up our findings to submit for publication, but I’m pleased to be able to share this data with all of the folks who participated in our research and those who helped us reach out to potential participants. We could not have done this without the magic of social media and all of your help!

I’m very appreciative and I hope that our findings help bring greater awareness and understanding to how the Internet and social media are impacting the psychotherapy relationship.

Many people have huge barriers to seeking help when they are struggling. Sometimes these barriers are financial. Some folks may not be in a location in which it is easy to find good care from a variety of providers. Some are unable to find the strength to reach out for help. Some folks want help but they may have difficulty finding a therapist who is sensitive to their cultural needs or who has expertise working with their particular issues.

This is one way that blogging and the Internet can increase access. It is becoming easier to find help, whether that comes through seeking online support or searching for a clinician. Some people are utilizing telehealth services to reach out to practitioners outside of their communities. Others are able to find information and resources shared by others and not feel so isolated.

One of my own practice specialties is working with sexual minority clients who have traditionally been pathologized by mental health professionals. It can be intimidating to seek care for anxiety, compulsive thoughts or behaviors, depression, or relationship concerns if you worry that your therapist will assume that your identity or lifestyle is a cause for concern. If you need help finding a therapist who is knowledgeable and accepting of your kink, poly, or LGBT identity, please see my favorite resources below:

• Kink-aware professionals is a directory to help you find a referrals to psychotherapeutic, medical, legal and other professionals who are knowledgeable about and sensitive to diverse expressions of sexuality.
• Poly-friendly professionals is a list of professionals who have been referred or who have identified themselves as being, open-minded about polyamory and polyamorous issues.
• Gaylesta is a Bay Area, CA resource providing therapist referrals, education, and consultation to LGBTQ clients, but there is likely a similar resource in your community.

For more general information and articles, I recommend people look at what is available at these sites:

• American Psychological Association: browse the psychology topics to learn more
• PsychCentral has become one of the largest and most resourced hubs of mental health information, support, and community on the web.

Lastly, here are two of my favorite mental health news items of this week:

• Self-compassion may matter more than self-esteem explains how developing the skills of mindfulness, common humanity and kindness can improve your mental health.

• If you think it’s hard to take the steps to seek mental health care, it may reassure you to know that the majority of mental health professionals believe in therapy for themselves. At this link, Suzanne Phillips, Psy.D., ABPP shares  some research reporting that 84% of psychologists and 85% of cross-discipline mental health professionals have also sought mental health treatment.

Those who only read the title The Wrong Kind of Talk Therapy or tag line (both written by the Times and not seen by me until the piece ran), may have gotten the false impression that I am against online reviews. I am not. But these sites do need a significant upgrade when it comes to reviewing health care services.

What struck me from the comments is the pain and frustration experienced by consumers of mental health care. Many expressed powerlessness and confusion when it comes both to finding good care and to understanding the process of psychotherapy. Such comments made it clear how important it is for mental health professionals to provide better information to demystify what it is that we do, how we work, and how we can help. It is also incumbent on mental health practitioners and organizations to let consumers know what they can do when they feel that something harmful has occurred in their treatment.

Most often, people simply struggle with a “poor match” when looking for a psychotherapist. It’s certainly hard to find someone who feels like the right fit. But when a clinician is impaired or is doing harm, licensing boards are a useful resource. Consumers can ask questions and make complaints to licensing boards. This is also the place to turn to when you want to verify that a clinician is licensed or if you want to see whether there are any disciplinary actions against a practicing professional. If you are seeking care anywhere, it is wise to choose a licensed professional partly because this means there is a governing body to turn to if something goes wrong.

In my office forms, I let my clients know that my presence on sites like Yelp is not a request for a testimonial, but I do remind them that they have the right to tell anyone about my services and how they feel about them whenever and wherever they wish. This right belongs to them.

For more on this topic, check out John Grohol’s Yelp and Therapist Reviews in which he makes some great points about the lack of reliability of the current rating sites and the problem of there being too many sites out there at this time for consumers to find meaningful data.

In the last week, I received two separate emails from clinicians asking my opinion on Groupon and other deal-of-the-day marketing sites for psychotherapists. In my experience, if a couple of people are asking me about it, there are probably many others considering it. Are these sites a good idea for mental health professionals? Are there any ethical issues to consider?

There are so many stories about businesses that get flooded with customers after their partnership with Groupon. Some clinicians might get the idea of using such a site to offer discounts on initial therapy sessions. This may seem like a good concept at first. But these forms of marketing are actually not such a great idea for mental health professionals

Let’s look at why.

Confidentiality

Groupon provides daily offers to people who sign up as members of the site. When a member purchases a Groupon, they are making a payment directly to the site.  Groupon then sends you a check and a list of the people who purchased the coupon. This helps you to track your customers when they redeem their coupon. What does this mean? It means that any psychotherapist offering a deal through Groupon is letting Groupon know the names of people who are contacting her or him for psychotherapy. So there is an inherent breach of confidentiality right there. Not good for you, and not good for your clients.

Fee Splitting

Groupon takes a portion of each Groupon you sell. In other words, you are splitting some of your earnings with the site. This is fee splitting. This is what the APA Ethical Principles of Psychologists and Code of Conduct says about splitting fees:

Standard 6.07 Referrals and Fees
When psychologists pay, receive payment from, or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, or other) and is not based on the referral itself.

Since Groupon is taking a percentage of your earnings in exchange for the referrals to your practice, the whole system is also a breach of the Ethics Code.

Avoiding exploitation of vulnerable populations

Groupon – and sites like it –  use the concept of collective buying. This means that a minimum number of people need to sign up for the deal in order for everyone to get it. Even without the breach to confidentiality or the problem of fee-splitting, this is probably not an ethical way to manage the business of psychotherapy.

What if one were to sell more appointments than they can reasonably accommodate? It can sometimes take months for a business to manage the volume of people who have purchased a Groupon. Since the people most likely to be seeking treatment may be vulnerable, having them purchase a session and then queuing them into a long waiting list may be exploitative of vulnerable populations. Since we are also unable to screen the people who purchase the Groupon, we are not in the position to assess their appropriateness for the service they are buying. Suppose they are in crisis or at risk for danger to self or others?

Conclusion

Clearly, it raises all sorts of ethical dilemmas to have people pre-purchase a therapy session through a third party. In this economy, it can be appealing to think that there are creative shortcuts to building a practice and getting people into our offices. But we have to be very careful in considering the impact of the new marketing and social networking tools. If you want to offer discounted intakes for psychotherapy, it’s probably best to offer that to consumers and have them purchase the service directly from you, assessing them at the time of “purchase.”  Groupon may offer great deals for customers, but in this case, it’s not a great deal for psychotherapists who may find themselves in hot water when trying to market discounted services.