By Arden McGregor, MA, CPsychAssoc, CBIST, and Dennis Radman, Hons. BSc, RRP, CBIST

Recent advances in technology have led the way to a myriad of face-to-face services being transplanted to the Internet. Rehabilitation professionals have begun to evaluate and harness the utility of email, instant messaging and video conferencing to serve their clients (Zack, 2008). Using the internet to conduct counseling, psychotherapy and even rehabilitation is a cutting-edge method of service delivery. Providing services without the hassle and cost of travel, traffic and parking is beneficial to both the client and professional alike. The convenience of being able to access rehabilitation services from the comfort of one’s own home broadens the catchment area to virtually eliminate the constraints of geography and busy lifestyle.

“Providing services without the hassle and cost of travel, traffic and parking is beneficial to both the client and professional alike.”

Can it be that simple – to forgo the traditional face-to-face therapy visit and make use of rehabilitation services online? The scope of the rehabilitation field is as broad as it is deep and requires the integration of a variety of schools, theories and disciplines. As rehabilitation tools become more sophisticated to meet the demands of the twenty-first century, so does the process of therapeutic delivery. The advantages are numerous as many of us are ‘plugged-in’ in so many ways. The regulatory bodies and professional associations to which rehab professionals traditionally turn to for guidance on such matters may not have ‘technology-specific’ guidelines, as their development requires keeping pace with current technology innovation, which has always been a struggle (Nicholson, 2011). As awesome as the utility and breadth these new technologies offer, rehabilitation professionals must heed the gravity of potential legal and ethical concerns.

Professionals conducting therapy and rehabilitation online are bound by the same professional ethics as apply to face-to-face treatment, including maintaining confidentiality, being available in case of emergency, intervening when a client is a danger to themselves or others, reporting the abuse of a minor, and following relevant regulations related to licensure (Finn & Banach, 2002; Zack, 2008).

Ethical issues related to providing online therapy and rehabilitation include:

  • Uncertain privacy and confidentiality of online communications
  • Provision of emergency assistance
  • Ability to fulfill mandatory reporting requirements
  • Reliance on a fragile technology
  • Billing, fees and jurisdiction (Finn & Barak, 2010)

Both the Vocational Rehabilitation Association of Canada (VRA) and Canadian Psychological Association (CPA) have codes of ethics with nearly identical guiding principles:

I: Respect for Dignity of Persons (a) Respect for the dignity, rights and autonomy of persons
II: Responsible Caring (b) Responsible caring for the best interests of person
III: Integrity in Relationships (c) Integrity in professional relationships
IV: Responsibility to Society (d) Responsibility to society

(Canadian Psychological Association, 2000; Vocational Rehabilitation Association of Canada, 2009)

Ontario’s Personal Health Information Protection Act (PHIPA) of 2004 stipulates that the health care professional “take steps that are reasonable in the circumstances to ensure that personal health information (PHI) … is protected against theft, loss and unauthorized use or disclosure” (PHIPA, 2012).

The CPA specifically addresses the issues concerning therapy conducted via electronic media with these guidelines:

  • “Psychologists educate themselves regarding current practices and security devices for electronic communications, and use those systems and practices that are reasonably available, and that best protect their clients’ privacy.”
  • “Psychologists keep up to date with the e-service literature, including research literature regarding the efficacy and effectiveness of services using electronic media, and take this literature into consideration when deciding what services to provide to which clients, with what methods, and under which circumstances.” (Canadian Psychological Association, 2012)

However, the CPA does not provide any guidelines that are specific to any particular type of technology. This makes sense, as it’s an exercise in futility to try to construct applicable guidelines to a moving target such as today’s technologies. With each new advance and innovation in technology ethical and legal issues do arise from their use. The four principles of both the VRA and CPA can and do serve as a framework to guide the rehabilitation professional towards protection of PHI and compliance with PHIPA.

To Skype or Not To Skype

Some technologies, such as Skype have made it easy, possibly too easy, to conduct therapy online. Let’s look at the Health Insurance Portability and Accountability Act (HIPAA), the US’ equivalent to PHIPA. HIPAA doesn’t certify software as being HIPAA compliant or not. Instead, various companies claim that their software is HIPAA compliant. Furthermore, HIPAA requires professionals (business associates) to sign an agreement with third parties such as software vendors (covered entities) if they are handling confidential information. How does this all apply to Skype? Skype does not state on its website that it is HIPAA compliant. Skype does not offer Business Associate contracts to therapists or clinics, which use it for online therapy purposes. Skype, by their own admission, fails to guarantee the privacy of its users by remaining mute on the matter. In fact Skype explicitly declines to meet with HIPAA’s standards. A representative from Skype shared the following, “Skype is not a business associate subject to HIPAA nor have we entered into any contractual arrangements with covered entities to create HIPAA compliant privacy and security obligations” (Zur, 2012). As Skype continues to abstain from transparent practices that promote the privacy and protection of those that use its products, how can we be sure that using Skype is safe and meets the requirements of PHIPA? Well, we can’t.

The terms “eCounselling” and “eHealth” have become commonplace, and describe vast categories of online treatment. Likewise, Brainworks has followed suit and coined the term “eRehabilitation”, as a comprehensive treatment platform that uses interactive audio, video, or data communications to provide rehabilitation services at a distance. Our eRehabilitation services can be linked to online at

eRehabilitation includes:

    • Rehabilitation counseling, consultation and therapy delivered via a secure web interface
    • Video on demand, Video conferencing
    • Interactive web based health metrics
    • Email, text messaging
    • Interactive web based learning modules

At Brainworks we ensured that privacy, and the protection of PHI and compliance with PHIPA was incorporated into the design of the eRehabiltiation platform.

Dr. Ann Cavoukian, Ontario’s Information and Privacy Commissioner, is the founder of Privacy by Design (PbD), a framework and approach of embedding privacy into the design specifications of various technologies. Dr. Cavoukian’s recent paper (Cavoukian & Alverez, 2012) recommends that the rehabilitation professional be proactive, not reactive; that privacy be the default setting and that privacy be embedded into design.

“The scope of the rehabilitation field is as broad as it is deep and requires the integration of a variety of schools, theories and disciplines.”

Privacy is not an option; rather it is incumbent for the rehabilitation professional conducting online therapy to integrate the principles of PbD into everyday practice. The onus is on the rehabilitation professional to implement good communication practices that include ensuring online interactions: meet clinical standards, are culturally sensitive, and are met with meticulous confidentiality procedures (Prabhakar, 2012). eRehabilitation and online therapy can be practiced in an environment where the client feels safe, facilitating full participation as “technology will continue to evolve, but the ethical principles remain constant” (Koocher & Keith-Spiegel, 2008).


References available upon request. Please contact us for more information and literature to support your referral!

This article was originally published in Rehab Matters, the Vocational Rehabilitation Association of Canada’s national magazine.