With the growth of technology and popularization of social media sites, it calls for a strong need for behavior analysts to be aware of the conduct they ought to portray and the ethics surrounding their conduct. Technology provides numerous advantages by introducing the concept of telehealth that helps rural communities have access to specialized services within an applied behavioral approach. Professional behavior analysts experience challenges within the scope of their operations. In managing ethical dilemmas, Bailey and Burch (2016), explain that the analyst should prepare for the various levels of complexity each situation carries with it. The Behavior Analyst Certification Board (BACB) provides guidelines for responsible conduct when dealing with clients. With case studies providing a conceptual framework to analyze ethical dilemmas and ethical decision making, the paper analyzes two case studies and provides supporting discussion for the appropriate course of action.
Case 1
The case study introduces apparent ethical dilemmas behavioral analysts face in their interactions with clients. It does so within the context of causing harm, maintaining the clients’ confidentiality, formation of multiple relationships, violation of the BACB code of ethics and managing the challenges of relocation and proper handover. Concerning causing harm to clients, behavior analysts’ responsibility to clients involves all parties affected by the behavior-analytic services. When there is an involvement of multiple parties, the analyst needs to establish a hierarchy of relationships, communicated at the onset of the relationship. Part of the guideline insists that analysts have to identify and communicate the primary beneficiary of the services (Guideline 2.01, BACB). In this case, the primary beneficiary is Sally with the multiple parties involving Sally’s parents. With both parents undergoing parent training to support Sally’s behavior modification, declining Sally’s mom friend request may cause harm to the therapeutic relationship with Sally. This is because she may interpret it negatively and question my competence in providing the best care for Sally. Sally’s mom is a legal guardian responsible for providing consent to the therapeutic services, introducing a struggle with guideline 2.05 (a) pointing out that analysts have to have in mind the legal rights and prerogatives of the client. With Sally’s mom being a parent and the legal custodian that provides consent for Sally’s therapy, refusing to share the photos may cause harm to Sally’s mom. Regardless of Sally’s mom being the legal custodian and the one responsible for providing informed consent, there is still an obligation to adhere to maintaining confidentiality with Sally and avoiding the involvement of Sally’s mom in any other capacity.
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In maintaining the clients’ privacy and confidentiality, consenting to sharing photos with Sally’s mom during therapy is in contradiction to Sally’s confidentiality. Guideline 2.06 on maintaining confidentiality posits that behavioral analysts have an obligation to uphold the confidentiality of those they work with. By sharing photos of Sally while in therapy with her, it introduces a loophole in privacy, as one on one therapy becomes a monitored activity, steering away from the private nature. Part (e) of the guideline reinforces confidentiality in that analysts should refrain from sharing identifying information (written, photographic, or video) about current clients and supervisees within social media contexts. This justifies the refusal to share the photos and serves as an ethical ground to refrain from doing so. As O’ Leary (2017) explains, there are various considerations to have in place with respect to interacting with clients on social media. Central to that is guideline 1.0 that requires behavioral analysts to conduct themselves in a professional manner. According to the BACB (2014), guideline 1.01 posits that behavior analysts rely on professionally derived knowledge based on science and research in behavior analysis. This applies when making scientific or professional judgments in human service provision or when engaging in scholarly or professional endeavors . In accepting the Facebook friend request, it is essential to have in mind conducting oneself in a professional manner, when interacting on a social platform. As Bailey and Burch (2016) explain, code 1.01 emphasizes on the practice having its foundation on science, with decisions made on a day-to-day basis following a scientific framework. By choosing not to share the photos, this is in compliance to guideline1.01 and 1.06. Central to behavioral analyst conduct is the respect accorded to the profession. The provision of services should be from a scientific or professional role with the sharing of photos being a deviation from the scientific role. Social media platforms carry on a casual nature that encourages interaction outside the therapeutic setting. Additionally, in accepting the friend request, I would be at the risk of exposing my private life to Sally’s mom and getting a peak of her private life. Following the relocation that would be happening in a month, being friends on Facebook encourages interaction outside the scope of practice. It presents a challenge in promoting objectivity and interferes with the handover process with the other behavioral analyst that will take over upon my relocation.
Another dimension the case study introduces is the introduction of multiple relationships. Bailey and Burch (2016), explain multiple relationships as arising when an analyst involves themselves in more than one capacity with the clients. Sally’s mom is a client as she participates in parent training. By being friends on Facebook and sharing photos of each other, this risks the development of a casual friendship with Sally’s mom, with the relocation providing justification for being friends with Sally’s mom, the nature of the friendship is likely to impair Sally’s therapeutic progress owing to her being the primary client. With Sally’s dad equally involved in the training, the friendship with mom impairs objectivity when working with both parents during training. Through sharing photos of Sally during the therapy, Sally’s mom may enquire on the nature of therapy and get ‘leaked’ information on the progress Sally has made so far. During training, the husband may feel like an outsider with both parents needing to the same services provided to them. The principle of justice sets the tone for refusal to share the photos, as both parents need involvement in the same measure regarding Sally’s progress. Justice centers in creating a therapeutic environment that communicates equality and fair treatment of all clients involved. By developing an outside relationship with Sally’s mom, it carries a form of favoritism.
In determining whether it is ethical to connect with clients on social media, there is need to evaluate the impact of the action on providing effective services to the client. With Sally’s case, the concern is not accepting the friend request on Facebook as there is no clear principle that advises against it, but the motive behind the acceptance. Sally’s mom hopes to use the platform to encourage photo sharing which is a violation of the guidelines surrounding privacy. The platform does not just involve Facebook but also Instagram and having such connections over multiple platforms may prove challenging in preventing the development of multiple relationships. Guideline 1.06 of the BACB highlights the possibility of the occurrence of multiple relationships. Behavior analysts should recognize the potential harmful effects of outside interactions on their work and the conflicts of interests involved, (BACB, 2014). As O’Leary (2017) explains, social relationships with clients outside the therapeutic setting, affects objectivity as the analyst has to struggle with meeting the needs of each individual, from the primary client.
With the time left with the family being only two months, relocation requires the adherence to the ethical guidelines pointed out in the BACB. Behavior analysts have to make reasonable and timely efforts for facilitating the continuation of behavior analytic services, in the event of unplanned interruptions, (BACB, 2014). As part of an ethical obligation, it is important to seek the clients consent and have someone in place that could come in following the relocation. In this sense, accepting the Facebook friend request allows the opportunity to further follow up on Sally’s progress. With the duration of therapy involving over a year and with the analyst deeply involved in the family’s activities, relocating to another state and failing to keep touch may cause the family harm.
As part of resolving ethical dilemmas, a decision making model is essential. The implementation of an evidence-based perspective represents a model of decision making that integrates best evidence, clients’ context, and clinical expertise to provide a decision outcome. The evidence based perspective focuses on the effect of evidence in decision-making and the resulting effect of improving decision outcomes. The best available evidence as explained by Slocum (2014) is the BACB code of ethics that provides context for the conduct of the behavioral analyst. From the case study, the BACB provides guidelines from maintaining confidentiality to multiple relationships with clients. The rules advocate for professional conduct and serve to protect the practitioner. Within the context of accepting the Facebook friend request, the EBP provides no systematic reviews considered problematic in accepting the request. However, guideline 1.06 outlines the need for behavioral analysts to be aware of situations that could encourage multiple relationships and explaining the implications of such a relationship. Another element of the model involves the client values. By communicating with Sally’s mom about the effect of sharing the photos on Sally’s therapeutic progress, it helps sets the tone for the need for professionalism and the consequences on their parent training with her husband. It is equally crucial to explain to Sally’s mom that though I may accept the friend request on Facebook, the focus would be on maintaining a professional relationship as per the mandate of guideline 1.01 that requires behavior analysts to conduct themselves professionally in their representation of the science. An overlooked dimension in decision-making is clinical expertise. As Slocum (2014) explains, clinical expertise involves having knowledge of research literature and its influence on clients. Additionally, it involves integrating a conceptual system of applied behavioral analysis, development of interpersonal skills to communicate to clients the ethical concerns and ongoing professional development.
Case 2
Telehealth technology is on the rise with it making health care services available to individuals in rural areas. It uses communication technology in the delivery of specialized services in real time, over a geographical distance, (Tse et.al 2014). It can provide specialized services to care for children with ADHD. Telehealth provides bandwidths of 380kb to 1MB/s, synchronized video, audio transmissions and resolutions similar to an in-person visit. In a study to evaluate the effectiveness of telehealth, the CATTS trial a community-based intervention, supported the use of telehealth in managing ADHD, (Tse et.al 2014). Key elements of practice for rural programs involve having cultural competence, understanding the limits of expertise, and effective supervision to encourage implementation of program outcomes. The popularity of the system has encouraged federal mandates to govern the practice such as the American Recovery and Investment act that encourages the use of information technology to make health care available. There is also the Patient Protection and affordable care act that proposes the meaningful use of telehealth technologies to improve the health of every citizen, (Myers, et.al 2015). Several studies as explained by Myers et.al (2015) support the growth of the approach with synchronous telehealth services that directly target children are feasible with caregivers supporting their implementation. There is still need for the establishment of effectiveness studies to build research and literature on the appropriate modes to improve the delivery of healthcare. ADHD as a disorder affects many children and adolescents of whom need treatment that is available through the technological platform. Health information technologies introduce critical aspects in adherence to moral precepts that govern the obligations of practitioners that use the system. As Fleming (2009), explains the principle of beneficence has in mind the principles of the client first while that of non-maleficence ensures the patient receives no harm throughout the course of service delivery. Other principles guiding the use of the technologies involve justice. This is as characterized by fair access to patients’ treatment and care. The patients’ autonomy takes center stage with respect accorded to patients to make informed decisions about their healthcare. Where clients are unable to do so because of legal mandates for example in the case of children, parents and legal guardians have a responsibility to do so. As a system of health delivery, its use raises several ethical issues from the violation of privacy through combining and mining data, financial and billing issues, and competency in the use of technological tools. Harry’ case outlines the practicality of using an agency that is two hours away, specializing in the provision of telehealth services. With it being two hours away, a one to one approach may be unfavorable as it is a considerable commute. The use of telehealth services is a favorable intervention.
Prior to arranging for the family to embrace the use of telehealth, it is essential to carry out a risk benefits assessment of the family to identify treatment needs, possible risks associated with treatment, and reasonable alternatives. Risk benefit analysis involves the comparison of the risk situation to the potential benefits, (Bailey and Burch, 2016). From a risk benefit perspective, the family’s location in the rural area makes it difficult to have a one on one service in place as the nearest telehealth behavioral support center is two hours away. The telehealth center can assist the family in providing convenient treatment services. As part of risk assessment, it is important for the behavioral analyst within the telehealth center to conduct a needs assessment risk and identify if the family has resources that would support the delivery of the service such as a computer with good video and sound quality and individual assessment of the primary client to identify the treatment modalities involved. With the telehealth center being two hours away, the center can arrange with local community agencies to mitigate in the case of emergencies and protect the client’s interest. With this in mind, behavioral analysts from the center should consider ethical obligations in their involvement with third party agents as per the BACB recommendations. Central to conducting a risk assessment is the utilization of a comprehensive consent form before the delivery of online services. Another overlooked element is the implication of culture calling the need to attend to cultural, ethnic, and language barriers that influence the ability to communicate with clients. The success of the intervention relies on successful risk management of various ethical issues such as the maintenance of records, billing issues and adherence to proper termination and abandonment guidelines, (APA, 2017).
Financial and billing challenges present an ethical concern following that provision of the services are in a rural area that may not be under the scope of the insurance cover. As Palmer (2010), points out, most rural patients have limited access to insurance services, with most of them being under Medicaid related programs. Prior to rolling out the service to the family, it is important to carry out an assessment of the home environment, identify the mother’s ability to cater for the health care expenses, and develop a financially sustainable model. Having in mind, that Harry’s mother is single and is the sole custodian of the family, she may not be in a position to meet the financial costs. Other billing issues especially with insurers revolve around their inability to cater for services involving telehealth. This is because they are unaware of the nature of care provided. Getting information on the specifics of client treatment may involve a breach in confidentiality that is against the established code of ethics of the BACB. As part of the requirements of the BACB (2014), guideline 2.12 (a) expounds on the obligations surrounding contracts, fees and financial arrangements. An integral aspect is section (a) that outlines the need for a signed contract to outline the responsibilities of each party. In this sense, having the agency explains the operations and its intention in assisting Harry through the telehealth platform is necessary. Section (b) mentions the provision to make early arrangements with the family on compensation and billing arrangements.
One of the ethical challenges in using telehealth involves patient confidentiality and autonomy. One of the advantages that have come with telehealth revolves around the satisfaction patients experience because of the focused attention they get. ADHD as explained by Palmer (2010) is a condition with a wide geographical distribution with the resources required to manage it being minimal. Technologies of different sophistications are available to establish connectivity using digital systems. As Palmer (2010) highlights, research supports secure connectivity with regulations for telehealth providing confidentiality to ensure end to end encryption of data shared. In encouraging privacy, behavioral analysts need to have technology related skills to identify creative ways of encoding information, for instance, using private virtual networks in interaction with clients. In using encryption protocols, it is crucial that they adhere to the Health Insurance Portability and Accountability Act (HIPAA). With telehealth involving the reliance on electronic records, there are guidelines outlined by the BACB that behavioral analysts should follow. Here, behavioral analysts should take the appropriate precautions in ensuring confidentiality in the maintenance of information, guideline, 2.07 (a). In the case study, the service should not only cover for Harry but also involve the mother. Being a single mother with two children and one of them having ADHD, she is likely to struggle with caregiver strain and parenting stress. Telehealth relies on the use of technology such as video conferencing, which may present a challenge in confidentiality, with the session ongoing in the home. An underlying concern revolves around information integrity as electronic devices in the home are in use in other contexts such as the car or office, (Fleming, 2009). There is not a sure way of establishing if during the sessions other activities in the house will not interfere with the session. Health care providers have an obligation to ensure that they build on the relationship with their patients such that they feel secure in sharing their information through the online platform. When working with children, interacting through games or role playing helps strengthen the privacy the analyst gets to have with the client as they can devise encrypted games that help in assessment and client’s response to treatment. As Fleming (2009) points out, external forces are likely to interfere with the therapeutic process. For example in Harry’s case, the little sister may walk in during the therapy sessions to try to play with Harry. Harry having ADHD would be excited at the prospect leaving behind the therapeutic session. By having discussions with the parent about creating an enabling environment, plays a role in streamlining the process. The behavioral analyst in this sense should not despair, but attempt to use professionally competent techniques to deliver the best quality of health care. Central to privacy concerns is the respect for autonomy that requires information gathered about the client be private. With the use of technology, there is a concern that someone could be tapping the conversation or monitoring the process. Analysts should discuss with the parents the scope of their involvement throughout the process to discourage the breaches of data. With the universality of the use of telehealth technologies, analysts have to have the necessary competencies to safeguard clients’ information from improper use.
Competency with regard to technological expertise is of concern in responsibility to clients when using a telehealth platform. There is a level of complication attached to encrypting data and safeguarding clients’ databases through well-coded server systems. With telehealth services involving collaboration with third parties such as software companies, there is need for behavior analysts to keep client information confidential. Privacy risks involve lacking control over the sharing of data With diagnostic capability involving the use of online platforms, decoding nonverbal behavior necessary for a comprehensive assessment is crucial as there could be loss of non-verbal information through inappropriate coding of information or poor video quality. Competency involves behavior analysts undergoing professional development to learn online strategies such as video conferencing etiquette, articulation of written information, and communication strategies aimed at helping the client better connect with the improvisation .The behavioral analyst assigned to the family should have had prior experience and competence in working with children with ADHD. Guideline 1.02 posits that behavioral analysts should provide services commensurate with their education, training and supervised experience.
Conclusion
The growth of technology and its implementation in applied behavioral analysis presents various ethical challenges for practitioners. In the first case, involving Sally’s mom the technological concern involved being friends on Facebook and sharing photos through social networks on the therapeutic process. The ethical codes in the BACB provide guidelines with the general principle being that behavior analysts ought to conduct themselves in a professional manner, and maintain clients’ confidentiality even in the presence of hierarchical relationships. With multiple relationships being an element practitioners find unavoidable, communicating such concerns at the onset of the delivery of services is central to reinforcing a sense of justice. A growing body of research supports the use of telehealth services in providing care to individuals in rural areas. In using such systems, there is need to ensure ethical standards are in place to protect clients from harm resulting from breach in confidentiality and other potential risks that involve the utilization of online platforms. More research needs to be in place to strengthen the code of ethics surrounding the use of such platforms. With ADHD being a prevalent condition among children and adolescents, having such a mode of care in rural areas gives hope to caregivers with the applied behavior analysis equally catering for them through parental training.
References
Bailey J. S. , Burch M. R. ( 2016 ). Ethics for behavior analysts ( 3rd Ed. ). New York, NY : Routledge .
Behavior Analyst Certification Board. ( 2014 ). Professional and ethical compliance code for behavior analysts. Retrieved from http://bacb.com/ethics-code/
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Palmer, N. B., Myers, K. M., Vander Stoep, A., McCarty, C. A., Geyer, J. R., & DE Salvo, A. (2010). Attention-deficit/hyperactivity disorder and telemental health. Current psychiatry reports , 12 (5), 409-417.
Slocum, T. A., Detrich, R., Wilczynski, S. M., Spencer, T. D., Lewis, T., & Wolfe, K. (2014). The evidence-based practice of applied behavior analysis. The Behavior Analyst , 37 (1), 41-56.
Tse, Y. J., McCarty, C. A., Stoep, A. V., & Myers, K. M. (2015). Teletherapy delivery of caregiver behavior training for children with attention-deficit hyperactivity disorder. Telemedicine and e-Health , 21 (6), 451-458.
