Ethical Considerations in Film and Video-Based Therapies

Chapter 2 

A Challenge to Readers: Ethical Considerations in Film- and Video-Based Therapies
J. Lauren Johnson and Joshua Cohen
Abstract
Film- and video-based therapies have existed in some form for decades, yet little has been written about the ethical challenges that arise with the therapeutic use of these technologies. In this chapter, we first outline the main ethical considerations in working with film- and video-based therapies, and then specific dilemmas that might arise for practitioners working in this field. We challenge readers by presenting these dilemmas without providing ready answers on how to face them; instead, we invite the readers to reflect upon their own ethical practices, professional guidelines, and jurisdictional considerations to guide their perspectives on these issues. 
Key words: therapeutic filmmaking ethics, ethics of film and video as therapy, digital media ethics.
A Challenge to Readers: Ethical Considerations in Film- and Video-Based Therapies
Introduction
It should come as no surprise to therapists practicing in this era of ubiquitous social media and Internet access that digital technologies have changed our profession. We are now able to advertise our businesses online; provide services remotely through e-mail, web chat, and video conferencing; and help our clients to cope with the overwhelming and constant barrage of work and social stressors that are a consequence of relentless connectivity. The development of these new technologies has been accompanied by many challenges to therapists, and these challenges have become especially relevant to therapists who use film- and video-based technologies as therapeutic interventions. 
Although film and video have been used in therapy for decades (Johnson & Alderson, 2008, Cohen, 2013), little has been written about the challenges that these media have introduced to ethical professional practice. In this chapter, we intend to bridge that gap by exploring the ethical considerations of using film and video as therapeutic interventions. It should be noted that we do not presume that the content of this chapter provides definitive ethical guidelines to conduct video therapy, nor do we present ourselves as legal or ethical experts in this field. Rather, we are writing as practitioners of this burgeoning field who have encountered our own ethical questions and challenges in our work, and we hope that our experiences and reflections might give insight to others who are working in or considering working in this field. As such, we hope to challenge the readers to think critically about the possible dilemmas that might occur while creating films or videos as part of therapy rather than as art or entertainment, and we welcome further discussion and debate about these pertinent and important issues. For this reason, we welcome readers to participate in this discourse through our online community (http://www.filmandvideobasedtherapy.com/), where we can take advantage of the dynamic and interactive capabilities of digital technologies to continue this discussion.
Though much has been written about the ethics of art therapy and the myriad art forms that might be included under that broad category, the media of film and video are unique in their combination of elements associated with performance, narrative, photography, drama, digital media, and music. Film and video are typically considered mass media, meaning that they are intended for mass distribution and consumption. As such, they have become increasingly implicated in the positive and negative therapeutic possibilities of the new and largely uncharted world of social media. With the increased use of film and video in therapy, ethical considerations now require that therapists not only reflect on what it means from an ethical standpoint to have clients represent themselves visually and aurally in their work but also consider the possibility that clients can instantly upload therapeutic films to YouTube, Facebook, and other social media sites. Therapists continue to be concerned about issues of ownership and privacy, but they now also must concern themselves with issues of access to and control of shared digital video, among others.
Film- and video-based therapies provide unique ethical challenges for therapists to consider, but we argue in this article that these challenges are not insurmountable. Rather, we welcome the ethical questions, dilemmas, discussions, and discomfort that might come from this distinct approach to practice. We believe that engaging in this dialogue could serve to strengthen the practice of film- and video-based therapies by collectively considering the positive and negative aspects of these legal and ethical dilemmas. 
The two sections of this chapter address the considerations that we have encountered and addressed in our work as well as the questions and dilemmas that we hypothesize might occur in our work and the work of others. In the first section, we discuss the ethical considerations that arise when applying ethical principles to film- and video-based therapies, particularly in regard to informed consent, confidentiality, privacy, and ownership. We then discuss possible dilemmas to incite debate among readers and other practitioners of this work. These dilemmas include the issue of social media, the implications of working with special populations, and the appropriateness of using film- and video-based therapies with clients in crisis. Our intention in structuring the chapter this way is to provide a foundational understanding of the ethical principles at play in this work and then challenge readers to apply their own professional ethics, local jurisprudence guidelines, and personal morals to the possible dilemmas that follow. 
Ethical Considerations
Informed Consent
One of the most pressing issues in any form of therapy is informed consent, which is especially important when working in relatively new areas of practice such as film- or video-based therapies. Therapists must inform clients of the novel nature of this approach, even though it is related to such established therapeutic approaches as psychodrama and art therapy, whose possible risks and benefits are more recognized. Despite being reasonably sure that film- or video-based therapies are no more risky than other forms of visual therapy, therapists do not yet know the long-term outcomes of this approach, so they must exercise full disclosure about their practice and the possible risks and benefits associated with it as best they can (Canadian Psychological Association [CPA], 2001). Because the CPA (2001) is similar to the American Psychological Association (APA, 2010), this chapter should reflect specific codes of the CPA; however, the spirit of the information might be universal. This information should be conveyed verbally to establish and protect the relationships with clients as well as in written form to ensure that legal interests are maintained. Through this verbal and written process, therapists can ensure that clients understand that participation in this type of therapy at this stage of its development might involve informed choices more than informed consent. 
Ensuring that clients can make informed choices requires that therapists review with them the potential benefits and risks of participation, with the understanding that all of the outcomes of the therapy are simply unknown at this stage and that some outcomes might lead to unanticipated effects. Some clients might need to be made acutely aware that they are not playing or performing, but are participating in creative videos that are, in fact, therapy (Alders, Beck, Allen, & Mosinski, 2011; Cohen, 2013). Knowing the potential risks involved, including the fact that some risks might even be unknown at this point, allows clients to decide whether to participate or decline. Participation ought to be based upon information given under full disclosure, meaning that nothing known by the therapists about the therapeutic approach, be it positive or negative, is kept from the clients. 
One concern about the practice of full disclosure relates to the prospect of therapists showing clients’ their own films or videos to audiences outside of the therapy room, thus allowing clients to be seen and heard by a broad audience (Brawner, 1993; Brawner & Emunah, 1992; Cohen 2013). If therapists can find ways to fully inform clients about the potential risks of this activity, including cyberbullying, exposure, and embarrassment, clients become more able to understand the potential risks and benefits, practice self-determination in deciding whether to proceed, and allow themselves to feel more emotionally safe in the therapy setting. 
Each new social media technology presents ethical challenges. Many editing programs, including Final Cut Pro X, which was used by many of the authors who contributed to this book, have automatic sharing features that immediately upload videos to popular social networks such as YouTube, Vimeo, and Facebook. The ease with which people can make very private videos public ought to be a real concern for therapists working with video as a component of therapy. 
The issue ought to be addressed at the informed consent stage and again when beginning the editing process. In this ongoing process, therapists would not only obtain informed consent at the beginning of the therapeutic process but also ensure that their clients are informed of the risks and benefits throughout the duration of therapy and have the opportunity to continue to participate in or withdraw from therapy. 
Confidentiality
With this approach to therapy, one major concern lies in determining what might constitute confidential information. Beyond the confidentiality considerations associated with all forms of therapy, film- or video-based therapies share with other visual forms of art therapy the difficulty of distinguishing what might be considered confidential aside from the verbal communication exchanged during the therapeutic process. According to the Canadian Art Therapy Association’s (CATA, 2003) standards of practice, art therapists are required to consider any information exchanged during therapy through verbal and visual avenues as confidential. Extrapolated to film- and video-based therapies, any films, clips, drawings, scripts, scenarios, and proposals produced during or for the therapeutic process ought to be treated as confidential information and require special consideration (CATA, 2003; CPA, 2001; Hammond & Gantt, 1998). In our clinical experience, such material, including electronic data stored in computers and on videotapes, has been kept confidential through the use of password-protected computer filing procedures and locked storage cabinets. 

Privacy
Privacy is what makes intimacy possible in therapy. Beyond the therapy setting, privacy also is implicated in the broader context of human dignity and rights. The issue of privacy is addressed in the first and most important ethical principle that guides the practice of psychology in Canada and in the United States (APA, 2010; CPA, 2001). If clients choose to share their work, they as well as their need to understand the possible consequences (Alders et al., 2011).
However, if clients choose not to share their work, their right to privacy should be honored by their therapists. The right to privacyhas been recognized as a basic human right by the United Nations (2014). Given this fact, therapists working with film and video as therapeutic strategies ought to be especially concerned about protecting clients’ privacy. 
At the same time, this particular type of therapeutic work poses challenges to the provision of therapeutic privacy. For instance, clients might record their own images in their therapeutic videos; record their therapists’ images; and include images, personal information, audio recordings, and other representations of themselves and others in their therapeutic videos. The mere existence of these recorded representations might already be problematic in terms of privacy, even when they are held strictly confidential within the confines of the therapy session. What happens, then, if clients want to share their videos with others?
According to the APA’s (2010) code of ethics, therapists must take reasonable measures to protect the privacy of their clients and ensure that they obtain permission from clients for any audio and/or visual recordings to occur in therapy. Therapists ought to take steps in advance to protect their clients’ private information in the event that computers, cameras, or other devices are lost, stolen, or damaged. In the context of particularly heated sessions, clients might become involved in emotional outbursts and destroy equipment holding other clients’ material and information. Encrypted backups of digital information might mitigate such situations. It also might be prudent to store the material in secure locations, such as therapists’ offices, rather than have clients store their own confidential material by, for example, allowing them to take home video cameras with therapeutic video footage on them. 
Once therapeutic videos have been completed, what is done with the recordings? For some clients and therapists, privately sharing therapeutic work with select individuals, perhaps through private e-mail communications or just between therapists and clients, might be one option. However, Internet security is never guaranteed, and even the most limited sharing of electronic information requires some practice guidelines. In the United States, the Art Therapy Credentials Board’s (ATCB, 2011) Code of Professional Practice states that art therapists must “address issues related to the difficulty of maintaining the confidentiality of electronically transmitted communications, and the difficulty in removing any information or imagery that has been posted electronically if consent is later revoked” (p. 12). 
If therapists or clients want to share therapeutic work more publicly, such as by posting therapeutic work online, privacy becomes especially difficult to maintain. The American Art Therapy Association’s (AATA, 2011) practice guidelines suggest that in the case of video- or film-based therapies, clients’ images should remain private for legal and ethical reasons. However, a dilemma arises when some clients feel the need to be seen and heard for the therapy to be effective (Brawner, 1993; Cohen, 2013); as such, it might be therapeutic for clients to share their private therapeutic work in public settings. 
In contrast to the AATA’s (2011) guidelines, the ATCB’s (2011) code, which is enforceable, stated that art therapists 
[Must] ensure that appropriate steps are taken to protect client identity and disguise any part of the notes, art expression or audio or video recording that reveals client identity unless the client or guardian specifically designates in the signed consent that their identity may be revealed. (p. 9) 
This statement suggested a more lenient perspective toward the public display of therapeutic videos. In addition to the issues of privacy and confidentiality, the prospect of publicly sharing therapeutic videos raises questions of ownership and control. For example, as therapists, do we have the right to restrict what clients can do with their own therapeutic artistic works? In cases such as these, therapists might be faced with the prospect of pitting their own legal protection against what might be best for the clients. 
 Legally, limitations exist about what can be posted online in regard to health information. For instance, Beck (2009) asserted that health practitioners such as therapists “cannot use any information that links an individual to their specific health information” (para. 4). If a person can be identified as a therapy client with a particular diagnosis based upon a video-based therapy session that is posted online, that person’s right to health information privacy has been compromised. As Beck argued, if one posts 
A video or pictures of a person in a way that makes it clear that they are a part of, for example, an autism group or receiv[ing] psychotherapy from a practitioner who specializes in eating disorders, it allows others to put [two and two] together. (para. 4) 
One response to this concern was addressed by the ethical principles of the AATA’s (2011). The ATCB (2011) included information in Section 3.9.1 stating that art therapists must “inform clients of the benefits and limitations of using information technology applications in the therapeutic process” (p. 12). This might involve allowing the clients or participants to understand the limitations of the technology as well as taking into consideration that their separate backgrounds in technology might influence their cognitive, physical, and emotional limitations throughout their work. Therapists should be aware of these limitations in video- or film-based therapies because they could influence how they work with clients clinically and ethically (Alders et al., 2011) as part of the informed consent process. 
The CATA (2003) took a similar stance on privacy: The standards of practice stated that art therapists must make “[e]very effort . . . to avoid undue invasion of the client’s privacy” 
(p. 3). Meanwhile, the CPA’s and (2001) code of ethics for psychologists dedicated six ethical standards to the topic of privacy, noting that psychologists must “take care not to infringe . . . on the personally, developmentally, or culturally defined private space of individuals or groups, unless clear permission is given to do so” (p. 12). Private space was interpreted broadly in this case, referring not only to physical space but also to any representation (i.e., image or sound) or information that was considered within the realm of privacy.
Informed Choice for Clients and Therapists
Regarding informed consent and the maintenance of the privacy of clients’ identities, it is important for artwork that could identify clients to be disguised, according to Section 4.5 of the AATA’s (2011) ethical principles. However, if a video is used in research, this principle might not apply (Rosenstain, 2002) because video sessions in therapy can be used in studies. Proper consent forms would need to be obtained in order for the video material to be covered in future research. In addition, any institution doing the research needs to approve the research of human subjects through the institution’s ethics review board (Alders et al., 2011).
One simple solution to potentially infringing upon clients’ privacy is to avoid the use of representative audio and images in therapeutic videos that have the potential to identify clients. However, we believe that this approach is pedantic and  robs clients of the potential for growth from exploring the self via video representations. We prefer to discuss the issue of privacy with clients during the film- and video-making process and find ways to proceed while safeguarding their privacy. For instance, it might be worthwhile to develop a release form with clients so that even if the boundaries of privacy are pushed in the creation of a therapeutic video, permission has been received to do so and, as such, would still comply with the CPA’s (2001) privacy principles already mentioned. Previous release forms developed by Dr. Alder/Pike have been proposed, but not yet published. 
In the process of maintaining clients’ privacy, it might be necessary to address the irreversible nature of information once it is posted online. Clients might have a strong need to be seen and heard, but they might not be aware of the potential harm of putting their work on the Internet. In regard to this topic, both the AATA (2011) and the ATCB (2011) have clearly advised art therapists to remind clients that maintaining confidentiality when using the Internet can be difficult, if not impossible, once information is posted. Clients also must be made aware that they can revoke their consent to have their work posted online at any time.
Ownership
According to visual researcher Prosser (2000), “The issue of ownership and control is central since disconcertingly, and unlike in word-orientated research, not only do participants have the opportunity to see themselves interacting with each other, but so too do others” (p. 129). This assertion is equally true when visual material is used in therapy. This concern about ownership and control relates to how the visual material is handled and, more importantly, who decides what happens with the information. 
Hammond and Gantt (1998) stated that the nature of the art produced in art therapy is extremely personal and that beyond concerns about confidentiality, it must sometimes be considered private information that should not be filed or shared with anyone who could misinterpret the contents. When the content of films or anything else produced during the process of therapeutic filmmaking is deemed potentially harmful, such as libelous claims about others or the use of people’s images without their consent, material not suitably related to the purposes of the therapy, and/or material open to misinterpretation by others, this content could be entitled to protection as private information (CPA, 2001; Hammond & Gantt, 1998). As such, clients must be informed of their responsibility to protect their own rights as well as the rights of individuals who might be mentioned or featured in their videos. This responsibility could involve the creation of release forms for collateral parties and release forms that must be signed by all custodial parents of children whose images might appear in therapeutic films.
However, going back to Prosser’s (2000) concerns about ownership and control, decisions about what is considered private and confidential should not be made by clinicians alone. Any information that could pose a risk to the privacy and confidentiality of the people involved ought to be addressed through ongoing consultations with clients regarding any potential harm, noting that harm is possible now and in the future, for example, when a child who is featured in a therapeutic film grows up. Through these discussions, clinicians and clients might mutually decide whether to include or remove material in films and/or in their files, including to what extent such material should be included, and how best to carefully store or ethically destroy that information.
  According to the standards of practice established by the CATA (2003), 
Art therapists shall advise clients at the commencement of treatment about ownership of the artwork within the treatment mandate. Art therapists shall approach the release and/or disposal of artwork as a treatment issue and shall decide upon its release and/or disposal in consultation with the client (or legal guardian). (p. 2) 
The AATA’s (2011) guidelines agreed with the CATA’s standards on this issue. As such, it would appear that although the issue of art ownership generally rests with clients, therapists ought to discuss the ownership, possession, and destruction of art materials with clients so that they can reach mutually acceptable decisions on these questions when they arise. A general reading of the CATA standards of practice suggests that such consultations ought to be ongoing and dynamic throughout therapy. 
Possible Dilemmas
We addressed some of the common ethical themes that arise when working with film and/or video as therapeutic tools in earlier sections. In this section, we move away from a discussion of the guidelines and standards and begin to consider the hypothetical concerns, possibilities, and questions that might arise as we continue our work in this field. As practitioners in a relatively new field, we have been asked many times to defend what we do, why we do it, and consider how we know that what we do is ethical. We have been challenged to consider when it would be inappropriate to use this approach and to address whether aspects of this work might be discriminatory (i.e., against people with disabilities who might not be able to use filmmaking equipment directly). For instance, “TAP uses the theory of Kramer’s third hand, an art therapy modality that is used when disabled clients are unable to do the artwork for themselves and need the therapist to do the work for them” (Austin, as cited in Cohen, 2013, 
p. 80). Given these experiences, we would like to pose some of these practical ethical questions to readers. We do not purport to have all of the answers to these questions, but we pose them because they are important to consider as we continue to expound on the legitimacy and acceptance of film and video as therapeutic tools. We welcome further discussion and debate about these issues in future publications and other modes of communication. 
What Makes a Film Therapeutic?
Although we fully believe in the power of film and video to heal, it is possible for people who are filmmakers or artists who are not licensed or accredited as therapists to do harm by claiming to be doing therapeutic work with their films. To reduce this potential for harm, we must differentiate between films intended for health reasons and those meant to provide entertainment. For example, films intended for entertainment are typically intended to move an audience to feel something and to be a good return on an investment; the latter films are intended to be a form of personal exploration and expression, and are primarily made for the filmmakers alone.
Filmmakers who are not therapists have a very different ethical commitment than licensed professionals to society at large and to the people whom they claim to be helping. Filmmakers are not bound by the same ethical oversight that we are, making them more free to participate in potentially harmful practices, such as the exploitation of documentary participants. As therapists and psychologists, we have an ethical duty to work for the good of society as a whole, as well as our clients specifically, and to conduct ourselves professionally in our work.
We have a duty to protect our professions and practices from association with those who might do harm, intentionally or unintentionally, and to distinguish between filmmakers and therapists. For these reasons, practitioners of therapeutic filmmaking need to further discuss what makes therapeutic films different from documentaries or fictional films that are intended as art or entertainment, and to ensure that both the public and our own professions understand this difference.
Film- and Video-Based Therapies and Crisis Situations
If clients are actively suicidal or homicidal and are deemed at high risk to act upon their ideations, would video therapy be the best intervention for them? We have reflected on this question quite often in our practices. This question is particularly challenging for therapists who are dealing with new clients. If clients have been seeing their therapists for years, the answer to this question might depend on the experience of the therapists and their familiarity with video therapy as an intervention. For instance, experienced therapists who have strong relationships with clients might be able to direct the clients’ harmful ideations towards nonviolent expression through the video production process, possibly leading to insight, catharsis, and a reduction of risk. However, given the level of risk in situations like these, a film- or video-based approach might not be recommended. Instead, therapists might need to abandon creative methods temporarily and use directive approaches involving the development of safety plans, referrals to emergency services, and preparation for the possible need to break the rules of client-therapist confidentiality. 
Questions Regarding Posttraumatic Stress Disorder 
Video-based therapies have been used in the treatment of posttraumatic stress disorder (PTSD), as detailed in this book in the chapters written by Patton and Tuval-Mashiach (Cchapter x12 and Mosinski (Cchapter11). Some therapists working with this treatment issue have determined that guiding clients in telling their trauma narratives through video is helpful in their recovery from trauma. In addition, it is possible for therapists to use the production and editing processes as a form of exposure or flooding that might help clients to process their traumatic experiences. Indeed, the multistage process of making videos could be a progressive exposure technique in which clients are first asked to imagine and discuss their traumatic events, represent them visually, and then represent them using audio and visual techniques so that the traumatic experiences become more realistic and more challenging with each progression. 
However, what might happen if clients are traumatized or memories are triggered by the images that they have produced? In this case, does the ethical issue become one of therapist competence and whether therapists have the training and experience to engage in certain therapeutic techniques such as exposure? Even if therapists have the training necessary to engage in exposure techniques, would psychologists specializing in behavioral or cognitive behavioral techniques be better trained to deal with potential crisis situations using more direct methods? These questions remain at the forefront of our consideration as we continue exploring this fascinating and potentially powerful area of practice.
Questions Regarding Working With Incarcerated Populations
Film- and video-based therapies have been used with incarcerated clients. For example, in an interview regarding the use of film and video in therapy, drama therapist Brawner (1993) discussed the ways in which correctional institutions can be safe environments for video therapy (Cohen, 2013). However, Brawner suggested that therapists engaging in this work with incarcerated individuals should not refer to it as therapy, given that the stigma of being in therapy might prohibit clients’ full participation and subsequently reduce the effectiveness of video therapy. This assertion brought about some pointed ethical questions for us: When faced with such a debilitating level of stigma, how can therapists ethically engage in video therapy? How can clients provide informed consent without agreeing that they are participating in therapy? How might one maintain the appeal of the project for clients who are resistant to participating in therapy without misleading them about what it is? Though these are questions that we have not addressed directly in our own work, we challenge readers to consider how the issues of stigma, consent, and confidentiality might intersect in the context of working with incarcerated individuals. 
Questions Regarding Working With At-Risk Youth 
In Cchapter 15, Austin demonstrates through a case example how film- and video-based therapies might work with at-risk youth. However, the members of this population provide an ethical challenge for film- and video-based therapists because if they are under the age of 18 years, they typically require the consent of a parent or a guardian to participate in therapy. Gaining this consent is sometimes difficult, particularly if the parent or guardian is part of the reason that the youth is considered at risk. 
Working with these clients presents unique challenges related to consent and privacy because of their age and vulnerability, but these challenges can be overcome. Austin explains in his chapter that through the use of film- and video-based therapies, the at-risk youth with whom he worked were able to transition into jobs and inhibit impulsive decision making. Nevertheless, many questions arose as we began to consider the prospect of working with members of this population, but rather than begin to answer them ourselves, we challenge readers to consider how they might answer them based upon their own professional standards and practices: How should therapists deal with accusations of abuse that might be recorded or dramatized in a video? What might the legal implications of accusations such as these be for the accusers; the accused; and witnesses to the accusations (i.e., therapists, the video’s audience, etc.)? How can informed consent be obtained? Should informed assent to participate be obtained from the youth? If this therapy is conducted in a group setting, what considerations around confidentiality, privacy, and physical and emotional safety might arise? 

Questions Regarding Working With the Issue of Domestic Violence
In this book, Mosinski (Cchapter 11) explores the issue of using a video-based intervention with clients who are the victims of domestic abuse, demonstrating that this intervention can be effective. Film- and video-based therapies can be used in a number of ways to help the victims and perpetrators of domestic abuse. For instance, producing creative videos about their experiences might give clients important insights, improve communication skills, promote the development of empathy, and provide other possible benefits. However, producing videos focusing on domestic abuse could lead to various ethical dilemmas: What might happen if victims’ videos were viewed by the perpetrators, who then objected to their portrayal? What might the legal and ethical implications be if accusations of abuse were disseminated through the public release of therapeutic videos? What steps should therapists take to ensure that their clients remain safe through the therapeutic process?
Questions Regarding Using Film- and Video-Based Therapies With Clients Who Are Severely Mentally Ill 
Though some of the earliest therapeutic use of film took place in the psychiatric ward of a hospital in Switzerland (Muller & Bader, 1972), little has been written about using film- and video-based therapies with individuals who are severely mentally ill. Though there has been little documentation, it does not mean that this approach to therapy cannot or should not be used with members of this population. For example, in Cchapter 3 Cohen describes a client suffering from bipolar disorder who uses video editing to focus her manic energy. In Cchapter14, Kavitski describes a client diagnosed with bipolar disorder who was able to reflect on his videotaped behavior and gain important insights into his manic state. However, important ethical questions arise in engaging in film- and video-based therapies with clients who have certain diagnoses, such as those involving psychosis. For instance, might creative endeavors encourage the propagation of clients’ delusions and fantasies, particularly when using technologies such as green screen, or could they provide safe ways of regulating the autonomic nervous system, as described by Levine (1997)? 
In addition, how might issues of safety and reality testing be addressed? How might psychiatrists, physicians, nurses, and other members of multidisciplinary health care teams respond to and work with this approach to therapy? Responses might involve a combination of stabilizing clients by using medication first and then requiring that they participate in talk therapy before being approved to join a video therapy group. Although film- and video-based therapies might not be universally appropriate for all people suffering from severe mental illnesses, the chapters in this book might provide hope that this approach could be appropriate and effective in working with these populations.
Conclusion
When faced with pioneering a new approach to therapy using technology, it is important to look back at what existed previously. Therapies using the expressive arts have helped to establish ethical standards and address ethical questions about the use of technology in therapy. Technology is becoming a more relevant and pervasive component of therapy, and with expansion of the Affordable Care Act in the United States and the use of electronic health records, along with other Internet-based and portable technologies such as Skype and iPads in therapy, we therapists must address the larger issue of how technology is changing the profession and how we ought to approach this change ethically. 
We pose this question to readers: How should we approach the technical, legal, and ethical challenges related to film- and video-based therapies? We encourage readers to think of possible challenges as well as reasons to support this therapeutic intervention. We invite readers to explore the rest of the book with the curiosity of children but the critical analysis of thinkers, philosophers, scientists, and anthropologists by reading each chapter carefully and with equal consideration to find ways to make their own film- or video-based practice meaningful, ethical, and safe.
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