__________________________________________________ Professional Boundaries in Mental Health Care
The NBCC recognizes that distance counseling presents unique ethical challenges to professional counselors; related technology continues to advance and be used by more profes- sionals; and that the use of technology by professionals contin- ues to evolve. In light of this information, the NBCC revised its Internet counseling policy and developed the NBCC Policy Regarding the Provision of Distance Professional Services [62]. This policy replaces previous editions. The revised policy includes use of the term “distance profes- sional services” to include other types of professional services that are being used more in distance formats. The policy addresses telephone-, email-, chat-, video-, and social network- based distance professional services that may be conducted with individuals, couples, families, or group members. The policy also identifies specific actions that NCCs should take when providing distance services. The policy supplements the directives identified in the NBCC Code of Ethics [6; 62]. The policy is available at https://www.nbcc.org/Assets/Ethics/ NBCCPolicyRegardingPracticeofDistanceCounselingBoard. pdf. According to the NASW ethics code, social work services assisted by technology “include any social work services that involve the use of computers, mobile or landline telephones, tablets, video technology, or other electronic digital technolo- gies [that] includes the use of various electronic or digital plat- forms, such as the Internet, online social media, chat rooms, text messaging, e-mail and emerging digital applications” [5]. Professionals are advised to “keep apprised of emerging technological developments that may be used in social work practice and how various ethical standards apply to them” [5]. In general, the ethical standards articulated in the NASW Code of Ethics are “applicable to all interactions, relationships, or communications, whether they occur in person or with the use of technology” [5]. Professionals who are involved in discoverable (by the client) “electronic communication with groups based on race, ethnicity, language, sexual orientation, gender identity or expression, mental or physical ability, reli- gion, immigration status, and other personal affiliations may affect their ability to work effectively with particular clients” [5]. Professionals interested in providing online interventions also should consider the potential for boundary confusion, inappropriate dual relationships, or harm to clients [5]. For example, instant message systems can alert clients each time the professional is online, allowing the client to send chat requests. Clients might access a professional’s personal webpage or sign onto online discussion groups to which the professional also belongs. Some may continue to send the professional emails after the termination of the relationship. E-counselors should consider their response to such ongoing contact. Potentially more seriously, clients may use the Internet to harass or stalk current or former counselors [63]. The best way to prevent potential problems is to discuss the boundaries with clients during the initial assessment. Being up front and clear with clients about limits and policies regarding the use of technol- ogy and social networking is recommended [64].
Miscommunication is a commonplace occurrence in the online world. Even the simplest things (e.g., punctuation marks) can be misinterpreted. Studies reveal that 7% of any message is conveyed through words, 38% through certain vocal elements, and 55% through nonverbal elements (e.g., facial expressions, gestures, posture) [65]. Some technology-based forms of com- munication can result in the loss of important nonverbal and vocal cues, leading to an increased risk for miscommunication between client and counselor. Interactive communication, such as texting and email, involves the loss of nonverbal social cues that provide valuable contextual information and interpreta- tion of meaning. Loss of these physical social cues may also increase the client’s tendency to project personal psychologic material onto the blankness of the communication. While this may be helpful in some forms of psychotherapeutic interventions and it may offer advantages over in-person communication, it also presents a potential risk for increased miscommunication [63]. The compassionate professional strives to communicate nonverbally to clients that he or she is listening to and in the moment with the client. Physical cues, such as nodding and eye contact, have been shown to be positively associated with the degree that clients feel the counselor is respectful and genuine [66; 67]. Much attention also is paid to the voice, as it carries the verbal message and people often believe the voice to be a more reliable indicator of one’s true feelings [68]. Because research exploring how empathy is experienced in an online environment is minimal, counselors should check with their clients to determine if the empathy is being transmitted in their text-based communications [10]. No matter what type of counseling is offered, a thorough initial evaluation should be completed to assess whether a cli- ent is appropriate for distance counseling. Practicing within recommended guidelines does not release counselors from the personal responsibility to be aware of, and to independently evaluate, the variety of ethical issues involved in the practice of online therapy [63]. Certain clients (e.g., those with suicidal, homicidal, or substance abuse history, clients with personality disorders) would not be suited to online therapy. LEGAL AND ETHICAL CONSIDERATIONS The challenges of online therapy lead to legal and ethical concerns associated with the delivery of mental health services via the Internet. Those opposed to online or distance therapy worry about licensure issues related to doing therapy across jurisdictional boundaries, legal responsibility in the event of a crisis, and the appropriateness of client anonymity [69]. Providing services across state lines is one of the biggest unre- solved issues. Although communication technologies allow counselors to reach clients anywhere, state licensing laws gener- ally do not permit out-of-state counselors to provide services via these methods. Some states offer guest licensure provisions, but most states require that the counselor hold a license in his or her own state and in the client’s state. Providing distance therapy within one’s own state is simpler, and it allows mental
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