Limiting risk in the practice of E-therapy Matthew Robb (2004) recommends the following for those practicing e-therapy: 1. Full disclosure : This relates to informed consent and the need to fully disclose the possible benefits and risks of distance counseling, including informing the client that this is a new area of practice, which has not had the benefit of long-term study. 2. Comprehensive assessment : Provide clients with detailed and complete assessment tools and encourage full disclosure by client. 3. Confidentiality and disclosure of safeguards : Take all precautions to safeguard the confidentiality of information and avoid misdirected emails, eavesdropping, hacking, etc. Alert the client to these potential risks as well. 4. Emergency contact : Obtain information for an emergency contact and together develop a clear emergency plan. 5. Consult your association’s code of ethics : Review standards regarding informed consent, confidentiality, conflict of interest, misrepresentation, etc. 6. Consult state licensing provisions : Research both the statutory regulations of your board and those in the client’s home state. 7. Consult a malpractice/risk management attorney : Consider asking a legal specialist to review website materials to determine compliance with standards of care and potential malpractice issues. 8. Provide communication tips : If communicating solely by text-based messaging, provide client with clear tips regarding communication. Texting has become more common in clinical practice. In spite of the imminent risk to client privacy and breach of confidentiality, some clients, especially adolescents, prefer this mode of communication. Practitioners using texting as a form of communication should have a clear policy outlining when texting will be used or is acceptable (NASW, 2017). Informed consent should also address and cover this risk. Should texts be included in the health record? The short answer is “Yes.” Whether to include the exact text or a summary of text discussion is at the discretion of the provider, but there should be some record of text communication. Texts, much like email, need to reflect the values, ethics, and mission of the practitioner’s profession (NASW, ASWB, CSWE, & CSWA, 2017; Reamer, 2018b; Sidell, 2015). Current guidelines for the use of technology are discipline-specific, and clinicians wishing to use technology in their practices should ensure that they are following their profession’s ethical and legal standards. When practitioners decide to engage in texting with clients, their policies should be provided to clients during the first session, and they should obtain informed consent. Therapeutic contact via texting is now being advertised. Although texting may be a comfortable means of communication for some clients, this means of engagement with clients can raise ethical and legal issues. Although companies providing therapeutic conversations have not been presenting their services as actual therapy, it is unclear that clients understand that this is the case. According to Groshong and Aronson (2019), texting might work as a way of beginning the therapeutic process, which could then move on to therapy conducted through videoconferencing or in person. Legal problems with this form of client engagement might result from privacy and security concerns, and specifically with HIPAA compliance. Furthermore, the commercial
nature of the texting being advertised could lead to ethical problems. Using email with clients poses other challenges that need to be addressed with clients. Although convenient for a number of purposes, including completing necessary paperwork before sessions, scheduling, or answering simple questions without playing “phone tag,” email carries inherent confidentiality and boundary risks. The need for informed consent, with its attendant implications and risks, must be taken into consideration. The added protection of an encryption program, as well as the use of a password or code words or an electronic signature system that verifies clients’ identities, could also be considered (Sidell, 2015). Both texting and emailing clients can pose ethical dilemmas and place practitioners at potential risk for favoritism, conflicts of interest, and boundary confusion (NASW, ASWB, CSWE, & CSWA, 2017). Furthermore, it is never possible to ensure that the intended person is receiving an electronic communication. Again, referring to professional guidelines for technology, along with ethical and legal standards, is key to effective and appropriate documentation. The National Association of Social Workers (2020b) presents a list of eight ethical considerations when starting a telehealth practice: 1. In keeping with Standard 1.04(a), Competence, in the NASW Code of Ethics, “Social workers should provide services only within the bounds of their education, training, license, certification, consultation received, supervised experience, or relevant professional experience.” In the context of telehealth, this means that social workers must receive adequate training and be competent in the work. In accordance with Standard 1.04(d), social workers need to understand the communication challenges of this type of work and be able to implement strategies to address the challenges. 2. In accordance with Standard 1.02, Self-Determination, social workers need to be aware of client preferences and capabilities. In accordance with Standard 1.03,(f) (g), Informed Consent, social workers must be aware of clients’ ability to understand and use such services. Also, Standard 1.05(d), Cultural Awareness and Social Diversity, requires that social workers understand issues such as culture, economic status, mental or physical abilities, and language issues that might influence the effectiveness of such services for clients. 3. In accordance with Standard 1.04(e), Competence, social workers need to be sure that they are appropriately licensed and adequately insured when providing telehealth services. 4. In accordance with Standard 1.07(m), Privacy and Confidentiality, social workers need to select a secure and HIPAA-compliant platform. 5. In accordance with Standard 1.13, Payment for Services, and 3.05, Billing, social workers need to pay attention to payment and billing requirements. Standard 1.07(m), Confidentiality, must also be addressed when third- party billers such as insurance companies, Medicare, or Medicaid are involved. 6. Social workers need to implement technology standards, policy, and procedures, in accordance with Standards involving informed consent, privacy and confidentiality, and conflicts of interest. 7. Because technology can be disrupted, social workers need to develop an emergency backup plant. 8. When necessary, social workers will need to seek consultation from technical experts, attorneys, or professional colleagues with relevant expertise and experience.
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