Digital technology has transformed the delivery of mental health services worldwide. Behavioural health professionals now have the option to provide remote and “distance” counselling services using a wide range of online tools, smartphone applications, video technology, and other technological innovations. This disruptive technology has enhanced consumers’ access to services. Yet, these impressive developments have ushered in a challenging array of ethical and risk-management challenges.
Since time immemorial, people have struggled with mental health challenges. Although formal diagnostic labels and nomenclature are of more recent origin, historical records are replete with accounts of what we now regard as major mental illness. The term psychosis is derived from the Greek psyche, meaning “soul,” “mind,” or “breath”. The ancient Greeks believed that breath was the animating force of life and that when it left the body, as happened in death, the soul left the body. A common belief in antiquity was that mental illness was bestowed by the gods. Many people sought cures via magical and religious rituals, including spending a night in a temple of the healing god Asclepius. Many historians believe that Socrates manifested symptoms of auditory hallucinations. Back then, the ancient Greek doctors did not have terms for what we now call schizophrenia.1
The concept of mental health counselling dates back to the nineteenth century, when the professions of psychiatry, psychology, and social work – what have become the principal behavioural health professions – were inaugurated. Since these professions’ creation, people who struggled with debilitating depression, anxiety, relationship conflict, addiction, and other mental health challenges typically have received in-person counselling and other assistance in inpatient psychiatric facilities and outpatient clinics or private offices. For more than a century, mental health counselling has entailed an essential feature: the client and behavioural health practitioner sit in a private room and engage in confidential discussions. For most, these services have been paid for by clients’ health insurers under their policies’ coverage or government-sponsored programmes. Some clients have chosen to pay for services out of pocket.
Fast forward. Today, many people who seek mental health counselling regard such face-to-face counselling sessions in brick-and-mortar clinics and offices as decidedly quaint. As with so many other areas of contemporary life, digital and other electronic technology has been transformative – and disruptive.
The Shifting Clinical and Ethical Landscape – Or “Webscape”
Behavioural health professionals’ use of digital and other technology to provide distance counselling services is proliferating.2 Increasing numbers of contemporary practitioners are using video counselling, email chat, social networking websites, text messaging (SMS), smartphone apps, avatar-based websites, self-guided web-based interventions, and other technology to provide clinical services to clients, some of whom they never meet in person. Digital technology has created unprecedented options for the delivery of mental health services. Increasing numbers of clinicians are relying fully or partially on various forms of digital and other technological options to serve people who are struggling with a wide range of mental health challenges. Clinical practice is no longer limited to office-based, in-person meetings with clients.
Some practitioners are using digital technology informally as a supplement to traditional face-to-face service delivery. Others have created formal “distance” clinical practices that depend entirely on digital technology. In addition, practitioners’ routine use of digital technology – especially social media and text (SMS) messaging – in their daily lives has created new ways to interact and communicate with clients.[ms-protect-content id=”9932″]
In light of these compelling developments, it is essential that behavioural health professionals – including those who provide services directly and those who serve as managers and administrators – address two key issues. First, practitioners must explore the ethical implications of their use of digital technology to communicate with clients in relatively new ways. Professionals’ use of digital technology poses novel challenges associated with traditional ethics concepts related to informed consent, privacy, confidentiality, professional boundaries, documentation, and client abandonment, among others. Second, practitioners must consider whether their use of digital technology and distance counselling services alters the fundamental nature of the therapeutic relationship, which has traditionally entailed opportunities to develop a deep therapeutic connection with a client in the context of ongoing face-to-face meetings.3
Digital technology in behavioural health is wide ranging. It includes the use of computers (including online chat and email) and other electronic means (such as smartphones and video technology using electronic tablets) to deliver services to clients, communicate with clients, manage confidential case records, and access information about clients. Practitioners’ use of digital technology to serve clients is controversial. Some mental health professionals relish their ability to enhance clients’ access to services using digital and other distance counselling tools and believe they can do so in a way that complies with prevailing ethical standards. They argue that distance counselling services offer a number of compelling advantages. For example, some individuals who want clinical services live in remote geographic areas and would have great difficulty travelling to a counsellor’s office. Physically disabled clients can use distance counselling options without enduring the logistical challenges and discomfort involved in arranging transportation and travelling significant distances. Also, individuals with overwhelming anxiety and agoraphobia can access help from home that they might not seek otherwise. People who are profoundly concerned about protecting their privacy can receive counselling without risking exposure in a therapist’s waiting room. The round-the-clock availability of remote counselling services, given the options people have to “connect” with a clinician somewhere in the world almost immediately any time of day or night, either online or by smartphone, also enhances practitioners’ ability to help people in crisis.
However, many practitioners are deeply troubled by these distance counselling options, arguing that some are unethical and expose clients to nontrivial risks.4 These clinicians worry that the use of digital and other distance counselling options undermines genuine therapeutic relationships and compromises practitioners’ ability to honour core ethical values and standards. Authentic clinical relationships, critics argue, depend on the kind of intense connection that only in-person contact enables. To provide effective clinical services, they claim, therapists must be in the same room with clients to truly connect with them and ensure the degree of trust that is essential for effective counselling. Clinical services provided remotely greatly increase the likelihood that counsellors will miss important clinical cues, for example, clients’ tears, gleeful expressions, or a client’s grimace or squirm in response to the therapist’s probing question or comment. Clinicians who offer distance counselling services may find it difficult to maintain clear boundaries in their relationships with clients, in part because of ambiguity surrounding the temporal limits of their interactions that are no longer limited to office-based visits during normal working hours. And, among other concerns, there are daunting challenges related to protecting and managing client confidentiality and responding to mental health emergencies.
Ethical and Risk-Management Challenges
The relatively recent proliferation of digital and distance behavioural health services has led to a wide range of ethical and related risk-management concerns. Professional associations, licensing boards, and other regulatory bodies are now immersed in efforts to identify pertinent ethical issues and develop reasonable, practical guidelines for practitioners. Recognising the legitimacy of ongoing debates about the appropriateness of this digital and distance technology, it behooves behavioural health practitioners and administrators to be aware of pertinent ethical issues and develop rigorous ethical guidelines.5 It is essential that professionals address these issues, and adhere to current and emerging standards, to enhance protection of clients and minimise the likelihood of ethics-related litigation and licensing board complaints alleging substandard or unethical practice.
Recent research and developments in behavioural health professions suggest that the most prominent ethical challenges pertain to informed consent; privacy and confidentiality; professional boundaries; practitioner competence; and documentation. For example, obtaining clients’ truly informed consent can be especially difficult when practitioners never meet their clients in person. Special challenges arise when minors contact practitioners and request distance counselling services, particularly when practitioners offer free grant-funded or pro bono assistance and do not require parents’ credit card information.
Also, the rapid emergence of digital technology and other electronic media used by behavioural health practitioners to deliver clinical services has added a new layer of challenging privacy and confidentiality issues. Professionals must be sure to use sophisticated encryption technology to prevent confidentiality breaches (hacking) by unauthorised parties and to comply with relevant privacy laws. Practitioners should be aware that email communications for therapeutic purposes create a permanent record of online messages (digital footprints). Further, practitioners may have no control over what clients choose to share with other parties electronically, in the form of forwarded or copied email or text messages.
In addition, practitioners who offer video counselling services must recognise that they have much less control over confidentiality than when they provide traditional office-based services. For example, a client receiving video counselling services could invite a family member or acquaintance to sit in on a session – outside of camera range – without the therapist’s knowledge or consent.
And, practitioners must use sound judgment about conducting online searches to gather information about clients (e.g. Google searches) without clients’ knowledge or consent. Some clients may feel over exposed and violated by clinicians’ attempts to conduct online searches for information about them.
Practitioners’ use of digital technology also has introduced new and complicated boundary issues. Consider, for example, a client who attempts to contact his therapist on the clinician’s personal Facebook site. Many practitioners receive requests from current and former clients asking to be social networking “friends”. Electronic contact with clients and former clients on social networking sites can lead to boundary confusion and compromise clients’ privacy and confidentiality. Electronic message exchanges between counsellors and clients that occur outside of normal business hours, especially if the counsellor uses a personal social networking site or email address, may confuse traditional practitioner-client boundaries. Further, clients who have access to practitioners’ social networking sites may learn a great deal of personal information about their therapist (such as information about the clinician’s family and relationships, political views, social activities, and religious activities), which may introduce complex confusion in the professional-client relationship.
Practitioners’ use of online and other electronic services also has posed unprecedented documentation challenges. Practitioners must develop strict protocols to ensure that clinically relevant e-mail, text, social networking (for example, Facebook), and telephone exchanges are documented properly in case records. To practice ethically, practitioners who use digital and other technology to provide distance services must develop documentation protocols that ensure proper encryption; reasonable and appropriate access by colleagues to pertinent records and documents (for example, when a counsellor is incapacitated and a colleague provides coverage); documentation of video counselling sessions, email, text messages, and cybertherapy communications; compliance with laws, regulations, and agency policies concerning record and document retention; and proper disposal and destruction of digital documents and records.
Behavioural health has been transformed or “disrupted” by the emergence of digital and other electronic technology. Today’s practitioners have the option to counsel clients they never meet in person. Even practitioners who maintain traditional office-based clinical practices can interact with clients outside the office using video counselling and social networking technology, email, text messaging, and avatars.
For some clinicians and clients, the traditional in-office therapeutic hour has become obsolete. Contemporary behavioural health professionals must think carefully about whether and to what extent they will incorporate digital and other electronic technology into their professional lives. Their judgments should draw on prevailing ethical standards and standards of care to protect clients and prevent litigation and regulatory body complaints. Practitioners should keep in mind that digital and electronic behavioural health service delivery is a rapidly developing aspect of professional life, one in which ethical and risk management standards will continue to evolve.
About the Author
Frederic G. Reamer, Ph.D is Professor at the School of Social Work, Rhode Island College. He is the author of many books and articles on Professional Ethics, including Risk Management in Social Work: Preventing Professional Malpractice, Liability, and Disciplinary Action (New York: Columbia University Press). Reamer Chaired the National Task Force that wrote the Code of Ethics adopted by the National Association of Social Workers.
1. Harris, W.V., ed. (2013). Mental disorders in the classical world. Leiden, Netherlands: Brill.
2. Gupta, A. , & Agrawal, A. (2012). Internet counselling and psychological services. Social Science International, 28, 105-122; Zur, O. (2012). TelePsychology or TeleMentalHealth in the digital age: The future is here. California Psychologist, 45, 13-15.
3. Lamendola, W. (2010). Social work and social presence in an online world. Journal of Technology in the Human Services, 28, 108-119; Lannin, D.G., & Scott, N.A. (2013). Social networking ethics: Developing best practices for the new small world. Professional Psychology: Research and Practice, 44, 135-141.
4. Reamer, F.G. (2015). Clinical social work in a digital environment: Ethical and risk-management challenges. Clinical Social Work Journal, 43, 120-132.
5. See, for example, Association of Social Work Boards (2015). Model regulatory standards for technology and social work practice. Culpeper, VA: Author; Joint Task Force for the Development of Telepsychology Guidelines for Psychologists (2013). Guidelines for the practice of telepsychology. American Psychologist, 68. 791-800.