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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
This landmark primer in telebehavioral health addresses the functional elements of technology-assisted therapy with individuals, couples, and families. Leaders and innovators in the field contribute unique perspectives to help students and practitioners prepare for and productively engage in virtual counseling and supervision. Using reader-friendly language, the authors discuss ethical, legal, regulatory, and practical considerations for using the right technology in secure and confidential ways to best serve clients and supervisees. Diverse case scenarios, questions for further discussion, and useful appendices enhance this rich and current resource.
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Veröffentlichungsjahr: 2020
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Table of Contents
Cover
Title Page
Copyright Page
Dedication Page
Preface
About the Editors
About the Contributors
Appendix Authors
Chapter 1: Ethical, Legal, and Risk Management Considerations: Understanding the Landscape of Telebehavioral Health and Supervision
Competency
Residency
Assessing Appropriateness for Technology-Assisted Services
Anonymity and Confidentiality
Security
Liability Insurance and State Licensure Regulations
Synchronous Videoconferencing
Texting
Social Media
Voice-Assisted Technology, Bluetooth, and Gaming Communication on Devices
Informed Consent
Additional Recommendations to Be Included in the Informed Consent
Distance Supervision
Scenarios for Discussion
Questions to Explore
Conclusion
References
Chapter 2: Certification and Regulation of Distance Counseling and Supervision
The Promise and Peril of Behavioral Telehealth Services
What Is Regulation and Why Is It Important?
The Case for Licensure
State Licensing Boards
Limitations of State Licensing Boards
The Role of Regulation in Telehealth
Questions to Explore
Best Practices for Practitioners
Scenario for Discussion
Conclusion
References
Chapter 3: Bridging the Generational Technology Divide in Counseling Training, Practice, and Supervision
Definition of Terms
Technology in the Counseling Profession
Scenarios for Discussion
Questions to Explore
Conclusion
References
Chapter 4: Navigating the Regulatory Gauntlet
The Current Landscape of Regulation and Oversight
Important Terminology
The Role of Regulatory Bodies
Professional Associations’ Codes of Ethics and Standards of Practice
HIPAA
HITECH
FERPA
Licensing Boards
Scenarios for Discussion
Questions to Explore
Conclusion
References
Chapter 5: Distance Supervision
Challenges to Finding Good Supervision
The History of Clinical Supervision
Questions to Ask a Potential Clinical Supervisor
Scenarios for Discussion
Conclusion
References
Chapter 6: The Tools of Telebehavioral Health: How to Identify, Vet, and Deploy the Right Technology in Practice
Federal Rules and Regulations: HIPAA and HITECH
Family Educational Rights and Privacy Act of 1974 (FERPA)
Security Standards
Identifying, Vetting, and Deploying the Right Technology
Types of Telehealth (Synchronous Video) Vendor Solutions
Questions to Explore When Choosing Telehealth Tools
What to Look for in a Vendor
Conclusion
References
Chapter 7: Counseling Training, Practice, and Supervision Using Avatars
History
Virtual Presence
Avatar Platforms
Qualities of Avatars
Qualities of the Environment
Application to Counseling and Counseling Preparation
Ethical Practice Concerns
Guidelines for Establishing Avatar-Based Practice
Legal Limitations of Practice
Conclusion
References
Chapter 8: Incorporating Online Therapy Into a Private Practice
Clinical Considerations
Getting Started
Clinical Strategies
Scenarios for Discussion
Conclusion
References
Appendix A: Readiness for Online Counseling: Client Checklist
Appendix B: Video Call EtiquetteVideo Call Etiquette
Appendix C: Clinical Supervision AgreementClinical Supervision Agreement
Appendix D: Information, Authorization, and Consent to Technology-Assisted ServicesInformation, Authorization, and Consent to Technology-Assisted Services
Faxing Medical Records
Index
Technical Support
End User License Agreement
List of Illustrations
Chapter 6
Figure 6.1 Sample Telehealth Workflow
Guide
Cover
Table of Contents
Begin Reading
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edited by
Jennifer Nivin WilliamsonDaniel G. Williamson
Distance Counseling and Supervision
A Guide for Mental Health Clinicians
6101 Stevenson Avenue, Suite 600Alexandria, VA 22304www.counseling.org
Copyright © 2021 by the American Counseling Association. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
American Counseling Association6101 Stevenson Avenue, Suite 600Alexandria, VA 22304
Associate Publisher Carolyn C. Baker
Digital and Print Development Editor Nancy Driver
Senior Production Manager Bonny E. Gaston
Copy Editor Beth Ciha
Cover and text design by Bonny E. Gaston
Library of Congress Cataloging-in-Publication Data
Names: Williamson, Jennifer Nivin, editor. | Williamson, Daniel G., editor.Title: Distance counseling and supervision : a guide for mental health clinicians / editors, Jennifer Nivin Williamson, Daniel G. Williamson.Description: Alexandria, VA : American Counseling Association, [2021] | Includes bibliographical references and index.Identifiers: LCCN 2020041305 | ISBN 9781556203930 (paperback)Subjects: LCSH: Mental health counseling. | Counseling psychology. | Medical telematics. | Counselors—Supervision of.Classification: LCC RC466 .D57 2021 | DDC 362.2/04256—dc23LC record available at https://lccn.loc.gov/2020041305
DEDICATION
The book is dedicated to our families,parents, mentors, students, and communities.You are the foundation and the future.
PREFACE
This book has been an exploration that began in 2016 when we were in an American Counseling Association (ACA) Ethics Committee town hall meeting. The conversation was rich with questions about telehealth, and there were more questions than answers. In an effort to better understand the complexities of this topic, we invited the leaders and many stakeholders from governing and advising bodies to contribute to a panel discussion. At that time, we included the cochair of the ACA Ethics Committee, the cochair of the ACA Policies and ByLaws Committee, the chair of the Council for Accreditation of Counseling and Related Educational Programs, the president of the American Association of State Counseling Boards, the founder of Motivo, the founder of WeCounsel, counselor educator and marriage and family leaders, and experts in the use of avatar and virtual platforms in counselor education. This conversation was so rich that this book was born.
As we were editing the final chapters in February and March 2020, we began to experience something completely unexpected because of Coronavirus (COVID-19). Most communities in the United States and many communities across the globe were ordered to shelter in place. Counselors and other mental health workers were attempting to balance the necessity of limiting exposure to themselves and their clients while still maintaining services for clients in need during an incredibly stressful time. Even the most conservative and technology-cautious professionals were attempting to offer virtual services. For the first time in our memory, the Health Insurance Portability and Accountability Act of 1996 and other privacy laws were temporarily relaxed because of the emergency. Governors, federal offices, and licensure boards eased restrictions on definitions around residency and restrictions on the use of technology in counseling and supervision. Although the relaxation of these standards might have been temporary, it ushered in a new era of technology-based counseling and supervision. During this time, most counselors, counselor educators, and supervisors used various platforms to continue providing services for clients. Synchronous videoconferencing platforms such as Zoom, Doxy.me, and Webex became common venues for counseling and supervision. Clinical spaces were created in parked cars, spare bathrooms, or makeshift home offices. Professional organizations, including ACA and its state and regional affiliates, rose to the occasion and organized trainings via videoconferencing in an effort to help counselors across the globe prepare for the task before them. During an emergency, such as the COVID-19 pandemic, it is important for professionals to attend to licensing authorities’ websites for their state, their state’s governor’s office, the U.S. Department of Health and Human Services, state and local professional organizations, and national organizations (including ACA). ACA has a web presence dedicated to telebehavioral health in its Knowledge Center (https://www.counseling.org/knowledge-center/mental-health-resources/trauma-disaster/telehealth-information-and-counselors-in-health-care/telebehavioral-health-licensure-and-liability-insurance).
This book is a tool for continuing the conversation among our colleagues to encourage the use of technology in productive, safe, and confidential ways so that we may better serve our clients, supervisees, and the profession. Although this resource offers suggestions for professional practice, it is our hope that it will provide insights and valuable questions for greater exploration as you venture further into telebehavioral health services.
All author proceeds from this book will go to Uganda Counseling and Support Services (ugandacss.org) in support of their efforts to bring counseling, education, and medical care to underserved communities throughout Uganda.
About the Editors
Jennifer Nivin Williamson, PhD, is a past senior cochair of the American Counseling Association (ACA) Ethics Committee and a current member of the Ethics Appeals Committee. Williamson, core faculty with Capella University and cofounder of PAX Consulting and Counseling PLLC, is a licensed professional counselor in Texas, licensed professional clinical counselor supervisor in Kentucky, approved clinical supervisor, and national certified counselor. She holds a doctorate from Baylor University and is a Fulbright specialist alumna in mental health. She has presented nationally and internationally on counselor ethics. She was the 2015 recipient of the Association for Counselor Education and Supervision (ACES) Counseling Vision and Innovation Award, the 2017 recipient of the European Branch of the American Counseling Association’s Professional Clinical Counselor of the Year Award, and the 2018 recipient of the Daya Sandhu Research and Innovation Award.
Daniel G. Williamson, PhD, is a past cochair of the American Counseling Association (ACA) Policies and Bylaws Committee and a current member of the ACA International Committee. Williamson, core faculty with Capella University and cofounder of PAX Consulting and Counseling PLLC, is a licensed professional counselor in Texas, licensed professional clinical counselor supervisor in Kentucky, approved clinical supervisor, and national certified counselor. He holds a doctorate from Baylor University and is a Fulbright specialist alumnus in mental health. He has presented nationally and internationally on counselor ethics. He was the 2015 recipient of the Association for Counselor Education and Supervision’s (ACES) Counseling Vision and Innovation Award, the 2017 recipient of the European Branch of the American Counseling Association’s Counseling Department Chair of the Year Award, and the 2018 recipient of the Daya Sandhu Research and Innovation Award.
About the Contributors
Susan E. Belangee, PhD, LPC, NCC, ACS, works in private practice in Canton, Georgia, specializing in using Adlerian strategies with clients struggling with body image and eating disorders. She has published several articles and contributed to book chapters on the topic as well. She serves as a supervisor in her practice for counselors pursuing licensure in Georgia and is a member of the Georgia Society of Adlerian Psychology. Susan is currently the past president of the North American Society of Adlerian Psychology (NASAP) as well as a diplomate of NASAP. She is a faculty member for the International Committee of Adlerian Summer Schools and Institutes; has worked as an associate professor at Holy Family University, where she served as institutional review board chair; and has taught online for Drake University and the Adler Graduate School. She presents regularly at local, regional, national, and international conferences on Adlerian psychology and its relevance to clinical research and practice. In addition to Adlerian organizations, Susan maintains membership in the American Counseling Association (ACA) and Chi Sigma Iota Academic and Professional Honor Society International.
Regina Bordieri, PhD, is a licensed marriage and family therapist who owns and operates a private practice with a physical location in New York City (www.familyandcoupletherapy.com). She earned her doctorate in psychology in Alliant International University’s Couple and Family Therapy Program (accredited by the Commission on Accreditation for Marriage and Family Therapy Education) and maintains her license as a marriage and family therapist in California. She regularly provides online therapy in her private practice, including therapy services that are conducted exclusively online, hybrid services that combine online and in-person therapy sessions, and stand-alone assessment and relationship enhancement programs. She has a unique specialty focused on couples coping with a bipolar diagnosis (bipolarcouples.com). She was the recipient of the 2017 American Association for Marriage and Family Therapy (AAMFT) Dissertation Award for her research on couples with a bipolar-diagnosed partner and has provided numerous clinical trainings at national and state conferences and in mental health facilities on the systemic treatment of bipolar disorder. She presented a career development seminar on incorporating online therapy into a private practice at the 2019 AAMFT Conference. She is currently an adjunct professor in the psychology department of the City University of New York at Brooklyn College. She has also taught as an adjunct professor in several marriage and family therapy graduate programs. She currently provides online supervision and clinical trainings in online therapy.
Mykia J. H. Griffith, MA, earned her master’s degree in clinical mental health counseling from the University of Mary Hardin-Baylor. She is currently a licensed professional counselor intern as well as a marriage and family therapist associate. She is a member of and has given presentations for both ACA as well as the International Association of Marriage and Family Counselors. She is also a member of the Association for Play Therapy and plans to focus her expertise in working with children and their families. She is currently working toward more publications while also directing time and energy to helping her community.
Marty Jencius, PhD, earned his doctorate in counselor education from the University of South Carolina in 1996. His 16 years of clinical experience include work as an addictions counselor, a clinical mental health counselor, a coordinator of services for severely emotionally handicapped children, and a counselor in a private practice serving business and industry. He is founder and list manager of CESNET-L (a professional listserv for more than 4,000 counselor educators), cofounding editor of The Journal of Technology in Counseling (a web-based, peer-reviewed journal), founder of Counselor Education in Second Life (virtual world counselor training; http://SL.CounselorEducation.org), founder and editor of The Counselor Audio Source (a podcast series for counselors; http://counseloraudio-source.net/), and producer of The Faculty Meeting (a podcast about faculty life; www.thefacultymeeting.net/). He is past president of the Association for Counselor Education and Supervision. Professor Jencius has more than 100 print publications in books, book chapters, journal articles, and articles along with an additional 40 digital podcasts related to counseling and counselor education.
Stephanie R. Marder, MA, MEd, LPC, LCDC II, is a doctoral candidate in Kent State University’s Counselor Education and Supervision program. Marder earned a bachelor’s degree in psychology from the University of New Hampshire and a master’s degree in psychology from Boston University. Several years later she graduated with her master’s degree in education in clinical mental health counseling from Kent State University and obtained her licensed professional counselor degree. She currently practices at Family Behavioral Health Services, LLC, in Mayfield Village, Ohio. Marder specializes in working with adolescents, emerging adults, and families. Her scholarly interests include using the latest technology to benefit clients and enhance treatment outcomes as well as developing tools to better assist adolescents and emerging adults manage anxiety concerns.
Jason K. Martin, PhD, is the clinical director and an associate professor of counseling at the University of Mary Hardin-Baylor. He is a licensed marriage and family therapist and licensed professional counselor in Texas and serves on the board of directors of the Texas Association for Marriage and Family Therapy (TAMFT). He is an AAMFT approved supervisor and has maintained a private practice for many years. Jason is a two-time recipient of the TAMFT Susan Speight Governmental Leadership Award (2015 and 2020). He has researched and published on the development of theoretical orientation among student counselors and the phenomenon of fatherhood. He holds a doctorate in marriage and family therapy from Michigan State University and a master’s degree in marriage and family therapy from Abilene Christian University.
Rachel McCrickard, MA, is a licensed marriage and family therapist and the founder/chief executive officer of Motivo, an online platform that connects therapists to clinical supervisors and peer consultants. After years of experience providing therapy and supervision in both urban and rural areas, Rachel began to recognize the difficulty many therapists experience when attempting to find quality clinical supervision. Impassioned by her entrepreneurial spirit, Rachel fostered the creation of Motivo in 2017 to create an easier path to licensure for therapists through the responsible use of technology.
Angela McDonald, PhD, is dean of the School of Health Studies and Education and a professor in the Department of Educational Leadership at Saint Joseph’s University in Philadelphia, Pennsylvania. She earned her doctorate in counselor education at the College of William and Mary in 2006. She has been a licensed counselor in North Carolina for 13 years, working in a variety of settings, and she has been published in several journals, including the Journalof Counseling & Development. She is also the past president of the American Association of State Counseling Boards and the past chair of the North Carolina Board of Licensed Professional Counselors. She is a national certified counselor.
Jeffrey Parsons, PhD, is a professor of counseling at Lindsey Wilson College and serves as the director of the Counselor Education and Supervision program. He is a licensed professional clinical counselor in the state of Kentucky. Prior to serving in his current role, Jeff served 7 years as director of program evaluation and technology for the School of Professional Counseling and 3 years as director of teaching and technology effectiveness for the Office of Academic Affairs. He recently completed a term as a board member (including 2 years as chair) for the Council for Accreditation of Counseling and Related Educational Programs.
Harrison Tyner is a social impact entrepreneur, technology innovator, and startup adviser to numerous early-stage tech companies. As founder and chief executive officer of WeCounsel Solutions, Harrison launched the first cloud-based software platform for behavioral health, which has facilitated more than 1 million virtual sessions to date. With expertise in telemedicine, health care, and software as a service, Harrison regularly collaborates with other startup founders to develop innovative solutions that make a positive impact on the community.
Appendix Authors
Kenda Dalrymple, JD, is an attorney and the managing partner of Dalrymple, Shellhorse, Ellis & Diamond, LLP, in Austin, Texas. She earned her undergraduate degree in communications from Baylor University and her Juris Doctor degree from Baylor University Law School. For the past 26 years, she has represented hundreds of professionals before their licensing boards on complaint and license-related cases. She also presents frequently on ethics, risk management, confidentiality of records, Health Insurance Portability and Accountability Act of 1996 and Health Information Technology for Economic and Clinical Health Act regulations, and other matters related to administrative law and mental health. Although she excels at helping professionals when a problem has arisen in their practices, she much prefers to educate and train them to recognize common pitfalls and avoid trouble, if possible. She is past president of the Austin Bar Association’s Administrative Law Section and the Kappa Alpha Theta Austin Alumnae Association and a past course director for the State Board of Texas Advanced Administrative Law Seminar, an annual 2-day continuing legal education seminar. For the past 10 years, she has been a member of the American Psychological Association (APA) Board of Directors’ Standing Hearing Panel, which hears and decides ethics cases brought by the APA.
Amber Hord-Helme, MA, LPCC-S, NCC, has been a licensed counselor for more than 15 years. She has owned her own private group practice in Versailles, Kentucky, for the past 10 years. She is currently a doctoral candidate in the Counselor Education and Supervision program at Lindsey Wilson College in Columbia, Kentucky. She has been an adjunct instructor for Lindsey Wilson College since 2017 and has supervised interns and provisionally licensed postgraduate practitioners since 2012. She is a former secretary of the Kentucky Mental Health Counseling Association and is currently president of the Kentucky Association for Assessment and Research in Counseling. Her current areas of research include counseling for clients with dyslexia, implementing telehealth counseling in private practice, and developing professional counselor identity in early professionals.
Chapter 1Ethical, Legal, and Risk Management Considerations: Understanding the Landscape of Telebehavioral Health and Supervision
Jennifer Nivin Williamson and Daniel G. Williamson
The ACA Code of Ethics (American Counseling Association [ACA], 2014) declares the following in the introduction to Section H:
Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. (p. 17)
This section on distance counseling, technology, and social media was among major revisions to the ethical standards and identifies technology as a part of the profession. Counselors have an ethical obligation to understand how new technologies might be used to serve clients and to use them responsibly. The introduction to Section H goes on to caution counselors to recognize the concerns with using these technologies, especially in terms of protecting confidentiality, and to recognize the ethical and legal requirements needed to implement these resources appropriately (ACA, 2014). The primary goal of integrating technology into counseling practice is to enhance human interaction (Association for Counselor Education and Supervision Technology Interest Network, 2007). As counselors engage in technology-assisted mental health services, it is imperative that they consider ethical, legal, and risk management standards in an effort to provide competent care to clients. In instances when the process is not clearly outlined, an ethical decision-making model should be used, the law should be explored, and the appropriate stakeholders should be consulted.
Providing some form of mental health services at a distance is not a new concept. Suicide hotlines have been in existence since the 1950s (Centore & Milacci, 2008), and poet Sylvia Plath continued to connect with her Boston-based psychiatrist after she moved to England by exchanging letters in the 1960s. Although Plath’s life ultimately ended in suicide, she described the letters as a lifeline (Alexander, 2018). This illustrates both the risk and benefit of distance counseling.
In 2014, ACA recognized “the evolving nature of the profession with regard to distance counseling, technology, and social media” (p. 17). In 2016, the National Board for Certified Counselors (NBCC) recognized the impact that computers and technology have had on the counseling profession, drafted a policy regarding the provision of distance services, and developed a distance counseling credential. Multiple terms are used to describe counseling activities that partly or completely use the internet, including “online counseling/therapy, technology-assisted counseling, e-therapy, psychotechnology, behavioral telehealth, distance professional services, internet counseling, cybertherapy, and distance counseling” (Wheeler & Bertram, 2019, p. 172). Harris and Birnbaum (2015) touted the possibility of technological advances to reach tens of millions of individuals who are currently underserved.
Legal and regulatory bodies struggle to keep up with the integration of technology into the profession, as do practitioners. VandenBos and Williams (2000) reported that in a survey of American Psychological Association members, 98% affirmed that they had provided counseling services over the phone. Although the use of technology in counseling and supervision has been present for decades, the use of modern technologies remains hotly debated.
During the 2020 Coronavirus (COVID-19) crisis, technology proved to be an opportunity for maintaining continuity of care, providing emergency services, and coping with the global pandemic. Many governing bodies, including state licensure boards and the U.S. Department of Health and Human Services, temporarily relaxed Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations in an effort to allow counselors and other mental health professionals to provide mental health services during this emergency (U.S. Department of Health and Human Services, 2020). It is possible that these experiences with online counseling will further expand the use of distance counseling. In addition, counseling supervision was provided via synchronous videoconferencing platforms in universities that traditionally only used face-to-face formats.
Competency
In many situations, counselors are responsible for identifying and demonstrating competency when determining their scope of practice. There are, however, specific laws or regulations for determining minimum standards. Some state licensure boards have identified minimum training standards through continuing education credits or university training, whereas other boards have not clearly articulated expectations. It has been a challenge for regulatory entities to stay current with the rapid evolution of technology and technological practices. It is clear in all situations that counselors must always function within their areas of competence and be able to provide evidence regarding their competence and adequate training. This is especially challenging as technology is constantly changing, and best practices in technology-assisted mental health services are in their infancy. ACA (2014) notes that “counselors who engage in the use of distance counseling, technology, and/or social media develop knowledge and skills regarding related technical, ethical, and legal considerations (e.g., special certifications, additional course work)” (Standard H.1.a.).
In addition, counselors must make clients and supervisees aware of the training, limitations, and protections offered by the counselor or supervisor (American Association for Marriage and Family Therapy, 2015). The Association of Marital and Family Therapy Regulatory Boards (AMFTRB; 2016) identified a minimum of 15 hours of initial training, including the appropriateness of teletherapy, teletherapy theory and practice, modes of delivery, legal/ethical issues, handling online emergencies, best practices, and informed consent. In addition, it requires five continuing education hours every 5 years. NBCC offers a nationally recognized credential, the board certified-telemental health provider (BC-TMH), who might be useful in training and the demonstration of skills. This provides counselors an opportunity to demonstrate formal training or skill attainment as a telemental health provider (Center for Credentialing and Education, 2020).
Residency
When counselors engage in technology-assisted counseling, they should be aware of the laws and regulations in their state of practice as well as the client’s state of residence. In most situations, counselors must adhere to the laws and regulations of both states (ACA, 2014; AMFTRB, 2016; NBCC, 2016b). When clients or counselors travel out of their state of residency (physically or virtually), counselors should be aware of the state’s definition of residency, as each state defines residency differently. Some states allow a client’s residency to be defined by the client’s home address, whereas others define residency as the physical locations of the counselor and/or client at the time of service delivery (AMFTRB, 2016). Some states allow for travel, but they may define the number of days outside of the home state. In this situation, an attorney and the licensure boards for the states in question should be consulted to fully understand the legal definition of residency. Once counselors have identified the legal regulations for their region, they should document their findings as well as their activities in their counseling records (NBCC, 2016b).
When counseling clients who are outside of the United States, it is important to identify the counseling regulations for the counselor’s home state as well as the country and/or region in which the client is living (ACA, 2014). It might be important to identify how mental health services are defined and regulated in the region, as the terms counselor or therapist might have different meanings in different regions. When counselors or clients reside on a military base, the regulations may also be very different. Many U.S. military bases are considered sovereign territory and possess their own regulations regarding licensure. Another factor to consider is where the counseling services are offered, either through a mental health office or through a chaplain’s office. Chaplain or faith-oriented services are sometimes subject to different rules, laws, and regulations, which has implications for confidentiality.
Several resources are available to assist counselors providing telebehavioral health services. ACA provides resources regarding client/counselor residency on their website (https://www.counseling.org) and specifically in the Government Resources section (https://www.counseling.org/government-affairs/government-resources-for-counselors).
Assessing Appropriateness for Technology-Assisted Services
Counselors must recognize that not all clients will be well served through telebehavioral health services; therefore, it is imperative for them to assess a client’s appropriateness for technology-assisted services prior to beginning distance counseling. The ACA Code of Ethics states that “counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client” (ACA, 2014, Standard H.4.c.). Counselors must recognize that distance counseling services are not appropriate for every client; in those situations, they should consider offering face-to-face services or providing appropriate referrals for those clients. This assessment of client appropriateness should be an ongoing process to ensure the client is using technology in an appropriate manner (ACA, 2014; Stolsmark, 2015). It is important for counselors to assess several categories of appropriateness, including access to and knowledge about technology, counseling space and netiquette, emotional stability, and safety and emergency risk management. It is recommended that counselors meet with clients in person when possible to conduct this assessment, to verify their identity, and to conduct an initial informed consent interview. When an in-person session is not possible, a synchronous videoconferencing session might be appropriate (AMFTRB, 2016). It is important for clients to understand the risks and limits to confidentiality prior to engaging in an initial session using technology. Clinicians should consider the following areas of appropriateness prior to engaging in virtual clinical services with clients.
Access to and Knowledge About Technology
Technology-assisted counseling sessions are most effectively conducted with clients who are very comfortable using similar technologies. It can be risky or stressful to use technology in the counseling session when the client has not used it in the past or when appropriate supports are not in place. In some cases, rural agencies have opted to send out technologists or case managers to assist clients in their homes during initial sessions when they are new to using virtual technology. Other providers have constructed telehealth rooms in their agencies that are monitored by administrative staff to support connections with counselors who are off-site. It is helpful to provide clients with a list of the required technologies prior to the first session. This list might include a computer with the capacity necessary to handle a teleconferencing program, a webcam with microphone, headphones with an integrated microphone, and an Ethernet-accessed internet connection. It is recommended that clients and counselors use Ethernet cables to connect to the internet, as wireless internet may not be secure and risk confidentiality breaches. It is also helpful when both clients and counselors use a virtual private network as a means to secure and protect confidentiality. HIPAA-compliant encrypted software should this time of crisis; however, it also recognized the need to continue to safeguard privacy:
If telehealth cannot be provided in a private setting, covered health care providers should continue to implement reasonable HIPAA safeguards to limit incidental uses or disclosures of protected health information (PHI). Such reasonable precautions could include using lowered voices, not using speakerphone, or recommending that the patient move to a reasonable distance from others when discussing PHI. (Office for Civil Rights, 2020, p. 3)
Emotional Stability, Safety, and Emergency Risk Management
It is important to assess the emotional and psychological stability of the client to ensure that virtual counseling services are appropriate. In situations in which involuntary commitment might become a necessity, technology-assisted therapy might not be the best choice. It might be important to assess for suicidal or homicidal ideation, hallucinations, or delusions prior to engaging in virtual services. This assessment for appropriateness of services should be ongoing and continue throughout treatment. For safety purposes, it is important to verify the client’s location at the beginning of each session and maintain a safety plan (AMFTRB, 2016). A safety plan should be proactive in considering the potential risks and potential needs of each individual client. It is recommended that an emergency contact (an adult older than age 18 who is able to respond) be identified who resides within 10 minutes of the client during scheduled sessions. Informed consent should provide permission for the counselor to speak with emergency contacts in case of an emergency. Local law enforcement, medical personnel/emergency medical services, and fire services in the client’s location should be identified as well. This safety plan should be kept current and up-to-date as the client moves or travels or as emergency contacts become unavailable. In addition, there should be a plan in place in case the technology fails. Counselors should be aware that state laws, liability insurance companies, supervision laws, and other governing and regulatory bodies do not view all technologies in the same manner. The counselor must be aware that if synchronous videoconferencing software fails, a phone call might address the client’s welfare, but it might not be bill-able or count toward counseling hours. Counselors and supervisors should identify the various technological methods that both serve clients’ needs and meet the expectations of insurance providers. Please see a sample Readiness for Online Counseling checklist in Appendix A.
Anonymity and Confidentiality
There are numerous benefits to engaging in distance counseling, including accessibility, anonymity, and comfort and convenience for the client (Harris & Birnbaum, 2015). However, the appropriate degree of anonymity is often uncertain and not always clearly defined. Counseling provided via teletherapy must be held to the same standard as face-to-face practice. ACA (2014) identified the need for counselors to provide adequate information about themselves and the counseling process, obtain informed consent, maintain records, and collaborate with clients around goals and treatment. AMFTRB (2016) established concrete guidelines and notes that “an appropriate therapeutic relationship has not been established when the identity of the therapist may be unknown to the client or the identity of the client(s) may be unknown to the therapist” (Guideline 3.B). This has very specific implications, especially for asynchronous counseling services. The benefit of anonymity and confidentiality primarily lies in a natural sense of what it entails (Harris & Birnbaum, 2015; Richards & Vigano, 2013). Some clients feel less fear of stigmatization seeking counseling services online than traveling to a counselor’s office (McAdams & Wyatt, 2010).
Limits and Risks of Confidentiality
Counselors must identify the limits of confidentiality when retaining electronic records or using technology in the counseling process. There are authorized and unauthorized risks involved in the use of technology. Counselors must inform clients of these risks. In addition, counselors should anticipate these potential risks and take appropriate precautions to mitigate them. Appropriate encryption should be used in an effort to protect confidential information. Client identification protocols should be in place to verify clients’ identity throughout the counseling process. Ongoing verification might include alpha or numeric code words, graphics, or other nondescript identifiers (ACA, 2014).
Security
Throughout this book, there are conversations around risk and recommendations to avoid intentionally or unintentionally breaching confidentiality; however, here are a few basic steps to follow to avoid breaches of confidentiality.
Remember the Two-Lock Rule
Remember that when physical client files are stored, they must be secured behind two locks (a file cabinet and a locked door or something similar). Consider where you leave your technology and who has access to it. Often, a phone or laptop is such an accoutrement to daily life that it can go unattended. Individuals allow children to play on work phones or watch videos and play games on their laptops. Be aware of the location of and contact that is allowed on work devices. It might be prudent to purchase separate devices for home use and work use to maintain healthy boundaries and security. Keeping digital devices secured physically and through encryption is as imperative as protecting a paper client file.
Use and Protect Security Settings
Counselors should remain aware of the security settings on their devices and understand how programs use them. Do not jailbreak or root devices in an effort to bypass security settings, and remain aware of a device’s capacity to use a kill switch or other mechanism in the event that it is lost or stolen (Wheeler & Bertram, 2015). Remain aware of loading applications that allow access to phones or computers, and use security settings. Remain aware of the way in which your phone or computer accesses the internet, and avoid public or unsecured Wi-Fi.
Liability Insurance and State Licensure Regulations
Each state has regulations governing various elements of distance counseling and technology integration that are constantly evolving. Many changes are made in response to questions or situations posed by practicing counselors or complaints from the public. It is essential to remain current on these ongoing changes by attending state licensure board meetings or visiting licensure board websites for updates and rule changes. In addition, it is important to explore your professional liability insurer’s risk management guidelines and policies to understand how they view technology-assisted services in contrast to face-to-face services. Additional insurance riders may be required to supplement the standard policy. The risk management team may also provide recommendations for safeguards. Wheeler and Bertram (2019) warned that eventually counselors may need to explore cyber-risk insurance as a part of their liability insurance coverage or as a stand-alone policy. Please explore Chapter 6 for more information on hardware and software safety.
Synchronous Videoconferencing
One of the major concerns with the integration of technology into the counseling process is the inability to read nonverbal cues and interpret nonverbal communication, as this provides critical information. Synchronous videoconferencing allows the counselor and client to see each other in real time and captures the facial and body signals communicated during the session. In addition, the synchronous connection has a significant impact on rapport and the therapeutic alliance. In some situations, licensing boards and insurance companies recognize synchronous videoconferencing similarly to face-to-face interactions, but they regard email and text services very differently.
Texting
The security of the texting platform is another aspect to consider, as many texting applications and services are not considered secure and others might be accessible from several access points. Text messaging in the therapeutic process is one of the more controversial modes of communication. Wade (2015) stated, “It may or may not be a good idea, and there are a number of considerations that can determine the answer” (p. 11). Counselors should identify whether clients are comfortable with the use of text, recognize and communicate the limitations of text messaging, and take precautions to ensure that they are texting with clients by using a code word or some form of identity verification. Counselors should consider whether they are comfortable with texting as a therapeutic process, whether they can successfully maintain appropriate therapeutic boundaries with clients, and whether texting is in the client’s best interest. Texting can be used in direct or indirect service delivery (AMFTRB, 2016). Counselors who support the use of texting with clients might argue that asynchronous communication has the potential to allow deeper reflection in the counseling process by both counselor and client, as well as greater availability (Harris & Birnbaum, 2015; Richards & Vigano, 2013). Other therapists might find it useful to limit texting to scheduling and communicating about appointments (i.e., “I’m running 10 minutes late,” “I have a flat tire”). Many do not support client-therapist texting, as content and urgency can get lost in translation.
Whatever decisions counselors make considering texting with clients, it is imperative that they clearly articulate the policies in the informed consent outlining boundaries for appropriate use and response time for text messaging. Documentation should be included in the client file as outlined by state and local statutes. Limits and potential risks to confidentiality should be explored with clients, who should be allowed to make informed choices.
Social Media
Social media is a ubiquitous part of modern life, and it becomes complicated when combined with HIPAA and Health Information Technology for Economic and Clinical Health Act regulations and counselor ethics. Counselors often use social media in their personal lives, to promote their practices, or to network with other mental health professionals in their area. It is imperative that they be mindful of the risks and maintain appropriate boundaries and confidentiality. It is a counselor’s ethical responsibility to understand the risks involved in using social media and take appropriate precautions. Counselors should construct and share with clients a clear policy regarding the use, limitations, and risks of social media with current and former clients. This policy should be included in the informed consent (ACA, 2014; AMFTRB, 2016; NBCC, 2016a, 2016b).
The first step in setting appropriate boundaries is to maintain separation between personal and professional social media use. It is recommended that separate accounts be created if a counselor plans to use social media for professional purposes. Just as one would maintain separate personal and professional lives, one’s virtual life should include similar boundaries (ACA, 2014; AMFTRB, 2016). Counselors should become aware of the security settings available on their various social media platforms and use them to protect the public accessibility of information. These boundaries should be clearly articulated in their social media policy included in the informed consent.
Discretion should be exercised when using and sharing social media. Counselors should never share confidential information in private or public chats and forums. They should refrain from diagnosing anyone even if they are historical or public figures. Counselors should avoid posting anything they would not say in real life (ACA Government Affairs, n.d.). Although venting about difficulties or frustration is common on social media platforms, it is recommended that counselors refrain from posting anything that would be deemed derogatory or unprofessional. Although separate accounts are recommended, there are times when personal social media accounts might be reviewed for jobs or for professional service (i.e., by state licensure boards, state committees, etc.).
Although it is common practice in social circles to research new people on social media, the ACA Code of Ethics (ACA, 2014) forbids counselors from exploring clients’ social media without written consent. This has been likened to peeping into a client’s living room windows without having been invited.
The risks of using social media should also be assessed. Counselors who use social media applications should remain aware of how the permissions settings in the platform function when creating social media accounts. Access to confidential client information might be allowed unintentionally. Most user agreements give access to other elements of the user’s device, including contacts, photos, and other content. Client information might be vulnerable to snooping and unintentionally breached. Doffman (2019) cautioned that appropriate protection from social media applications comes down to the users themselves.
Voice-Assisted Technology, Bluetooth, and Gaming Communication on Devices
On many mobile devices, such as cell phones and tablets, voice-assisted technology is common. Arcuri Sanders (2020) noted that many are familiar with Apple’s Siri, Amazon’s Alexa, and Google’s Assistant, and it is important to know that when voice-assisted technology is enabled, the device may be constantly listening. This can create an issue for counselors who use technology as well as for any technology that may enter a counseling office. Voice-assisted devices are designed to listen for commands and to hear information to adapt and customize services to the individual user. Clients, office staff, and counselors could be breaching confidentiality without realizing that this is happening. A few steps can be taken to help safeguard clients’ privacy and limit this digital snooping. First, it is imperative that counselors turn off voice-assisted technology that is connected to Wi-Fi, cell phones, tablets, computers, and any other electronic devices. Second, they should craft policies that instruct clients to turn off voice-assisted technology, especially in situations in which they may compromise others’ confidentiality as well as their own (e.g., group counseling settings). Finally, counselors should include in the informed consent language that outlines the risks of voice-assisted technologies and instructions for clients to temporarily disable those services (Arcuri Sanders, 2020).
Bluetooth connections might also unintentionally compromise the confidentiality of clients. Counselors must encourage clients to be aware of their Bluetooth connections and to take measures to avoid unintentional breaches of confidentiality. For example, if a client is accessing counseling services through a videoconferencing app on their phone, and the phone is linked to their car’s Bluetooth, anyone in the car might have access to the session. Programs that run in the background might also pose a risk to clients. For instance, programs such as Discord and Overtone, which are used to communicate in online gaming, often run in the background and might be such an integral part of clients’ social life that they do not remember to disable them while engaging in telebehavioral health services. This is another consideration worth mentioning during intake and informed consent, especially when the client identifies as a gamer.
Informed Consent
One of the most critical elements of risk management is a thorough addition to a standard informed consent. The ACA Code of Ethics (ACA, 2014) recommends that the document contain the typical components of a face-to-face counseling informed consent with the following additional elements.
Distance Counseling Credentials
Many states have requirements for specific training or continuing education. Distance counseling training and credentials should be clearly outlined.
Physical Location of the Practice and Contact Information
Although mailing addresses and phone numbers are typically included in an informed consent, it is imperative to include the physical location of the counseling practice, even when one is meeting primarily in an online format. This has legal implications on various levels. If the counselor will practice in a location outside of the practice, this should be disclosed.
Time Zone
Counselors should identify any differences in time zone between themselves and their clients. (This can be an issue in some states, even when one is providing face-to-face counseling.)
