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Journal of Social Work Education

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Informed Consent Agreements: Standards of Care for Digital Social Work Practices

Marian Mattison

To cite this article: Marian Mattison (2018) Informed Consent Agreements: Standards of Care for Digital Social Work Practices, Journal of Social Work Education, 54:2, 227-238, DOI: 10.1080/10437797.2017.1404529

To link to this article: https://doi.org/10.1080/10437797.2017.1404529

Published online: 01 May 2018.

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Informed Consent Agreements: Standards of Care for Digital Social Work Practices Marian Mattison

ABSTRACT The inclusion of remote digital practices (e-mail, texting, blogging, social media) to deliver social work services raises unique ethical and legal chal- lenges for client and practitioner. Competent care necessitates providing clients with information that would materially affect clients’ decisions whether to assume the risks, benefits, and conditions associated with e-practices. As standards of care for distance service provision have not been firmly established, social workers are duty bound to be well-informed about current laws, duties, and obligations including specific rules govern- ing the practice of social work in the states where they deliver remote services. This article identifies distinct threats to privacy and confidentiality associated with e-practices and offers suggested content for a comprehen- sive informed consent policy.

ARTICLE HISTORY Accepted: April 2017

Changing nature of professional service delivery

It is indisputable that newer forms of digital communication used for personal, recreational, informational, and professional purposes have created a virtual tidal wave of change in our com- munication habits and the ways interpersonal relationships and exchanges of information take place. Digital media content is routinely communicated through e-mail, text messaging, blogging, Facebook, Instagram, and Twitter; each allowing nearly immediate communication with others twenty-four hours a day, seven days a week. Over a relatively short span of time, our habitual use of communication practices involving technology have drastically transformed daily routines and lives in ways that are not yet fully clear. Friedman (2012) wrote, “The world has gone from connected to hyperconnected in just seven years” (para. 3). Technology has not merely provided new ways to do old things; technology has become “the key to thinking about and knowing about the world” (Prensky, 2013, para. 3).

A study investigating the use of cyber communications (e-mail, texting, and social network sites) in the social worker–client relationship (Mishna et al., 2012) concluded that “cyber communication has dramatically impacted traditional social work practice in clinical, practical, ethical, and legal ways” (p. 280) and “revolutionized the communication of practitioners and clients, even those engaged in traditional face-to-face therapy” (p. 283). Mishna et al. (2012) acknowledge that whether intended or unintended, cyber communication has inched its way into professional service relation- ships, and this trend is likely to accelerate. They point out that clients are more likely to be the initiators of cyber contacts with social workers, often without the intentional consent of the clinician. Even when texting and e-mailing are initiated exclusively for scheduling purposes, workers fear the potential boundary crossings and violations that may arise when the relationship strengthens, and clients feel increasingly comfortable sharing therapeutic dialogue in e-mail exchanges. Foeday (2011) asks, “Can social workers, like practitioners in other disciplines, effectively provide services in a technology-free environment? The answer to this obvious question is an obvious NO” (p. 1). With an estimated 10,000 Baby Boomers retiring and leaving the workforce each day (Williams, 2016),

CONTACT Marian Mattison [email protected] 100 Fountain Street, Unit 4B, Providence, RI 02903. © 2018 Council on Social Work Education

JOURNAL OF SOCIAL WORK EDUCATION 2018, VOL. 54, NO. 2, 227–238 https://doi.org/10.1080/10437797.2017.1404529

upcoming generations of social workers will shoulder the responsibility for adopting computer- mediated communication technologies to meet the legal and ethical standards for 21st-century social work practice.

This article addresses specific legal and ethical dimensions of informed consent associated with computer-mediated service delivery. The information in this article will assist social workers to competently operationalize the obligations associated with developing informed consent policies and practices for digital communications with clients as required by the newly released Standards for Technology in Social Work Practice (National Association of Social Work [NASW], Association of Social Work Boards [ASWB], Council on Social Work Education [CSWE], & Clinical Social Work Association [CSWA], 2017).

Education for social work practice must ensure that adequate information regarding commu- nication technologies is inclusive of the specific obstacles, threats, and benefits associated with this emerging modality. I identify the unique threats to privacy and confidentiality associated with e-practices and offer suggested scripts for a comprehensive informed consent policy designed to obviate these risks. This information is intended to provide instructional content for educators preparing students to anticipate and avert boundary crossings and manage the ethical and legal threats to privacy and confidentiality associated with digital practices.

Absence of sanctioned guidelines

Although the advantages of digitally communicating with clients are many and include client preference, client empowerment, increased therapeutic contact and buttressing the therapeutic relationship, convenience, improved accessibility, and feelings of safety and reduced vulnerability, these must be balanced against identified risks (Cartwright, Gibbon, McDermott, & Bor, 2005; Elleven & Allen, 2004; Harris & Birnbaum, 2015). Known risks include threats to privacy and confidentiality, absence of formal training in text-based counseling techniques by practitioners, unequal access based on socioeconomic status, misinterpretation of written messages, missed verbal and nonverbal cues, technology glitches, and access to computer-mediated communications by unauthorized and unintended recipients (Harris & Birnbaum, 2015). The newly revised National Association of Social Workers Code of Ethics (NASW, 2017) at long last addresses technology- assisted social work practices. Until now, the absence of sanctioned guidelines and an adaptable ethical framework for recommended conduct and practices for emerging methodologies has left social workers to make individualized, reasoned judgments in applying e-practices. Adding to the uneven delivery of online practices, organizations and agencies have avoided forming written policies leaving individual clinicians “to decide for themselves whether the work they do meets the current ethical standards of their state” (Ragusea & VandeCreek, 2003, p. 101). The new Standards for Technology in Social Work Practice recommend that agency administrators actively develop social media policies in order to provide direction to social worker employees (NASW, ASWB, CSWE, & CSWA, 2017, Standard 2.27). Adding to the uneven delivery of online practices, organizations and agencies have avoided forming written policies leaving individual clinicians “to decide for themselves whether the work they do meets the current ethical standards of their state” (Ragusea & VandeCreek, 2003, p. 101).

Standards for technology practices

A collaborative effort involving NASW, ASWB, CSWE, and CSWA resulted in newly constituted standards for the use of technology in social work practice (2017). These standards codify collective obligations and basic legal and ethical requirements for the provision of professional social work services using electronic means. These protocols attempt to parallel the technology standards promulgated by other behavioral health professional associations (American Association for Marriage and Family Counselors, 2015; American Counseling Association, 2014; American

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Psychological Association, 2013; British Association of Social Workers, 2012; International Society for Mental Health Online, 2000) by establishing recommended practices for social workers providing technology-enabled services to clients. Given the acceptance of behavioral health services delivered online, “to remain relevant and viable in the marketplace,” (Maheu, Pulier, McMenamin, & Posen, 2012, p. 615), providers of behavioral health services need to familiarize themselves with the risks and benefits of the delivery of online services to clients. It is forecast that “social workers who lack technological know-how will not be prepared to meet the many challenges inherent in 21st Century practice” (NASW, 2011, para. 2).

Evolving client preferences

Not only will the expanded use of communication technologies fit with the habits and practices of social workers who have grown up digitally, they are also likely to serve future generations of clients by expanding

options outside of traditional mental health care that might better meet their access needs because of cost, location, time of day, language, social class, educational level, available social support and other circum- stances … specifically services available in their hip pockets, through a mobile device. (Maheu et al., 2012, p. 615)

The foremost challenge for the profession going forward is to be mindful to address how technology has “changed the way many of our clients think and live and about how to integrate Internet technologies into our own clinical practices” (Zur, 2012, para. 5).

Need for advanced education and training

The NASW (2017) Code of Ethics Standard 1.04 obligates social workers to practice only within the scope of their education, training, and competency and advises that

when generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps (including appropriate education, research, training, consultation, and supervision) to ensure the competence of their work and to protect clients from harm. (Standard 1.04 c)

Social workers are cautioned to avoid addressing client problems in an online format if the practitioner lacks the expertise to treat a similar problem in person. The CSWE’s (2015) accredita- tion standards impose an additional professional obligation requiring social workers to “use tech- nology ethically and appropriately to facilitate practice outcomes” (p. 7). To date, there is no recommended academic curriculum requiring minimum digital ethics proficiencies for those in social work degree programs, and core competencies for e-practices have yet to be promulgated. There are, however, a select few MSW curricula now offering courses in telebehavioral mental health, including the University of Alaska Anchorage and Indiana University (Knight, 2016); a Canadian university’s graduate social work program offers cybercounseling course work and training (completed online) that leads to a cybercounseling certificate (Murphy, MacFadden, & Mitchell, 2008). A more widespread inclusion of similar course offerings is recommended.

At present, social work education continues to “emphasize the importance and development of in-person relationships, while little attention is given to understanding the role of online relation- ships and computer-mediated relationships” (Perron, Taylor, Glass, & Margerum-Leys, 2010, p. 5). Determining what constitutes “competence” in online counseling remains somewhat ambiguous as there are “unique obstacles” (Mallen, Vogel, & Rochlen, 2005, p. 778) and “many nuances to fully understand text-based communications” (p. 786). Although all ethical principles that apply to face-to -face interactions apply to online interactions, the laws and standards regulating online practices are less established and tested. In the absence of educational competencies and certifications expected of

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social workers who provide e-services, the public is at risk for the delivery of homegrown technology applications that fall short of best practice standards.

Practice competency

The therapeutic communication skills required to establish online relationships with clients are decidedly different from those used in face-to-face encounters. A clinician skilled in face-to-face communications and interventions cannot assume that these skills will instinctively transfer to text- based competency in the online environment (Mallen et al., 2005, p. 768). “Text talk is a skill and an art, not unlike speaking, yet in important ways different than speaking. Proficiency in one does not guarantee success in the other” (Suler, 2007, “Let’s Text,” para. 1).

Recognizing that distance counseling is an area of specialization requiring supplementary pre- paration for clinicians, regulatory bodies in some states now require additional training, education, and supervision for e-counselors prior to and throughout the delivery of such services (American Counseling Association, 2016). Arkansas has taken the step of requiring providers of distance counseling to not only meet additional requirements for relevant training but to procure a technol- ogy-assisted counseling specialization license (Counselor-License, 2018). Licensing entities such as the Center for Credentialing & Education (2016) “train counselors in best practices for delivering traditional counseling through technological means” leading to a qualification as a distance creden- tialed counselor (para. 1). A leader in promoting empirically based best practices for online counselors, the TeleMental Health Institute (2016) offers theoretical and applied trainings for mental health providers at basic and advanced levels. It should be noted that comprehensive training and credentialing specific to the telebehavioral health services delivered by social workers are sorely lacking (Knight, 2016).

Modernizing informed consent policies

When incorporating digital communication practices, social workers are obligated to uphold the NASW’s (2017) Code of Ethics for maintaining clients’ privacy and confidentiality (Standard 1.07). These include the protection of all confidential client information electronically transmitted or received. This standard also obligates social workers to share with clients “the nature of confidentiality and limitations of clients’ right to confidentiality” relative to computer-mediated communications (Standard 1.07e). Clients must be informed that should online content intimate threats or harms to self or others, or they are suggestive of child or elder abuse, this content is subject to mandated reporting laws.

Because digital technologies pose greater risks to client privacy and confidentiality, clients must be fully apprised, in writing, of the risks associated with this newly emerging practice modality. At a most elementary level, security measures such as encryption and authentication become the respon- sibility of the social worker to arrange (Jordan et al., 2014; Rosik & Brown, 2001). According to Morgan, clients must provide expressed agreement to engage in digital exchanges with the social work practitioner to ensure “that the convenience of new technologies does not override the professional values of client self-determination, informed consent and confidentiality” (as cited in Sfiligoj, 2009, p. 4).

Social workers are urged to develop written guidelines and conditions (reflective of their rules for practice) for those technology-assisted distance services that will be employed in the treatment relationship and those excluded from use (International Society for Mental Health Online, 2000); social workers who choose not to employ digital practices should make this known to clients. When a social worker is technically and clinically prepared and trained to use technology for therapeutic purposes, the specific conditions and parameters for text-based exchanges must be explained. It should be noted that disclaimers offer some protection but cannot fully exempt

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social workers from their legal and ethical responsibilities to protect client privacy and confidentiality.

Detailed informed consent polices addressing the distinct nature of e-practices will assist social workers to circumvent ethical conflicts by documenting that clients knowingly and willing under- stand and assume the risks to privacy (Kaplan, Wade, Conteh, & Martz, 2011). Media polices must be thoughtfully developed to reflect the individual social worker’s policies and practices regarding a variety of digital media platforms (Online Therapy Institute, 2010). In cases where clients repeatedly fail to adhere to the agreed-on parameters, or the digital exchanges prove to be counterproductive to the therapeutic goals, social workers should reserve the right to limit or terminate the electronic communication exchanges and require clients to meet face-to-face.

Client suitability for e-services

Prior to consenting to employ distance professional services, a social worker must assess each client’s suitability for this method of treatment to determine if e-services are a viable alternative to in-person treatment (National Association of Social Workers & Association of Social Work Boards, 2005; National Board for Certified Counselors, 2016). Suitability factors include, but are not limited to, client preference for computer-mediated exchanges, clients’ facility with computer technology and ability to troubleshoot technological problems, attitudes toward text-based exchanges versus in-person conversations, relationship building in an online environment, and the social worker’s clinical assess- ment of diagnostic factors that may amplify client pathology (LA Writer, 2015; Suler, 2001).

Record storage

As with in-person communications, clients have a right to be informed about the storage of case records and documentation, whether some or all text-based communications will be included in their permanent file (paper copies or encrypted electronic storage), the risks associated with printed transcripts, and that under some conditions, messages may be subpoenaed as required by law (Mallen et al., 2005). Clients must be instructed in the types of content suitable for digital commu- nication such as appointment scheduling, sharing of educational resources, between-session updates on progress toward goals, reports of critical incidents, and so on.

Message content and response time

The addition of text-based communications to the therapeutic work raises time management concerns for many social workers. Clinicians question how to apportion time in each day not only to complete their expected workload responsibilities but to check and respond to e-mail messages while also leaving time to manage the unanticipated emergencies that routinely arise (Cartwright et al., 2005). Practitioners, already feeling overworked and overburdened, have concerns that text-based commu- nication will extend the therapeutic relationship and “add to an already full workload” with “clients having increased access to staff at various hours of the day” (Cartwright et al., 2005, p. 201).

Although the inclusion of therapeutic text-based exchanges does not obligate the social worker to check messages according to any particular schedule, clients must be informed how frequently the practitioner will check e-mails and text messages and whether or how he or she will respond and according to what time frame (Zur, 2012). If practitioners agree to exchange digital messages, the worker then holds a legal and ethical responsibility of a timely turnaround (Bradley, Hendricks, & Kabell, 2011, p. 75). Social workers are encouraged to set parameters for recommended limits to the length of messages to avoid situations where clients might be sending multiple pages of digital messages requiring more than a reasonable amount of time for the social worker to review.

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Billing and reimbursement

Adding remote behavioral health services as an accompaniment to face-to-face services is stymied by the current state of reimbursement for these services. As the costs of the technology to provide remote services falls, and access to technology increases, “no obstacle looms larger than the issue of payment” (Quashie, 2012, para. 1). The status of insurance reimbursement for telehealth services differs from state to state, and there is “no consistent pattern regarding which private payers are progressive about telemental health reimbursement” (Squyres & Maheu, 2012, para. 2). A national shortage of mental health clinicians has driven providers to press “for reimbursement parity laws that ensure payment at or near what they would receive for in-person visits” (Frandsen, 2016, Licensing and Reimbursement, para. 10). This effort is obstructed by the lack of consensus among states to establish a unified definition of telemental health and rules to govern its practice across state lines. Alexander (2013) predicts that the reimbursement practices of private insurers will be instru- mental in moving telemedicine “from the margins of healthcare to mainstream acceptance” (para. 6).

On a routine basis, clients must be informed about applicable charges (if any), rates, and billing procedures associated with reading and responding to text-based messages outside in-person sessions (Reamer, 2013). Social workers must be knowledgeable about state and licensing provisions for billing and reimbursement and whether e-services are reimbursable under telemental health service provisions in their jurisdiction (Zur, 2015). It must be made clear to clients that e-mail and text messaging are never to be used in cases of emergency; clients should be advised to access a local provider or crisis resource such as a hospital emergency room, and they should be instructed to contact the social worker by telephone to schedule an in-person meeting should an emergency arise (American Psychological Association, 2013; International Society for Mental Health Online, 2000).

Interjurisdictional practice

Federal and state regulatory bodies vary in their definition, statutes, and regulation of distance mental health services and permissible actions available to aggrieved clients filing a complaint or grievance against a service provider. Issues of interstate practice and jurisdiction arise when social workers provide services to clients who are physically located in a state where the social worker is not licensed to practice (Herbert et al., 2012; Zack, 2008). Clients are unlikely to be aware that state licensing boards provide consumer protection and are authorized to discipline practitioners licensed in their state. When social workers provide service in a state where they are not licensed, the state may or may not have the authority (or resources) to act on clients’ complaints for the purpose of investigating and potentially reprimanding or censuring a clinician’s actions. In the absence of portable or national licensing, questions persist about the need for social workers to be licensed in their state of residence and in the state where the client is residing (or is physically located at the time of service delivery; DeAngelis, 2012). It is the obligation of the social worker to be aware of applicable licensing require- ments and professional standards of care across jurisdictions and to inform clients how these affect service practices (NASW, n.d.; Zack, 2008). Clients must be advised that the social worker is licensed in a particular state or states and thereby obligated to practice according to the laws of the designated states. Short-term exceptions (guest licensure) may be granted by some states when practitioners deliver temporary services in jurisdictions where they are not licensed (Zur, 2016).

The suggested text for the following consent forms defines the scope of appropriate ethical and legal digital communication practices for social workers; these are meant to serve purely as guide- lines. These guidelines have not been reviewed by legal counsel and should not be considered legally binding. Social workers are encouraged to alter the suggested policies, practices, and text to correspond to their state licensing regulations, individual client needs, and the particular dimensions of their practice.

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E-mail practices

An e-mail consent agreement might include the following content or some variation of this content.

Please be advised that e-mail (similar to traditional U.S. Postal Service mail and other forms of written correspondence) is not a completely secure or confidential method of communication; human and technical errors can be made in the transmission of information by e-mail such as sending a message to the wrong recipient. Additionally, e-mails are stored in the archives of the sender’s and the recipient’s Internet service providers. This allows others, including system administrators and Internet service providers to access archived e-mails. Please be advised that it is my practice to print hard copies and retain all e-mail correspondence related to your treatment in your clinical file. As a part of your file, these e-mail messages would be available to third parties as is permitted or dictated by law. In the event of a legal investigation, e-mails may be subpoenaed under the law. Please be aware that all online material and information discerned by me (including threats of harm to self or others, child or elder abuse) become subject to state-mandated reporting laws. For these reasons, I use e-mail primarily to arrange or modify appointments except when we have agreed to exchange e-mails in conjunction with our face-to-face sessions. Examples of the types of between-session e-mail exchanges that may aid in your treatment include reporting your progress toward cognitive or behavioral goals, forwarding recommended writing assignments and psychoeducational resources, and materials or written documents you would like me to review in advance of our next session. Please limit e-mail messages to brief responses of 350 words or less and require no more than about 5 minutes for review. E-mails exceeding this length may be subject to professional service fees charged for time spent reading and responding; charges will be applied in 15-minute increments.

It is my policy to review between-session materials forwarded to me between 5:00 p.m. and 6:00 p.m. each weekday; emergency matters or scheduling conflicts may prevent me from doing so on any given weekday. Between-session materials will be discussed together in our next in-person meeting. I will not provide detailed responses to text-based messages received.

Please do not use e-mail for emergencies. I do not always have immediate access to my e-mail, and I cannot guarantee that I can respond to e-mails the same day they are received. In the event of an emergency, please be in direct communication with your predetermined emergency contact, dial 911, or go to your closest hospital emergency room. You are advised to telephone me in the event of urgent matters to set up a face-to-face appointment. Please be aware that I will not use e-mail to conduct treatment if you are temporarily or permanently visiting or residing in a state other than the state or states where I am professionally licensed as this may be in violation of state laws governing interstate practice.

Also be aware that if at any point in the course of your treatment I judge the digital exchanges to be counterproductive to the agreed-on …

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