Digital technology has created unprecedented options for the delivery of clinical social work 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 challenges, including mood disorders, anxiety, addictions, and relationship issues. Clinical practice is no longer limited to office-based, in-person meetings with clients. Today large numbers of clinical social workers are using video counseling, email chat, social networking websites, text messaging, avatar-based websites, self-guided web-based interventions, smartphone apps, and other technology to provide clinical services to clients, some of whom they never meet in person (Chester and Glass 2006; Kanani and Regehr 2003; Lamendola 2010; Menon and Miller-Cribbs 2002; Reamer 2012a, 2013a; Zur 2012). Some social workers are using digital technology informally as a supplement to traditional face-to-face service delivery. Other practitioners have created formal “distance” clinical practices that depend entirely on digital technology.

In addition, social workers’ routine use of digital technology—especially social media and text messaging—in their daily lives has created new ways to interact and communicate with clients. These common forms of modern communication also raise ethical issues, even when social workers do not use digital technology—such as online therapy or video counseling—to provide clinical services per se.

In light of these compelling developments, it is essential that clinical social workers address two key issues. First, clinical social workers must explore the ethical implications of their use of digital technology to communicate with clients in relatively new ways. Social workers’ 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, clinical social workers must consider whether social workers’ use of digital technology and distance counseling services alters the fundamental nature of the therapeutic relationship, which has traditionally entailed opportunities to develop a rich therapeutic alliance with a client in the context of ongoing face-to-face meetings (Cooper and Lesser 2010; Reamer 2013c).

The principal purpose of this article is to identify pertinent ethical and ethically-related risk-management issues that clinical social workers should consider if they contemplate using this technology to assist people in need. This is essential if social workers are to protect clients from harm and prevent lawsuits and licensing board complaints associated with their use of digital technology and provision of distance counseling services. These ethical issues involve application of traditional, widely embraced, and time-honored social work ethics concepts to new challenges created by digital technology.

Digital technology in the human services 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 (a) deliver services to clients, (b) communicate with clients, (c) manage confidential case records, and (d) access information about clients (Lee 2010; Menon and Miller-Cribbs 2002; Zur 2012). Social workers’ use of digital technology to serve clients is not without controversy. Many clinical social workers celebrate their ability to enhance clients’ access to services using digital and other distance counseling tools and believe they can do so in a way that honors and adheres to prevailing ethical standards in social work (Dowling and Rickwood 2013; Mattison 2012). They argue that distance counseling services offer a number of compelling advantages. Some individuals who want clinical services live in remote geographic areas and would have great difficulty traveling to a social worker’s office. Physically disabled clients can use distance counseling options without enduring the logistical challenges and discomfort involved in arranging transportation and traveling significant distances. 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—especially if they are well known in their local community—can receive counseling without risking exposure in a clinician’s waiting room. The 24/7/365 availability of counseling 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 social workers’ ability to help people in crisis.

Not surprisingly, many seasoned clinical social workers find these distance counseling options disquieting and, for some, even abhorrent and unethical (Lamendola 2010; Mattison 2012; Santhiveeran 2009). These clinicians worry that the advent and expanding use of digital and other distance counseling options dilutes the meaning of therapeutic relationship and alliance and compromises social workers’ ability to comply with core ethical values and standards related to informed consent, privacy, confidentiality, professional boundaries, competent practice, and termination of services, among others. Authentic clinical relationships, critics argue, depend on the kind of deep connection that only in-person contact enables. To provide effective clinical services, they claim, social workers must be in the same room with clients to truly connect with them and ensure the degree of trust that is essential for effective helping. Clinical services provided remotely greatly increase the likelihood that social workers will miss important clinical cues, for example, tears welling up in a client’s eyes, joyful expressions, or a client’s grimace or squirm in response to the social worker’s probing question or comment. Clinicians who offer distance counseling 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 nagging challenges related to protecting and managing client privacy and confidentiality.

The Contours of Digital and Distance Clinical Social Work

Mental health resources and services emerged on the Internet as early as 1982 in the form of online self-help support groups (Kanani and Regehr 2003; Reamer 2013a). The first known fee-based Internet mental health service was established by Sommers in 1995; by the late 1990s, groups of clinicians were forming companies and e-clinics that offered online counseling services to the public using secure Web sites (Skinner and Zack 2004). In social work, the earliest discussions of electronic tools focused on practitioners’ use of information technology (Schoech 1999) and the ways in which social workers could use Internet resources, such as online chat rooms and Listservs joined by colleagues, professional networking sites, news groups, and e-mail (Finn and Barak 2010; Grant and Grobman 1998; Martinez and Clark 2000).

Clinical social work services now include a much wider range of digital and electronic options to serve clients who struggle with mental health and behavioral issues (Chester and Glass 2006; Kanani and Regehr 2003; Lamendola 2010; Menon and Miller-Cribbs 2002; Reamer 2012a, 2013a; Rummell and Joyce 2010; Zur 2012).

Online counseling

Hundreds of online counseling services are now available to clients (Anderson and Guyton 2013; Barak et al. 2008; Chang 2005; Midkiff and Wyatt 2008; Richards and Vigano 2013; Santhiveeran 2009). People who struggle with depression, borderline and bipolar issues, addiction, marital and relationship conflict, anxiety, eating disorders, grief, and other mental health and behavioral challenges can use electronic search engines to locate clinical social workers who offer counseling services using live online chat (Haberstroh 2009). Clients can purchase online therapeutic chat services in various time increments paid for by credit card.

Live online chat is an example of what computer experts call synchronous communication (Mallen et al. 2011), meaning it occurs simultaneously in real time (Gupta and Agrawal 2012). This contrasts with asynchronous communication, where communication is not synchronized or occurring simultaneously (for example, when a client sends a social worker an e-mail message regarding a clinical issue and waits for a time-delayed response).

Telephone counseling

Some social workers provide local and long distance counseling services by telephone, sometimes to clients they never meet in person. After providing a counselor with a user name and credit card information, clients receive telephone counseling. Some social workers provide telephone counseling as a formal service. Others supplement traditional face-to-face counseling with occasional telephone counseling, for example, when clients or clinicians are traveling or in crisis situations.

Video counseling

Clinical social workers also offer clients live distance counseling using webcams, pan-tilt zoom cameras, and monitors. Some social workers use video counseling software that claims to be HIPAA compliant, while others do not (Lindeman 2011).

Cybertherapy and avatar therapy

Some social workers offer individual and group counseling services to clients by using a 3-D virtual world where clients and practitioners interact with each other visually with avatars rather than real-life photos or live images. An avatar is a digitally generated graphic image, or caricature, that clients and social workers use to represent themselves in a virtual world that appears on their computer screen. Clients and social workers join an online therapy community, create their avatars, and electronically enter a virtual therapy room for individual or group counseling.

Self-guided Web-based interventions

Clinical social workers now have access to a wide variety of online interventions designed to help people who struggle with diverse mental health and behavioral issues. Users complete online questionnaires concerning their mental health and behavioral challenges, and then receive electronic feedback and resources that can help them decide whether to address their issues. Users who indicate a wish for help are then provided links to service providers who offer distance counseling services.

Smartphone apps

Many social workers incorporate smartphone apps as clinical tools that clients can use. An increasing number of clinical programs encourage or require clients to download apps on their smartphones to record information about their clinical symptoms, behaviors, and moods; receive automated messages from treatment providers, including positive and supportive messages; obtain psychoeducation information; and obtain links to local resources, including locations of 12-step meetings. Clients who want to avoid high-risk locations can program addresses into the app, which is programmed to send the client an electronic text warning if the client is in or near the high-risk location (for example, when a client who is in recovery wants to avoid certain neighborhoods or bars).

Electronic social networks

Social networking sites, such as Facebook and LinkedIn, are now pervasive in both clients’ and social workers’ lives. Some clinicians believe that maintaining online relationships with clients on social networking sites can be used as a therapeutic tool (Barak and Grohol 2011; Graffeo and La Barbera 2009; Lannin and Scott 2013); they claim that informal contact with clients on social networking sites empowers clients, humanizes the relationship, and makes practitioners more accessible.

Some clinical social workers—a small minority, it appears—are using social networking sites with clients much less formally. These clinicians believe that informal contact with clients on the social workers’ personal (not professional or agency-based) social networking site can be valuable therapeutically.

E-mail

Many Web sites offer people the opportunity to receive mental health services by exchanging therapeutic e-mail messages with clinical social workers. Typically these practitioners invite users to e-mail a therapy-related question for a flat fee and guarantee a response within 24–48 h. Some clinicians offer clients monthly e-mail packages that include a set number of e-mail exchanges (for example, six to eight). Other practitioners choose to exchange occasional clinically relevant e-mails with clients as an extension of their office-based services (Finn 2006; Gutheil and Simon 2005; Peterson and Beck 2003; Zur 2011).

Text messages

Some practitioners have chosen to exchange text messages with clients informally, for example, when clients wish to cancel or reschedule an appointment or provide the social worker with a brief update during a crisis (Barak and Grohol 2011; Zur 2011). Other practitioners and some social service programs have incorporated text messaging as a formal component in their intervention model. In these protocols, clinicians may draw on cognitive-behavioral treatment concepts to provide clients with automated positive and supportive text messages.

Case Examples

Case A: “I need help! And I need it NOW!”

A 37-year-old man, Alvan K., was desperate for mental health counseling. Earlier in the day, Mr. K.’s wife informed him that she was moving out of their home, seeking a divorce, and petitioning for legal and physical custody of their two children. At 11:30 p.m., Mr. K. was experiencing severe anxiety and felt he needed help, but knew he would not be able to find a therapist at that hour with whom he could meet in-person. Mr. K. went online and found a website that offers immediate online counseling from licensed clinicians, including social workers. Mr. K. filled out a brief assessment form, provided his credit card information, and within five minutes connected online with a clinician who works more than 500 miles from Mr. K.’s home. The Website did not include a detailed statement about encryption, confidentiality, anonymity, potential benefits and risks, and HIPAA compliance. The social worker and Mr. K. had seven online clinical encounters using live online chat and email. Over time Mr. K. became dissatisfied with the social worker’s services. Eventually he filed a complaint with the social worker’s licensing board alleging that the social worker was not available consistently, provided superficial assistance, and did not have a license to practice social work in Mr. K.’s state of residence, as required by law in Mr. K.’s state for distance counseling services.

Case B: “I live 67 miles from your clinic. Is there a way you can help me online?”

A 20-year-old woman, Tanya G., called an independent clinical social worker seeking counseling. Ms. G. explained that she recently dropped out of college after struggling with depression and an unplanned pregnancy. She told the social worker that she had received therapy briefly from the university counseling center but was no longer eligible to receive it since dropping out of school and moving back home to live with her parents. Ms. G. told the social worker she found counseling helpful but, due to living in a small town in a very remote part of the state, no counseling services were available within convenient driving distance. Ms. G. asked the social worker if she could provide Ms. G. with a combination of office-based and remote (online and video) counseling services; Ms. G. explained that traveling to the social worker’s physical office weekly would be difficult, given the geographic distance, but she understood the importance of occasional in-person meetings and was willing to make the drive sporadically if much of the counseling could be provided remotely. The social worker agreed to provide distance counseling services, including video sessions via Skype and email. The social worker was not aware that many attorneys do not consider Skype to be HIPAA compliant.

Case C: “I’m an injured Afghanistan war veteran and can’t drive because of my injuries. Do you provide video counseling?”

A 28-year-old Army veteran, Everett L., contacted the regional Veterans Administration center by telephone seeking counseling. Mr. L. had been diagnosed with Post Traumatic Stress Disorder and alcohol addiction following his medical discharge. He told the intake counselor that he was injured by an IED (improvised explosive device) and lost both legs above the knee. Mr. L. told the VA counselor he was eager to get counseling but had difficulty arranging transportation to the mental health clinic. He asked whether the VA would be able to provide him with remote video counseling. The VA offered Mr. L. synchronous and asynchronous distance counseling using its Telehealth software. The clinical social workers who provided the distance counseling services received extensive training on the strengths and limitations of this therapeutic option and on ethical issues related to informed consent, privacy, confidentiality, privileged communication, documentation, and termination of services.

Ethical and Risk-Management Challenges

The relatively recent proliferation of digital and distance clinical services in social work has led to a wide range of ethical and related risk-management issues. 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. While some clinical social workers oppose the use of distance services and communications in any form, it is clear that this technology is, and will continue to be, a significant component of the contemporary clinical landscape. Even social workers who oppose the use of this technology in clinical work must be familiar with the options to which their clients are being exposed and about which clients may inquire.

Recognizing the legitimacy of ongoing debates about the appropriateness of this digital and distance technology, given this new reality it behooves clinical social workers to be aware of pertinent ethical issues and develop rigorous ethical guidelines. It is essential that clinical social workers address these issues, and adhere to current and emerging standards, to enhance protection of clients and minimize the likelihood of ethics-related litigation and licensing board complaints alleging, for example, failure to protect clients from harm associated with distance counseling, obtain proper informed consent, protect clients’ confidentiality, document services, and be available when needed.

It is particularly important that social workers in the U.S. adhere to relevant standards in the National Association of Social Workers (NASW) Code of Ethics. Because this is the most widely recognized ethics code in the U.S., social workers are held to its standards, even if they are not members of NASW. In litigation cases, the NASW Code of Ethics is routinely introduced as evidence of the profession’s standards of care, even when a social worker who is a party in the litigation is not an NASW member. Further, many social work licensing statutes and regulations in the U.S. draw on the NASW Code of Ethics, in whole or in part, and hold licensed practitioners to them, even if they are not NASW members (Association of Social Work Boards 2014).

Recent research and developments in clinically oriented professions suggest that the most prominent ethical challenges concern six core, traditional social work ethics concepts that pertain to the delivery of clinical services using digital technology: informed consent; privacy and confidentiality; boundaries, dual relationships, and conflicts of interest; practitioner competence; records and documentation; and collegial relationships (Berg et al. 2001; Campbell and Gordon 2003; Grimm et al. 2009; Hu et al. 2010; Madden 2003; Morgan and Polowy 2011; Reamer 2013b; Recupero and Rainey 2005; Sidell 2011; Zur 2007):

Informed consent

Clinical social workers are held to demanding informed consent standards (Berg et al. 2001; Reamer 2013b). The availability of distance counseling and other social services delivered electronically has enhanced social workers’ ethical duty to ensure that clients fully understand the nature of these services and their potential benefits and risks. In Case A, for example, the social worker must ensure that Mr. K. thoroughly understands the potential benefits and risks associated with distance counseling. According to the NASW Code of Ethics (2008; standard 1.03[a]),

Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients’ right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions.

Obtaining clients’ truly informed consent can be especially difficult when social workers never meet their clients in person or have the opportunity to speak with clients about informed consent. Special challenges arise when minors contact social workers and request distance or remote services, particularly when social workers offer free services and do not require credit card information; state laws vary considerably regarding minors’ right to obtain mental health services without parental consent (Madden 2003; Slater and Fink 2011).

Although state and federal laws and regulations vary in interpretations and applications of informed consent standards, in general professionals agree that a client must be mentally capable of providing consent. Clearly, some clients (for example, young children and individuals who suffer from serious mental illness or dementia) are unable to comprehend the consent procedure. Other clients, however, may be only temporarily unable to consent, such as individuals who are under the influence of alcohol or other drugs at the time consent is sought or who experience transient psychotic symptoms. In general, social workers are expected to assess clients’ ability to reason and make informed choices about their receipt of distance counseling services, comprehend relevant facts and retain this information, appreciate current circumstances, and communicate wishes. Such assessment can be especially challenging when social workers interact with clients only electronically, do not meet with them in person, and may have difficulty confirming their identity and age (Reamer 2013b; Recupero and Rainey 2005).

Privacy and confidentiality

Throughout the profession’s history, social workers have understood their obligation to protect client privacy and confidentiality and to be familiar with exceptions (for example, when mandatory reporting laws concerning abuse and neglect require disclosure of information without client consent or when laws or court orders require disclosure without client consent during legal proceedings). As the NASW Code of Ethics (2008; standard 1.07[c]) states,

Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation that social workers will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a client or other identifiable person. In all instances, social workers should disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made should be revealed.

However, the rapid emergence of digital technology and other electronic media used by social workers to deliver clinical services has added a new layer of challenging privacy and confidentiality issues. For example, the social worker in Case B, who may use e-mail, live chat, and video counseling in her work with Ms. G.—both formally and informally—must be sure to use sophisticated encryption technology to prevent confidentiality breaches (hacking) by unauthorized parties and to comply with strict HIPAA guidelines. Fortunately, currently available encryption technology protects client confidentiality very effectively and is HIPAA-compliant; in fact, such encryption offers significantly more protection than do traditional paper documents (Hu et al. 2010). The social worker serving Ms. G. must also recognize that email communications for therapeutic purposes create a permanent record of online messages; this would not occur in a typical in-office clinical session. The social worker may have no control over what Ms. G. chooses to share with other parties, in the form of forwarded or copied email messages.

Social workers who offer video counseling services, as in Cases B and C, must recognize that they have much less control over confidentiality than when they provide traditional office-based services. For example, a client receiving video counseling services may invite a family member or acquaintance to sit in on a session—outside of camera range—without the social worker’s knowledge or consent.

Encryption of clinical social work services provided online is more challenging with some forms of technology than others. With regard to Skype, for example, NASW attorneys reviewed relevant research and legal guidelines and concluded that “assuring that clients’ confidential communications via Skype will be adequately protected is a difficult and uncertain task” (Morgan and Polowy 2011). According to the NASW Code of Ethics, “social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible” (standard 1.07[m]). Further, the National Association of Social Workers and Association of Social Work Boards (2005) standards on practitioners’ use of technology state, “Social workers shall protect client privacy when using technology in their practice and document all services, taking special safeguards to protect client information in the electronic record” (p. 10). Social workers are wise not to assume that Internet sites and electronic tools they use are necessarily encrypted; the ethical burden is on the social worker to ensure trustworthy encryption by carefully examining statements and guarantees made by software vendors.

To practice ethically, clinical social workers who use digital and other technology to provide distance services must develop privacy and confidentiality protocols that include several key elements. Clinicians must review and adhere to relevant laws and regulations, including federal laws (e.g., 42 CFR Part 2 and HIPAA) and state laws pertaining to the confidentiality of mental health records and exceptions to clients’ right to confidentiality to protect clients and third parties from harm. They 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 (Clinton et al. 2010).

Also, clinical social workers must develop confidentiality agreements when conducting group treatment online. In addition, practitioners must know how to respond to subpoenas and court orders to release what lawyers refer to as electronically stored information (ESI); legal and ethical standards are evolving regarding third parties’ right to ESI during legal proceedings and clinicians’ ability to protect this information (Grimm et al. 2009). In Case A, for example, the lawyer for Alvan K.’s estranged wife subpoenaed the social worker’s electronic records, including email exchanges between Mr. K. and the social worker, in conjunction with Mr. K.’s child custody dispute with his wife. The wife’s lawyer was eager to review the electronic records and communications for evidence of Mr. K.’s mental health challenges and emotional instability, to support her client’s claim for full legal and physical custody of the couple’s children.

Boundaries, dual relationships, and conflicts of interest

Historically, social workers have understood their duty to avoid conflicts of interest that may harm clients (Brownlee 1996; Campbell and Gordon 2003; Daley and Doughty 2006; Reamer 2012b; Zur 2007). For example, clinical social workers understand they must be careful to avoid inappropriate self-disclosure and intimate relationships and friendships with clients. They must also avoid financial conflicts of interest; for instance, social workers must not enter into business relationships with clients, and clinicians who work full-time in an agency setting should not refer clients to their own part-time online private practice for additional services. The NASW Code of Ethics (2008; standard 1.06) highlights these key concepts:

  1. (a)

    Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients’ interests primary and protects clients’ interests to the greatest extent possible. In some cases, protecting clients’ interests may require termination of the professional relationship with proper referral of the client.

  2. (b)

    Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests.

  3. (c)

    Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries. (Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)

Social workers’ use of digital technology has introduced new and complicated boundary issues. Consider, for example, that the client in Case C, Mr. L., attempts to contact his social worker on the clinician’s personal Facebook site. Many social workers receive requests from current and former clients asking to be social networking “friends” or contacts. 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 social workers and clients that occur outside of normal business hours, especially if the social worker uses a personal social networking site or email address, may confuse practitioner-client boundaries.

Further, clients who have access to social workers’ social networking sites may learn a great deal of personal information about their social worker (such as information about the social worker’s family and relationships, political views, social activities, and religion), which may introduce complex transference and countertransference issues in the professional-client relationship. Some social workers have managed this risk by creating two distinct Facebook sites, one for professional use (known as a Facebook page) and one for personal use (Facebook profile).

Moreover, clients’ postings on social networking sites may lead to inadvertent or harmful disclosure of private and confidential details. In addition, social workers who choose not to accept a client’s “friend” request on a social networking site may inadvertently cause the client to feel a deep sense of rejection.

In addition, novel forms of distance counseling may introduce conflicts of interest that were previously unknown in social work. For example, some video counseling sites are offered free to social workers; the websites’ sponsors pay for its development and maintenance. In return, sponsors post electronic links on the counseling screen that take users to their websites that include information about their products and services. Clients may believe that their social workers endorse these products and services or benefit from sales.

To practice ethically, clinical social workers who use digital and other technology to provide distance services must develop protocols concerning boundaries, dual relationships, and conflicts of interest that include several key elements. Clinicians must develop sound guidelines governing their contact with current and former clients on social networking sites (e.g., Facebook, LinkedIn) and their willingness to provide clinical services to people they first met socially on social networking sites. Practitioners must be careful to avoid inappropriate disclosure of personal information in digital communications (e.g., email messages, text messages, and social network postings) and should establish clear guidelines concerning interactions with clients online and via other digital and electronic means at various times of day and night, weekends, and holidays. The 24/7/365 access that digital communications make possible creates elastic boundaries that are new to clinicians who otherwise have been able to maintain clear boundaries when services are provided in person during traditional working hours. Clinical social workers must also think carefully about maintaining digital and electronic relationships with former clients; easy access via electronic means can introduce ethical and clinical challenges related to boundaries and dependency.

Practitioner competence

Clinical social workers have always understood the importance of competent practice. Throughout social work’s history, clinical competence has entailed knowledge and skills related to assessment, treatment and intervention planning, clinical intervention, and outcome assessment and evaluation. For decades clinical social workers have refined these areas of knowledge and skill. According to the NASW Code of Ethics (2008; standard 4.01), “Social workers should strive to become and remain proficient in professional practice and the performance of professional functions. Social workers should critically examine and keep current with emerging knowledge relevant to social work. Social workers should routinely review the professional literature and participate in continuing education relevant to social work practice and social work ethics.”

The relatively recent emergence of digital clinical tools and other technologically-driven options has added a new set of essential competencies for clinicians who choose to incorporate them in their work with clients. Use of this technology requires a great deal of technical mastery in addition to awareness of, and compliance with, rapidly developing standards of care and ethical guidelines. To practice ethically, clinical social workers who use digital and other technology to provide distance services—such as the social worker in Case A who used online chat to provide crisis services to Mr. K. and the social worker in Case B who used videoconferencing to counsel Ms. G. after she dropped out of college—must seek training and continuing education focused explicitly on the use of distance counseling technology, including developing protocols for screening potential clients, obtaining clients’ informed consent, assessing clients’ clinical needs, maintaining confidentiality, implementing distance interventions and services, maintaining clear boundaries, managing documentation and client records, and terminating services.

In addition, clinical social workers, such as the practitioner in Case A who provided Mr. K. with counseling services that were delivered electronically across state lines, must keep current with evolving licensing laws and regulations regarding provision of distance counseling services across jurisdictional lines. Some state laws prohibit social workers from providing distance services that are received in states in which the social workers do not hold a license. Practitioners must also develop protocols for collegial consultation when they provide distance services. In general, clinical social workers must keep current with research developments and evolving practice standards related to distance clinical services.

Records and documentation

Maintaining high quality records is essential in clinical social work. Records are necessary for thorough client assessment; planning and delivering services; accountability to clients, insurers, agencies, other providers, courts, and utilization review organizations; to ensure continuity and coordination of services; to provide quality supervision; and to evaluate services (Sidell 2011). According to the NASW Code of Ethics (2008; standard 3.04[b]), “Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future.”

Social workers’ use of online and other electronic services has posed documentation challenges. Social workers 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. These are new expectations that are not reflected in social work’s long-standing training and literature on documentation (Sidell 2011). For example, the private-sector clinicians who plan to serve Mr. K. (Case A) and Ms. G. (Case B) must develop documentation procedures that meet social work’s standards of care and comply with federal (e.g., HIPAA) and state regulations concerning the protection of electronically stored clinical information. Social workers employed in public-sector settings, such as the social worker in Case C, must ensure that their employers have documentation protocols that meet the profession’s ethical standards.

To practice ethically, clinical social workers who use digital and other technology to provide distance services must develop records and documentation protocols that include several key elements. Social workers must develop guidelines that ensure proper encryption; reasonable and appropriate access by clients and colleagues to records and documents (for example, when a social worker is incapacitated and a colleague provides coverage); documentation of video counseling 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 documents and records.

Collegial relationships

Social workers have long understood their ethical duty to treat colleagues with respect. According to the NASW Code of Ethics (2008; standard 2.01),

  1. (a)

    Social workers should treat colleagues with respect and should represent accurately and fairly the qualifications, views, and obligations of colleagues.

  2. (b)

    Social workers should avoid unwarranted negative criticism of colleagues in communications with clients or with other professionals. Unwarranted negative criticism may include demeaning comments that refer to colleagues’ level of competence or to individuals’ attributes such as race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.

Traditionally, collegial interactions among social workers have occurred in person, in the context of agency-based meetings, and by telephone. Increasingly, however, collegial interactions are occurring online and in other remote forms, thus requiring new protocols and guidelines governing these interactions (Mainiero and Jones 2013). To practice ethically, clinical social workers who use digital and other technology to provide distance services must develop protocols governing collegial relationships that include several key elements. Social workers must ensure that they treat colleagues with respect when posting comments online; avoid cyberbullying and collegial harassment; avoid derogatory and defamatory postings; respect colleagues’ privacy (e.g., avoiding gratuitous and unwarranted Google searches for unprofessional purposes); respect colleagues’ online work products (e.g., avoiding plagiarism, unauthorized uploads); and respond appropriately and to colleagues’ unethical conduct (e.g., inappropriate postings, cyberbullying).

Managing Risk

Clinical social workers’ increasing use of digital and other technology to provide distance services and communicate with clients significantly increases potential risks to clients and practitioners. Improper or unethical use of this technology can expose clients to harm as a result of inadequate informed consent procedures; privacy and confidentiality breaches; mismanaged boundaries and dual relationships; conflicts of interest; practitioner incompetence; inadequate recordkeeping and documentation; improper termination of services; and mistreatment of colleagues. Further, practitioners’ improper or unethical use of digital technology can expose them to the risk of litigation and allegations of professional malpractice.

Risk management is a broad term that refers to efforts to protect clients, practitioners, and employers (Carroll 2011). In social work risk management includes the prevention of lawsuits and licensing board complaints. Lawsuits allege professional malpractice; licensing board complaints allege violation of standards of practice set forth in licensing laws and regulations. Lawsuits can result in monetary judgments against social workers; licensing board complaints can result in fines, revocation or suspension of a professional license, probation, mandated supervision and continuing education, reprimand, or censure.

Professional malpractice is generally considered a form of negligence. The concept applies to professionals who are required to perform in a manner consistent with the legal concept of the standard of care in the profession, that is, the way an ordinary, reasonable, and prudent professional would act under the same or similar circumstances (Bernstein and Hartsell 2004; Reamer 2003). Malpractice in social work usually is the result of a practitioner’s active violation of a client’s rights (in legal terms, acts of commission, misfeasance, or malfeasance) or a practitioner’s failure to perform certain duties (acts of omission or nonfeasance).

Some malpractice and liability claims result from genuine mistakes or inadvertent oversight on the part of social workers (a social worker sends an email message containing confidential information to the wrong recipient or neglects to document a telephone counseling session); others ensue from a deliberate decision (a social worker engages with a client online on a social networking site or decides to divulge confidential information about a client who sent a threatening email message in order to protect a third party who was mentioned in the message). A social worker’s unethical behavior or misconduct (for example, engaging in an inappropriate and salacious online relationship with a former client) also triggers claims.

In general, malpractice occurs when there is evidence that

  1. 1.

    At the time of the alleged malpractice, a legal duty existed between the practitioner and the client (for example, in Cases A, B, and C, the clinical social workers who provide distance clinical services would owe a duty to their clients, even if they never meet them in person).

  2. 2.

    The practitioner was derelict in that duty, either through an omission or through an action that occurred (for example, if the social worker in Case A failed to use proper informed consent procedures before embarking on a distance counseling relationship, failed to be available when needed, or failed to protect clients’ electronically stored confidential information).

  3. 3.

    The client suffered some harm or injury (for example, if there is evidence that the client in Case B suffered emotional distress and required additional psychiatric care after the social worker who provided her with distance counseling services was not available in an emergency and did not provide the client with information about what to do in the event of an emergency).

  4. 4.

    The professional’s dereliction of duty was the direct and proximate cause of the harm or injury (for example, if there is evidence that the client in Case B suffered injuries as a direct result of the social worker’s mismanagement of the distance counseling relationship).

In contrast, in licensing board cases judgments against social workers do not require evidence that their actions (commission) or inactions (omission) caused harm. Rather, social workers can be sanctioned based simply on evidence that their conduct violated standards contained in licensing statutes and regulations.

Clinical social workers who use digital technology and provide distance counseling services can take a number of steps to protect clients and themselves (Reamer 2013a). Although these steps cannot guarantee clear outcomes with which all practitioners agree—especially considering the ambiguity and controversy surrounding social workers’ use of digital technology—they can enhance social workers’ efforts to protect clients and themselves. The challenge for social workers is to exercise good-faith judgment systematically while being mindful of the profession’s time-honored ethical standards.

  1. 1.

    Consult colleagues Social workers who contemplate using digital and distance counseling tools should consult colleagues who have specialized knowledge or expertise related to these issues. Social workers in private or independent practice should participate in peer consultation groups to discuss their use of distance counseling technology. Social workers employed in settings that have ethics committees (committees that provide staff with a forum for consultation on difficult cases) should take advantage of this form of consultation when they face complicated ethical issues involving their use of digital technology (Reamer 2013b). Moreover, social workers who are sued or who are named in licensing board complaints can help demonstrate their competent decision-making skills by showing that they sought consultation.

  2. 2.

    Obtain appropriate supervision Social workers who have access to a supervisor should take full advantage of this opportunity. Supervisors may be able to help social workers navigate complicated circumstances involving their use of digital and distance technology to provide clinical services. Moreover, social workers who are sued or named in a licensing board complaint can help demonstrate their competent decision-making skills by showing that they sought supervision.

  3. 3.

    Review relevant ethical standards It is vitally important that social workers become familiar with and consult relevant codes of ethics, especially the current National Association of Social Workers code (Reamer 2006, 2013b). The current NASW code provides extensive guidelines concerning ethical issues that often form the basis for malpractice claims and lawsuits, for example, confidentiality, informed consent, conflicts of interest, boundary issues and dual relationships, client records, defamation of character, and termination of services (Reamer 2006). In addition, the code’s standards provide the basis for adjudication of ethics complaints filed against NASW members; further, many state licensing boards and courts of law use the code, or portions of it, when addressing complaints filed against licensed social workers, whether or not the social worker is a member of NASW. Also, a number of national and international organizations have developed guidelines for mental health professionals who offer distance counseling services, for example, the Association of Social Work Boards, International Society for Mental Health Online, American Distance Counseling Association, Association for Counseling and Therapy Online, and the Online Therapy Institute.

  4. 4.

    Review relevant regulations, laws, and policies Social workers who make difficult judgments that have legal implications should always consider relevant federal, state, and local regulations and laws. Many regulations and laws have direct relevance to clinical social workers’ use of digital and distance technology; prominent examples concern the confidentiality of alcohol and drug treatment records, the confidentiality of students’ educational records, and the confidentiality of health care and mental health treatment records. A number of states have adopted laws and regulations that explicitly govern social workers’ provision of distance counseling services (for example, requiring social workers to have a license in the client’s state of residence, even if the social workers live elsewhere). In addition to state laws, key federal laws may be relevant to social workers’ use of digital and distance technology (such as HIPAA, 42 CFR Part 2: Confidentiality of Alcohol and Drug Abuse Patient Records, and FERPA: The Family Educational Rights and Privacy Act).

  5. 5.

    Develop a social media policy for clients and staffers Social workers who consider engaging with clients electronically and providing clients with distance counseling services would do well to develop a social media policy that they share with clients. Discussing these issues with clients at the beginning of the working relationship can help avoid boundary confusion and confidentiality breaches. Typical social media policies inform clients about how the clinician manages use of social networking sites, email, text messages, and electronic (e.g., Google) searches, focusing especially on relevant informed consent, privacy, confidentiality, and boundary issues. Kolmes (2010) offers a useful template that addresses policies concerning practitioners’ use of diverse digital and related technology. Social workers are quickly discovering that a social media policy reflecting current ethical standards can simultaneously protect clients and practitioners.

In addition, many mental health agencies have developed policies for employees outlining what is and is not permitted conduct with regard to their use of digital technology. Typical agency policies address employees’ online interactions with clients and former clients, use of social networking sites (e.g., Facebook, LinkedIn), email and text message communications, and personal blogs.

  1. 6.

    Review relevant literature Social workers should always keep current with professional literature pertaining to their use of digital and distance technology. When faced with challenging decisions, social workers should make every reasonable effort to consult pertinent literature in an effort to determine what authorities in the field say about the issues and whether they agree or disagree. Such consultation can provide useful guidance and also provides helpful evidence that a social worker made a conscientious attempt to comply with current standards in the field. That a social worker took the time to consult pertinent literature “looks good,” as a defense lawyer might say. In addition, social workers can expect that opposing lawyers will conduct their own comprehensive review of relevant literature in an effort to locate authoritative publications that support their clients’ claims. Lawyers often submit as evidence copies of publications that, in their opinion, buttress their legal case. Lawyers may use the authors of influential publications as expert witnesses.

  2. 7.

    Obtain legal consultation when necessary Social workers who consider using digital and distance technology would do well to consult with a health care attorney who is familiar with relevant laws and regulations. In this emerging area of the law, statutes, regulations, and court decisions may address, for example, authorization to practice, confidentiality, privileged communication, informed consent, documentation, conflicts of interest, and termination of services (Madden 2003). In addition, the fact that a social worker took the time to obtain legal consultation provides additional evidence of having made conscientious, diligent efforts to use digital and distance technology professionally.

  3. 8.

    Document decision-making steps Comprehensive records are necessary to ensure documentation of practitioners’ proper use of digital and distance technology to assess clients’ circumstances; plan and deliver services; facilitate supervision; be accountable to clients, other service providers, funding agencies, insurers, utilization review staff, and the courts; evaluate services provided; and ensure continuity in the delivery of future services (Kagle and Kopels 2008; Madden 2003; Sidell 2011). Thorough documentation also helps to ensure quality care if a client’s primary social worker becomes unavailable because of illness, incapacitation, vacation, or employment termination; colleagues who provide coverage will have the benefit of up-to-date information. In addition, thorough documentation can help protect social workers who are named in ethics complaints and lawsuits (for example, documentation that a social worker obtained consultation, consulted relevant codes of ethics and ethical standards, referred a high-risk client for specialized services, obtained a client’s informed consent for release of confidential information, or managed a client’s suicide risk competently).

Conclusion

Clinical social work has been transformed by the emergence of digital and other electronic technology. Most contemporary social workers completed their formal education and entered the profession before currently available technology was invented, at a time when clinical relationships were limited to ongoing face-to-face meetings and the in-person development of a therapeutic alliance. Today’s practitioners have the capacity to counsel clients they never meet in person. Even social workers who maintain traditional office-based clinical practices have the option to interact with clients outside the office using video counseling technology, email, text messaging, and avatars. For some clinicians and clients, the traditional in-office therapeutic hour has become an anachronism; the boundaries of the clinician-client relationship are now much less clear and much more fluid and ambiguous.

Contemporary clinical social workers must make thoughtful decisions about whether and to what extent they will incorporate digital and other electronic technology into their professional lives. They must reflect on the meaning and nature of the therapeutic relationship, and the ways in which digital technology enhances or detracts from it. Social workers’ judgments should draw on prevailing ethical standards and standards of care. Clinical social workers should keep in mind that this is a rapidly developing aspect of professional practice, one in which ethical and risk management standards will continue to evolve.