13.2 Ethical Issues in Technology
Competency
According to Davies (2020), to improve client’s access to web-based therapies, mental health professionals need to receive the necessary education, familiarization, and training for the smooth integration of virtual therapies into their practice. Moreover, the ACA and NAADAC ethical codes provide guidelines for using technology for mental health services, beginning with knowledge and legal considerations.
The ACA (2014) Code of Ethics highlights the importance of knowledge and competency:
“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.).
The NAADAC (2021) Code of Ethics also stresses the importance having competency training when using technology:
“Addiction professionals who choose to engage in the use of technology for e‐therapy, distance counseling, and e‐supervision shall pursue specialized knowledge and competency regarding the technical, ethical, and legal considerations specific to technology, social media, and distance counseling. Providers shall be trained and current in their knowledge of e‐therapy technologies and techniques” (Standard VI-2).
Therefore, mental health and substance use disorder counseling agencies must provide adequate training to staff on how to navigate particular platforms used by the organization. It is also the responsibility of counselors to keep themselves informed of technological advancements or updates regarding the provision of virtual mental health services. This can be achieved through research, peer consultations, and frequent discussions with respective supervisors. A counselor must also ensure that telehealth services comply with federal and state laws and guidelines, including confirming the clients’ state of residence.
Social Media
In the past decade, there has been a steady increase in people engaging in social media, some of them making high incomes from becoming social media influencers. What happens when a counselor does part-time work as a social media influencer? What happens when clients begin to look for counselor information online or when a counselor gets curious about a client’s social media use? Let’s look at a case study example to get a better understanding of how social media can pose an ethical dilemma.
Case Example: Social Media
Fiona Davis is an addiction and mental health counselor at a local treatment center. Before establishing herself in the field, she had the side hustle of running a public Instagram page that provides makeup tutorials and skincare tips. However, she has been discreet with her clients about her social media profile. Fiona had been meeting with a client to provide mental health services and other appropriate care areas. During her third session with the client, the client disclosed her interest in researching people and had stalked the counselor on social media. The client praised Fiona for her makeup skills and asked about certain makeup styles. Fiona attempted to redirect the client to focus on mental health care, but the client insisted on discussions on makeup and skincare routine. After the session, Fiona thought about how to continue care as the client now described herself as Fiona’s biggest fan. Fiona thought that terminating care would jeopardize a client’s access to care. On the other hand, shutting down her online platform would mean losing her side income and her profile on which she had worked hard to get followers and advertising gigs.
There are two issues to consider in Fiona’s case. First, Fiona’s presence on social media may have self-disclosure details, potentially leading to the client knowing much more about the counselor than needed. Moreover, instead of focusing on her therapy, the client is now more involved in Fiona’s expertise in makeup. This could lead to dual relationships or other boundaries being crossed. Second, the client’s mental health care is at stake, as termination would mean the client will no longer have access to the care needed until finding a new therapist.
The ACA (2014) Code of Ethics offers a solution:
“Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media” (Standard H.6.b.).
Based on this code, we can determine that Fiona and her client can discuss using social media and maintaining boundaries. Social media use can be discussed with our clients as part of informed consent when counselors have a public social media presence. This helps to manage any potential breach in boundaries, hence avoiding the need to terminate the therapeutic relationship.
The NAADAC (2021) Code of Ethics provides further guidance when it comes to informed consent regarding use of technology:
“Addiction professionals shall execute thorough e‐therapy informed consent prior to starting technology‐based services. A technology‐based informed consent discussion shall include, but shall not be limited to:
- contact information of the client, counselor/provider and supervisor;
- e‐therapy is not always an appropriate substitute or replacement for face‐to‐face counseling;
- all of the procedures that apply to delivery of in‐person services shall apply to the e‐delivery of services;
- duty to warn and mandatory reporting laws that shall apply to all counseling services, including e‐therapy;
- confidential and privacy rules and laws, and exceptions to those rules and laws;
- issues related to security and privacy of information, and potential for hacking or other unauthorized viewing;
- access to counseling services and to technology assistance to use e‐therapy;
- benefits and limitations of engaging in the use of distance counseling, technology, and/or social media;
- potential misunderstandings due to limited visual and auditory cues;
- potential for confusion often present in e‐delivery of services;
- response time to asynchronous communication (emails, texts, chats, etc.);
- possibility of technology failure and alternate methods of service delivery;
- emergency protocols to follow;
- procedures for when the counselor is not available;
- consideration of time zone differences;
- policy regarding recording of sessions by either party;
- cultural and/or language differences that may affect delivery of services;
- possible denial of insurance benefits; and
- social media policy” (Standard VI-4).
One can further elaborate on the social media policy to help establish clear boundaries. As described in the above case study example, Fiona could benefit from providing detailed informed consent under social media policy to establish clear boundaries with clients about her online presence. Moreover, Fiona can keep self-disclosure to a minimum on her online platform to reduce further boundary crossing. Fiona, as a licensed professional, cannot accept follow-up requests from clients and may have to discuss social media boundaries with clients. According to NAADAC (2021), counselors must provide clear explanations to clients and supervisees during the informed consent process regarding the benefits, inherent risks (including potential breaches of confidentiality), and necessary boundaries related to social media use. Professionals must also outline their specific policies and procedures concerning the use of social media in clinical relationships. Additionally, providers must respect the client’s or supervisee’s privacy on social media and refrain from investigating them without obtaining prior consent.
Social Media for Business
On the other hand, social media is a great tool to promote business and reach out to communities that can benefit from the services an organization provides. According to Latha (2020), social media has helped to increase better social engagement, especially in low-resource settings. Promoting mental health using online platforms reduces costs, connects communities from long distances, and is helpful for cost-effective mass media campaigns (Latha et al., 2020).
The ACA (2014) provides guidance on this:
“In cases where counselors wish to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles are created to clearly distinguish between the two kinds of virtual presence” (Standard H.6.a.).
Therefore, when using social media, organizations provide detailed information on the services offered and the counselors available to provide them. Another code specifies the client’s right to know the counselor’s relevant educational and licensure information.
The ACA (2014) highlights that:
“Counselors who offer distance counseling services and/or maintain a professional website provide electronic links to relevant licensure and professional certification boards to protect consumer and client rights and address ethical concerns” (Standard H.5.b.).
The NAADAC (2021) Code of Ethics details further potential benefits to using social media or electronic medium to deliver mental health services:
“Examples of potential benefits of using e‐delivery for counseling services shall include, but shall not be limited to: (a) reducing geographical barriers, (b) provision of services to those with physical or psychological disorders, and (c) working with individuals and families who would not take advantage of traditional services. Examples of potential limitations of using e‐delivery for counseling services shall include, but shall not be limited to: (a) concerns about maintaining confidentiality, (b) challenges associated with developing a therapeutic alliance, (c) inability to assess nonverbal communication, (d) determining and resolving practice and licensure jurisdiction concerns, and (e) assessment and provision of emergency services” (Standard VI-1).
NAAAC (2021) code also speaks to electronic platforms that can be used to promote and deliver mental health services:
“Electronic platforms shall include, but shall not be limited to: land‐based and mobile communication devices, fax machines, webcams, computers, laptops, tablets, flash drives, external hard drives, and cloud storage. E‐therapy and e‐supervision shall include but shall not be limited to the following delivery platforms: tele‐therapy, real‐time video‐based therapy and services, emails, texting, chatting and instant messaging. Providers and clinical supervisors shall be aware of the unique challenges created by electronic forms of communication and the use of available technology, and shall take steps to ensure that the provision of e‐therapy and e‐supervision is as safe and confidential as possible” (Standard VI-2).
Electronic Record Keeping
While technology provides significant benefits to promoting mental health care, it comes with the potential risk of breach of confidentiality. Therefore, precautions must be taken when maintaining records on online platforms and conducting group or individual sessions. Let’s look at a case study.
Case Example: Email Confidentiality
This case speaks to a potential breach of confidentiality. The personal email addresses shared with other participants would mean clients could now send each other email addresses without the receiver’s consent.
The ACA (2014) covers this in its Code of Ethics:
“Counselors use current encryption standards within their websites and/or technology-based communications that meet applicable legal requirements. Counselors take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means” (Standard H.2.d.).
Raji’s case depicts an ethical violation leading to the need for immediate remediation. In case of such a potential breach of confidentiality, counselors are responsible for informing the clients about the breach, providing details on what information was shared, and discussing possible solutions to maintaining boundaries. Counselors must also report to appropriate authorities about violations of confidentiality and follow any recommendations provided by the authorities.
When maintaining electronic health records, treatment organizations need to utilize HIPAA-compliant software with appropriate security measures, such as passwords and authorization when logging in and limiting access to the website. Counselors are responsible for providing relevant details in informed consent when discussing confidentiality maintained by the organization.
The ACA (2014) Code of Ethics also covers limitations of confidentiality in electronic records and transmission:
“Counselors acknowledge the limitations of maintaining the confidentiality of electronic records and transmissions. They inform clients that individuals might have authorized or unauthorized access to such records or transmissions (e.g., colleagues, supervisors, employees, information technologists)” (Standard H.2.b.).
In the first session with clients, counselors must inform clients about the online platform used to store their records and who has access to them. They can also talk about breaches of confidentiality that are not within the organization’s control, such as the possibility of the system getting hacked or a computer virus causing data loss.
According to the NAADAC (2021) Code of Ethics:
“Addiction professionals shall be aware of the inherent dangers of electronic health records. Providers shall inform clients/supervisees of the benefits and risks of maintaining records in a cloud-based file management system and discuss the fact that nothing that is electronically saved on a Cloud is secure and confidential. Providers shall ensure that Cloud-based file management shall be encrypted, secured, and HIPAA-compliant. Providers shall use encryption programs when transmitting client information to protect confidentiality” (Standard VI-16).
According to ACA (2014) Code of Ethics:
“Acknowledgment of Limitations; Counselors inform clients about the inherent limits of confidentiality when using technology. Counselors urge clients to be aware of authorized and/or unauthorized access to information disclosed using this medium in the counseling process” (Standard H.2.c.).
It is also beneficial to include in the informed consent around who has access to the records and caution against unauthorized use of data.
Key Takeaways
- Mental health professionals must receive education and training to integrate virtual therapies smoothly into their practice, aligning with ethical codes such as ACA (2014) and NAADAC (2021).
- Counselors are responsible for maintaining competency in using technology, ensuring compliance with legal, ethical, and technical standards.
- Informed consent should include detailed discussions on technology use, including benefits, risks, and social media boundaries, as highlighted by ACA and NAADAC ethical guidelines.
- Clear separation of professional and personal social media presence helps maintain boundaries and avoid dual relationships, as outlined by the ACA Code of Ethics.
- Secure, HIPAA-compliant electronic record-keeping systems are essential to ensure confidentiality, with proper encryption and safeguards for client information.
- Counselors must acknowledge and educate clients about the limitations of confidentiality when using technology and electronic records, as per ACA and NAADAC standards.