Confidentiality and mandate reporting

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Chances are someone has asked you to keep a secret at some point in your life. But what if that secret involved someone harming themselves or another person who was in immediate danger? Would you feel compelled to tell?

Thankfully, this question of when to divulge information to outside parties is not a mystery in social work. There are strict laws that govern when a social worker must report to authorities a client’s disclosures. At the beginning of treatment, the social worker should inform the client of these limits to confidentiality in order to avoid any confusion or feelings of distrust.

In this Discussion, you examine the requirements of mandated reporting and your views about confidentiality.

 

  • Describe at least two circumstances when you are legally mandated to break client confidentiality and disclose selected privileged information without the client’s consent.
  • Identify a time when someone broke your confidence, and explain how it made you feel.
  • Describe how your experiences related to confidentiality have shaped your view on mandate reporting.

References

https://www.sciencedirect.com/science/article/abs/pii/S0145213406000500?via%3Dihub

https://www.socialworkers.org/about/ethics/code-of-ethics

 

Cummins, L., K., & Sevel, J., A. (2017). Social work skills for beginning direct practice: Text, workbook, and interactive web based case studies (4th ed.). Upper Saddle River, NJ: Pearson Education.

  • Appendix B, “HIPAA and Confidentiality Issues” (pp. 299-303)

Social Work in a Digital Age: Ethical and Risk
Management Challenges

Frederic G. Reamer

Digital, onhne, and other electronic technology has transformed the nature of social work
practice. Contemporary social workers can provide services to chents by using onhne
counsehng, telephone counsehng, video counseling, cybertherapy (avatar therapy), self-
guided Web-based interventions, electronic social networks, e-mail, and text messages.
The introduction of diverse digital, online, and other forms of electronic social services has
created a wide range of complex ethical and related risk management issues. This article
provides an overview of current digital, onhne, and electronic social work services; identi-
fies compelling ethical issues related to practitioner competence, chent privacy and confi-
dentiality, informed consent, conflicts of interest, boundaries and dual relationships,
consultation and chent referral, termination and interruption of services, documentation,
and research evidence; and offers practical risk management strategies designed to protect
clients and social workers. The author identifies relevant standards from the NASW Code
of Ethics and other resources designed to guide practice.

KEY WORDS; digital; electronic; ethics; online; risk management

M any readers of this article began their
social work careers when telephones
were always attached to walls by

cords, progress notes were produced on typewrit-
ers, professional journals and books appeared only
in hard copy, and services were provided to clients
exclusively in physical offices or homes. Fast for-
ward. Social workers entedng the profession today
have the option to communicate with chents on
social networking sites, provide onhne and video
counseling services to people they never meet in
person and who live thousands of miles away, save
electronic records in the virtual “cloud,” and
exchange e-maü and text messages with chents by
using their respective smartphones.

Social work’s pioneers in the late 19th and early
20th centuries could not have imagined that
the profession’s tools in the 21st century would
include onhne social networking, video counseling,
e-maü, and cybertherapy. Yet here we are, provid-
ing services to chents in remarkably novel—albeit
complex and controversial—ways that challenge
social workers’ understanding of the boundades of
ethical practice. Emerging fonns of digital and elec-
tronic practice have unleashed a staggering anay
of ethical and dsk management issues involving
pracddoner competence, chent pdvacy and confi-
dendahty, infomied consent, conflicts of interest.

boundades and dual reladonships, consultation and
chent referral, termination and interruption of ser-
vices, documentadon, and research evidence.

THE DIGITAL LANDSCAPE

Mental health services emerged on the Internet as
early as 1982 in the form of online self-help sup-
port groups (Kanani & Regehr, 2003). The first
known fee-based Internet mental health service
was established by Sommers in 1995; by the late
1990s, groups of chnicians Avere forming compa-
nies and e-clinics that offered onhne counseling
services to the pubhc using secure Web sites
(Skinner & Zack, 2004). In social work, the earh-
est discussions of electronic tools focused on pracd-
tioners’ use of information technology (Schoech,
1999) and the ways in which social workers could
use Internet resources, such as onhne chat rooms
and Listservs joined by colleagues, professional
networking sites, news groups, and e-mail (Grant
& Grobman, 1998; Martinez & Clark, 2000).

Today’s social work services include a much
wider range of digital and electronic opdons,
including a large number of tools for the dehvery
of services to clients (Chester & Glass, 2006; Kanani
& Regehr, 2003; Lamendola, 2010; Menon &
Miller-Cdbbs, 2002; WeUs, Mitchell, Finkelhor, &
Becker-Blease, 2007; Zur, 2012).

doi: 1O.1O93/sw/swtOO3 O 2013 National Association of Social Woriters 163

Online Counseling
The Internet now features hundreds of online
counseling services (Barak, Hen, Boniel-Nissim,
& Shapira, 2008; Midkiff & Wyatt, 2008;
Santhiveeran, 2009). People who struggle with
depression, addiction, marital and relationship
conflict, anxiety, eating disorders, grief, and other
mental health and behavioral chaUenges can use
electronic search engines to locate cUnical social
workers who offer counseUng services using live
online chat. According to one service.

Chat counseling offers you the anonymous
writing experience of etherapy with the benefit
of an immediate response from an individual
online therapist. It is even possible to have sev-
eral health care professionals in the same chat
counseling experience. This enables us to
ensure you a multi-discipUnary approach to the
health issue that is most important to you . . .
and allows our staff to view your health care
problem as a whole. This is a much more effec-
tive way to treat an individual, but has been too
impractical and expensive before the advent of
etherapy. (www.asktheintemettherapist.com)

CUents can purchase online chat services in
30-min increments paid for by credit card.

Live online chat is an example of what com-
puter experts call synchronous communication,
meaning it occurs simultaneously in real time.
This contrasts with asynchronous conimunication,
where communication is not synchronized or
occurring simultaneously (for example, when a
client sends a social worker an e-mail message
regarding a cUnical issue and waits for a time-
delayed response).

Telephone Counseling
Some social workers provide local and long distance
counseUng services entirely by telephone to cUents
they never meet in person. After providing a coun-
selor with a user name and credit card infomiation,
cUents receive anonymous telephone counseUng.
According to one provider, “You do not need to
schedule a session or be at your computer. You can
speak with our professionals at any time of the day
or night from anywhere in the US (hopefully the
world some day). This is truly unique and power-
ful” (http://www.luiTiinentcounseUng.com).

Video Counseling
An increasing number of social workers offer cU-
ents Uve distance counseUng using webcams, pan-
tüt zoom cameras, monitors, and such services as
Skype and vyzit. For example, vyzit “allows health
care providers to engage in secure video consulta-
tions with patients, care-givers, and specialists at
no cost, and without changing the way they prac-
tice.” The vyzit Web site features a typical sce-
nario where video counseUng may be useful:

Terry lives 50 mues from the nearest mental
health provider. He needs frequent counsel-
ing, and travel to his provider’s clinic can be
difficult. With vyzit Terry is able to engage
with his provider through secure, onUne video
connection. When travel is difficult, and Terry
needs help, vyzit allows him to engage safely
and conveniently, (http://www.vyzit.com)

The University of Southern California offers USC
Telehealth, “a completely virtual counseUng and
therapy cUnic that uses the latest online and video
technologies to serve a diverse set of cUents includ-
ing adults, children, couples, families, and military
penonnel” (http://www.usctelehealth.com).

Cybertherapy
Some clinicians offer individual and group coun-
seUng services to cUents by using a 3-D virtual
world where cUents and practitioners interact with
each other visually with avatars rather than real-life
photos or Uve images. An avatar is a digitally gen-
erated graphic image, or caricature, that cUents and
social workers use to represent themselves in a vir-
tual world that appears on their computer screen.
CUents and social workers join an online therapy
community, create their avatars, and electronically
enter a virtual therapy room for individual or
group counseling. Many providers use software
known as Second Life, a massive multiplayer uni-
verse set in a 3-D virtual world.

Self-Guided Web-based Interventions
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. For example, a Web site known
as Drinker’s Check-up encourages individuals
who are concerned about their alcohol use and

164 Social Work VOLUME 58, NUMBER 2 APRIL 2013

abuse to “develop a better understanding of your
dtinking including any tisks (for example, your
health) it could pose; consider whether you might
want to change your dtinking; and understand the
ways you could change if you decide to” (www.
dtinkerscheckup.com). Users complete online
questionnaires concerning their dtinking use, pat-
terns, and habits and then receive electronic feed-
back and resources that can help them decide
whether to change their alcohol use.

Another novel Web site. Personal Investigator,
is designed for mental health professionals who
provide services to adolescents. Recognizing that
many adolescents find online services more
appealing than in-office services—given their pre-
occupation with computer-based technology—
Personal Investigator uses solution-focused therapy
ptinciples to help adolescents address challenges in
their lives. In the online game, adolescents visit a
detective academy and play the role of a personal
investigator hunting for clues that will help them
solve a personal problem. Players are given a
detective notebook, where they are asked to
record their thoughts and ideas. Five solution-
focused conversational strategies are mapped into
five distinct game areas. In each area, the player
meets a character who talks with the player in an
informal way and asks the player to answer ques-
tions in the notebook. Three of the convenations
incorporate •videos of adolescents desctibing how
they overcame penonal problems by using the
strategies desctibed. To complete the game and
graduate from the academy, players must complete
the tasks set by each character. Upon completing
the game, they receive a ptintout of their note-
book (www.aplayspace.com).

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 & Grohol, 2011; Graffeo & La Barbera,
2009); they claim that informal contact with cli-
ents on social networking sites humanizes the rela-
tionship and makes practitioners more accessible.

As an example of innovations using online
social networking, the Substance Abuse and Men-
tal Health Services Administration (U.S. Depart-
ment of Health and Human Services) and the

National Suicide Prevention Lifeline collaborate
with Facebook to help people in ctisis. The ser-
vice enables Facebook users to report a suicidal
comment posted by a ftiend to Facebook adminis-
tratoR by using either the Report Suicidal Content
link or the report links found throughout the site.
The person who posted the suicidal comment will
then immediately receive an e-mail from Face-
book encouraging him or her to call the National
Suicide Prevention Lifeline or to chck on a link to
begin a confidential chat session with a ctisis
worker (Substance Abuse and Mental Health Ser-
•vices Administration, 2011).

E-Mail
Multiple Web sites offer people the opportunity
to receive mental health services by exchanging
e-mail messages with chnical social workers. Typi-
cally these practitioners invite users to e-mail a
therapy-related question for a flat fee and guaran-
tee a response within 24-48 hr. Some practitioners
offer clients monthly e-mail packages that include
a set number of e-maü exchanges (for example, six
to eight). Other practitioners choose to exchange
occasional clinically relevant e-maüs with clients as
an extension of their office-based services (Finn,
2006; Gutheü of Simon, 2005; Peterson & 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
btief update duting a ctisis (Barak & Grohol,
2011; Zur, 2011). Other practitioners and some
social service programs have incorporated text
messaging as a formal component in their inter-
vention model. For example, staffers in some pro-
grams that serve adolescent clients have concluded
that they should follow the long-standing social
work axiom “start where the client is” and engage
with adolescents •via text messaging because that is
many adolescents’ communication medium of
choice. In a randomized double-blind controlled
study, Whittaker et al. (2012) drew on evidence-
based cognitive—behavioral therapy techniques
designed to prevent depression to deliver two
mobüe telephone messages to adolescents for 9
weeks. The intervention used 15 key messages
detived from cognitive-behavioral therapy.

REAMER / Sociat Work in a Digital Age: Ethical and Risk Management Ghaltenges 165

Intervention group participants reported that the
intervention helped them to be more positive
(66.7 percent) and to get rid of negative thoughts
(50.2 percent)—significantly higher than propor-
tions in the control group, which received placebo
messages focused on healthy eating, sustainability
of the environment, and safe practices for using
the Internet and mobile phone (cybersafety).

ETHICAL CHALLENGES

These diverse digital, online, and electronic tools
pose compeUing ethical issues for social workers.
Since social work’s formal inauguration in the late
19th century, the profession has developed
increasingly sophisticated and comprehensive ethi-
cal standards (Banks, 2006; Barsky, 2009; Con-
gress, 1999; Dolgoff, Loewenberg, & Harrington,
2008; Reamer, 2006b). The first NASW Code of
Ethics, implemented in 1960—five years after the
association was bom and decades before the avail-
ability of digital and electronic tools for service
delivery—was one page long and consisted of 14
brief, first-person proclamations concerning, for
example, every social worker’s duty to give prece-
dence to professional responsibüity over personal
interests; respect client privacy; give appropriate
service in pubUc emergencies; and contribute
knowledge, skills, and support to human welfare
programs. In 1967, a 15th principle pledging non-
discrimination was added.

The second major NASW Code of Ethics was
adopted in 1979. It included six sections of brief,
unannotated principles with a preamble setting
forth the code’s general purpose. The major sec-
tions focused on social workers’ general conduct
and ethical responsibüities to cUents, coUeagues,
employers, employing organizations, the social
work profession, and the broader society. The
1979 code was revised twice, eventually including
approximately 80 principles.

A completely new code of ethics was ratified by
the NASW governing body in 1996; this is the
current code in the United States, with several rel-
atively minor revisions since then (Reamer,
2006a). In addition to new sections that include a
mission statement for the profession and an over-
view of core values and broad ethical principles,
this code includes 155 specific ethical standards
designed to guide social workers’ conduct and
provide a basis for adjudicating ethics complaints.

Significandy, for the first time in social work’s
history, the current code includes explicit refer-
ences to social workers’ use of electronic media to
deUver services to cUents, particularly with respect
to issues of informed consent, privacy, and confi-
dentiality. However, these standards were ratified
in 1996, long before the invention of many forms
of digital technology social workers currendy use.
For example, Facebook, the most popular elec-
tronic social network site, was created in 2004;
Linkedin, Skype, and Second Life launched in
2003.

In addition to pertinent ethical standards,
NASW and the Association of Social Work Boards
(ASWB) coUaborated on standards for social work-
ers’ use of technology, a number of which focus
on ethical concerns (NASW & ASWB, 2005).
These standards address such issues as cultural com-
petence, technical competence, privacy and confi-
dentiality, confirmation of cUent identity,
documentation, and risk management.

A number of compeUing ethical issues are
emerging as social workers make increasing use of
a wide range of digital and other electronic
technology (Abbott, Klein, & Ciechomski, 2008;
Bamett, 2005). Key issues include practitioner
competence, client privacy and confidentiaUty,
informed consent, conflicts of interest, boundaries
and dual relationships, consultation and client
referral, tennination and interruption of services,
documentation, and research evidence.

Practitioner Competence
Social workers have a duty to meet minimum
standards of competence when providing services
to cUents, particularly when they use novel and
emerging intervention protocols. According to
the NASW Code of Ethics,

Social workers should provide services in sub-
stantive areas or use intervention techniques or
approaches that are new to them only after
engaging in appropriate study, training, con-
sultation, and supervision from people who
are competent in those interventions or tech-
niques, (p. 8, standard 1.04[b])

When generally recognized standards do not
exist with respect to an emerging area of prac-
tice, social workers should exercise careful

166 Sociat Work VOLUME 58, NUMBER Z APRIL 2013

judgment and take responsible steps (including
appropdate education, research, training, con-
sultation, and supervision) to ensure the com-
petence of their work and to protect clients
from harm. (p. 9, standard 1.04[c])

Thus, social workers who choose to use digital
and other electronic forms of technology to serve
chents have a moral obhgation to review pertinent
research and pracdce hterature and become famil-
iar with rapidly emerging ethical standards. As part
of this assessment, social workers must examine
the quality of the available research evidence, giv-
ing pdodty to results obtained from properly
designed randomized controlled tdals. The
NASW and ASWB (2005) standards for pracd-
donen’ use of technology state, “Social workers
shall be responsible for becoming proficient in the
technological skuls and tools required for compe-
tent and ethical practice and for seeking appropd-
ate training and consultation to stay current with
emerging technologies” (p. 7).

Client Privacy and Confidentiality
For decades, social worken have understood their
obhgation to protect chent pdvacy and confidenti-
ality and to be familiar with exceptions (for exam-
ple, when mandatory reporting laws concerning
abuse and neglect require disclosure of informa-
tion without client consent or when laws or court
orders require disclosure without chent consent to
protect a third party from harm). However, the
rapid emergence of digital technology and other
electronic media used by social worken to dehver
services has added a new layer of challenging pd-
vacy and confidentiality issues. For example, social
workers who deliver services using e-maü, avatars,
hve chat, and video counsehng must be sure to use
sophisdcated encryption technology to prevent
confidentiality breaches (hacking) by unauthodzed
parties and comply with stdct Health Insurance
Portability and Accountabihty Act (HIPAA)
guidehnes. Fortunately, currently available encryp-
tion technology protects chent confidentiality
very effectively and is HIPAA compliant; in fact,
such encryption offers significantly more protec-
tion than do traditional paper documents (Hu,
Chen, & Hou, 2010).

That said, encryption is more challenging with
some forms of technology than othen. With
regard to Skype, for example, NASW attorneys

reviewed relevant research and legal guidelines and
concluded that “assudng that clients’ confidential
communications via Skype wiU be adequately pro-
tected is a difficult and uncertain task” (Morgan &
Polowy, 2011). According to the NASW Code of
Ethics, “social workers should take precautions to
ensure and maintain the confidentiality of infor-
mation transmitted to other parties through the
use of computen, electronic maO, facsimile
machines, telephones and telephone answedng
machines, and other electronic or computer tech-
nology. Disclosure of idendfying infomiadon
should be avoided whenever possible” (p. 12,
standard 1.07[m]). The NASW and ASWB (2005)
standards on practitionen’ use of technology state,
“Social worken shall protect chent pdvacy when
using technology in their practice and document
all services, taking special safeguards to protect ch-
ent information in the electronic record” (p. 10).
Social workers are vise not to assume that Internet
sites and electronic tools they use are necessadly
encrypted; the ethical burden is on the social
worker to ensure trustworthy encryption.

Informed Consent
In recent years, social workers and other health
care providers have been held to increasingly
demanding informed consent standards (Berg,
Appelbaum, Lidz, & Parker, 2001). The recent
advent of distance counsehng and other social ser-
vices delivered electronically has enhanced social
workers’ ethical duty to ensure that chents fuUy
understand the nature of these services and their
potendal benefits and dsks (see NASW Code of
Ethia, standards 1.03[a—f]). This can be difficult
when social worken never meet their clients in
penon or have the opportunity to speak with ch-
ents about informed consent. Special challenges
adse when minon contact social worken and
request electronic services, pardcularly when social
worken offer free services and do not require credit
card information; state laws vary considerably
regarding minon’ dght to obtain mental health ser-
vices without parental consent (Madden, 2003).

Although state and federal laws and regulations
vary in interpretations and apphcations of informed
consent standards, in general, professionals agree
that the following standards must be met for con-
sent to be considered vahd: (a) Coercion and
undue influence must not have played a role in the
chent’s decision. Practitionen who provide onhne

REAMER / Social Work in a Digital Age: Ethical and Risk Management Challenges 167

and other distance or remote services must ensure
that chents do not feel pressured to grant consent,
(b) 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 demenda) are unable to compre-
hend the consent procedure. Other clients, how-
ever, 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 psychodc symptoms.
In general, social workers should assess clients’ abil-
ity to reason and make informed choices, compre-
hend relevant facts and retain this information,
appreciate current circumstances, and communicate
wishes. Such assessment can be especially challeng-
ing when social workers interact with clients only
electronically, do not meet with them in person,
and may have difficulty confirming their identity
and age. (c) Online consent forms and procedures
must be valid. Social workers sometimes present
clients with general, broadly worded consent forms
that may violate clients’ right to be informed and
may be considered invalid if challenged in a court
of law (Recupero & Rainey, 2005).

Conflicts of Interest
Historically, social workers have understood their
duty to avoid conflicts of interest that may harm
clients (see NASW Code of Ethics, standards 1.06
[a][b]). For example, social workers who work
full-time in an agency setting should not refer ch-
ents to their own part-time online private practice
for additional services.

Novel forms of distance counseling may intro-
duce conflicts of interest that were previously
unknown in social work. For example, the video
counseling site vyzit is offered free to social work-
ers and their clients; the Web site’s Sponsore pay
for its development and maintenance. In retum,
Sponsore post electronic links on the consultation
screen that take usere to their Web sites that
include information about their products and ser-
vices. Chents may beheve that their social workere
endoree these products and services.

Boundaries and Dual Relationships
In recent yeare, social workere have paid increasing
attention to boundary and dual relationship issues
(see NASW Code of Ethics, standard 1.06[c]). Key
examples include social workere’ management of

self-disclosure to chents, relationships with former
chents, gifts and invitations offered by and to cli-
ents, barter for services, and relationships with ch-
ents in small and rural communities (Brownlee,
1996; Campbell & Gordon, 2003; Daley &
Doughty, 2006; Reamer, 2012).

Social workere’ use of digital technology has
introduced new and complicated boundary issues.
For example, social workere face several challenges
involving their use of social networking sites such
as Facebook. Firet, many social workere receive
requests from current and fomier clients—either
dehvered electronically or in person—asking to be
social networking “friends” or contacts. Electronic
contact with chents and former chents on social
networking sites can lead to boundary confusion
and compromise chents’ privacy and confidential-
ity. Clients who have access to social workers’
social networking sites may learn a great deal of
pereonal information about their social worker
(such as information about the social worker’s
family and relationships, political views, social
activities, and rehgion), which may introduce
complex transference and countertransference
issues in the professional-client reladonship. Some
social worken have managed this risk by creating
two distinct Facebook sites, one for professional
use (known as a Facebook page) and one for per-
sonal use (Facebook profile).

Moreover, chents’ postings on social network-
ing sites may lead to inadvertent or harmful disclo-
sure of private and confidential details. In
addition, social workere who choose not to accept
a client’s “friend” request on a social networking
site may inadvertendy cause the client to feel a
deep sense of rejection.

Consultation and Client Referral
Social workere who provide ordine and electronic
services to clients they never meet in pereon must
take assertive steps to ensure that chents are famü-
iar with the information they would need to
locate and access emergency, counseling, case
management, and other supportive services (see
NASW Code of Ethics, standard 2.06[a]). In addi-
tion, ethically competent social workers are asser-
tive about collaborating with chents’ other service
providers and facilitating ancillary services when
needed (see NASW Code of Ethics, standards 2.05
[a][b]). This may be difficult or impossible to do
when social workere never meet their chents in

168 Social Work VOLUME 58, NUMBER Z APRIL 2013

person, do not hve in the same community, and
do not have professional relationships with clients’
other service providers. The result may be inade-
quate coordination of services and incomplete or
inaccurate clinical assessments, particularly when
clients are at tisk of harming themselves or others.

Termination or Interruption of Services
Social workers who provide online and electronic
services also face unique tisks related to what law-
yers refer to as abandonment. Abandonment occurs
when a social worker-chent relationship is termi-
nated or interrupted and the social worker faüs to
make reasonable arrangements for the continua-
tion of services, when needed. Online and elec-
tronic services could be terminated for a vatiety of
reasons. Clients may terminate services abruptly,
“disappear,” or otherwise faü to respond to a social
worker’s e-maü, text messages, or telephone mes-
sages. Social workers may terminate or interrupt
services, perhaps inadvertently, because of com-
puter or other electronic equipment faüure or
because a social worker faüs to respond to a client’s
e-maü, text, or telephone message in a timely
fashion. The NASW Code of Ethics (standards 1.16
[b][e]) holds social worken to sttict standards
regarding termination of services.

Documentation
There are compelling reasons for social workers to
document clinicaDy relevant information electron-
ically; in ptinciple, properly encrypted electronic
records are more secure than traditional paper
records. Yet social workers’ use of online and
other electronic services has posed unprecedented
documentation challenges. Social workers must
develop sttict protocols to ensure that clinically
relevant e-maü, text, social networking (for exam-
ple, Facebook), and telephone exchanges are doc-
umented properly in case records (see NASW
Code of Ethics, standards 3.04[a][b]). These are new
expectations that are not reflected in social work’s
long-standing literature on documentation guide-
lines (SideU, 2011).

Research Evidence
Social workers are obligated to base practice inter-
ventions on the best avaüable empitical evidence
(see NASW Code of Ethics, standard 4.01 [c]). Ide-
ally, social workers should base interventions on
evidence obtained from well-designed controlled

studies; if such studies are not avaüable, social
workers should draw on, in order of preference,
nonrandomized controlled ttials with predeter-
mined eligibility ctitetia and outcome measures
and opinions of respected authotities based on
clinical expetiences, desctiptive studies, or reports
of expert committees (GtinneU & Unrau, 2011;
Rubin & Babbie, 2011). Unfortunately, currently
avaüable digital and other electronic intervention
tools are so new that there is very little high-
quality, compeUing research evidence demonstrat-
ing their effectiveness (Barak & Grohol, 2011;
Barak et al., 2008; Ritterband & Täte, 2009).

RISK MANAGEMENT STRATEGIES

It is not surprising that social workers’ use of online
and other electronic tools to provide services
includes potential benefits and tisks. Clients who
struggle with anxiety or extreme shyness, for exam-
ple, may prefer to engage with a social worker
remotely, at least initially. Also, clients who are
severely disabled physically or who live great dis-
tances from social workers’ offices may benefit from
online and other distance services that they would
otherwise have great difficulty accessing. In addi-
tion, people who feel the need for help during
nonworking hours or whose work schedules do
not align conveniently with social workers’ office
hours can access services remotely any hour of the
day or night. And people who are in ctisis typically
can access assistance by telephone or Internet almost
immediately, often at a cost that is lower than fees
for in-person services. Denying services to people
in need simply because social workers are not com-
fortable with reputable digital and electronic tech-
nology is not consistent with social workers’ ethical
obligation to meet the needs of vulnerable people
(Grant & Grobman, 1998; NASW, 2008).

However, online and other distance services
also come with considerable tisks (Barak & Gro-
hol, 2011). Social workers fuUy understand how
important visual and nonverbal cues are when
providing clinical services; it is easy to miss these
cues entirely when services are provided only
orüine and by telephone. The tisk of communica-
tion misunderstandings may increase when social
workers and clients are not together in person.
Also, some clients, such as those who struggle
•with severe and persistent mental ülness, may not
be well served by chnical services dehvered by
social workers they never meet in person. Further,

REAMER / Social Work in a Digital Age: Ethical and Risk Management Ghatlenges 169

there is always the possibility, although perhaps
not the probability, of technology faüure and con-
fidentiaUty breaches that could harm cUents.

In addition, cUents who e-mail or text social
workers may not have realistic expectations of a
reasonable tumaround time for responses, and this
may lead to misunderstandings and conflict in the
social worker—client relationship. Social workers
who provide digital and telephone counseUng ser-
vices across state lines run the risk of violating
licensing laws that require social workers to be
Ucensed in the state in which the client resides
(McAdams & Wyatt, 2010; NASW & ASWB,
2005). Finally, social worken who provide services
using digital and other electronic technology run
the risk of encountering identity fraud engaged in
by cUents they never meet in person. According
to the NASW and ASWB (2005) standards on
social workers’ use of technology, “Social worken
who use electronic means to provide services
shaU . . . make efforts to verify client identity and
contact infomiation” (p. 10).

To protect clients and themselves, social work-
ers must be cognizant of three sets of ethical risks:
ethical mistakes, ethical decisions, and ethical
misconduct.

Ethical Mistakes
Ethical mistakes can occur by omission or commis-
sion. Examples of mistakes of omission include fail-
ing to Umit cUents’ access to personal information
on the social worker’s electronic social network-
ing site, to obtain cUents’ fuUy informed consent
before providing online services, to obtain a social
work Ucense to practice in the state in which the
cUent resides, to comply with HIPAA confidenti-
ality requirements pertaining to electronic com-
munications, and to respond in a timely fashion to
clients’ e-mail or text messages. Examples of mis-
takes of commission include terminating online
services to cUents abruptly, claiming expertise
regarding the provision of online services that is
outside the scope of one’s education and training,
and providing distance services to cUents whose
cUnical needs are so severe that they require
in-person services.

Ethical Decisions
In contrast to ethical mistakes, which are often
unintentional, social workers sometimes face cir-
cumstances that require deliberate ethical

decisions. Examples include whether to provide
cybertherapy or avatar therapy to cUents with dis-
sociative disorders, use an electronic social net-
working site as a therapeutic tool, and provide
video counseUng to cUents who Uve in remote
geographical areas.

Ethical Misconduct
Social workers who consider providing digital ser-
vices must be careful to avoid engaging in any
fomi of ethical misconduct. Potential pitfaUs
include misrepresenting one’s credentials and
expertise online, engaging in inappropriate dual
relationships with clients electronically (for exam-
ple, on Facebook or via e-mail), extending online
services to clients beyond what is cUnicaUy war-
ranted to enhance revenue, and biUing for digital
services that were not provided.

RESOURCES AND GUIDELINES

In recent years, a number of prominent organizations
have emerged whose goal is to promote the use of
digital and online social services and promulgate eth-
ical standards and guideUnes (Ragusea & Vande-
Creek, 2003). For example, the Intemational Society
for Mental Health OnUne (ISMHO) was fomied to
“promote the undemanding, use and development
of online communication, information and technol-
ogy for the intemational mental health community”
(www.isniho.oi^). The ISMHO has developed a
comprehensive set of ethical principles concerning
informed consent, privacy and confidentiaUty,
records and documentation, and management of
emergencies. The UK-based Association for Coun-
seUing and Therapy Online, the American Distance
CounseUng Association, and the American Tele-
medicine Association also provide use&l resources
and guideUnes designed to promote the quaUty of
onUne and electronic services and protect the pubUc.
In addition, there are handbooks for practitioners
who plan to use digital and online technology (Jones
& Stokes, 2009; Kraus, Strieker, & Speyer, 2011).

One practical measure social workers can take to
use digital and electronic technology ethically and
protect cUents is to develop what has become
known as a sodal media policy. Social workers are
quickly discovering that a social media poUcy reflect-
ing current ethical standards can simultaneously pro-
tect clients and practitioners. A carefuUy
constructed social media policy that social worken
share with their cUents can prevent confusion and

170 Sociat Work VOLUME 58, NtnuBER 2 APRIL 2013

minimize the likelihood of ethics-related problems
concerning boundaries, dual relationships, informed
consent, confidentiality, privacy, termination and
interruption of services, and documentation. Ide-
ally, a comprehensive social media ethics pohcy
addresses the most common forms of electronic
communication used by chents and social workers.
It explains to clients clearly and directly social
workers’ policy concerning the use of social net-
working sites, e-mail, text messaging, electronic
search engines, and other online and electronic
tools (Kolmes, 2010; Reamer, 2011).

CONCLUSION

Like people, professions mature and develop over
time. Social work is now well over a century old.
During its evolution, some social workers have
moved from delivering in-person services exclu-
sively to providing services using digital and other
electronic tools.

It would be a mistake to conclude that social
workers should avoid all nontraditional treatment
protocols and interventions that involve digital
and electronic tools. Creative and fruitful innova-
tion in a profession requires its practitioners to
push the boundaries of traditional practice in a
constructive effort to create, implement, and eval-
uate new, yet effective ways of helping people
who struggle in life.

The enduring challenge in social work is to
locate and walk what can be a fine hne between
valuable innovation that has therapeutic benefits
and harmful, possibly exploitative treatment of
vulnerable clients. Social work’s task going for-
ward is to assess, thoughtfully and in a construc-
tively critical way, the acceptability of digital,
onhne, and electronic tools. Further, social work-
ers must embark on rigorous, well-designed evalu-
ation of outcomes associated with these novel
interventions.

Social work’s remarkable strength as a profes-
sion is in large part the result of impressive and
creative advances in its models and methods of
interventions. Practice-based innovations should
be viewed somewhat tentatively, with a commit-
ment to critical thinking as an adequate body
of sound outcome research evolves over time.
Indeed, today’s novelty may become tomorrow’s
standard of practice. Social workers should
continue their open-minded pursuit of new
ways of helping, recognizing that these efforts

must fall within the profession’s venerable moral
tradition. HS3

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Advance Access Publication March 24, 2013

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