Social Work in a Digital World: Ethical and Risk-Management Challenges

2015 ASWB Spring Education Meeting

Presented by:Frederic G. Reamer, Ph.D.

ProfessorSchool of Social WorkRhode Island College

Providence, Rhode Island

1

The Good(?) Old Days: The Way It Used to Be

2

More Nostalgia

3

A Little More Nostalgia

4

Just A Little More Nostalgia

5

And Now We Have . . .

Cybertherapy

6

7

Key Stages

• Morality period (late 19th to early 20th

century)

• Values Period (up through 1970s)

• Ethical dilemmas and decision making (late 1970s to present)

• Ethics risk management (early 1990s to present)

• Digital era (mid 2000’s to present)

8

Digital Trends in Clinical Practice: The Changing Nature of Mental Health Services

• What do we mean by relationship?

• Who do we aim to serve?

• What do we mean by privacy?

• What are the boundaries of professional-client relationships?

• What do we mean by informed consent?

• How do we manage and access clinically relevant information?

9

Terminology

• Internet-supported Intervention• web-based therapy• e-interventions • computer-mediated interventions• online therapy• online counseling• technology assisted distance counseling (TADC) • e-therapy/e-counseling• cybertherapy/cybercounseling• e-health• psycho-technology • Tele-Health • Internet counseling• Therap-E-Mail

10

Forms of Electronic Services and Interventions

• E-therapy chat (live)• Moderated forum• Web-based psychoeducation• Self-guided Web-based interventions with automated feedback (e.g., anxiety,

phobia, self-esteem, anger, weight loss)– Human support– No human support

• Video conferencing• Social networking • Telephone therapy• Avatar therapy• Expert systems• Email exchanges • Text messages• Client Blogs • Client Twitter

11

Examples of e-Therapy Websites

• http://www.asktheinternettherapist.com/• https://www.breakthrough.com/• https://virtualtherapyconnect.com/• http://www.talkspace.com/• https://www.buddyapp.co.uk/• http://www.onlinecounseling.org/• https://pfh.org/virtual-world/• http://www.youtube.com/watch?v=bYYc9Dk2NQk• http://www.wfaa.com/news/health/Dallas-center-uses-avatars-in-virtual-

world-to-help-autistic-children-116899863.html• http://t2health.dcoe.mil/video• http://www.veterantraining.va.gov/movingforward/#• http://t2health.dcoe.mil/apps/virtual-hope-box• http://www.usctelehealth.com/• http://www.vyzit.com/

12

Examples of Electronic Servicesand Interventions

• Computerized expert systems: http://easydiagnosis.com/cgi-bin/expert/start.cgi?mod=Depression

• Open clinical notes: http://www.bidmc.org/Patient-and-Visitor-Information/OpenNotes.aspx• MedHelp Moody Me smartphone app: http://www.medhelp.org/land/mood-diary-app• M3 score for mental health monitoring (iPhone/iPad and Droid):

http://www.whatsmym3.com/Default.aspx• Beating the Blues: http://www.beatingtheblues.co.uk/patients/• Addiction intervention: http://chess.wisc.edu/chess/projects/AddictionChess.aspx• PTSD intervention: https://www.youtube.com/watch?v=PbWQfyW3Vqc• SPARX for treatment of depression: http://linkedwellness.com/sparx-game/• Transitional services for adolescents: http://www.secondnature360.com/services/• HIPAA Compliant Live Chat: http://help.livehelpnow.net/article/1/3518/livehelpnow-pci-

certification-hipaa-compliance-and-safe-harbor-compliance• Lifeline Crisis Chat: http://www.crisischat.org/• Unsuicide: http://unsuicide.wikispaces.com/Online+Suicide+Help#.UdHC2py8NEM• Facebook and SAMHSA: http://www.samhsa.gov/newsroom/advisories/1112125820.aspx• Veterans Administration: http://www.va.gov/health/newsfeatures/20120813a.asp• Personal Investigator: http://aplayspace.com/mm/pi• Peer consultation: http://www.peeradigm.com/

13

Key Ethical Issues

• Informed consent

• Privacy and confidentiality

• Boundaries, dual relationships and conflicts of interest

• Practitioner competence

• Records and documentation

• Collegial relationships

14

Informed Consent

• Verification of client identity

• Capacity to consent (e.g., age, competence)

• Potential risks (e.g. confidentiality breach, emergency services, interruption of services, language, literacy)

15

Privacy and Confidentiality

• Privacy protection and encryption

• Adherence to relevant laws and regulations

• Conducting Google search

• Confidentiality agreements when conducting group treatment

• Exceptions to clients’ confidentiality rights (e.g., disclosures to protect clients from self harm, third parties, mandatory reporting, court orders)

16

Boundaries, Dual Relationships and Conflicts of Interest

• Social networking (Facebook, LinkedIn)• Current clients

• Former clients

• Former Facebook friend becomes client

• Social worker self-disclosure

• Social worker-client access• Time of day/night

• Form of access, e.g., text message, email

• Relationships with former clients

• Conflicts of interest, e.g., commercially sponsored video conferencing software with ads

17

Practitioner Competence

• Training (screening potential clients, assessment, interventions, encryption, documentation, termination of services)

• License (jurisdictional issues)

• Consultation and supervision

• Keeping up with research developments and evolving practice standards

18

Records and Documentation

• Encryption

• Access

• What and how to document (email, text, cybertherapy communications)

• Retention

• Disposal and destruction

• Relevant laws and regulations

19

Collegial Relationships

• Treating with respect

• Avoiding derogatory and defamatory postings

• Respecting colleagues’ privacy (e.g., Google searches)

• Respecting colleagues’ work products (plagiarism, unauthorized uploads)

• Responding to colleagues’ unethical conduct (e.g., inappropriate postings, cyberbullying)

• Avoiding cyberbullying, collegial harassment

20

Research on Effectiveness:Digital Technology as a Treatment Tool

• http://www.jmir.org/2012/1/e13/

• http://clinicaltrials.gov/ct2/show/NCT01180829?term=text+message&rank=3

• http://clinicaltrials.gov/ct2/show/NCT01823120?term=text+message&rank=5

• http://clinicaltrials.gov/ct2/show/NCT00184340?term=etherapy&rank=1

• http://clinicaltrials.gov/ct2/show/NCT01476891?term=etherapy&rank=2

21

Potential Advantages

• Emotionally safe (e.g., shy, anxious client)

• Semi-anonymity regarding self-disclosure

• Increased chance of candor

• Convenience

• Absence of geographical barrier– Rural areas

– Clients with disabilities

• Immediacy

• Flexible scheduling

• Cost effective

22

Potential Risks and Challenges

• Loss of human factor, nonverbal cues

• Misunderstandings

• Compromised privacy and confidentiality

• Boundary issues (ambiguous access, self-disclosure)

• Difficulty addressing long-term, complex problems

• Delayed response

• Feeling rushed to respond to emails, texts

• Emergencies

• Identity fraud

• Interstate practice without a license

• Technological failure

23

High-risk Clients

• suffering from psychiatric disorders needing immediate attention

• significantly depressed• a danger to themselves or others• struggling with serious substance abuse issues• presenting psychotic or actively suicidal concerns• struggling with psychological disorders characterized by

distortion of reality• highly reactive and potentially dangerous• struggling with certain personality disorders such as those

with borderline personality disorder, paranoia or dissociative disorders

24

Online Services: Resourcesand Ethics Guidelines

• International Society for Mental Health Online: http://ismho.org/• American Distance Counseling Association: http://www.adca-online.org/• Online Therapy Institute: http://onlinetherapyinstitute.com/ethical-

training/• American Telemedicine Association:

http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3604• The Use of Technology in Mental Health: http://www.amazon.com/The-

Use-Technology-Mental-Health/dp/0398079536• Online Counseling: A Handbook for Practitioners (Jones and Stokes, 2009):

http://www.amazon.com/gp/product/0230201954/ref=pd_lpo_k2_dp_sr_1?pf_rd_p=486539851&pf_rd_s=lpo-top-stripe-1&pf_rd_t=201&pf_rd_i=0124259553&pf_rd_m=ATVPDKIKX0DER&pf_rd_r=09T6Z8A12GZ17387HCCR

• Online Counseling: A Handbook for Mental Health Professionals (Kraus, et al., 2004): http://www.amazon.com/Online-Counseling-Professionals-Practical-Professional/dp/0124259553

25

Developing a Social Media Policy

• “Friending” on Facebooko Boundaries issueso Rejection issueso Privacy issues (e.g., acquaintances in common)

• Electronic interactions (Facebook, email)– Privacy issues– Documentation issues

• To Google or not to Googleo “Curiosity” searcheso Crisis searches

• Business review sites (e.g., Yelp, Healthgrades)• Location-based services (e.g., Foursquare, Gowalla, Loopt)• Example of a social media policy:

http://www.drkkolmes.com/docs/socmed.pdf

26

An Example of a Health System’s Social Networking Policy

Inova Health System: Social Networking and Communications Policy: http://www.inova.org/upload/docs/about-Inova/Social%20Networking%20Policy.pdf

27

“Uh oh, I better be careful!”

http://www.communitycare.co.uk/2014/09/10/social-worker-given-conditions-practice-order-disrespectful-facebook-posts/

28

“Friending” Clients on Facebook: Questions to Consider

• What is on the Facebook profile?o Facebook Page: professional use, one-wayo Facebook Profile: personal content, photos, etc.

• Are privacy controls set?o Digital “natives”o Digital “immigrants”

• What is the context of therapy? (e.g., client age, culture, clinical setting, therapeutic approach, size of community)

• Who is the client? (e.g., clinical issues, boundary instincts)• Why did the client post the request?• Will this set a challenging precedent for other clients? • What are the HIPAA and documentation implications?• Will “Friending” a client create complex boundary issues?

(see Zur)

29

Email Considerations• Is the email communication for administrative or

therapeutic purposes?

• How often must I check my email messages? (provide clients with written and verbal information about your policy)

• Does email communication fall under HIPAA?

• What are the confidentiality and privacy issues?

• Do I need to document emails in the clinical record?

(see Zur)

30

Facebook Privacy Disclaimer

“Risks inherent in sharing information. Although we allow you to set privacy options that limit access to your information, please be aware that no security measures are perfect or impenetrable. We cannot control the actions of other users with whom you share your information. We cannot guarantee that only authorized persons will view your information. We cannot ensure that information you share on Facebook will not become publicly available. We are not responsible for third party circumvention of any privacy settings or security measures on Facebook. You can reduce these risks by using common sense security practices such as choosing a strong password, using different passwords for different services, and using up to date antivirus software.”

31

Core Ethics Knowledge:Electronic Services and Interventions

• Ethical dilemmas

• Ethical decision-making

• Ethics risk management

32

Potential Ethics Risks:Electronic Services and Interventions

• Ethical mistakes

• Deliberate ethical decisions

• Ethical misconduct

33

Key Ethics Risk Areas:Electronic Services and Interventions

• Client rights

• Confidentiality and privacy

• Informed consent

• Service delivery

• Boundary issues

• Documentation

• Defamation of character

• Client records

• Supervision

• Consultation

• Client referral

• Fraud

• Termination of services and client abandonment

34

Relevant Laws:Electronic Services and Interventions

• Statutory law

• Regulatory law

• Case law

35

Examples of Ethical Standards:Digital Services and Interventions

• http://www.apa.org/ethics/education/telephone-statement.aspx

• http://www.nbcc.org/assetmanagerfiles/ethics/internetcounseling.pdf

• https://ismho.org/suggestions.asp

• http://www.acto-uk.org/professionalconduct.htm

36

Standard of Care

“What an ordinary, reasonable, and prudentprofessional, with the same or similar training, would have done under the same or similar circumstances.”

37

Standards of Care

• Substantive standard of care

• Procedural standard of care

– Consult colleagues and supervisors

– Review relevant ethical standards

– Review relevant laws, policies, and regulations

– Review relevant literature

– Obtain legal consultation, when necessary

– Consult ethics committee, if available

– Document decision-making steps

38

Professional Negligence

• A duty exists

• Dereliction or breach of the duty

• Damage or injury

• Causal connection between the breach of the duty and the damage or injury (proximate cause or “cause in fact.”)

39

Forms of Negligence

• Misfeasance: Commission of a proper act in a wrongful or injurious manner or the improper performance of an act that might have been performed lawfully.

• Malfeasance: Commission of a wrongful or unlawful act.

• Nonfeasance: The failure to perform an act that is part of one’s responsibility.

40

Confidentiality Issues

• Duty to protect/warn

• Mandatory reporting

• 42 CFR Part II

• FERPA: Family Education Rights & Privacy Act

• HIPAA: Health Insurance Portability and Accountability Act

• Disclosure: Other agencies

• Disclosure: Within agencies

• Peer Consultation

• Group counseling• Self-help groups• Minors• Bill collection• Deceased clients• Sexual misconduct by professionals• News media• Law enforcement• Interns• Personal notes

41

Duty to Protect

• Threat of violence

• Foreseeable threat

• Imminent threat

• Identifiable potential victim

42

Informed Consent

• Voluntary and informed

• Content of Form

• Process

43

Informed Consent: Content of Form

• Detailed statement of purpose

• Right to refuse and withdraw

• Reasonable alternatives

• Costs/Benefits

• Jargon

• Blank forms

• Exceptions: Emergency, therapeutic privilege, client waiver

• Expiration date

• Acknowledgment statement

44

Informed Consent: Process

• Competence

• Verbal explanation

• Opportunity for Q&A

• Language barriers

45

Consent to Intervention: Key Elements

• Provider’s credentials and qualifications• Client’s needs and goals• Description and purpose of intervention• Potential benefits and risks of electronic intervention and nonintervention• Alternative interventions• Overview of confidentiality rights and exceptions• Overview of supervision, consultation, disclosures• Overview of relevant boundary issues• Intervention details: timeframe, schedule, fees• Overview of documentation and access• Disclosures to insurers and managed care organizations• Emergency procedures and protocol• Overview of client’s rights (e.g., treatment planning, grievance)

46

Defamation of Character:Risks in Electronic Communications

• Libel (written) and Slander (verbal)

• Key elements

– Untrue statements

– Knowingly untrue or should have known to be untrue

– Damage or injury

47

Subpoenas

• Subpoena duces tecum; Subpoena ad testificandum

• Possible responses:

– Motion to quash

– Motion for protective order

– Request for finding of relevance (“in camera” review)

– Request to modify subpoena

– Object to subpoena

48

Negligent Electronic Services Intervention

• High-risk techniques

• Inadequate training or expertise

49

Boundary Issues

• Boundary crossings v. boundary violations

• Types of dual or multiple relationships

– Intimate relationships

– Personal benefit

– Emotional and dependency needs

– Altruism

– Unavoidable and unanticipated circumstances

50

Supervision

• Key concepts: Respondeat Superior & vicarious liability

• Key elements:

– Content of supervision

– Frequency of supervision

– Duration of supervision

– Boundaries between supervisor and supervisee

• Documentation

51

Termination of Electronic Services and Interventions

• The concept of abandonment

• Guidelines to protect clients and minimize risk

52

Termination Guidelines to Protect Clients and Minimize Risk

• Provide clients with names, addresses, and telephone numbers of at least 3 appropriate referrals when it is necessary to terminate.

• Follow up with a client who has been terminated. If the client does not go to the referral, write a letter to him or her about relevant risks.

• Provide as much advance warning as possible

• When clients announce their decision to terminate prematurely, explain risks involved and suggestions for alternative care. Include this information in a follow-up letter.

(cont’d.)

53

Termination Guidelines to Protect Clients and Minimize Risk (cont’d.)

• Carefully document in the case record all decisions and actions related to termination.

• In cases involving discharge from residential facilities, prepare a comprehensive discharge plan and notify significant others (inform clients of this.)

• Provide clients with clear instructions to follow in the event of an emergency. Ask clients to sign a copy acknowledging receipt and that the instructions were explained to them.

54

Termination Guidelines to Protect Clients and Minimize Risk (cont’d.)

• When leaving an employment setting, inform clients of appropriate options for continuation of services (e.g., transfer or continuation) and related benefits and risks.

• Consult with colleagues and supervisors about termination strategy and decisions.

• Consult relevant Code of Ethics standards.

55

Documentation of Electronic Services and Interventions: Key Issues

• The role of documentation and case recording in professional practice

– Assessment

– Planning and delivering services

– Accountability: Clients, insurers, agencies, other providers, courts, utilization review

– Continuity and coordination of services

– Supervision

– Evaluation of services

56

This presentation draws on material from the following resources:

• Deardorff, William, “Internet-Based Treatment: A Comprehensive Review and Ethical Issues”: http://www.behavioralhealthce.com/index.php/component/courses/?task=view&cid=69

• Kolmes, Keely, My Private Practice Social Media Policy: http://www.drkkolmes.com/docs/socmed.pdf

• Reamer, Frederic G., Risk Management in Social Work: Preventing Professional Malpractice, Liability and Disciplinary Action. New York: Columbia University Press, 2015.

• Reamer, Frederic G., Social Work Values and Ethics (4th ed.). New York: Columbia University Press, 2013.

• Reamer, Frederic G., The Social Work Ethics Casebook: Cases and Commentary. Washington, DC: NASW Press, 2009.

• Reamer, Frederic G., Boundary Issues and Dual Relationships in the Human Services. New York: Columbia University Press, 2012

• Reamer, Frederic G., Ethical Standards in Social Work: A Review of the NASW Code of Ethics (2nd ed.). Washington, DC: NASW Press, 2006.

57

This presentation draws on material from the following resources (continued):

• Reamer, Frederic G., “Digital Technology in Social Work." In Cynthia Franklin (editor-in-chief), Encyclopedia of Social Work Online. New York and Washington, DC: Oxford University Press and NASW Press, 2015.

• Reamer, Frederic G., "Distance and Online Social Work Education: Novel Ethical Challenges," Journal of Teaching in Social Work, 33(4-5), 2013, pp. 369-384.

• Reamer, Frederic G., "Social Work in a Digital Age: Ethical and Risk Management Challenges," Social Work, 58(2), 2013, pp. 163-72.

• Reamer, Frederic G., "The Digital and Electronic Revolution in Social Work: Rethinking the Meaning of Ethical Practice," Ethics and Social Welfare, 7(1), 2012, pp. 2-19. Reamer, Frederic G., The Social Work Ethics Audit: A Risk-management Tool. Washington, DC: NASW Press, 2001.

• Reamer, Frederic G., “Eye on Ethics: Novel Boundary Challenges—Social Networking,” Social Work Today: http://www.socialworktoday.com/news/eoe_111309.shtml

• Zur Institute , Digital Ethics—Internet and Therapy: http://www.zurinstitute.com/articles.html#boundariesemail

58