Professional Association Codes of Ethics On Out-of-Office Experiences and Therapy Outside the Office's Walls
such as telehealth, phone, home visits, attending patients’ graduation, wedding, confirmation, etc., equine therapy, adventure therapy, hospital visits & much more
By Ofer Zur, Ph.D.
See our online course on Out-of-Office Therapy
Table Of Contents
- American Association of Marriage and Family Therapists (2015)
- American Counseling Association (2014)
- American Mental Health Counselors Association (2020)
- American Psychological Association (2016)
- Association of State and Provincial Psychology Boards (2018)
- California Association of Marriage and Family Therapists (2019)
- Canadian Counselling and Psychotherapy Association (2020)
- Canadian Psychological Association (2017)
- National Association for Addiction Professionals (2016)
- National Association of Social Workers (2017)
- National Board for Certified Counselors (2016)
American Association of Marriage and Family Therapists (AAMFT, 2015):
TECHNOLOGY-ASSISTED PROFESSIONAL SERVICES
6.1 Technology Assisted Services.
Prior to commencing therapy or supervision services through electronic means (including but not limited to phone and Internet), marriage and family therapists ensure that they are compliant with all relevant laws for the delivery of such services. Additionally, marriage and family therapists must: (a) determine that technologically-assisted services or supervision are appropriate for clients or supervisees, considering professional, intellectual, emotional, and physical needs; (b) inform clients or supervisees of the potential risks and benefits associated with technologically-assisted services; (c) ensure the security of their communication medium; and (d) only commence electronic therapy or supervision after appropriate education, training, or supervised experience using the relevant technology.
6.2 Consent to Treat or Supervise.
Clients and supervisees, whether contracting for services as individuals, dyads, families, or groups, must be made aware of the risks and responsibilities associated with technology-assisted services. Therapists are to advise clients and supervisees in writing of these risks, and of both the therapist’s and clients’/supervisees’ responsibilities for minimizing such risks.
6.3 Confidentiality and Professional Responsibilities.
It is the therapist’s or supervisor’s responsibility to choose technological platforms that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology.
6.4 Technology and Documentation.
Therapists and supervisors are to ensure that all documentation containing identifying or otherwise sensitive information which is electronically stored and/or transferred is done using technology that adhere to standards of best practices related to confidentiality and quality of services, and that meet applicable laws. Clients and supervisees are to be made aware in writing of the limitations and protections offered by the therapist’s or supervisor’s technology.
6.5 Location of Services and Practice.
Therapists and supervisors follow all applicable laws regarding location of practice and services, and do not use technologically-assisted means for practicing outside of their allowed jurisdictions.
6.6 Training and Use of Current Technology.
Marriage and family therapists ensure that they are well trained and competent in the use of all chosen technology-assisted professional services. Careful choices of audio, video, and other options are made in order to optimize quality and security of services, and to adhere to standards of best practices for technology-assisted services. Furthermore, such choices of technology are to be suitably advanced and current so as to best serve the professional needs of clients and supervisees.
American Counseling Association (ACA, 2014):
A.6. Managing and Maintaining Boundaries and Professional Relationships
A.6.b. Extending Counseling Boundaries
Counselors consider the risks and benefits of extending current counseling relationships beyond conventional parameters. Examples include attending a client’s formal ceremony (e.g., a wedding/commitment ceremony or graduation), purchasing a service or product provided by a client (except in gun restricted bartering), and visiting a client’s ill family member in the hospital. In extending these boundaries, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no harm occurs.
A.6.c. Documenting Boundary Extensions
If counselors extend boundaries as described in A.6.a. and A.6.b., they must officially document, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. When unintentional harm occurs to the client or former client, or to an individual significantly involved with the client or former client, the counselor must show evidence of an attempt to remedy such harm.
F.10. Roles and Relationships Between Counselor Educators and Students
F.10.f. Extending Educator–Student Boundaries
Counselor educators are aware of the power differential in the relationship between faculty and students. If they believe that a nonprofessional relationship with a student may be potentially beneficial to the student, they take precautions similar to those taken by counselors when working with clients. Examples of potentially beneficial interactions or relationships include, but are not limited to, attending a formal ceremony; conducting hospital visits; providing support during a stressful event; or maintaining mutual membership in a professional association, organization, or community. Counselor educators discuss with students the rationale for such interactions, the potential benefits and drawbacks, and the anticipated consequences for the student. Educators clarify the specific nature and limitations of the additional role(s) they will have with the student prior to engaging in a nonprofessional relationship. Nonprofessional relationships with students should be time limited and/or context specific and initiated with student consent.
Distance Counseling, Technology, and Social Media
Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.
H.1. Knowledge and Legal Considerations
H.1.a. 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).
H.1.b. Laws and Statutes
Counselors who engage in the use of distance counseling, technology, and social media within their counseling practice understand that they may be subject to laws and regulations of both the counselor’s practicing location and the client’s place of residence. Counselors ensure that their clients are aware of pertinent legal rights and limitations governing the practice of counseling across state lines or international boundaries.
H.2. Informed Consent and Security
H.2.a. Informed Consent and Disclosure
Clients have the freedom to choose whether to use distance counseling, social media, and/or technology within the counseling process. In addition to the usual and customary protocol of informed consent between counselor and client for face-to-face counseling, the following issues, unique to the use of distance counseling, technology, and/ or social media, are addressed in the informed consent process:
- distance counseling credentials, physical location of practice, and contact information;
- risks and benefits of engaging in the use of distance counseling, technology, and/or social media;
- possibility of technology failure and alternate methods of service delivery;
- anticipated response time;
- emergency procedures to follow when the counselor is not available;
- time zone differences;
- cultural and/or language differences that may affect delivery of services;
- possible denial of insurance benefits; and
- social media policy.
H.2.b. Confidentiality Maintained by the Counselor
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).
H.2.c. 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.
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.
H.3. Client Verification
Counselors who engage in the use of distance counseling, technology, and/ or social media to interact with clients take steps to verify the client’s identity at the beginning and throughout the therapeutic process. Verification can include, but is not limited to, using code words, numbers, graphics, or other nondescript identifiers.
H.4. Distance Counseling Relationship
H.4.a. Benefits and Limitations
Counselors inform clients of the benefits and limitations of using technology applications in the provision of counseling services. Such technologies include, but are not limited to, computer hardware and/or software, telephones and applications, social media and Internet-based applications and other audio and/or video communication, or data storage devices or media.
H.4.b. Professional Boundaries in Distance Counseling
Counselors understand the necessity of maintaining a professional relationship with their clients. Counselors discuss and establish professional boundaries with clients regarding the appropriate use and/or application of technology and the limitations of its use within the counseling relationship (e.g., lack of confidentiality, times when not appropriate to use).
H.4.c. Technology-Assisted Services
When providing technology-assisted services, counselors make reasonable efforts to determine that clients are intellectually, emotionally, physically, linguistically, and functionally capable of using the application and that the application is appropriate for the needs of the client. Counselors verify that clients understand the purpose and operation of technology applications and follow up with clients to correct possible misconceptions, discover appropriate use, and assess subsequent steps.
H.4.d. Effectiveness of Services
When distance counseling services are deemed ineffective by the counselor or client, counselors consider delivering services face-to-face. If the counselor is not able to provide face-to-face services (e.g., lives in another state), the counselor assists the client in identifying appropriate services.
Counselors provide information to clients regarding reasonable access to pertinent applications when providing technology-assisted services.
H.4.f. Communication Differences in Electronic Media
Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically.
H.5. Records and Web Maintenance
Counselors maintain electronic records in accordance with relevant laws and statutes. Counselors inform clients on how records are maintained electronically. This includes, but is not limited to, the type of encryption and security assigned to the records, and if/for how long archival storage of transaction records is maintained.
H.5.b. Client Rights
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.
H.5.c. Electronic Links
Counselors regularly ensure that electronic links are working and are professionally appropriate.
H.5.d. Multicultural and Disability Considerations
Counselors who maintain websites provide accessibility to persons with disabilities. They provide translation capabilities for clients who have a different primary language, when feasible. Counselors acknowledge the imperfect nature of such translations and accessibilities.
H.6. Social Media
H.6.a. Virtual Professional Presence
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.
H.6.b. Social Media as Part of Informed Consent
Counselors clearly explain to their clients, as part of the informed consent procedure, the benefits, limitations, and boundaries of the use of social media.
H.6.c. Client Virtual Presenc
Counselors respect the privacy of their clients’ presence on social media unless given consent to view such information.
H.6.d. Use of Public Social Media
Counselors take precautions to avoid disclosing confidential information through public social media.
American Mental Health Counselors Association (AMHCA, 2020)
B. Counseling Process
6. The Use of Technology Supported Counseling and Communications (TSCC)
CMHCs recognize that technology has become culturally normative worldwide and may employ modern technology communications judiciously, attentive to both the benefits and risks to clients and to the therapeutic process of using technologies to arrange, deliver, or support counseling.
- a. CMHCs understand that the uses of TSCC in counseling may be considered to fall under the following categories:
- i. The use of TSCC as the medium for counseling, also called “telehealth” or “distance counseling,” which includes but is not limited to the delivery of counseling by video call (e.g., internet, video chat), by voice (e.g., telephone), by synchronous text (e.g., chat or SMS), or by asynchronous text (e.g., email)
- ii. The use of TSCC as an adjunct to counseling (i.e., for arranging, coordinating, or paying for counseling services), including the use of payment processing services that are integrated with TSCC (e.g. PayPal, Stripe, Zelle) for receipt of payment for counseling services
- iii. The use of online “cloud-based” services for the storage of counseling records
- iv. Marketing, educational forums, and other TSCC to include blogs, webpages, chatroom, etc.
- b. CMHCs recognize that federal, state, and local laws prevail and that the standard of care for TSCC is expected in the same manner as face-to-face and in-office counseling. Continuity of care is crucial and, at times, may conflict with local laws and regulations. CMHCs should employ a solid ethical decision-making model to secure continuity of care.
- c. CMHCs are not required to provide services via TSCC or may decide not to offer services based on appropriateness.
- d. CMHCs only provide telehealth or distance counseling when they have had sufficient training which can be gained through education, supervision, or other appropriate activities (see the TSCC section of AMHCA Standards for the Practice of Clinical Mental Health Counseling in Appendix B of the “Essentials of the Clinical Mental Health Counseling Profession” text or online at www.amhca.org/publications/standards).
- e. CMHCs need to be familiar with state laws and regulations in both the state in which the CMHC is licensed and the state in which the client is presently located.
- f. At the beginning of a course of distance counseling, CMHCs acquire the contact information for emergency services in the location of the client and develop a procedure to follow in the event of a psychiatric or health emergency.
- g. In states where there is a legal requirement that CMHCs must include in the client record client communications through TSCC, CMHCs inform the client of that fact.
- h. Unless email and text messages are encrypted or otherwise secured or confidential, the client should be informed of the risks and discouraged from using as a means to disclose personal information.
- i. Chat Rooms: Typically, unsecured, open chat rooms are discouraged as a platform for communicating with clients.
- j. CMHCs may maintain professional profiles that are kept separate from personal profiles. CMHCs need to be aware of their impact on clients should personal information or opinions be disclosed in a public platform. When applicable, CMHCs educate clients on confidentiality, implications for client activity on these pages, and appropriate channels for contacting CMHCs.
- k. CMHCs only seek information about their clients through internet searches for the purpose of determining their own or their client’s safety, as necessary to conduct a forensic evaluation, or at the client’s request.
B. Counseling Process
2. Informed Consent
d. CMHCs inform the client of specific limitations, potential risks, and/or potential benefits relevant to the client’s anticipated use of online counseling services.
American Psychological Association (APA, 2016)
Also see the APA’s Guidelines for the Practice of Telepsychology: https://www.apa.org/practice/guidelines/telepsychology
Introduction and Applicability
This Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, Internet, and other electronic transmissions.
3.10 Informed Consent
(a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code. (See also Standards 8.02, Informed Consent to Research; 9.03, Informed Consent in Assessments; and 10.01, Informed Consent to Therapy.)
4.02 Discussing the Limits of Confidentiality
(c) Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.
Association of State and Provincial Psychology Boards (ASPPB, 2018):
In its most recent code of ethics (2018), the Association of State and Provincial Psychology Boards does not detail specifics regarding outside the office therapy nor telephone or technology-based therapy. However, the ASPPB refers psychologists to the APA’s Guidelines for the Practice of Telepsychology: https://www.apa.org/practice/guidelines/telepsychology
California Association of Marriage and Family Therapists (CAMFT, 2019)
Marriage and family therapists recognize that ongoing technological developments promote availability and access to healthcare and expand opportunities to provide their services outside of the therapy office. When utilizing Telehealth to provide services to clients/patients, marriage and family therapists consider the welfare of the client/patient, the appropriateness and suitability of the modality in meeting the client’s/patient’s needs, make appropriate disclosures to the client/patient regarding its use, exercise reasonable care when utilizing technology, and remain current with the relevant laws and regulations.
Marriage and family therapists take precautions to meet their responsibilities to clients/patients who are not physically present during the provision of therapy. Prior to utilizing Telehealth, marriage and family therapists consider the appropriateness and suitability of this therapeutic modality in meeting the client’s/patient’s needs and do so competently. The suitability and appropriateness of Telehealth includes consideration of multiple factors such as the client’s/patient’s familiarity with the modality, the issues to be addressed, the therapeutic orientation, and other pertinent factors.
6.2 COMPLIANCE WITH TELEHEALTH LAWS:
Marriage and family therapists, prior to engaging in Telehealth, are familiar with the state and federal laws governing Telehealth and ensure compliance with all relevant laws.
Marriage and family therapists inform clients/patients of the potential risks, consequences, and benefits of the Telehealth modality, including but not limited to issues of confidentiality, clinical limitations, and transmission/technical difficulties.
6.4 ELECTRONIC MEDIA:
Marriage and family therapists are aware of the possible adverse effects of technological changes with respect to the dissemination of client/patient information, and take care when disclosing such information. Marriage and family therapists are also aware of the limitations regarding confidential transmission by Internet or electronic media and take care when transmitting or receiving such information via these mediums.
Canadian Counselling and Psychotherapy Association (CCPA, 2020):
H. Use of Electronic and Other Technologies
Recent decades have witnessed global growth in technology-based, electronic, and online communication. This expansion of technology in both personal and professional domains has been accompanied by developments in the counselling/therapy profession. Programs and services may be assisted, supported, or delivered by technology. For example, counselling/therapy may involve synchronous approaches such as phone conversations or online meetings, and asynchronous approaches such as text and email correspondence, any of which may take place across vast distances.
Foundational ethics for the counselling/therapy profession remain at the cornerstone of all actions; however, counsellors/therapists face additional considerations when utilizing technology for administrative and/or therapeutic purposes, including public health and privacy acts.
H1. Technology-based Administrative Functions
As part of the informed consent process, counsellors/therapists indicate to clients at the outset of services whether digital records will be kept. If electronic record-keeping is to be implemented, counsellors/therapists ensure that digital security measures necessary to protect client confidentiality and privacy are in place (e.g., encryption, firewall software). (See also B2, B4, B6, B7, E2)
H2. Permission for Technology Use
Counsellors/therapists seek client informed consent prior to using Internet-based communication with clients (e.g., email, texting, and related forms of digital communication). Counsellors/therapists take necessary precautions to avoid accidental breaches of privacy or confidentiality when using Internet-based communication devices and apprise clients of associated risks. (See also B4, B6, E2)
H3. Purpose of Technology Use
Counsellors/therapists clarify under which circumstances and for which purposes technology-based-communication will be used (e.g., setting up appointments, counselling/therapy sessions, record-keeping, billing, assessment, third-party reporting) and they review their related policy as part of the informed consent process with clients. (See also B4)
H4. Technology-based Service Delivery
When technology-based applications are incorporated as a component of counselling/ therapy programs and services, counsellors/therapists ensure that (a) they have demonstrated and documented competence through appropriate and adequate education, training, and supervised experience; (b) necessary digital security measures are in place to protect client privacy and confidentiality; (c) technology applications are tailored or matched to unique client concerns and contexts; (d) research evidence supports the efficacy of the technology for the particular purpose identified; (e) decisions to implement new and emerging technologies that are not yet accompanied by a solid research foundation are based on sound clinical judgment and the rationale for their selection is documented; (f) client preparedness to use the specific technology-based application is assessed and education and training are offered as warranted; and (g) informed consent is tailored to the unique features of the technology-based application being used.
In all cases, technology-based applications do not diminish the responsibility of the counsellor/therapist to act in accordance with the CCPA Code of Ethics and Standards of Practice, and, in particular, to ensure adherence to the principles of confidentiality, informed consent, and safeguarding against harmful effects. (See also A3, B2, B4, C1, C5)
H5. Technology-based Counselling/Therapy Education
Counsellor/therapist educators who use technology to provide or enhance instruction in fully online or blended counselling/therapy programs have demonstrated competency in this mode of delivery through their education, training, and/or experience.
H6. Personal Use of Technology
In their use of social media and related technology in their personal lives, counsellors/ therapists monitor the style and content of their communication for ethical congruity and professionalism. They attend to privacy/security features, continue to honour client confidentiality, demonstrate respect for and valuing of all individuals, and represent themselves with integrity. (See also B2, G2)
H7. Jurisdictional Issues
Counsellors/therapists who engage in the use of distance counselling/supervision, technology, and social media within their therapeutic practice understand that they may be subject to laws and regulations of both the counsellors’/therapists’ practicing location and the client’s place of residence. Counsellors/therapists ensure that clients are aware of pertinent legal rights and limitations governing the practice of counselling/supervision across provincial/territorial lines or international boundaries. (See also A5)
Canadian Psychological Association (CPA, 2017):
In its most recent code of ethics (2017), the Canadian Psychological Association does not detail specifics regarding outside the office therapy nor telephone or technology-based therapy. However, the preamble states the following:
The ethical principles and values also are applicable regardless of the communication modality used (e.g., spoken, written, or printed; in person, or remotely through telephone, text, audio, video, online communication or other means).
National Association for Addiction Professionals (NAADAC, 2016):
PRINCIPLE VI: E-THERAPY, E-SUPERVISION, AND SOCIAL MEDIA
“E-Therapy” and “E-Supervision” shall refer to the provision of services by an Addiction Professional using technology, electronic devices, and HIPAA-compliant resources. Electronic platforms shall include and are not limited to: land-based and mobile communication devices, fax machines, webcams, computers, laptops and tablets. E-therapy and e-supervision shall include and are not limited to: tele-therapy, real-time video-based therapy and services, emails, texting, chatting, and cloud storage. Providers and Clinical Supervisors are 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 safe and as confidential as possible.
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. Competency shall be demonstrated through means such as specialized certifications and additional course work and/or trainings.
VI-3 Informed Consent
Addiction Professionals, who are offering an electronic platform for e-therapy, distance counseling/case management, e-supervision shall provide an Electronic/Technology Informed Consent. The electronic informed consent shall explain the right of each client and supervisee to be fully informed about services delivered through technological mediums, and shall provide each client/supervisee with information in clear and understandable language regarding the purposes, risks, limitations, and costs of treatment services, reasonable alternatives, their right to refuse service delivery through electronic means, and their right to withdraw consent at any time. Providers have an obligation to review with the client/supervisee – in writing and verbally – the rights and responsibilities of both Providers and clients/supervisees. Providers shall have the client/ supervisee attest to their understanding of the parameters covered by the Electronic/Technology Informed Consent.
VI-4 Informed Consent
A thorough e-therapy informed consent shall be executed at the start of services. A technology-based informed consent discussion shall include:
- distance counseling credentials, physical location of practice, and contact information;
- risks and benefits of engaging in the use of distance counseling, technology, and/or social media;
- possibility of technology failure and alternate methods of service delivery;
- anticipated response time;
- emergency procedures to follow;
- when the counselor is not available;
- time zone differences;
- cultural and/or language differences that may affect delivery of services; and
- possible denial of insurance benefits; and
- social media policy.
Addiction Professionals who engage in the use of electronic platforms for the delivery of services shall take reasonable steps to verify the client’s/supervisee’s identity prior to engaging in the e-therapy relationship and throughout the therapeutic relationship. Verification can include, but is not limited to, picture ids, code words, numbers, graphics, or other nondescript identifiers.
VI-6 Licensing Laws
Addiction Professionals shall comply with relevant licensing laws in the jurisdiction where the Provider/Clinical Supervisor is physically located when providing care and where the client/supervisee is located when receiving care. Emergency management protocols are entirely dependent upon where the client/supervisee receives services. Providers, during informed consent, shall notify their clients/supervisees of the legal rights and limitations governing the practice of counseling/supervision across state lines or international boundaries. Mandatory reporting and related ethical requirements such as duty to warn/notify are tied to the jurisdiction where the client/supervisee is receiving services.
VI-7 State & Federal Laws
Addiction Professionals utilizing technology, social media, and distance counseling within their practice recognize that they are subject to state and federal laws and regulations governing the counselor’s practicing location. Providers utilizing technology, social media, and distance counseling within their practice recognize that they shall be subject to laws and regulations in the client’s/supervisee’s state of residency and shall be subject to laws and regulations in the state where the client/supervisee is located during the actual delivery of services.
Addiction Professionals recognize that electronic means of communication are not secure, and shall inform clients, students, and supervisees that remote services using electronic means of delivery cannot be entirely secured or confidential. Providers who provide services via electronic technology shall fully inform each client, student, or supervisee of the limitations and risks regarding confidentiality associated with electronical delivery, including the fact that electronic exchanges may become part of clinical, academic, or professional records. Efforts shall be made to ensure privacy so clinical discussions cannot be overheard by others outside of the room where the services are provided. Internet-based counseling shall be conducted on HIPAA-compliant servers. Therapy shall not occur using text-based or email-based delivery.
Addiction Professionals shall assess and document the client’s/supervisee’s ability to benefit from and engage in e-therapy services. Providers shall consider the client’s/supervisee’s cognitive capacity and maturity, past and current diagnoses, communications skills, level of competence using technology, and access to the necessary technology. Providers shall consider geographical distance to nearest emergency medical facility, efficacy of client’s support system, current medical and behavioral health status, current or past difficulties with substance abuse, and history of violence or self-injurious behavior.
Addiction Professionals shall inform clients that other individuals (i.e., colleagues, supervisors, staff, consultants, information technologists) might have authorized or unauthorized access to such records or transmissions. Providers use current encryption standards within their websites and for technology-based communications. Providers take reasonable precautions to ensure the confidentiality of information transmitted and stored through any electronic means.
VI-11 Multidisciplinary Care
Addiction Professionals shall acknowledge and discuss with the client that optimal clinical management of clients may depend on coordination of care between a multidisciplinary care team. Providers shall explain to clients that they may need to develop collaborative relationships with local community professionals, such as the client’s local primary care provider and local emergency service providers, as this would be invaluable in case of emergencies.
VI-12 Local Resources
Addiction Professionals shall be familiar with local in-person mental health resources should the Provider exercise clinical judgment to make a referral for additional substance abuse, mental health, or other appropriate services.
Addiction Professionals shall appreciate the necessity of maintaining a professional relationship with their clients/supervisees. Providers shall discuss, establish and maintain professional therapeutic boundaries with clients/supervisees regarding the appropriate use and application of technology, and the limitations of its use within the counseling/supervisory relationship.
Addiction Professionals shall take reasonable steps to determine whether the client/supervisee physically, intellectually, emotionally, linguistically and functionally capable of using e-therapy platforms and whether e-therapy/e-supervision is appropriate for the needs of the client/supervisee. Providers and clients/supervisees shall agree on the means of e-therapy/ e-supervision to be used and the steps to be taken in case of a technology failure. Providers verify that clients/supervisees understand the purpose and operation of technology applications and follow up with clients/supervisees to correct potential concerns, discover appropriate use, and assess subsequent steps.
VI-15 Missing Cues
Addiction Professionals shall acknowledge the difference between face-to-face and electronic communication (nonverbal and verbal cues) and how these could influence the counseling/supervision process. Providers shall discuss with their client/supervisee how to prevent and address potential misunderstandings arising from the lack of visual cues and voice inflections when communicating electronically.
Addiction Professionals understand the inherent dangers of electronic health records. Providers are responsible for ensuring that cloud storage sites in use are HIPAA compliant. Providers 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 confidential and secure. Cloud-based file management shall be encrypted, secured, and HIPAA-compliant. Providers shall use encryption programs when storing or transmitting client information to protect confidentiality.
Addiction Professionals shall maintain electronic records in accordance with relevant state and federal laws and statutes. Providers shall inform clients on how records will be maintained electronically and/or physically. This includes, but is not limited to, the type of encryption and security used to store the records and the length of time storage of records is maintained.
Addiction Professionals who provide e-therapy services and/or maintain a professional website shall provide electronic links to relevant licensure and certification boards and professional membership organizations (i.e., NAADAC) to protect the client’s/supervisee’s rights and address ethical concerns.
Addiction Professionals shall not accept clients’ “friend” requests on social networking sites or email (from Facebook, My Space, etc.), and shall immediately delete all personal and email accounts to which they have granted client access and create new accounts. When Providers choose to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles are created that clearly distinguish between the professional and personal virtual presence.
VI-20 Social Media
Addiction Professionals shall clearly explain to their clients/supervisees, as part of informed consent, the benefits, inherent risks including lack of confidentiality, and necessary boundaries surrounding the use of social media. Providers shall clearly explain their policies and procedures specific to the use of social media in a clinical relationship. Providers shall respect the client’s/supervisee’s rights to privacy on social media and shall not investigate the client/supervisee without prior consent.
National Association of Social Workers (NASW, 2017):
1.03 Informed Consent
(e) Social workers should discuss with clients the social workers’ policies concerning the use of technology in the provision of professional services.
(g) Social workers who use technology to provide social work services should assess the clients’ suitability and capacity for electronic and remote services. Social workers should consider the clients’ intellectual, emotional, and physical ability to use technology to receive services and the clients’ ability to understand the potential benefits, risks, and limitations of such services. If clients do not wish to use services provided through technology, social workers should help them identify alternate methods of service.
(d) Social workers who use technology in the provision of social work services should ensure that they have the necessary knowledge and skills to provide such services in a competent manner. This includes an understanding of the special communication challenges when using technology and the ability to implement strategies to address these challenges.
(e) Social workers who use technology in providing social work services should comply with the laws governing technology and social work practice in the jurisdiction in which they are regulated and located and, as applicable, in the jurisdiction in which the client is located.
1.05 Cultural Awareness and Social Diversity
(d) Social workers who provide electronic social work services should be aware of cultural and socioeconomic differences among clients and how they may use electronic technology. Social workers should assess cultural, environmental, economic, mental or physical ability, linguistic, and other issues that may affect the delivery or use of these services.
1.06 Conflicts of Interest
(e) Social workers should avoid communication with clients using technology (such as social networking sites, online chat, e-mail, text messages, telephone, and video) for personal or non-work-related purposes.
(g) Social workers should be aware that personal affiliations may increase the likelihood that clients may discover the social worker’s presence on Web sites, social media, and other forms of technology. Social workers should be aware that involvement in electronic communication with groups based on race, ethnicity, language, sexual orientation, gender identity or expression, mental or physical ability, religion, immigration status, and other personal affiliations may affect their ability to work effectively with particular clients.
(h) Social workers should avoid accepting requests from or engaging in personal relationships with clients on social networking sites or other electronic media to prevent boundary confusion, inappropriate dual relationships, or harm to clients.
1.07 Privacy and Confidentiality
(i) Social workers should not discuss confidential information, electronically or in person, in any setting unless privacy can be ensured. Social workers should not discuss confidential information in public or semi-public areas such as hallways, waiting rooms, elevators, and restaurants.
(m) Social workers should take reasonable steps to protect the confidentiality of electronic communications, including information provided to clients or third parties. Social workers should use applicable safeguards (such as encryption, firewalls, and passwords) when using electronic communications such as e-mail, online posts, online chat sessions, mobile communication, and text messages.
(o) In the event of unauthorized access to client records or information, including any unauthorized access to the social worker’s electronic communication or storage systems, social workers should inform clients of such disclosures, consistent with applicable laws and professional standards.
1.09 Sexual Relationships
(a) Social workers should under no circumstances engage in sexual activities, inappropriate sexual communications through the use of technology or in person, or sexual contact with current clients, whether such contact is consensual or forced.
1.11 Sexual Harassment
Social workers should not sexually harass clients. Sexual harassment includes sexual advances; sexual solicitation; requests for sexual favors; and other verbal, written, electronic, or physical contact of a sexual nature.
1.12 Derogatory Language
Social workers should not use derogatory language in their written, verbal, or electronic communications to or about clients. Social workers should use accurate and respectful language in all communications to and about clients.
1.15 Interruption of Services
Social workers should make reasonable efforts to ensure continuity of services in the event that services are interrupted by factors such as unavailability, disruptions in electronic communication, relocation, illness, mental or physical ability, or death.
2.10 Unethical Conduct of Colleagues
(a) Social workers should take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues, including unethical conduct using technology.
National Board for Certified Counselors (NBCC, 2016):
19. NCCs shall recognize the potential harm of informal uses of social media and other related technology with clients, former clients and their families and personal friends. After carefully considering all of the ethical implications, including confidentiality, privacy and multiple relationships, NCCs shall develop written practice procedures in regard to social media and digital technology, and these shall be incorporated with the information provided to clients before and during the initial session. At a minimum, these social media procedures shall specify that personal accounts will be separate and isolated from any used for professional counseling purposes, including those used with prospective or current clients. These procedures shall also address “friending” and responding to material posted.
20. NCCs shall not use social media sources (e.g., updates, tweets, blogs, etc.) to provide confidential information regarding client cases that have not been consented to by the client. To facilitate the secure provision of information, NCCs shall inform clients prior to or during the initial session about appropriate ways to communicate with them. Furthermore, NCCs shall advise clients about the potential risks of sending messages through digital technology and social media sources.
21. NCCs who use digital technology (e.g., social media) for professional purposes shall limit information posted to that which does not create multiple relationships or which may threaten client confidentiality.
54. NCC’s shall include all electronic communications exchanged with clients and supervisees, including those through digital technology and social media methods, as part of the record, even when strictly related to clerical issues such as change of contact information or scheduling appointments. All electronic therapeutic communication methods shall use encryption and password security.