Reach Out Pro Module - Connecting Our Worlds Part 4 As with any therapeutic intervention, the use of technology in clinical practice is not without its ethical and professional difficulties. This part of the education module has been developed to help you understand and address the professional and ethical issues that arise from using technology in your work with young people.

1. Part 4 -
Professional issues,
boundaries, privacy
and guidelines
Connecting Our Worlds
ReachOutPro.com.au Educational Module
Part 4. Professional issues & guidelines

2. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
Part 4- Professional
issues, boundaries,
privacy and guidelines
As with any therapeutic intervention, the use of technology in clinical practice
is not without its ethical and professional difficulties. This part of the education
module has been developed to help you understand and address the professional
and ethical issues that arise from using technology in your work with young
people.
Learning objectives:
Through the use of this part, you will gain an understanding of:
• Maintaining professional boundaries when using technology;
• Ethical issues including privacy, confidentiality, security and use;
• How to manage concerns associated with using technology.
At the end of Part 4, you will be able to test your understanding of these concepts
by completing the quiz.
In completing this part, please note that the evidence for technology in therapeutic
interactions is still emerging and that this part is not exhaustive in its coverage.
We have aimed to address common ethical issues and professional challenges,
but there will be occasions when issues arise that are not covered within the
content of this section. When this does arise, we encourage you to consult
the professional and ethical guidelines of your organisation and professional
association for guidance.
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3. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
1. Professional boundaries
in the digital world
Embracing new technology does not mean that you need to forget old clinical
habits and practices. Professional boundaries need to be just as clearly defined
when using technology as they are in traditional face-to-face consultations.
What makes this more pertinent is the potential to be more easily contacted
in this current age through SMS, IM, email and mobile. Due to the reduced
interpersonal boundaries online, often the professional relationship may seem to
blur. Patients might send you a friend request on Facebook, message you outside
of work hours, or send you crisis emails when you are on leave. Understanding
how best to manage these issues is crucial to both the young person’s and the
professional’s safety.
Professional boundaries in the cyber world should mirror that of face-to-face
consultations. Just as you would not arrange social activities with a client, you
should not accept friend requests for your own personal social networking sites
(see below for guidelines on how to decline friendship requests). If you are not
on call when you leave your office, you should not respond to SMS or email
communication when outside of the office. These expectations need to be clearly
defined early in contact with clients.
Checking and responding
If intending to use digital communications with clients, clinicians need to discuss
with clients the timeframes around expected responses. This is particularly
pertinent for clinicians who work part time and who do not or are unable to check
their email/mobile phones outside of work hours. Clients therefore need be clearly
informed about availability to contact their clinicians and the timeframe in which
the clinician is likely to respond [3].
Additionally, it is recommended that there is an escalation of the communication
plan for crisis contact. Specifically, if the clinician does not respond within the
pre-defined time frame, who does the client then contact if they are in crisis or
need an urgent response? Such a plan should be clearly documented in a client’s
file and provided to the client at the outset of providing the parameters for digital
communications.
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4. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
2. Clinical issues relating to privacy,
confidentiality, security and use
The following section provides an outline of key issues when using technology
to communicate with your clients. Whilst we have attempted to address the key
issues, this list is by no means exhaustive and may not cover all the issues you face
within your organisation and practice. For further information about general privacy
guidelines and storage of information see Privacy Act and Information Privacy
principles which can be accessed here:
http://www.privacy.gov.au/materials/types/infosheets/view/6541
If you are unsure about how best to manage an issue raised when using technology
in your consultations, it is recommended that you refer back to the ethical guidelines
for your appropriate professional organisation [1]. As with any role or therapy, it’s
important to recognise and work within your areas of competence and to ensure that
the selected tool does not harm your clients in any way [2].
Defining appropriate use
The reduced personal boundaries of cyberspace can mean that the clarity around
contact boundaries can be blurred. Where clients may have been previously reluctant
to contact a clinician by phone, they may more readily write and email or send a SMS.
Whilst this is beneficial in terms of reducing access barriers, it has implications for
safety and professional responsibility. You may also want to consider if the young
person would benefit from using technology, and if they will do so appropriately.
Before initiating electronic contact with clients, it is important that both the client and
the clinician agree on the boundaries of appropriate use [3]. This includes clarity about
the types of communication that are appropriate (e.g., confirmation of appointments
vs. crisis contact), the times when this communication can be used (eg., during work
hours or available 24 hours per day), and the potential outcomes of such contact. Key
points to clarify with clients include;
• Whether you will initiate contact or whether the client can.
• When you are contactable (days and hours).
• What mode of communication is appropriate (e.g., email, SMS, tweets, etc.,).
• What is appropriate communication?
• What is the likely response from the communication?
• What information will be recorded in the young person’s file?
It is beneficial to set expectations and guidelines in the first session and to document
these where appropriate. Contact management plans also need to be implemented to
ensure the client also knows how else to access help if required.
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5. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
Confirming the client’s identity
It can be difficult to confirm a client’s identity when communicating electronically.
Many young people allow their peers to access their phone and so you can never be
absolutely sure that you are communicating with the young person themselves. It is
important to raise this with the young person and to reach an understanding that you
will assume that the person responding to the communication is the young person
you intended. In saying this, where possible, it is best to limit the level of detail and
sensitive communication when communicating electronically to avoid inadvertent
disclosure.
Alternatively, you may want to organise some form of identification process with the
young person to ensure that you are communicating with the person you assume it
to be. This could include a code word or confirmation of information such as previous
appointment time to help validate an identity. It is beneficial to discuss this with the
young person prior to commencing communication.
Privacy
If using digital communications it is important for the client to understand that potential
for other people to see the communication. It is important to discuss the potential for
their friends to read their SMS messages from you, or that if they leave their emails
open others may see the communication. Highlighting this with young people is
important early on in the decision to use digital communication in a therapeutic manner.
Secure storage of information.
Whilst many clients are happy to communicate electronically with clinicians, it
is important to recognise the limitations of confidentiality in the digital age. It is
encouraged that clinicians should utilise encryption services when communicating
sensitive information, and should discuss limitations with clients [1, 3, 4].
Whilst organisations often have firewalls and measures to ensure confidentiality, it is
important to highlight the potential difficulties of confidentiality when communicating with
clients electronically. A 2006 study by Finn, indicated that 1 in 20 social workers
reported that a client’s confidentiality was compromised due to email use [5]. Given this,
when communicating with clients it is important to highlight that whilst efforts to ensure
confidentiality with be implemented, it cannot be guaranteed that confidentiality can be
maintained [3].
Recording of contact
All communications with clients need to be documented in the client’s file. This includes
noting down the time of contact, who initiated the contact, and what was the purpose
and outcome of the contact.
An advantage of email communication over telephone calls is the ability to record
verbatim the client contact. Emails can be printed off or stored electronically in the
client’s file [3] which provides a more accurate depiction of the communication.
Signatures and sign-offs
Finally, it is important to consider what you finish your communication with. Email
signatures are important as they can provide emergency contact details, which may
be particularly important if the client is unable to contact you. It is recommended that
all email communication contain a professional signature which consists of contact
information, and information about confidentiality, unauthorised access and intended
uses [6]. In addition to this, emergency contact details are also recommended.
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6. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
3. Personal issues relating to
privacy and confidentiality
In addition to the professional issues of using social networking and internet
interventions, clinicians need to be aware of the implication of their online personal
behaviour and how this may reflect upon them professionally. Particularly as we
know that many of the young people we work with will Google us. This means
that it is important to be aware of your online presence and what information is
available.
Online accounts are not as secure as we are lead to believe, and even with high
privacy settings, information can be accessed by others. Be aware that your status
updates may appear in searches, your profile photos might be made available for
anyone to see, and your comments on other people’s pages may also be visible. It
is important to be aware of the privacy policy and settings of each individual site.
It also pays to be aware of what your friends are posting about you. Given this,
it’s important to Google yourself periodically to determine what information is
being linked to your name. If you find something that you do not consider to be
appropriate, address it with that friend and ask them to remove it.
Additionally, be aware that once you upload information or images to a site, the
site may then take over ownership. Many sites such as Facebook and flickr
take ownership of the photos that are uploaded and these may be accessible to
others. Given this, it is important to consider the implication of the images you are
uploading.
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7. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
4. Additional concerns associated
with using technology with young
people
Managing Facebook friend requests
The shift in the nature of the therapeutic relationship and the availability of
information about health professionals may result in some clients requesting
connections through social networks. When considering a friend request it is
important to note the professional implications of this. Becoming a friend is likely
to blur the therapeutic relationship through self-disclosure of personal information
to the client; they will be able to see your posted photos, status updates and the
comments your friends make on your page. Likewise, they will be able to comment
on your activity.
When having a friendship requested, it is advised that you follow the code of
conduct for your profession and organisation. If you do wish to decline the
request, the following guidelines may be of assistance;
1. Where possible, discuss the decline face-to-face;
2. Thank the young person/parent for their request for friendship;
3. Validate the qualities that would make them a good friend/someone you would
want to have a networked relationship with;
4. Explain that your professional/organisation does not allow you to have
personal relationships with clients;
5. An example might go like “Sam, I saw you requested to be my friend on
facebook this week. I wanted to talk to you about this because while I think
you’re a really great person and are really kind and thoughtful, I can’t be your
friend online. This is because the code of conduct that tells me how I should
act in my role as a psychologist indicates that I can’t have a professional and
a personal relationship with a client. This is mainly for your safety as it means
that if I have a personal relationship with you, my ability to help you might
be affected by stuff outside of our professional relationship. Meaning that
if we are Facebook friends, you may not get the best support from me as a
therapist that you need.”
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8. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
Addressing high risk communications
Providing alternative means for communication can also mean that there are
alternative ways for a young person to communicate risk with you. It is important
to have risk protocols in place that can be implemented when risky behaviours are
communicated. This includes what will happen if the young person communicates
risk, who will be contacted, and how confidentiality will be managed. It is
important to have set these guidelines in the first session and to have an action
plan documented. Such a plan should include;
• What will happen if the young person communicates risk – does the
communication continue in SMS or email form? Or do they expect a phone
call?
• Clarification about what will happen if risk is ascertained – who will be
contacted and how?
• What will be documented?
Introducing risk communication conversations
“Part of making sure you can access support when you need it is giving you my
mobile number. This is my work mobile so it’s only turned on during the time that
I’m at work – this means that you can get hold of me from Monday-Thursday, and
between the hours of 8:30 am – 5:30 pm. When you text me, you need to give me
a chance to reply which will most likely be within an hour. If you don’t hear from
me within two hours, I might not be at work so if it’s urgent you need to call the
clinic… There are also some rules around this though. If you contact me because
you’re feeling down or if you want to harm yourself I am probably going to call
you. I’ll do this because I’ll need to check in with you about how safe you are and
what I need to do to help you. This means that by texting me indicating you need
help, you accept that I will probably need to call you about put our safety plan into
action.”
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9. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
5. Links to relevant papers/articles
and studies using technology
Further information about ethical issues can be sought from the following
international sites.
Publications about ethical issues
• Childress, C.A., Ethical issues in providing psychotherapeutic interventions.
Journal of Medical Internet Research, 2000. 2(1): p. e5. http://www.jmir.
org/2000/1/e5/
• Coffield, R. L., Joiner JE. Risky Business: Treating/Tweeting the Symptoms
of Social Media. AHLA Connections, 2010;14 (3):10-14. http://www.
healthlawyers.org/News/Connections/CurrentIssue/Documents/2010%20
Connections%20Full%20issues/AC_March2010.pdf
• Manhal-Baugus, M., E-therapy: practical, ethical, and legal issues.
Cyberpsychol Behav, 2001. 4(5): p. 551-63.
• MacDonald J., Sohn, S., Ellis, P,. Privacy, professionalism and Facebook: a
dilemma for young doctors. Medical Education, 2010. 44:805-813
• Shapiro, D.E. and C.E. Schulman, Ethical and legal issues in e-mail therapy.
Ethics Behav, 1996. 6(2): p. 107-24.
• Marson, M. M., Internet ethics of social workers. http://libres.uncg.edu/ir/
uncp/f/Internet%20Ethics%20for%20Social%20Workers.pdf. Accessed
April 9th, 2011.
• Thompson, L. A., Dawson, K., Ferdig, R., et al. The intersection of
online social networking with medical professionalism. J Gen Intern Med
2008;23:954–7
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10. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
Professional associations and guidelines on use of
technology
The following organisations have made a direct reference to use or impact of
technology on consultations. Where an organisation hasn’t been listed, it is
recommended that the appropriate association and ethical guidelines are referred
to in place of specific technology guidelines.
• The Australian Psychological Society – The internet’s ethical challenges for
psychologists http://www.psychology.org.au/publications/inpsych/2010/
august/symons/?ID=3248
• The Australian Counselling Association – Internet resources for counsellors
http://www.theaca.net.au/documents/Internet%20Resources%20for%20
Counsellors%202011.pdf
• The Australian Medical Association – Social Media and the Medical
Profession: A guide to online professionalism for medical practitioners and
medical students http://ama.com.au/socialmedia
In addition to consulting the appropriate professional bodies, we also recommend
consulting your organisational policies and guidelines.
One of the difficulties with electronic communication is
the lack of non-verbal cues that can provide context.
Given this, it is recommended that communication be
explicit when it comes to risk, and that if you are unsure
about risk, err on the side of caution. Similarly, if you
are not getting the responses desired from the young
person, do not hesitate to phone them.
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11. ReachOutPro.com.au Educational Module Part 4. Professional issues & guidelines
References
1. Manhal-Baugus, M., E-therapy: practical, ethical, and legal issues.
Cyberpsychol Behav, 2001. 4(5): p. 551-63.
2. The American Psychological Association. APA Statement on Services by
Telephone, Teleconferencing, and Internet - A statement by the Ethics
Committee of the American Psychological Association. 2011; Available from:
http://www.apa.org/ethics/education/telephone-statement.aspx.
3. Bradley, L.J. and B. Hendricks, E-mail and Ethical Issues. The Family Journal,
2009. 17(3): p. 267-271.
4. Shapiro, D.E. and C.E. Schulman, Ethical and legal issues in e-mail therapy.
Ethics Behav, 1996. 6(2): p. 107-24.
5. Finn, J., An exploratory study of e-mail use of direct service social workers.
Journal of Technology in Human Sciences, 2006. 24: p. 1-20.
6. Zur, O. I Love These E-Mails, or Do I? The Use of E-Mails in Psychotherapy
and Counseling 2008 [cited 2011 April 9th, 2011]; Available from: http://www.
zurinstitute.com/e-mail_in_therapy.html.
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