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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

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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.

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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

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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

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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 gr

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