Part 4 - Notes


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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.

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Part 4 - Notes

  1. 1. Part 4 -Professional issues,boundaries, privacyand guidelinesConnecting Our Educational Module Part 4. Professional issues & guidelines
  2. 2. 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. Page 2
  3. 3. 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. Page 3
  4. 4. 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: 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. Page 4
  5. 5. 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. Page 5
  6. 6. 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. Page 6
  7. 7. 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.” Page 7
  8. 8. 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.” Page 8
  9. 9. 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. 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. 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 Page 9
  10. 10. 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 august/symons/?ID=3248 • The Australian Counselling Association – Internet resources for counsellors Counsellors%202011.pdf • The Australian Medical Association – Social Media and the Medical Profession: A guide to online professionalism for medical practitioners and medical students 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. Page 10
  11. 11. 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: 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. Page 11