A minimum of  3 scholarly peered reviewed article  must be sited using APA format 500 words for each topic 7 and 8

    

Topic 7 DQ 

There is much controversy on record keeping. Agencies require records after each session, and private therapists say less is better so courts cannot interpret the notes in the wrong context. What do you feel is practical and still within the psychologist’s legal obligation? 

Topic 8 DQ 

Describe how website advertising can potentially lead to the violation of other ethical standards.

Canwe ask clients for testimonials?

Full Text

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Dilemmas

This month’s dilemma Sherifa completed her counselling qualifications three years ago. However, she has been

unable to find paid employment as a counsellor. Although she has continued to work in a voluntary capacity in order

to maintain her practice, she has become increasingly frustrated and has decided to set herself up in private practice.

As a first step, she enrolled on and completed a business start-up course, where she was advised to set up a website

and to include testimonials from her current clients at her placement. However Sherifa has just seen a conversation

on a social networking site where some members have suggested that this is not wise. What are the ethical issues

involved and what should Sherifa do? Opinions expressed in these responses are those of the writers alone and not

necessarily those of the column editor or of BACP.

Andrea Sheehy

Marriage and couple counsellor, website design and development
I can understand why Sherifa’s business start-up course has recommended that she use client testimonials. They can

be powerfully persuasive in a marketing package that includes a professional-looking website, high quality

photographs and verifiable details.

However, the essence of this dilemma is to be found in the conflict of interest between the benefits for the therapist

of obtaining a testimonial and ensuring the integrity of the relationship for the client.

The BACP Ethical Framework suggests that a resolution of this conflict should be biased heavily in the best

interests of the client. Therefore Sherifa should discuss the soliciting of testimonials with her placement manager

and supervisor before proceeding. For example, I can see a conflict of interest if testimonials from placement clients

are used to promote Sherifa’s private practice.

In addition, supposing Sherifa were to solicit her clients for testimonials. I wonder how many would feel free to

express reservations or refuse. Sherifa would need to satisfy herself (and her placement manager) that she was

ensuring the integrity of the relationship, and this may be difficult to do. Wouldn’t it be anti-therapeutic for a client
who is being treated with dignity and respect possibly for the first time in their life to be asked this? Aren’t they

going to feel obliged to help the person who has helped them?

Arguably the soliciting of a testimonial creates a dual relationship. The Ethical Framework says: ‘The existence of a

dual relationship with a client is seldom neutral and can have a powerful… impact… For these reasons practitioners

are required to… avoid entering into relationships that are likely to be detrimental…’

A problem with testimonials is that they can imply that a benefit that one client has experienced from therapy will be

universally available to all potential clients. This is not the nature of such a diverse practice as therapy and such

testimonials could be interpreted as a misrepresentation of the work of the therapeutic community. While it is true

that some therapists produce consistently better outcomes for their clients than others, arguably what these therapists

are good at is motivating the client to engage in the work that they themselves need to do for therapy to be effective.

Testimonials can be anti-therapeutic because they collude with the client who seeks to project the responsibility for
effecting change onto the therapist. It could also be argued that the client who writes a glowing testimonial is

discounting the work that they have put in and their courage in facing their demons.

Monitoring our services through feedback is vital and positive feedback is always gratifying but there are many

sound ethical reasons not to make them public. Satisfied clients often do become our best sources of future referrals

and there are plenty of ways that Sherifa’s clients can make their voices heard effectively without involving her

directly.

Rob Hammond

Personal consultant, integrative coach-therapist

Sherifa should first consider the ethical guidelines of her professional body. There maybe nothing specific about

testimonials in the guidelines but they will make clear that the individual practitioner is accountable for her actions

and needs to be able to justify them if she is challenged.

Ultimately those of us in private practice are running a business and ‘social proof in the form of client testimonials is
a powerful advertising tool. But before requesting client testimonials Sherifa must consider the ability of each client

to be objective about her request. Therapy should work towards a client being self-directing in their life. However,

given the in-built power imbalance within the therapeutic relationship, extreme care must be taken that a client

https://app-na-readspeaker-com.lopes.idm.oclc.org/cgi-bin/rsent?customerid=5845&lang=en_us&readid=rs_full_text_container_title&url=https%3A%2F%2Fweb-a-ebscohost-com.lopes.idm.oclc.org%2Fehost%2Fdetail%2Fdetail%3Fvid%3D1%26sid%3De57d6487-5074-45e1-8541-7c75a9077b5c%2540sessionmgr4008%26bdata%3DJnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl&speedValue=medium&download=true&audiofilename=Canweaskclientsfor-20141101

doesn’t feel under an obligation to provide a testimonial. Equally, Sherifa needs to be sure that her client isn’t

investing her with undue responsibility for their wellbeing, thereby negating their own part in their progress.

On the other hand, to deny a client the opportunity to publicly state their successful outcome from therapy, in the

interest of future clients, would seem unfair.

Sadly there is still a certain amount of social stigma around receiving therapy. Client testimonials help to reduce the
stigma of therapy and reinforce the notion that it is natural and acceptable. If a potential client is feeling nervous

about starting therapy, or is unsure of what to expect, feedback from previous clients can be a useful way to make

them feel more at ease.

There are numerous ways for Sherifa to gather testimonials. She could give clients a satisfaction questionnaire, with

a box to tick to give permission to use their comments and a stamped, addressed envelope for them to post it back to

her when they are ready. She could send clients a follow-up email once therapy has ended asking if they would

consider supplying a testimonial.

Sherifa should always explain how their feedback will be used (eg on her website), whether it will be anonymised,

how long will it be on view etc, and obtain the client’s permission for this.

If the option of testimonials is openly discussed and the client is fully able to be objective about the request and to

make an informed decision, then I don’t see that there is any problem.

Helen Cooke
Volunteer MBACP (Accred) counsellor

The pages of Therapy Today are heavy with references to the lack of paid work in our profession and Sherifa’s

dilemma reflects this difficult issue. Her situation has left me wondering what drives her counselling career and

about the nature of her professional relationships.

For example, what do we understand by having ‘completed’ our qualifications? Counselling training is not a finite

process and is often described as a journey, but Sherifa talks of ‘maintaining’ her practice rather than developing it

(and herself). Perhaps her motives are purely strategic, so frustration at being unable to take the next step to

employment is completely understandable. Will she devote energy to processing these feelings before she risks

carrying them forward into the work with her private practice clients?

Sherifa’s entrepreneurial flair is to be encouraged. However, she has chosen what sounds like a generic business

course where the unique aspects of our profession are unlikely to be catered for. The BACP Ethical Framework
encourages us to be open to and conscientious in considering feedback from colleagues, and we can benefit

enormously from their guidance and advice. Have Shefira’s peers fallen by the wayside in her quest for progression?

Similarly, the question of whether or not to publish client testimonials on her website has arisen vicariously, through

coming across online postings between other people. Her dilemma centres on client confidentiality, which is a

hugely significant and precious element, yet she seems so isolated professionally.

Her intention to acquire testimonials from placement clients sounds very worrying. Trustworthiness, the BACP

Ethical Framework tells us, requires us to ‘restrict any disclosure of confidential information about clients to

furthering the purposes for which it was originally disclosed’, so client feedback provided to the agency cannot be

‘lifted’ for secondary uses. There are also Data Protection Act implications. For Sherifa to seek feedback separately

and overtly for her own promotional purposes, even with the knowledge and blessing of the agency, leaves me

struggling to imagine how this could be safely managed. Crucially, what are the implications for the therapeutic

relationship of this potential ‘gift’ from the client, or for clients who refuse the request?
Sherifa needs to discuss all her plans with her placement supervisor without delay to ensure there are no current or

potential boundary breaches. Here they might explore ways to help her connect and flourish, including exploration

of the wealth of resources that BACP membership confers (eg relevant CPD workshops, the BACP Private Practice

division, regional networking days, local network groups, perhaps even setting one up in her area).

Sherifa might also take time to reflect on the personal moral qualities of humility and integrity while assessing her

priorities as a practitioner. She may decide to slow down her business-minded drive for the time being if it risks

overtaking the application of good ethical practice. Glowing testimonials are of no value if the method of acquisition

sends her crashing headlong into the sanctions pages of Therapy Today.

December’s dilemma Ken and Rob both work for a telephone counselling organisation and chat via Skype once or

twice a month, often about clients.

One day Rob confides that he is not qualified; he completed a four-year psychotherapy training but did not take the
final examinations. His CV states that he is a trained psychotherapist and he was not asked to produce documents

before being appointed. Ken is rather shocked but decides to do nothing as Rob has not actually lied about his lack

of qualifications.

However, Rob is now under investigation as a former client has complained that he was not qualified or competent

to deal with her needs and terminated therapy with him abruptly. Rob has asked Ken to write a letter of support, in

particular saying that he is familiar with his work and that he is competent to deal with complex issues.

What are Ken’s options and what should he do? Email your responses (500 words maximum) to Heather Dale at

hjdale@gmail.com by 26 November 2014. Readers are welcome to send in suggestions for dilemmas to be
considered for publication, but these will not be answered personally.

Copyright of Therapy Today is the property of British Association for Counselling & Psychotherapy and its content

may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written

permission. However, users may print, download, or email articles for individual use.

Volume 35INumber 3IJuly 2OI3iPage$ 211-

227

Text Messaging and Private Practice:
Ethical Challenges and Guidelines for
Developing Personal Best Practices

Michael E. Sude

The impact of technology on mental health practice is currently a concern in the counseling
literature, and several articles have discussed using different types of technology in practice.
In particular, many private practitioners use a cell phone for business. However, no article has
discussed ethical concerns and best practices for the use of short message service (SMS), better
known as text messaging (TM). Ethical issues that arise with TM relate to confidentiality,
documentation, counselor competence, appropriateness of use, and misinterpretation. There
are also such boundary issues to consider as multiple relationships, counselor availability, and
billing. This article addresses ethical concerns for mental health counselors who use TM in
private practice. It reviews the literature and discusses benefits, ethical concerns, and guide-
lines for office policies and personal best practices.

Teehnology is evolving rapidly (Haberstroh, Parr, Bradley, Morgan-
Fleming, & Gee, 2008) and ean help elinicians free up time and spaee
(MeMinn, Orton, & Woods, 2008). In partieular eounselors are using cell
phones to eonduet business (Baker & Bufka, 2011; McMinn et al., 2008)
because they provide options for communicating with clients at the clini-
cian’s convenience (McMinn et al., 2008).

Cell phones can be used to connect with clients for administrative tasks
like scheduling, cancelling, and rescheduling; to send appointment remind-
ers; and to communicate brief thoughts or questions between face-to-faee
(FTF) meetings. Smartphones may have the ability to connect to the Internet
and interact with others in a variety of ways, but almost all cell phones at least
have a text message option.

Individuals are increasingly communicating via short message service
(SMS), better known as texting or text messaging (TM; Boschen & Casey,
2008; Militello, Kelly, & Melnyk, 2012). TM is now used clinically to provide
support or interventions for certain conditions and populations (Merz, 2010).
Text messages can include pictures, videos, and text up to 160 characters

Michael £. Sude is affiliated with La Salle University and maintains a private practice in the suburbs
of Philadelphia. Correspondence about this article can be directed to Dr. Michael £. Sude. La Salle
University, Psychology Department, 1900 West OIney Avenue, Philadelphia, PA, 19141. Email: sudem@
lasalle.edu.

Journal of Mental Health Counseling 2 | |

(Coss & Ferns, 2010; Merz, 2010; Militello et al., 2012). Although TM usu-
ally occurs between cell phones, messages can also be sent ftom email and
web sites (Merz, 2010). For counselors in private practice, TM is a low-cost
and convenient tool.

All forms of technology have ethical implications that raise concerns
for counselors (Baker & Bufka, 2011; Baltimore, 2000; McMinn et al., 2008;
Van Allen & Roberts, 2011; Zur, 2010). As a result, every conversation about
using technology in practice must discuss ethics and ethical decision-making
(McMinn et al., 2008). Centore and Milacci (2008), who studied distance
counseling, reported that counselors experienced decreased ability to fulfill
their ethical duties for all types of distance counseling, which underscores
the need for training on the ethical issues in using technology in practice.
Studies addressing best practices for specific types of technology (Baker &
Bufka, 2011), including TM, are lacking.

This article explores TM benefits and ethical concerns for counselors
in private practice and offers guidelines for personal best practices. It reviews
the literature on use of technology in private practice and of TM for clinical
interventions. Spécifie clinical benefits and ethical concerns are outlined.
Although they are likely to use TM to communicate with clients, because
private practitioners are not likely to have received technology training,
they have the greatest need to manage ethical risks carefully. As Bradley,
Hendricks, Lock, Whiting, and Parr (2011) said about e-mail, my purpose is
not to decide for counselors whether or not they should use TM in private
practice but rather to raise awareness of ethical concerns to help them make
more informed decisions.

RESEARCH ON USE OF TECHNOLOGY IN PRACTICE

Private Practice
McMinn, Buchanan, Ellens, and Ryan (1999) conducted one ofthe

earliest studies on use of technology in private mental health practice (N =
429). Behaviors cited most often as unethical were compromising client con-
fidentiality by allowing others to access client information and conducting
any clinical services online or through email.

In another early study, Negretti and Wieling (2001) explored issues for
marriage and family therapists (N = 42) in terms of boundaries, being avail-
able to clients out of session, and engaging in ethical practice. Only 50% of
the clinicians then surveyed used email and only 36% cell phones, compared
to 40% who used pagers. None ofthe respondents who gave out their email
addresses reported charging for email interactions, and only 13% who used it
warned clients about confidentiality’ and privacy risks.

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Text Messaging and Private Practice

Recently, McMinn, Bearse, Heyne, Smithberger, and Erb (2011) exam-
ined the responses of private psychologists (N = 296) to questions about the
ethical implications of technology use, including email, cell phones, and
TM. Respondents most often reported using cell phones to provide clinical
services and store client contact information, and scheduling appointments
through email. The biggest ethical concerns were providing clinical services
via TM and email.

Perceptions of Technology Use

Centore and Milacci (2008) surveyed clinicians about how they used
different fypes of distance counseling. Online, real time text-chat was
reported by 5.6% of participants and 28.1% reported using email; of all fypes
attitudes toward text-chat were most negative, among them perceptions of
decreased abilify for counselors to build rapport with clients and decreased
abilify to assess and treat clinical issues and deal with crises.

Two studies (Haberstroh, Duffy, Evans, Cee, & Trepal, 2007; Leibert,
Archer, Munson, & York, 2006) investigated client perceptions of technol-
ogy-mediated counseling. Leibert et al. (2006) found that email and instant
messaging (IM) were the most common fypes of communication reported,
and both studies reported convenience and privacy/comfort as benefits.
Participants in both reported that the lack of audio/visual cues impacted
interactions, but anonymify provided safefy for self-disclosure (Haberstroh et
al., 2007; Leibert et al., 2006).

TEXT MESSAGING AND OTHER TEXT-BASED COMMUNIGATION

Two reviews of TM in clinical practice (Militello et al., 2012; Wei,
Hollin, & Kachnowski, 2011) concluded that it may be a helpful adjunct to
FTE services; however, the limitations of the few studies make it impossible
to draw clear conclusions about its clinical effectiveness. Recent studies
were related to crisis intervention (Coss & Ferns, 2010) and eating disorders
(Bauer, Okon, Meermann, & Kordy, 2012; Shapiro etal., 2010). TM may also
help prevent relapse after termination (Aguilera & Munoz, 2011; Shapiro &
Bauer, 2010; Shapiro et al., 2010); initiate search for mental health services
(Coss & Ferns, 2010; Joyee & Weibelzahl, 2011); and help individuals pursue
outpatient services after inpatient treatment (Bauer et al., 2012).

Furber et al. (2011) studied TM between youth in treatment and thera-
pists and discovered that most of the interaction dealt with coordinating FTF
meetings. In a small pilot study, patients in a psychotherapy group reported
that TM helped with attendance (Aguilera & Munoz, 2011). In a much
larger pilot study in the United Kingdom (UK), sending clients text messages
several days before scheduled appointments improved attendance 25-28%. If

213

the rates for the clinics studied were extended to the entire UK, the annual
national savings would be close to US$250 million (Sims et al., 2012).

No other published research into individual counselors sending and
receiving text messages with clients could be found. In other words, all the
studies listed involve programmable software that manages sending text mes-
sages to certain populations or clientele at certain days and times. Gounselors
in private practice will likely not have the training or the software for that;
they will probably be sharing TM through their cell phones. More research is
therefore needed on the benefits and risks of TM interactions for counselors
in private practice.

Advantages of Text-Based Interactions
Electronic text-based interactions include TM, IM, and email, which

all have benefits for both clients and counselors. One advantage is flexi-
bility (Shapiro et al., 2010); text-based communication may be used both
synchronously (immediate response) and asynchronously (lag time between
responses; Suler, 2000). Also, the stigma of speaking with a counselor is less-
ened because ofthe anonymity of text-only interactions (Gentore & Milacci,
2008; Suler, 2000), which may lead clients both to be more candid (Suler,
2000) and to experience increased ownership of the counseling process
(Gentore & Milacci, 2008). The pace and process of writing in asynchronous
interactions can, like journaling, help clients process and express thoughts
and feelings (Gentore & Milacci, 2008; Haberstroh et al., 2007; Suler,
2000). Some clients may express themselves better in writing (Suler, 2000),
and text-based counseling helps clients feel less pressure about disclosing
(Haberstroh et al., 2007; Suler, 2000).

Beyond the clinical benefits, cell phones are so common that they
attract little attention from others, so individuals can use them with little fear
of social stigma (Boschen, 2009; Gentore & Milacci, 2008). TM, in particu-
lar, is widely available (Militello et al., 2012) because it costs little (Aguilera
& Muñoz, 2011; Boschen, 2009; Boschen & Gasey, 2008; Shapiro et al.,
2010) and does not require a smartphone (Aguilera & Muñoz, 2011). TM is
also convenient (Goss & Ferns, 2010; Shapiro et al., 2010); is accessible at
any time (Boschen, 2009; Gentore & Milacci, 2008; Militello et al., 2012;
Shapiro et al., 2010); and offers privacy and anonymity (Goss & Ferns, 2010).
Individuals who are highly sensitive to others’ perceptions or reactions may
prefer a method of communicating that feels safer (Gentore & Milacci, 2008;
Haberstroh et al., 2008; Leibert et al., 2006).

For counselors, text-based interactions are easily documented (Suler,
2000). Haberstroh et al. (2008) reported among the clinical advantages the
ability to review the transcript ofthe interactions during the session to clarify

214

Text Messaging and Private Practice

previous wording, and the slower pace allowing more time to reflect on the
clinician’s own responses.

TM also offers the ability to have regular contact between sessions
(Aguilera & Muñoz, 2011) and to remind clients of skills learned ETE to
help prevent relapse between meetings (Boschen, 2009). Eor administrative
tasks like scheduling, cancelling, or rescheduling appointments and sending
billing or appointment reminders, TM can save private counselors time
beeause it can be read and responded to asynchronously (Boschen, 2009;
Sims e t a l , 2012).

Eor some elients TM can also serve as a transitional object or a tangible
way to remain connected to the counselor (Neimark, 2009). TM may help
elients through the times between therapy sessions, much like ealling a
eounselor’s voice mail and leaving messages that do not need to be returned
(Gutheil & Simon, 2005). Texts from counselors to clients also serve as
transitional objects, similar to the letter-writing common in narrative therapy
(Winek, 2010).

In family counseling, TM can help family members who struggle to
interact with eaeh other in real time. Asynchronous TM allows them to take
time to make meaning of messages received and to formulate responses that
can be edited before being sent. The counselor can be eopied on messages
between family members so that there is no eonfusion about the words eom-
munieated, and so that there is a monitor of the communication. Koocher
(2009) described using email with separated or divorced parents to commu-
nicate about visitation schedules and other parenting issues.

TM has also been cited as a particularly helpful adjunct for Gognitive-
Behavioral Therapy (GBT; Boschen, 2009; Boschen & Gasey, 2008; Shapiro
& Bauer, 2010). It can be used for self-monitoring (Boschen & Gasey, 2008;
Shapiro & Bauer, 2010) and to report on or complete homework (Boschen,
2009; Boschen & Gasey, 2008; Shapiro & Bauer, 2010). TM lessens the
possible shame of carrying around paper and pen and allows clients to
send counselors information and reeeive feedback more quickly (Shapiro
et al., 2010). TM time and date stamping helps keep the information being
exchanged more accurate than is possible with journals (Shapiro & Bauer,
2010). Messages can be sent at set times and can be helpful when ETE or
phone contact is not possible or appropriate. Asked by TM for information,
counselors can respond immediately, respond later, and store communica-
tions electronically (Boschen & Gasey, 2008). Einally, as distance counsel-
ing, TM is an option for clients who live in rural areas or cannot leave home
because of disability or illness (Gentore & Milacci, 2008).

215

Limitations of Text-Based Interactions
One limitation is the lack of a sense of therapeutic presence (McAdams

& Wyatt, 2010; Suler, 2000)—clients may have difficulty feeling connected
to counselors because there are no audio or visual cues (Centore & Milaeci,
2008; Haberstroh et al., 2007; Haberstroh et al., 2008; Siiler, 2000). They
may also feel less understood, less cared for, and less safe (Centore & Milaeci,
2008). Text-based interactions may also lack spontaneity (Suler, 2000), and
the slower pace eould limit disclosure (Haberstroh et al., 2007).

Another limitation can be the technology itself (Haberstroh et al.,
2007; Haberstroh et al., 2008). TM technology can fail, so that messages are
never sent or received (Shapiro & Bauer, 2010). Also, some clients may not
know how to use cell phones or be able to read messages because of limited
eyesight, and some may be unable to afford TM (Aguilera & Muñoz, 2011;
Shapiro & Bauer, 2010).

The main limitations of TM interactions are the ethical concerns they
raise and the lack of regulations and ethical guidelines for best practices.
Wliat follows addresses the guidelines that do exist and then explores specific
issues that are important for counselors to consider if they choose to use TM
in private practice. The last section suggests best practices for each of the
ethical concerns raised.

Ethical and Regulatory Guidelines
Technology evolves so quickly that state regulatory boards and profes-

sional organizations may never be able to provide guidance for using specific
types in practice (McAdams & Wyatt, 2010; McMinn etal., 2008; Nicholson,
2011; Van Allen & Roberts, 2011). However, some state boards and pro-
fessional organizations do provide general guidance for doing so (Baker &
Bufka, 2011; McAdams & Wyatt, 2010).

Bradley etal. (2011) noted that the American Mental Health Counselors
Association (AMHCA) Code of Ethics (2010) is current on providing guid-
ance for the use of technology. The seetion dedicated to technology-assisted
counseling provides guidelines for preserving confidentiality when transmit-
ting and storing information electronically. The AMHCA has also published
a white paper (2012) as a companion to the Code of Ethics (2010) that makes
recommendations for technology-assisted counseling. The white paper
recommends, for instance, that counselors be “technologically savvy in the
modality of communication being used,” plan for crises and use with at-risk
clients, and encrypt all text-based communication.

The American Counseling Association (ACA) Code of Ethics (2005)
also has guidelines for counselors using technology in practice. It addresses
confidentiality, encryption, counselor competence, appropriateness for treat-

216

Text Messaging and Private Practice

ment, emergency protocols, expectations of responses, and billing policies
(Bradley et al., 2011; Trepal, Heberstroh, Duffey, & Evans, 2007).

Furthermore, as of mid- to late-2008, 14 state boards had issued reg-
ulations for technology-assisted counseling, and 20 more were drafting or
discussing such regulations (McAdams & Wyatt, 2010). Ten states have pro-
hibited technology use, and many boards have supported it conditioned on
special circumstances (McAdams & Wyatt, 2010).

ETHICAL CONCERNS FOR PRIVATE COUNSELORS

Although counselors can currently use several types of technology
in practice, many have little understanding of the associated ethical risks
(McAdams & Wyatt, 2010). For eounselors using TM as an adjunct to FTF
services, ethical concerns include confldentialify, documentation, counselor
competence, appropriateness of use, and misinterpretation. Boundary issues
to consider include multiple relationships, counselor availability, and billing.

Confidentiality
The primary ethieal concern for counselors who use TM is informa-

tion security (Bosehen & Casey, 2008; Merz, 2010) because ofthe risk of
violating client eonfidentialify (Bradley et al., 2011; Furber et a l , 2011; Zur,
2010). Among TM identifleation problems are not knowing whether a elient
is alone when receiving a text, whether the client is actually the one texting,
and whether someone else has access to the client phone and saved conver-
sations (Suler, 2000). Like email (Barnett & Scheetz, 2003), text messages
are more like postcards than private letters and, like voice mail, clients may
assume that only counselors can access them (McMinn et al., 1999). Also
like email (Cutheil & Simon, 2005; Van Allen & Roberts, 2011), they can
accidently be sent to the wrong person.

Portable electronics and the information stored on them can be easily
lost or stolen (Van Allen & Roberts, 2011; Zur & Barnett, 2008), and even the
digital contact list on a counselor’s cell phone can compromise eonfidential-
ify. Finally, keeping information confidential is not completely in the control
ofthe phone owner (Van Allen & Roberts, 2011). For example, counselors
need to consider the risk to confldentialify if TM is intercepted by hackers
(Merz, 2010).

Documentation
Besides protecting the information exchanged, counselors need to

know how to securely document and store text messages. McMinn et al.
(2008) questioned what constitutes secure password protection or encryption
for electronic records storage and transfer, and what can be done to ensure

217

that confidential information cannot be retrieved when electronic devices
are disposed of. As clinical contacts (Zur, 2010), like e-mail (Bradley &
Hendricks, 2009; Gutheil & Simon, 2005; Zur, 2008, 2010), text messages
can be subpoenaed as part ofa client’s file. Providers also must be prepared
for technology “death” and have secure backup services and a protocol for
disposing of dead technology (McMinn et al., 1999).

The counselor must give precedence to the client’s rights to privacy and
confidentiality over any personal convenience (Nicholson, 2011), and how to
do this for TM is not clear. For example, email should be printed and placed
with notes, but it is more like a transcript than a session summary (Gutheil
& Simon, 2005). TM is a transcript of interaction as well, but may have less
information because of the character limits.

Counselor Competence, Appropriateness, and Misinterpretation
Beyond confidentiality, there are ethical concerns related to counselor

competence, the appropriateness of using TM, and misinterpretation of
interactions. Gounselors are rarely prepared or trained to use technology
properly within professional relationships (Neimark, 2009; Van Allen &
Roberts, 2011). For instance, as Haberstroh et al. (2008) noted for online
counseling, TM leaves open the possibility of interacting with several clients
at the same time, which can lead to distractions and mistakes.

Once counselors are trained to use TM, they will need to decide
what types of interactions to use it for. TM can be a quick way to contact
counselors in crisis situations, any day or time, but Haberstroh et al. (2008)
reported on situations when text-based interactions may not be appropriate,
and self-harm was one. There are also practical barriers to the use of TM in
emergencies. Gounselors may not receive messages immediately or be able to
reach clients in crisis (Shapiro & Bauer, 2010), and neither party may know
whether messages were received. In short, counselors must determine when
and how it is appropriate to use TM with clients.

There is also a higher chance of misinterpretation, misunderstandings,
and confusion in text-based communication, especially with culture-specific
language and a lack of audio or visual cues (Baltimore, 2000; Barnett &
Scheetz, 2003; Koocher, 2009). Glient difficulties with expressing themselves
in writing (Suler, 2000) may be magnified in TM because it is so hard to
explain something lengthy or complex in a limited space (Shapiro & Bauer,
2010). Moreover, the lack of audio or visual cues may limit ability to make
meaning of interactions, so counselors must be able to tolerate ambiguity
(Trepal et al., 2007) and check out assumptions.

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Text Messaging and Private Practice

Boundary Concerns

One possibility for misinterpretation is the counseling relationship
being interpreted differently. Counselors must be careful to avoid treating
electronic communication with clients as off the record or casual. The possi-
bility that casual or informal interactions might lead to boundary confusion
for clients has been explored for email (Bradley et al., 2011; Cutheil &
Simon, 2005), and the risk is higher with TM because it is less common in
professional relationships. Counselors may also reeeive inappropriate mes-
sages from clients by mistake, or because TM is disinhibiting (Suler, 2000).

Furthermore, interactions through TM can be time-consuming, and
there is less time for actual exchange than in the same amount of FTF time
(Trepal et a l , 2007). This is a consideration for billing: Should TM be billed
per text? per minute? or how? (Zur, 2008).

Cutheil and Simon (2005) raised concerns about billing for email inter-
actions with clients. If email contact is not billed, clients could interpret it as
social interaction. Failure to bill for clinical emails could also lead to issues
of countertransferenee if counselors come to feel resentful. Furthermore,
counselors who fail to bill for email contact could be unknowingly collud-
ing with clients to extend sessions. For example, many emails, ranging from
long stories to seemingly easy questions expressed in one sentence, can take
a great deal of time to read and respond to (Cutheil & Simon, 2005; Zur,
2008). This can fit for TM as well, because one limitation of asynchronous
communication is boundary confusion around appointments (Suler, 2000).
Time spent communicating with clients through asynchronous communica-
tion must be established by counselors (Bradley & Hendricks, 2009; Bradley
et a l , 2011; Negretti & Wieling, 2001; Shapiro & Bauer, 2010; Zur, 2008) in
order to model self-care and boundaries. Counselors will need to determine
personal best practices based on how they feel about being available outside
of session.

CUIDELINES FOR PERSONAL BEST PRACTICES

Van Allen and Roberts (2011) stated that newer generations of mental
health professionals, who have grown up with modern technology, often
are naive about its privacy, security, and professional implications. In other
words, familiarity with technology does not mean that counselors know how
to avoid professional problems. Clinicians tend to use new forms of tech-
nology in practice before fully understanding the risks. They do not need to
become experts but should understand the technology they are using, weigh
risks as well as benefits, and make decisions in terms of upholding ethical
codes and regulations—the ethical responsibility always lies with the pro-
fessional (McAdams & Wyatt, 2010; Nicholson, 2011; Van Allen & Roberts,

219

2011). The following section addresses specific issues already raised, but first
addressed are general recommendations for private counselors who use TM.

The basic decision private counselors must make is whether or not to
use separate cell phones for their business and personal hves. For counsel-
ors in full-time private practice, a separate business phone may make sense
because of the volume of contacts. Part-time counselors may choose to use
their personal cell phone to conduct business, designate their voice mails
“confidential,” and provide emergency contacts for clients in crisis. However,
it is recommended that counselors not use personal cell phones for clinical
practice in order to protect the data exchanged, the therapist’s privacy, and
clinical boundaries (Shapiro & Bauer, 2010).

After securing a separate business cell phone, counselors should find
out what technology-assisted services are covered by their hability insurance
before using the phone as an adjunct to FTF practice (Baker & Bufka, 2011;
Bradley & Hendrieks, 2009; Bradley et al., 2011). This is vital. Counselors
working in agencies often have guidelines for how they can and cannot inter-
act with clients, but private counselors decide for themselves.

If covered by liability insurance, the third step is for counselors to write
up consent policies addressing technology-assisted services (Baker & Bufka,
2011; Barnett & Scheetz, 2003; Bradley & Hendrieks, 2009; Bradley et al.,
2011; Merz, 2010; Negretti & Wieling, 2001; Trepal etal., 2007; Van Allen
& Roberts, 2011; Zur, 2008, 2010; Zur & Barnett, 2008). Signed client
informed consent is one ofthe clearest ways to manage risk and limit liabil-
ity, and it allows clients to make informed choices about clinical services.
The policies should be reviewed in a conversation at the start of services
and periodically thereafter (Barnett & Scheetz, 2003; Bradley & Hendrieks,
2009; Bradley et al., 2011; Merz, 2010; Trepal et al., 2007; Zur, 2008; Zur &
Barnett, 2008). Each counselor must decide what the policies should cover.

Most state boards agree that the policies should inform clients of what
can be expected in terms of technology-assisted services (McAdams & Wyatt,
2010). Policies should address confidentiality (Baltimore, 2000; Barnett &
Scheetz, 2003; McAdams & Wyatt, 2010; Trepal et al., 2007; Zur, 2008,
2010); security measures to protect electronic information (Zur, 2010; Zur &
Barnett, 2008); how to handle emergencies (Bradley et al., 2011; McAdams
& Wyatt, 2010; Zur, 2008); what is appropriate to send to a counselor
electronically (Baltimore, 2000; Bradley & Hendrieks, 2009; Zur, 2008);
appropriate times and ways to contact the therapist out of session (Negretti &
Wieling, 2001); the times and frequencies when the therapist will communi-
cate out of session (Bradley & Hendrieks, 2009; Bradley et al., 2011; Negretti
& Wieling, 2001; Zur, 2008); and fees or billing policies for non-FTF contact
(Bradley et al., 2011; Negretti & Wieling, 2001; Zur, 2008). The following

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Text Messaging and Private Practice

subsections explore guidelines for drafting personal best practices for these
specific ethical issues.

Confidentiality
As with email (Bradley et a l , 2011), counselors must inform clients that

third parties may be able to access electronic interactions. Private counselors
can do several things to help protect the information transmitted and stored
on cell phones. Zur and Barnett (2008) provided practical recommendations
for protecting portable electronic devices, sueh as removing unnecessary files
when traveling, never leaving deviees unattended, and never letting anyone
borrow them.

The SIM card in cell phones stores text messages, so password security
for cell phones is also recommended. Furthermore, eounselors should send
and read text messages in private; eell phones should have spyware and
antivirus software to help ensure privaey (Merz, 2010); and settings should
be adjusted so that messages do not appear when the phone is locked. On
some cell phones counselors and elients can also set an option to send
“read receipts” that will help both parties know whether text messages were
received.

The use of a secure server and software that manages the texting is rec-
ommended (Shapiro & Bauer, 2010), and any digitally stored information
on portable devices should be without identifiable confidential information
(Nieholson, 2011). Although it would be more convenient for counselors to
store contacts by full names, it is recommended that they use only initials.
Furthermore, passwords for files are insufficient; counselors should learn
to code or enerypt confidential data stored on portable electronic devices
(Boschen & Casey, 2008; Nicholson, 2011) and transmitted electronically
(Trepal et a l , 2007).

Counselors can encrypt messages using technology from cellular serviee
providers or using third parties (Merz, 2010). For smartphone owners, apps
offer options. Both sender and receiver may need the apps to decrypt mes-
sages, or only messages already sent or reeeived (stored) may be enerypted,
leaving them unprotected during transmission.

Confirming identity in each contact is also important (Baltimore, 2000;
Barnett & Scheetz, 2003). There is no clear way to do this securely, but one
option is for clients to use a code word to identify themselves. Another is for
clients to begin eaeh TM interaction by answering a question agreed upon
at the start of services. As a general rule, a eounselor communicating with
clients through TM should pay close attention to the client’s language to
see if it is aligned with previous TM interactions. Counselors should also be
vigilant to double-check who the message is being sent to in order to avoid
accidentally breaking confidentiality (Van Allen & Roberts, 2011).

221

Documentation
Counselors also need to decide how to store and document text mes-

sages after transmission. Text messages, like voice messages and emails, are
clinical contacts (Zur, 2010). In order to limit the information stored on
highly portable cell phones, counselors may wish to transfer stored informa-
tion. Archiving text messages involves either forwarding them to email to be
saved or printed, taking screen shots of them with a smartphone and then
sending them to email, or using third-party services to archive them (Zur,
2010).

There must also be a plan for disposal of cell phones used for therapy that
is communicated to clients (Bosehen, 2009). When disposing of cell phones,
counselors should wipe the data from the devices by resetting or reformatting
them (Barnett & Scheetz, 2003; Merz, 2010). Cell phone manufacturers can
explain how counselors can erase or reformat their cell phones.

Counselor Competence, Appropriateness, and Misinterpretation
Counselors must consider their comfort level, competence with tech-

nology, and knowledge of TM before using it in practice (Bradley et al.,
2011; Merz, 2010). They will need to determine how TM will be used with
each client (administrative tasks, support, intervention, etc.), and regularly
evaluate its helpfulness (Merz, 2010). They should be trained before using
any type of TM software, take time to learn to use the programs properly, and
be able to troubleshoot problems (Baker & Bufka, 2011; Bradley et al., 2011;
Merz, 2010; Shapiro & Bauer, 2010). Counselors interacting with clients
through TM from home should have a designated space, sueh as a home
office, to limit distractions and keep interactions professional (Haberstroh et
al., 2008).

For some clients, TM may not be appropriate or helpful (Shapiro &
Bauer, 2010). Counselors must assess whether each client can use the tech-
nology effectively (Bradley et al., 2011). Just as counselors must be familiar
with the technology used in practice (Negretti & Wieling, 2001), so must cli-
ents. This would include how often elients use TM in daily life, how familiar
they are with common TM emoticons and acronyms, whether or not they
can afford the service, and whether they have reading or eyesight limitations.

If counselors determine that a client is competent with TM, they can
have a conversation to decide if the client would consider TM as an adjunct
to FTF treatment (Bosehen, 2009). In these conversations counselors need
to address handling clinical emergencies, such as self-harm, and discuss
emergencies, including having another way to contact the client, and another
contact person for the client in case of emergency (Shapiro & Bauer, 2010).

Counselors should also be aware of different ways messages might be
interpreted, and discuss with clients at the start of services a protocol for

222

Text Messaging and Private Practice

handling misinterpretation (Shapiro & Bauer, 2010). They need to attend to
both TM content and process, be sensitive to cultural issues and stereofypes
(Trepal et a l , 2007), and be able to process TM interactions in FTF sessions
(Neimark, 2009).

To help limit misinterpretation, both parties may add visual cues
through in-text graphics, spacing, punctuation, and use of caps (Suler, 2000).
Counselors also need to become familiar with common acronyms used in
text-based communication, such as, “LOL (laugh out loud), ROTFL (rolling
on the floor laughing), AFK (away from keyboard),” and the use of emoti-
cons or characters to convey emotions (i.e., 🙁 – sad or annoyed; 🙂 – happy;
“(::( )::) = a band-aid used to represent help)” (Trepal et a l , 2007, p. 272).
Counselors can also write out their own reactions and nonverbal responses
(i.e., « s m i l i n g » , « l a u g h i n g » , etc.; Haberstroh et a l , 2008; Trepal et
a l , 2007).

Boundary Concerns
When using TM in practice, particular attention should be paid to its

tone and the professional language. This is difficult because the TM inter-
action is designed to be concise. Counselors should reread text messages
before they hit “send,” asking themselves whether they would say it the same
way in an FTF session. If not, language or tone must be changed (Cutheil
& Simon, 2005).

Counselors who receive text messages from clients that they interpret
as out of character or unprofessional should address their concerns with
clients in therapeutic, nonconfrontational ways (Cutheil & Simon, 2005).
Neimark (2009) depicted a scenario in which a client texts a clinician to say
that the previous session was “useless,” and the clinician is unsure whether or
how to respond. Counselors should discuss with clients what information is
appropriate to exchange through TM (Shapiro & Bauer, 2010). A counselor
who believes that a message received was inappropriate can respond thera-
peutically by describing her or his own experience of the message, asking
about the client’s intentions, not pathologizing the interaction, and giving
precedence to the client’s needs.

To avoid feeling on call, counselors should also decide how much time
they will be available through TM and communicate the decision to clients
(Koocher, 2009; Shapiro & Bauer, 2010). As with any other technological
adjunct, there must be clear agreement on TM boundaries and billing poli-
cies (Boschen, 2009; Shapiro & Bauer, 2010). One option is for clients to be
able to send messages any time, and for counselors to respond at predeter-
mined times (Shapiro & Bauer, 2010). Similarly, Bradley et al. (2011) sug-
gested setting a time of day to check and return emails and setting boundaries

223

around when they are not checked or returned, such as nights and weekends.
Presented in this way, it is made clear that TM is asynchronous only.

Gounselors must also decide how to bill for TM because in private prac-
tice time is money. Haberstroh et al. (2008) reported that the slower pace of
text-based sessions meant that less material was covered than in FTF settings,
even though counselors may spend a great deal of time responding to short
TM messages or questions.

It is recommended that private counselors who agree to TM interactions
beyond administrative tasks make clear the fee for reading and sending each
message. For some TM plans, customers are charged per message or given
a limited number of monthly messages. Gharging per message read and
received is in line with many cell phone contracts, and is a more concrete
way for counselors to set boundaries than recording time spent reading, for-
mulating, and responding to text messages. The private counselor thus has
the option to set boundaries around the time and energy spent on these tasks,
knowing it will be compensated.

Training
It appears that no study has yet looked at ways graduate training programs

address or fail to address the ethical risks of using TM in practice. However,
several articles have called for graduate ethics courses to address issues of
professionalism when posting on and searching the Internet (Lehavot, 2009;
Myers, Endres, Ruddy, & Zelikovsky, 2012; Van Allen & Roberts, 2011).
The consensus is that because they are the best way to address ethical uses
of technology, vignettes summarizing risks and benefits of TM use should be
incorporated into graduate ethics courses. Finally, the benefits and risks of
using many forms of technology should be addressed as needed in clinical
supervision and through professional development activities (Lehavot, 2009;
Lehavot, Barnett, & Powers, 2010; Myers et al., 2012) for both graduate stu-
dents and working professionals.

CONCLUSION

Technology-based counseling services will continue to grow (Gentore
& Milacci, 2008; Haberstroh et al., 2007; McAdams & Wyatt, 2010). Rather
than closing off to new technology, it may be more effective for mental
health counselors to learn about the benefits, risks, and ethical issues related
to using it in practice (Barnett & Scheetz, 2003). TM is possibly the most
inexpensive and widely available technology that can impact mental health
treatment (Aguilera & Muñoz, 2011). It is expected to become more popular
because of its advantages as a tool for contact between sessions, so counselors
may need to embrace it to some degree (Merz, 2010). Distance counseling,

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Text Messaging and Private Practice

including TM, is also likely to continue to grow because it lowers overhead
eosts and also offers counseling options for clients who cannot access ETE
services because of where they live or their health problems (Gentore &
Milacci, 2008). Glinicians need to inform colleagues through professional
publieations of the benefits and challenges of using technology so that best
practices can be formulated (MeAdams & Wyatt, 2010). Eor private mental
health counselors using TM, this is a beginning.

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Journal o f Applied Rehabilitation Counseling

Boundaries with Social Media: Ethical
Considerations fo r Rehabilitation Professionals
Ashley K. Crtalic
Reg L. Gibbs
Matthew E. Sprang
Tom F. Dell

Abstract — The increase in social networking media, online and distance counseling, and the
ubiquitous use o f laptops, hand-held devices, and internet connected devices at home and in
work settings have resulted in the need f o r ethical standards to help guide rehabilitation p ro ­
fessionals in service delivery. In response, the Commission on Rehabilitation Counselor Cer­
tification (CRCC) has incorporated Section J: Technology and Distance Counseling into the
CRCC Code o f Ethics. Additionally, the CRCC released a social media policy on their
website. However, specific ethical standards addressing the use o f social media have not been
implemented. The purpose o f this manuscript is to address potential issues that can arise in
interacting with clients through social media. Specifically, we will discuss the follow ing ar­
eas: (1) digital immigrants and natives, (2) social media mechanics, (3) advantages o f using
social media, (4) disadvantages o f using social media, (5) social media and the CRCC Code
o f Ethics, (6) using social media professionally, privately, or not at all, and (7) implementing
a social media policy. Discussion and recommendations are provided.

The increase in social networking media, online and distance counseling, and the ubiquitous use o f laptops, hand-held devices, and internet connected devices at
home and in work settings have resulted in the need for
counseling professions to provide ethical standards to
address privacy and security concerns (Mui, Sprong, Lee,
Chowdhury, & Flowers, 2013). One such counseling
organization that has developed ethical guidelines to
address the potential ethical concerns o f the use of
technology in distance counseling is the Commission on
Rehabilitation Counselor Certification (CRCC). The
CRCC is a professional organization that establishes a
standard o f quality for rehabilitation professionals working
in different avenues o f service delivery (Parker & Patterson,
2012). The primary focus o f this profession is to improve
the subjective well-being (feeling o f satisfaction with life)
o f persons with disabilities by addressing their vocational,
medical, psychological, and social needs (Rubin &
Roessler, 2008).

The CRCC has established certification procedures
for rehabilitation professionals (Certified Rehabilitation
Counselors [CRC]) interested in “providing services
w ithin the scope o f p ractice for rehabilitation

professionals…while demonstrating the beliefs, attitudes,
knowledge, and skills, to provide competent counseling
services to work collaboratively with diverse groups of in­
dividuals…” (CRCC Code o f Ethics, 2009, p. 1). Further­
more, the CRCC has developed comprehensive ethical
guidelines to help facilitate effective service delivery. A
current topic o f interest and potential ethical concern is in­
teracting with clients via social media by rehabilitation pro­
fessionals in a world where the use o f social media as a
communication medium is becoming increasingly popular.
According to Kaplan and Haenlein (2010), social media is
“a group o f Internet-based applications that … allow the
creation and exchange o f User Generated Content” (p. 61),
and include websites such as Facebook, Twitter, and
Linkedln. These websites are experiencing much growth, as
users continue to subscribe to social media platforms every
day. For example, Facebook has grown to 1.39 billion
monthly active users, including 890 million who used
Facebook on a daily basis (Facebook Newsroom, 2015).

With the increased use o f technology in counseling,
the CRCC Code o f Ethics incorporated “Section J: Tech­
nology and Distance Counseling” to provide specific guide­
lines to help foster effective and efficient service delivery

44

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46

, Number 3, Fall 2015

online. The subsections provide specific areas to consider
when utilizing technology in service delivery (e.g., accessi­
bility, confidentiality, informed consent, distance counsel­
ing security and business practices). However, the current
CRCC Code o f Ethics does not have specific standards in
Section J. that clearly address social media usage. The pur­
pose o f this manuscript is to address potential issues that can
arise in interacting with clients through social media. Spe­
cifically, we intend to discuss the following areas: (1) digi­
tal immigrants and natives, (2) social media mechanics, (3)
advantages o f using social media, (4) disadvantages o f us­
ing social media, (5) social media and the CRCC Code of
Ethics, (6) using social media professionally, privately, or
not at all, and (7) implementing a social media policy. It is
apparent that potential ethical issues with social media may
impact all counseling disciplines.

Digital Immigrants & Natives
While websites such as Facebook have commonly

been used primarily by the traditional college-aged demo­
graphic, currently the most rapidly growing segment of
Facebook users is women ages 55 and older (Kaplan, Wade,
Conteh, & Martz, 2011). According to a Salary Report
(2008) conducted by the Commission on Rehabilitation
Counselor Certification, almost half o f all rehabilitation
professionals are age fifty or older. Thus, many current cer­
tified rehabilitation professionals were likely not raised in a
generation that experienced interacting via social media
from an early age. The future generations o f certified reha­
bilitation professionals can be termed “digital natives”, be­
cause they were bom into a world where the internet and
other technologies are learned along with primary language.
On the other hand, the older generations o f certified rehabil­
itation professionals can be thought o f as “digital immi­
grants” because they were bom in a different time and now
must leam the new language and culture o f the digital na­
tives so they are better able to communicate with them
(Lehavot, Barnett, & Powers, 2010).

Generational differences occur not just in the per­
sonal use of social media, but there are also discrepancies in
what constitutes ethical use o f social media as a professional
between different generations. Lannin and Scott (2013) re­
viewed research that addressed age-related differences in
social media use and found discrepancies. For example, one
study o f doctoral psychology students found that while
three out o f four students used online social networking of­
ten to communicate with friends, most established psychol­
ogists did not use social networking in their practice.
Furthermore, in another study, 98% o f doctoral psychology
students reported that they had used the internet to search
for at least one client’s information over the past year, a
practice that is often frowned upon and seen as an invasion
o f privacy by established practitioners. However, according
to Smith and Skaflen (2011), between 5,000 and 25,000
online contacts take place between counselors and clients
each day.

Social Media Mechanics
Before deciding if and how to use social media with

clients, it is important that the rehabilitation professional be
fully educated and have a thorough understanding o f the
various mechanics o f the social media site they may be us­
ing. Section J.l.a. o f the CRCC Code o f Ethics clearly
states that “rehabilitation counselors are held to the same
level o f expected behavior and competence as defined by
the Code regardless o f the technology used [e.g., cellular
phones, email, facsimile, video, audio, audio-visual] or its
application [e.g., assessment, research, data storage]” (p.
28). Social media websites use multiple terms that may be
unfamiliar to non-users.

While a thorough explanation o f privacy settings
and mechanics o f all social media networks is well beyond
the scope o f this article, one example o f how to abide to the
confidentiality o f client information (J.3.a.) is presented for
the social media website titled “Facebook.” Currently the
largest social networking website in the world (Statistica,
2015), Facebook is a social networking website that allows
its members to share pictures, information, and personal
messages with one another. Each user selects his or her own
privacy settings from a continuum, determining who is able
to see each piece o f infonnation or photo he or she posts.
The least restrictive setting would be “Public”, which would
mean that each photo, link, or piece o f infonnation the user
posts is available for anyone on Facebook to review. Many
users choose the setting “friends only”. In this case, only the
individuals the user has added as “friends” can see the infor­
mation posted. When a user adds another user as a “friend”,
a request is sent to the user asking them to approve or deny
the friendship request. If the request is approved, the user’s
content now is accessible to the “friend.” If a user decides he
or she no longer wants the “friend” to have access to the
posts, the user can “un-friend” the individual. After a user is
“un-friended”, the individual will no longer be able to see
posts from the user. However, if they share friends, the user
may still be able to see other pictures or infonnation the in­
dividual is “tagged in”. Being “tagged” on Facebook links
content (such as a picture or “status update”) from another
user to an individual’s Facebook page. Facebook also has
features that make it possible for a user to be “blocked” .
When a user is “blocked” from a profde, the individual can
no longer see that the person interacts on Facebook. Reha­
bilitation professionals who choose to use social media may
want to consider the potential implications and issues that
could arise in the counseling relationship, should a client
discover he or she has been un-friended or blocked by the
counselor. It is important to note that new features are con­
tinuously being added, and privacy settings are often
changing. It is the user’s responsibility to ensure they are
staying on top o f this new information in order to prevent
breeches in privacy or other problems.

Other social media platforms (e.g., Linkedln,
Google Community, Instagram) provide similar settings to
allow for certain infonnation to remain confidential. How­
ever, it should also be noted that the policies on what re­
mains confidential and what is available to the public will

45

Journal o f Applied Rehabilitation Counseling

change occasionally, and the rehabilitation professional
should be aware o f such changes as to remain in adherence
to the code o f ethics (e.g., maintain confidentiality). Al­
though the complications in maintaining confidentiality
may seem overwhelming, there are advantages o f using
social media in service delivery.

Advantages o f Using Social Media
Choosing to use electronic correspondence as a re­

habilitation professional in a clinical setting has many ad­
vantages. Kaplan et al. (2011) asserted that electronic
interactions can result in less anxiety during self-disclosure
and can increase feelings o f emotional safety, which may
make it a particularly useful tool when working with clients
who have experienced social marginalization or judgment
from others. Previous research that shows that people with
severe mental illness and/or disabilities are stigmatized and
often discriminated against have been well-documented
(e.g., Corrigan, 2002; Drehmer & Bordieri, 1985). Like­
wise, research also indicates that individuals who seek out
counseling often feel ashamed and embarrassed, and often
avoid counseling because o f perceptions o f public stigma
and social norms (Vogel, Wade & Hackler, 2007; Vogel,
Wester & Larson, 2007). For example, Paulson and
Krippner (2007) stated that many veterans that are in
post-secondary institutions often have difficulties adjusting
to college due to significant psychological problems. More­
over, many veterans have difficulty expressing their diffi­
culties, feelings, and emotional regulation. Brown, Creel,
Engel, Herrell, and Hoge (2011) asserted that stigma to­
wards mental health services is one o f the factors that con­
tributes to why combat veterans do not seek counseling
services. Clinical services that are offered via social media
may be one way to eliminate the stigma associated with
walking into a counseling office (e.g., increases the poten­
tial o f being noticed for pursuing mental health services).
With respect to clients with physical disabilities, Reamer
(2013) suggested that informal contact on social media sites
can be seen as “humanizing” the therapeutic relationship,
and using electronic correspondence can be beneficial for
clients with severe physical disabilities or for clients who
live long distances from the counselor’s office. It may also
be beneficial to assist clients who need assistance in a crisis
situation during non-traditional office hours.

Utilizing social media in a vocational rehabilitation
setting also has potential benefits. For example, it can be
used to assist clients in identifying jobs, to connect with cli­
ents, and to gather feedback. Furthermore, for clients who
live in rural areas, utilization o f social media is beneficial
for those who have difficulty traveling long distances due to
his or her disability, or have other transportation-related is­
sues (e.g., lack o f public transportation). Within this con­
text, social media can be used to enable the rehabilitation
professional to potentially reach more clients than they
could using face-to-face interactions alone, and it provides
the client with greater accessibility to the counselor. Social
media use is convenient, and also has benefits from a busi­
ness standpoint. Whether the rehabilitation professional is

looking to promote his or her own private business, or are
looking to promote their services as a whole, social media
provides increased awareness o f their services, and in­
creases traffic to professional websites. For example, reha­
bilitation professionals can provide links for specific
services on social media platforms that can help clients lo­
cate specific services within his or her community they may
not have been aware of. Social media can also be used to
better understand clients and their wants and needs from a
business perspective. For example, it can be used to gauge
what types of services clients are the most interested in, and
what types of settings they prefer to receive them in. Addi­
tionally, social media provides users an opportunity to pro­
mote the quality services rehabilitation professionals
provide and helps build stronger and more successful busi­
ness relationships (CRCC, 2012). For example, rehabilita­
tion professionals can connect with other professionals
across the country via social media to brainstorm strategies
and new service approaches without ever having to leave
their office or wait for a yearly conference to connect with
other professionals in the field. On the other hand, the
CRCC are also aware o f the potential perils o f using social
media in VR or clinical settings. For example, the CRCC
(2012) has warned “if you’re online, you’re on the record –
everything on the Internet is public and searchable” (p. 3).

Disadvantages o f Using Social Media
As the CRCC outlines in Section J, “Technology

and Distance Counseling”, technology usage in counseling
may have potential pitfalls. For example, technology is of­
ten used to store, retrieve, and analyze client information
(Mui et al., 2013), and accessibility to this information may
be obtained by theft (e.g., hacking software), personal and
unauthorized usage o f agency software and hardware, or
unauthorized use/modification o f agency-controlled infor­
mation (Calluzo & Cante, 2004; Mui et al., 2013). Further­
more, since communication is often delivered in a
non-face-to-face format, it may be difficult to detennine if
you are actually communicating with a client or if someone
else is attempting to portray themselves as your client. The
CRCC Section J.3.C asserts that rehabilitation professionals
must utilize “encrypted and/or password-protected Internet
sites and/or email communications to help ensure confiden­
tiality when possible…ensure confidentiality o f information
transmitted through the use o f computers, email, facsimiles,
telephones, voicemail, answer machines, or other
technology” (p. 28).

Another disadvantage, as is the case with all elec­
tronic correspondence: non-verbal communication is often
lost in an online platform and may lead to conflict in the
counseling relationship. For example, when transmitting
information via email or another online platform, the client
may become confused with the meaning behind a message.
Moreover, the rehabilitation professional will not be able to
observe this confusion. Likewise, the rehabilitation profes­
sional may portray a message and the client may perceive
the meaning o f the message differently than what was in­
tended, causing a breakdown in the natural communication

46

Volume 46, Number 3, Fall 2015

process. Another example may include technology break­
down. For instance, a client’s internet connection may not
be available during a major storm, power outages, or due to
glitches in service through his or her internet provider.
Likewise, the rehabilitation professional may be unavail­
able and the client may have an emergency or needs access
to his or her assigned counselor. Ethical standard(s) J.lO.a.
(“Technological Failure”), J.lO.b. (“Unavailability”),
JlO.c. (“Crisis Contact), and J.12.b. (“Inappropriate Appli­
cation”) provide a description o f how rehabilitation profes­
sionals should proceed when these issues arise. For
example, rehabilitation professionals should provide an al­
ternative method o f communication in the event that there
is a technological failure, provide instructions to the client
in the event the rehabilitation professional is unavailable,
provide referral information in the event a crisis
intervention is needed for the client, and utilize
“face-to-face services when technology-assisted distance
counseling serves are inappropriate” (p. 30).

Social Media and the CRCC Code o f Ethics
The issue o f maintaining professional boundaries is

perhaps one o f the most difficult to navigate, and can lead to
potential ethical dilemmas in the counseling relationship.
Lannin and Scott (2013) encouraged psychologists to con­
sider comparing and contrasting the benefits and limitations
o f social media usage with providing counseling services in
a rural community. This statement can also apply to rehabil­
itation professionals. For example, there may be potential
boundary violations or issues with self-disclosure. Many
professionals that work in a small-rural community will
know their clients, and thus there is a greater potential for
dual relationships. A similar possibility occurs when reha­
bilitation professionals consider using social media with
clients. Therefore, extra caution should be utilized when
considering whether to become associated via social net­
working websites. It is essential that the rehabilitation pro­
fessional remember his or her roles, functions, scope o f
practice, and ethical guidelines when using social media
with clients.

Section J. (Technology and Distance Counseling)
provides a general framework regarding technology and
distance counseling. However, instructions and ethical
standards that involve the use o f social media (e.g.,
Facebook, Linkedln, and Google Community) are not spe­
cifically stated. For example, Section J. does not provide
details regarding communication through social network­
ing platforms such as Facebook. However, there is general
guidance in the CRCC Code o f Ethics that can be applicable
to counselors who are struggling with ethically using social
media. While the CRCC has posted a “Social Media Pol­
icy” (2012) on their webpage, it still does not address
boundary and relationship issues in using social media with
clients. Furthermore, it does not provide clear instructions
on appropriate ethical procedures. Since specific social me­
dia standards are not explicitly stated in the CRCC Code of
Ethics, we believe that other sections o f the Code o f Ethics

may be valuable to consider in addition to the social media
policy and Section J. Incorporating the other sections will
help reduce the likelihood o f engaging in unethical practice.

The statement regarding the primary responsibili­
ties o f rehabilitation professionals is provided in Standard
A .I., reminding rehabilitation professional that their pri­
mary responsibility is to “respect the dignity and promote
the welfare o f clients” (CRCC Code o f Ethics, p. 3). Keep­
ing this ethical guideline in mind, along with the A.4.a.
Standard to “avoid harm”, it is important to discuss with the
client the potential boundary issues that can occur when us­
ing social media. Perhaps the standard with the most rele­
vance to boundary issues that arise using social media is
section A .5., “Roles and Relationships with Clients.” Ac­
cording to this standard, rehabilitation professionals are
cautioned to avoid nonprofessional relationships to the best
o f one’s ability. This does not only include current clients,
but also nonprofessional relationships with former clients,
their romantic partners, or their immediate family mem­
bers. The exception to this ethical guideline to avoid these
non-professional relationships is if the association is bene­
ficial to clients or former clients. If a non-professional rela­
tionship is formed, rehabilitation professionals must
document this and obtain informed consent from the client.
The relationship must be time limited or context specific; in
other words, “free-standing friendships are prohibited.” Al­
though this standard doesn’t specifically address “virtual”
relationships, it is reasonable to turn to it for guidance in the
decision to accept or deny “friend” requests on social media
sites such as Facebook. As always, it is important to keep in
mind Standard(s) B. 1 .b-d which require rehabilitation pro­
fessionals to respect client’s privacy and confidentiality
and to ensure that the limitations o f both are thoroughly ex­
plained to the client and included in the informed consent
process. For example, the possibility for a breach in confi­
dentiality when using social media sites to communicate
should be fully explored and discussed. Even if rehabilita­
tion professionals use Section J in combination with other
standards, it will be beneficial for the CRCC Ethics Advi­
sory board to consider implementing specific social media
standards in the next version o f the code o f ethics. Two
examples o f how the CRCC Code o f Ethics Advisory Board
could incorporate social media standards in the CRCC
Code o f Ethics include (Guided by Ethical Standards
H.6.a-d. Social Media o f the ACA Code o f Ethics, 2014);

• Standard J.16.a. Professional Boundaries in Social
Media. Rehabilitation counselors provide information
about their use of social media in the counseling relation­
ship and discuss how social media will be incorporated.
Such areas include: (1) how will the use of social media be
beneficial to the counseling relationship, (2) how will per­
sonal and professional social media platforms be utilized in
relation to the counseling process, and (3) how tennination
of services will impact networking on social media plat­
forms.

• Standard J.16.b. Confidentiality and Social Media. Re­
habilitation counselors who incorporate social media

47

Journal o f Applied Rehabilitation Counseling

within their service delivery will provide individuals
receiving services information related to confidenti­
ality. Such areas include: (1) security-related infor­
mation regarding how personal and demographic
information will be stored and protected, (2) who will
have access to this data, (3) precautions the counselor
will take in preventing disclosure of confidential in­
formation, and (4) examples of information that is
deemed appropriate and inappropriate for social
media.

Although such standards are not currently available to reha­
bilitation professionals, it is important that rehabilitation
professionals understand how using social media will im­
pact service delivery and benefit consumers.

Using Social Media Professionally, Privately, Or
Not At All

The rehabilitation professional may choose to use
social media professionally, electing to engage clients in the
social media process; they may choose to use it privately,
not intending any interaction with clients; or they may
choose not to use any social media at all. These choices may
have ethical implications based on counseling guidelines
previously discussed. Although many counselors may use
social media in their personal lives, and may not feel it is an
appropriate format to use with clients, it cannot be guaran­
teed that social media issues will not arise in the counseling
relationship. For example, a client may easily search for his
or her counselor’s personal page on social media sites and
request to have a relationship with the counselor. At this
point, w’hether the counselor wanted to or not, he or she will
now be forced to address the social media issue with his or
her client. It is perhaps naive to think that the rehabilitation
professional will be able to keep his or her social media use
completely private and never have it enter the counseling
relationship. Because the use o f social media is becoming
more common, it is increasingly likely that clients will
search for their counselor on social media sites. Therefore,
it is important for rehabilitation professionals to be knowl­
edgeable about privacy settings o f their social media ac­
counts, as information the counselor shares with friends and
believes to be private may in fact be available to the public
and to his or her clients.

With so many potential ethical dilemmas surround­
ing the use o f social media, rehabilitation counselors might
believe “shunning” the use o f social media in order to avoid
these ethical dilemmas is the only route to take. However, is
this point o f view realistic for all rehabilitation counselors?
Should we expect counselors, in general, to not engage in
personal social media use just because o f their chosen pro­
fession? In an increasingly digital world it may be unrealis­
tic to assume that all rehabilitation professionals renounce
social media even for private use in order to avoid potential
ethical issues with clients. Furthermore, an argument could
be made that purposely choosing to ignore social media
may not be in the best interest o f certain clients. Ultimately,
the question rehabilitation professionals need to consider is,

what is in the best interest o f the client in regards to social
media use with his or her counselor?

If a rehabilitation professional decides to use social
media with clients, perhaps he or she could utilize the
American Counselor Association’s (ACA) Code o f Ethics
(2014) as a guide of how to conduct oneself professionally.
The ACA has incorporated Section H.6., “Social Media”,
which includes four sub-standards that specifically address
the use o f social media. The ACA has stated in Standard
H.6.a. (“Virtual Professional Presence”) that counselors
who wish to use social media both personally and profes­
sionally create “separate professional and personal web
pages and profiles” in order to “clearly distinguish between
the two kinds o f virtual presence.” (p. 18). Standard(s)
H.6.b. (“Social Media as a Part o f Infonned Consent”),
H.6.c. (“Client Virtual Presence”), and H.6.d. (“Use of Pub­
lic Social Media”) provide additional details o f how social
media should be utilized and incorporated in the counseling
relationship. However, to avoid being involved in an ethical
dilemma, perhaps the best practice for rehabilitation profes­
sionals is to prevent them in the first place. In the opinion of
Kaplan et al. (2011), “85% o f all ethical dilemmas can be
avoided with thorough and complete informed consent pro­
cedures” (p. 7). When working with clients who use social
media, it is extremely important to educate clients about the
lack o f privacy o f social media and infonnation posted on­
line, even when appropriately using privacy settings.
Equally important is the potential permanency o f informa­
tion posted on the internet. To illustrate this point, take for
example a photo posted to a rehabilitation professional’s
personal social media page. The rehabilitation professional
has the privacy level for this photo set as “friends only”
which means only people whom they are friends with are
able to see the photo. After a few minutes the rehabilitation
professional determines the photo may not be appropriate
and decides to delete it permanently from his or her profile.
However, while the photo was up, one o f their online
friends saved it to their computer or cell phone and now
they are able to post it whenever and wherever they choose.

Social Media Policy
A thorough social media policy included as a part

o f the counselor’s informed consent is perhaps the best way
to address potential boundary issues before they arise. Even
if a counselor decides against using social media with cli­
ents, it may be wise to include a social media policy stating
this fact. One example o f how to address social media with
clients is by providing a social media policy that is reviewed
by the rehabilitation professional and the client during the
initial meeting. Kolmes (2010) stated that a social media
policy should include statements on whether or not the
counselor will accept friend requests, and whether or not
text messages or Facebook messages can be used to interact
with the counselor. Reviewing Kolmes’ policy is a good
place for rehabilitation professionals to start when they be­
gin to craft their own version. In addition, it is important
that if the rehabilitation professional does choose to use so-

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cial media, that the content is Health Insurance Portability
and Accountability Act (HIPAA) compliant and does not
contain session related disclosures or treatment informa­
tion, and that the client provides written permission to inter­
act informally via Facebook, text messages, etc. (Kaplan et
al., 2011). HIPPA is a law that protects confidentiality and
security o f healthcare infonnation. As Kaplan and col­
leagues state, the informed consent should address confi­
dentiality-related issues with regards to the use o f social
media. Likewise, they recommend exchanging a confiden­
tial password prior to using online interfaces in order for the
rehabilitation professional to confirm they are talking to the
“real” client.

Additionally, the infonned consent might also ad­
dress whether or not the rehabilitation professional will ac­
cept friend requests from clients, and if they will accept
friend requests in the future (for example, once the counsel­
ing relationship is terminated). Also, the rehabilitation pro­
fessional might include a plan and policy for denying friend
requests or for “un-friending” clients if necessary. Ethi­
cally, the rehabilitation professional may need to be aware
o f the implications for the counseling relationship if he or
she chooses to either accept or deny a friend request, and
should be prepared to discuss this issue with clients. Poten­
tial issues include a client feeling rejected or disliked by
their counselor if the counselor chooses to deny a friend re­
quest. On the other hand, a client may believe the rehabilita­
tion professional is now more o f a friend than a professional
if he or she has access to the counselor’s personal social me­
dia page. Such a perception may limit the effects of the
counseling process because the client may not take the reha­
bilitation professional seriously. Clients need to be in­
formed o f the potential break in confidentiality that can
occur simply from “friending” their rehabilitation
professional, because o f their presence on the counselor’s
friend list which can be available to the public

It is important to determine if and when to use so­
cial media personally versus professionally. For example,
the rehabilitation professional needs to decide if he or she
will have both a professional and a personal Facebook page.
If the rehabilitation professional decides to have both, how
will he or she address clients who attempt to use the per­
sonal page when interacting with the counselor? If the
counselor chooses only to have a personal page, how will he
or she address clients who attempt to use it to contact them?

The rehabilitation professional also needs to define
how soon he or she can be expected to respond to the client
via social media. Will the rehabilitation professional be
available twenty-four hours per day, seven days per week?
Will he or she only be available Monday through Friday
from 8 a.m. to 5 p.m.? Can the client use social media to
contact the rehabilitation professional in crisis situations?
This issue may need to be re-visited throughout the counsel­
ing relationship as well, as a client can become used to the
instant nature o f interacting on social media and expect that
the rehabilitation professional will respond more quickly
than is realistic.

Conclusion
Social media use by rehabilitation professionals

may still be considered a new frontier. Existing within this
domain are opportunities to serve more clients and to do so
more effectively. However, social media use also increases
the possibilities of ethical dilemmas, particularly concern­
ing boundary-related issues. Because the current code of
ethics does not specifically address the intricacies and spe­
cific dilemmas inherent in social media use, rehabilitation
professionals must navigate these issues with guidance
from Section J (Technology and Distance Counseling) and
other applicable sections o f the current code. However,
even without a current consensus on what constitutes “best
practice” for using social media, each rehabilitation profes­
sional must take responsibility for his or her current social
media practices, keeping the best interests o f the client first
and foremost.

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Author Note — Declaration of Conflicting Interests: The authors de­
clared no potential conflicts o f interests with respect to the authorship
and/or publication o f this article. Financial Disclosure/Funding: The
authors received no financial support for the research and/or authorship

o f this article. Corresponding Author: Ashley Crtalic, Department of
Rehabilitation Counseling & Human Services, 1500 University Drive,
Montana State University, Billings, MT 59101, USA. Email:
a.crtalic@gmail.com

Ashley K. Crtalic, M.S., CRC is a vocational rehabilitation
counselor and researcher at Rocky Mountain Rehab in Bill­
ings, Montana, as well as an adjunct professor in the De­
partment o f Rehabilitation and Human Services at
Montana State University – Billings.
Contact info: a.crtalic(d).smail. com

Reg L. Gibbs, M.S., CRC, LCPC, CBIS, CLCP is founder
and president o f Rocky Mountain Rehab in Billings,
Montana. He form erly was an adjunct professor o f rehabil­
itation counseling at Montana State University – Billings.
Contact info: rgibbs@rmrehab.com

Matthew E. Sprong, Ph.D., CRC, LCPC is a Visiting Assis­
tant Professor in the Rehabilitation Services and Rehabili­
tation Counseling program at Northern Illinois University.
Contact info: msprongl@niu.edu

Thomas F. Dell, Ed.D., CRC, LCPC is an assistant profes­
sor in the Department o f Rehabilitation and Human Ser­
vices at Montana State University – Billings. Contact info:
tdell@msubillings.edu

50

http://www.psvc.imu.edu/counseling/…/VACESConferenceP

http://www.statista.com/statistics/272014/global-social-netw

mailto:a.crtalic@gmail.com

mailto:rgibbs@rmrehab.com

mailto:msprongl@niu.edu

mailto:tdell@msubillings.edu

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