Electronic Communication: Ethical Considerations for Mental Health Professionals
Introduction
It could be argued that confidentiality is perhaps one of the most important aspects of the mental health profession. Indeed, without the guaranteed privacy offered by the ethical adherence to confidentiality by mental health professionals, would the general public risk consulting with counselors, psychologist, or social workers? Most people seek to keep their personal and/or health matters private. Many disorders and disease carry with them a stigma, but none more so than mental health disorders. It is, therefore, essential that mental health professionals adhere to the principals of confidentiality in order to ensure that the general public will have trust in the mental health profession (Koocher & Keith-Spiegel, 2008).
With the rapid development of new technologies in recent years, the mental health profession has had to remain vigilant about potential breaches in confidentiality that may accompany these emerging technologies. For example, advances in electronic communication present numerous opportunities where confidentiality can be compromised (Car & Sheikh, 2004). In the following paper, I will discuss ethical considerations regarding electronic communication and confidentiality.
For the purpose of this paper, electronic communication will refer to written text transmitted electronically via fax machine, computer, telephone, etc. This may include, but is not limited to email, sms/text messages, facebook posts (or other social media), forums, faxes, etc. Throughout this paper I interchangeably use the terms counselor, psychologist, and therapist to indicate mental health professional.
Generally, most people are quite comfortable using various forms of electronic communication in multiple facets of their lives. One study found that 90% of people questioned favored the use of email to communicate with their doctors. The study found that 37% said that they would be willing to pay for consultations by email (Car & Sheikh, 2004). In fact, there are a growing number of psychologists and counselors who offer counseling by email (Koocher & Keith-Spiegel, 2008). It should come as no surprise that those seeking mental health services would be quite pleased to extend their psychotherapy into the realm of electronic communication.
Although electronic communication may be very convenient, using it to communicate with clients may not always be in the clients’ best interest. Therefore, it is the duty of the mental health professional to explain to the client the risks of using electronic communication. Laypeople not involved in the mental health profession may never have taken time to consider such risks (Corey, Corey, & Callanan, 2011).
Pitfalls of Electronic Communication: Confidentiality and Emergencies
There are several potential pitfalls that may present themselves if a mental health professional chooses to use electronic communication to communicate with his or her clients. Mental health professionals should be proactive in considering what pitfalls may arise, as well as be sure to explain these potential pitfalls to his or her clients. Below I will discuss two issues surrounding the use of electronic communication—breaches to confidentiality and dealing with emergencies via electronic communication.
Indeed, any communication between clients and mental health professionals may be at risk for breach of confidentiality, if it is not done face to face in a private area. For example, speaking with a client over the phone may not always be 100% confidential, as you cannot be completely sure that someone else is not listening in on another line. Likewise, communication sent via post or fax machine may not always go to the intended recipient. Although there is always a risk that confidentiality could be lost, electronic communication seems to be at increased risk. An inadvertent stroke of a key on a counselor’s keyboard may be all that is needed for a client’s record to be made public (Drude & Lichstein, 2005).
One obvious threat to confidentiality is hacking. In recent years there have been many high profile cases in which huge amounts of data have been hacked from personal computers. Any electronic communication stored on a psychologist’s/counselor’s computer is subject to being hacked. Mental health professionals should take reasonable steps to guard against hacking, which includes keeping their security software up to date. Although keeping your software up to date improves your computer’s security, it does little to protect communications sent by you to a client and stored on the client’s computer, if the client software is not up to date. Some mental health professionals may choose to encrypt emails, though this requires specialized software that both the mental health professional and client would have to install on their respective computers. This is an added expense which also requires the client’s cooperation (Drude & Lichstein, 2005).
Hacking, though a dramatic example, is actually probably a less likely scenario in which confidentiality may be breached. There are other far more likely ways that confidentiality may be breached which may involve an error by the psychologist or deceit by others. Take for example a counselor who is responding to a client’s question by email and accidentally CC’s another client of his who is good friends with the aforementioned client. In this case the counselor compromised his client’s security by accidentally CC’ing another client. When it comes to electronic communication and confidentially, a single keystroke or click of the mouse can prove disastrous (Drude & Lichstein, 2005).
Another probable scenario in which confidentiality can be compromised when using electronic communication may involve deceit and/or ill intent by another person. For example, when emailing with a client one cannot be sure with whom one is communicating. Perhaps, a scorned lover or nosey mother has stolen your client’s email password and is posing as your client in order to find out information about your client’s mental health and/or personal matters. Psychologists/counselors who freely communicate with their client’s via email may unwittingly find themselves being accomplices in a scheme to expose sensitive client details. Such situations as these may be more likely in divorces or child custody proceedings (Drude & Lichstein, 2005).
Another important consideration for mental health professionals regarding electronic communication involves its use during emergencies. Unlike an emergency on-call phone, a mental health professional may only access his or her email once or twice per day. If a client is suicidal or having some other psychiatric emergency and chooses to email you instead of calling or coming to your office, the client may be left feeling abandoned when the counselor or psychologist does not immediately respond to his/her email. For someone in the midst of a crisis, this could prove detrimental or even life threatening. This scenario could apply to all forms of electronic communication, such as social media, sms/text, etc. (Corey, Corey, & Callanan, 2011).
Furthermore, many therapists have websites in which they list their email addresses. Clients may seek out mental health treatment through internet web searches in which they find the therapist’s email address. A client’s first contact with the therapist could come via email while the client is in the midst of a crisis. How should mental health professionals handle this situation and the other scenarios described above? Below I will discuss how counselors may mitigate the risks associated with using electronic communication with clients.
Avoiding Pitfalls of Electronic Communication
In my opinion, the best way to reduce the risk associated with using electronic communication is to take a proactive role and try to anticipate potential problems before they happen. A very simple way for mental health professionals to be proactive is to address the potential problems associated with electronic communication during the intake session. It is also advisable to put in the client disclosure statement how the counselor expects to use electronic communication with the client while under the counselor’s care. Some mental health professionals may also choose to list this information on their website.
In addition, counselors should discuss with their clients the risks to confidentiality presented by electronic communication. Counselors should make clear in what ways they are willing to use electronic communication. For example, is the counselor willing to use it to schedule appointments, answer clients’ questions between sessions, or even to conduct psychotherapy?
In my opinion, electronic communication should only be used to schedule appointments. In other words, it should not be used to discuss particulars of treatment or provide counseling. If counselors fail to clarify this, they may find that clients will go into great detail about treatment issues via email (even when the initial reason for sending the email was to reschedule an appointment).
In addition, counselors should point out to clients not to use electronic communication for emergencies. They should make it clear that email may not always be accessible and they should encourage clients to call emergency services when it is a serious emergency. Likewise, counselors should let clients know how often they typically check their email (or other devices with which they communicate electronically), such as once or twice per day. Additionally, counselors should inform their clients how long it may usually take for him/her to reply to email (such as within 24 to 48 hours) (Drude & Lichstein, 2005).
Lastly, mental health professionals should encourage their clients not to be overly detailed in their descriptions when scheduling their appointments via electronic communication, such as “I’d like to schedule an appointment for my depression.” Clients should simply request an appointment without giving the reason (if it is done so by electronic communication). Counselors must realize that they are responsible for educating their clients on the appropriate ways to use electronic communication; otherwise, failure to do so may lead to the counselor being blamed when something goes wrong (such as a breach of confidentiality).
Conclusion
As mentioned earlier, most people are quite comfortable with using electronic communication. Clients may even request to have counseling or psychological services done via email or other forms of electronic communication. Clients may offer the psychologist payment or threaten to go to a different psychologist, if the psychologist does not go along with their requests. Therefore, mental health professionals must be prepared to go against the client’s requests and adhere to his or her own ethical standards. Although it may be argued that we have the clients’ best interests at heart, we are also protecting ourselves from unnecessary litigation by taking the above-mentioned precautions.
Confidentiality is one of the most important aspects of the therapeutic relationship between mental health professionals and their clients. Indeed, who would go to a counselor if he or she thought it would be broadcast on the internet? Although this is a dramatic example, it is not impossible in this day and age when electronic communication is so frequently used (Koocher & Keith-Spiegel, 2008).
Electronic communication poses several risks to confidentiality that counselors should take steps to guard against. This includes guarding against hacking, placing limits on how he or she uses electronic communication, as well as educating his or her clients on the pitfalls of electronic communication. Additionally, counselors must consider how electronic communication may be used in an emergency, as well point this out to his or her clients.
All of this information (mentioned above) should be included in the client disclosure statement, which the client signs at the beginning of treatment. This ensures that the client is informed of the pitfalls, as well as ensures that the counselor in protected from potential litigation, complaints, etc. Electronic communication is here to stay. Therefore, it is imperative that the mental health professionals adapt to it, since the frequency with which it is used will surely only continue to increase.
Bibliography
Car, J. & Sheikh, A. (2004). Email consultations in health care: Acceptability and safe application. BMJ, 329, 439-442.
Corey, G., Corey, M.S., & Callanan, P. (2011). Issues and Ethics in the Helping Profession, International Edition, 8th edition, Brooks/Cole. ISBN-13: 9780495904687
Drude, K. & Lichstein, M. (2005). Psychologist use of email with clients: Some ethical considerations. The Ohio Psychologist, Aug., 13-17.
Koocher, G.P. & Keith-Spiegel, P.A. (2008). Ethics in Psychology and the Mental Health Professions: Standards and Cases. New York: Oxford.
