ECM8495 - SECTION 8: ADDITIONAL ETHICAL AND CLINICAL CONSIDERATIONS FOR E-COMMUNICATIONS
There are just a couple of additional considerations that must be known and understood when engaging in e-communication with clients. First, there is a phenomenon called the “online disinhibition effect”, noted by psychologist John Suler. This states that communication that takes place via non-face to face formats is prone to be accompanied by a diminishment of social inhibitions.
From a practical perspective, this means that clients may be inclined to reveal personal and private information more quickly and more easily when they are communicating via cell/smart phone, teleconferencing, text or email than they might when meeting face to face. This can create problems for the pacing of the therapeutic process, where clients are given the opportunity to reveal difficult information at a more comfortable pace.
If any substantial portion of the clinical process is likely to proceed in distance formats via any of the available media, it is wise for the clinician to have some discussions with the client about the disinhibition effect and to monitor the pacing of the presentation of new material. At times, it may be necessary for the clinician to help the client slow down the pace of revelations, so the client does not scare themselves with how much they reveal.
A second consideration has to do with the culture of e-communication, particularly text based interactions. Because of the development of Twitter and other similar sites whose emphasis is on the concise delivery of information, a new kind of online language has emerged with its own idiosynchratic vocabulary.
This vocabulary will contain information in an extreme shorthand, such as “LOL” for laugh out loud, “143” for I love you, and an whole host of other language with its own set of meanings. Some of the language is in the form of acronyms, like LOL, while other language is in the form of words that have been assigned meaning in the online culture, i.e., Dip (to leave) or Manky (dirty, nasty). There are also emojis and emoticons, each of which has its own shorthand meaning. (Example: ;-) = wink, wink)
If a clinician is prepared to engage in communication of this sort, he/she should be prepared to research some of the more common elements of this vocabulary, and be prepared to work out with the client how differences in understanding in the use of this slang vocabulary will be handled, so there are not serious failures in communication.
It is also recommended that some thought be given as to how much the clinician chooses to utilize this slang in the course of clinical work. This slang has the purpose of creating shared connections between people whose social life occurs in the world of e-communications. Particularly for some teenagers, it is a way to create distance and differentiation between themselves and the adult world in order to shape a separate identity.
If a clinician chooses to utilize this slang as an act of joining or mirroring, it poses risks for honoring the autonomy and differentiation efforts of the client. It may also create some harm to the maintenance of professional authority, since the clinician is departing from a more “adult” – and less “cool” – position, and this may not be what the client is seeking from the clinician. Choices to apply online slang must be made consciously and with forethought about the possible effects to the therapeutic relationship.
For a website dedicated to providing updates on the latest internet slang, you may consider going to the following link:
http://www.internetslang.com/
If a choice is made to utilize text based modes of communication, it is also important to make sure to that the message that is intended is actually being sent. The misuse of online slang is one potential danger in this area, but there are other risks and dangers, too.
Many texting applications have autocorrect functions that automatically edit the words that are being composed for a text message. There is a considerable amount of difference between the meanings of “family mediation” and “family medication”, but the two phrases have only a single letter difference in how they are spelled. Autocorrecting might select one over the other and edit your meaning. Just as it is important to double check email addresses before messages are sent out to make sure that the email doesn’t get sent to the wrong address, it is important to double check the text of both emails and text messages to make sure that no errors in meaning have been produced.
There are a number of different web sites composed entirely of highlighting the humorous messages that occur when autocorrecting is not caught before the message is sent. Please be aware that autocorrecting can not only occur with words inside the message, but with your name or signature at the bottom of the page. A kindly, old grandmother attempting to send a Facebook message to a family members had a name that was slightly too close to the name of a certain action hero, causing her message to be closed as follows: “Much love, Jean Claude van Damme”
The humor of the miscorrected message can have a very different effect when it is performed in the context of a therapeutic relationship. Text messages cannot be unsent, so it is worth a few seconds of extra time to double check everything before it gets sent.
These are all problems that are of recent origin and only intrinsic to these new modes of communication. As a final review of some of the issues presented in this course, we will offer a couple of slides to help the clinician ask the right questions concerning how well privacy is being protected in his/her practice.
Final Questions
¥ What kind of security arrangements do you make to ensure that both you and the client are utilizing secure phone lines for telephonic contact?
¥ What protections do you employ to ensure that email communications offer privacy to the client, both in terms of emails on the client’s email system and your own email system?
¥ What measures do you use with regard to informed consent concerning issues of privacy in preparing the client for the use on distance modes of communication?
¥ What formal and written policies and procedures have you developed concerning issues of privacy in preparing the client for the use on distance modes of communication?
¥ Are those policies and procedures available to your clients prior to the decision to engage in distant modes of communication?
¥ What formal and written policies and procedures have you developed concerning issues of duty to warn and duty to protect while using distant modes of communication?
¥ Have you notified the client of these policies and procedures prior to engaging in distance modes of communication during treatment?
Final Recommendations and Important Links for 21st Century Clinical Practice in the Era of Social Media and E-communications
Because of the Covid-19 crisis, there has been a substantial reconceptualization of clinical practice in the 21st Century. Telemental Health, which was beginning to emerge as a potentially useful adjunct to face to face practice, has become the predominant mode of practice as of the fall of 2020. There are some theoreticians who suggest that this will facilitate a move to preferential use of Telemental Health even as the Covid-19 crisis comes to a close.
This suggests additional responsibilities for the mental health clinician moving forward. In order to support trainees in attending to these new responsibilities, we have organized a list of helpful links to organizations at the forefront of working with clients from a distance. This set of links may be found below. It is strongly recommended that you highlight this set of links, then copy and paste them into a Word file to be saved on your hard drive for later use.
Of particular note, a law practice in Washington DC, Epstein, Becker and Green, has assembled and maintains a list of laws in each state concerning the use of Telemental Health. Since practice across state lines is a key issue in mental health practice, this is a very useful resource to maintain in your hard drive. For ease of use, this resource is also available as an App that can be downloaded to your phone.
Please also note the link to the International Society of Mental Health Online. This organization helps to set standards and organize resources for Telemental Health. For 21st Century clinicians, this should be considered as a site to maintain on your favorites page on your internet browser.
Useful Links for TMH
Practice Guidelines for Video Based Online Mental Health Services from the American Telemedicine Association
https://www.integration.samhsa.gov/operations-administration/practice-guidelines-for-video-based-online-mental-health-services_ata_5_29_13.pdf
HIPAA Survival Guide HiTech Act Summary
http://www.hipaasurvivalguide.com/hitech-act-summary.php
Association of Social Work Boards (“ASWB”) Standards for Technology and Social Work Practice, 2005
https://www.aswb.org/news/technology-standards-in-social-work-practice/
University of Zurich Research on Telemental Health
https://www.media.uzh.ch/en/Press-Releases/archive/2013/psychotherapie-via-internet-wirkt-gleich-gut-oder-besser-wie-im-sprechzimmer.html
HHS.GOV Understanding Health Information Privacy
www.hhs.gov/ocr/privacy/hipaa/understanding
HHS’s HIPAA technology Guidelines for email use
http://www.hhs.gov/ocr/privacy/hipaa/faq/health_information_technology/570.html
Link for testing the speed of your internet connection
www.speedtest.net
Link to site reviewing and comparing providers of services and portals for TMH practice
http://telementalhealthcomparisons.com
International Society for Mental Health Online
https://ismho.org/resources
Site for review of where telehealth is at in every state and what the current laws and rules are.
http://www.ebglaw.com/telemental-telebehavioral-survey/
http://www.EPSTEIN-BECKER-GREEN-2017-APPENDIX-50-STATE-TELEMENTAL-HEALTH-SURVEY.pdf
Site for Northwest Regional Telehealth Center with good resources:
https://www.nrtrc.org/telehealth-article-41