Cybertherapy

Emerging Issues: Cybertherapy

Social work practitioners engaged in clinical practice are hearing more and more about online counseling, e-therapy or cybertherapy. While many social workers look at the provision of clinical services in cyberspace as absurd and/or frightening, others are exploring its possibilities, and a few are even putting their services online using both email and chatroom software applications. While these early adapters are primarily private practitioners, a few agencies are experimenting with using interactive web pages to provide at least psycho-educational feedback to their website visitors. Clients can email a question to the agency and get a reply from the agency staff member. Clients are also beginning to present problems that are specific to the technology itself (computer addictions and online stalking, to name a few). These clients naturally turn to the technology itself to find solutions for these computer generated problems. Many professionals, generally psychologists and counselors, are making services available to assist these clients in need. More that a few uncredentialed quacks are practicing online too.

As the technology pioneers encourage all social workers to recognize and embrace the potential benefits of online services, and as more and more clients seek out such services, social workers need to explore how and when cyberspace can be used effectively in meeting client needs for service.

Advocates point out that social workers have long used the telephone to provide long distance service reaching clients in remote areas and the homebound. Online services offer social work an opportunity to reach out to populations that are undeserved due to the constraints of distance or the fear of talking face to face with a professional. The fear of being negatively labeled when seen walking in the agency's front door has long presented a barrier to people seeking needed services. Providing individual or group counseling online could afford social workers the opportunity to provide service circumventing both these geographical, psychological, and social roadblocks.

Individuals whose jobs keep them traveling on the road for long periods of time, or who are working abroad and yet need access to social services are beginning to request online services. A good example would be adult children who must care for aging parents at a distance. While these requests are coming from middle class professionals seeking some form of help, the use of online services needs to be explored as well with other populations such as prison inmates, the homeless, runaway youth, those in crisis, the homebound elderly, and people with disabilities. Online services with these populations may in the long run have the greatest impact on social work practice. Social work is most likely to advocate for online services for these more vulnerable and difficult to reach populations. Online services potentially could expand social work services by screening clients prior to providing face to face service, by affording client contact between face to face sessions, and by reinforcing service outcomes with online follow up after face to face contacts have ended.

Some clients may communicate more effectively online than in person resulting in both more effective and shorter term service. Online support groups can offer clients a safe environment in which to experiment with new ways of interacting with others. Success in expressing one's thoughts and feelings and asserting oneself online can motivate clients to attempt these behaviors offline. Objectivity may also be increased when working across age, gender, class, racial and cultural boundaries especially when visual cues are less prominent.

Last, social workers can also refer clients to the numerous online resources to augment and support their work together online. More and more clients and their families are using the Web on their own to find information specific to their concerns. Often clients do not know how to evaluate the quality of the information they find. Alerting clients to websites that the social worker can vouch for can be easily done when working with a client online.

Before social workers can fully embrace the provision of social services online, considerable research needs to be done on the effectiveness of the various online interventions (email, videoconferencing, or speakerphone). Social workers need to know what services can be provided online to which populations and for what problems. Early adapters will need to document their experiences and well controlled studies need to be designed and executed. More than the technology itself should determine whether or not clients receive online services. In the meantime, practitioners need to proceed with caution and inform clients about the experimental nature of online services.

Practice Tips:
If you are considering using technology to expand your practice or are exploring providing some of your agency's services online, you need to first educate yourself. Begin by reading NASW's recent practice update regarding online therapy. You can order a copy of OnLine Therapy and the Clinical Social Worker at http://www.naswdc.org/practice/update/online.htm. Take a look at websites like that of the International Society for Mental Health Online at http://www.ismho.org and begin by thinking through issues around informed consent and security.

You would not try using physical restraints or CPR without first knowing how to do so and having had ample opportunity to practice these specialized skills. Become proficient using email, listserv and chat room software before you consider practicing online. Learn the basic rules of netiquette since these behavior standards are unique to cyberspace. Practice using emoticons in your email postings. Emoticons are character-built symbols that express feelings and gestures that can not be directly seen on line such as "I'm surprised" :-o or "My lips are sealed" :-#. You'll need to use these with clients to clarify the meaning of your text, and to reduce the misunderstandings that can occur online. Set up an electronic group with colleagues and moderate it to become familiar with how such technology works. You can set up an electronic group at no cost through e Groups at http://www.egroups.com.

Plan on using the same ethical protocals you would follow in your face to face contacts with clients and colleagues. While the NASW Code of Ethics may not specifically address online services, you will want to follows its guidelines off and online. Some professional organizations like the National Board of Certified Counselors (NBCC) http://www.nbcc.org/ethics/wcstandards.htm have created ethical guidelines for online practice. Review these guidelines. While they represent an early attempt and will no doubt be refined in the future, they do give social workers some understanding of the ethical issues involved.

If you decide to pursue even limited online practice, you will need to inform your clients about the benefits and risks related to such service including the safeguards you will use to minimize the risks. Have a heart- to- heart conversation with your Internet Service Provider (ISP) about their privacy policies and how they minimize confidentiality breaches. You can promise your clients no more than what your and your client's ISP provides when it comes to privacy and confidentiality. Develop a detailed privacy policy and make it available to potential clients. This is as important as informing clients about fees and emergency procedures. Also, tell clients up front about turnaround time. If your client emails you with an emergency at 2:00 a.m. they need to know when you are likely to reply.

Clients need to understand what online services are and are not. Web sites like Metanoia http://www.metanoia.org/imhs/ can provide clients with general information about online therapy. It is crucial that clients know that online communication can lead to misunderstandings since there is a dependence on the written word. Discuss alternative approaches to online service. Such a discussion may alleviate fears the clients has about receiving face to face services that have a proven effectiveness.

Do not provide services anonymously. Your first client contact should provide information about your education, training, credentials, professional and institutional affiliations as well as information on how to contact you offline. Make it easy for potential clients to verify your background information.

Protect yourself as well as your client. Make sure you have a rationale for providing online services since the effectiveness of such services are not backed by outcome studies. Are face to face services not available? Is the client too fearful of pursuing traditional services? If there is a refusal, then why? Document what goes into your decision to provide online services. Avoid high risk client contacts. Providing service to suicidal clients or those engaged in high risk behaviors is difficult enough when visual and auditory cues are available. It just is not appropriate to attempt such assessments online. Develop a list of online practitioners with various areas of expertise to whom you can make a referral should you discover your client requires the services of someone with more expertise than you possess.

Be aware that clients can easily misrepresent themselves online by assuming a false identity. Hotlines have long had to deal with the occasional crank call designed to shock or deceive rather than obtain assistance. Don't practice with anyone whose identity you cannot verify.

Keep in mind that a record of all your online interventions can be stored not only on your computer, but also on your client's computer. While this makes record keeping for you a breeze, you also may have to live with your written communications for a long time. Computers can crash, so back up everything related to your online practice. Take the time to reflect on what you are about to communicate online to a client, and use emoticons to clarify the meaning of the text you send to clients. Tell clients you expect them not to forward your electronic communication to others, just as you will not forward their communications without their permission or a written consent. We tend to be focused on client confidentiality and may forget that clients now can easily keep records too.

Discuss with your professional insurance carrier your liability coverage before you begin practicing online. There may be differences in what NASW's American Professional Agency covers and what an agency's liability insurance carrier covers. Know where you stand.

Refuse to take any security risks with which you are uncomfortable, even if your client wants to do so. Your client may be comfortable working with you online at their place of employment, but their employer is the legal owner of all employee online communications. Consider using encryption to protect confidentiality.

While internet practice is only beginning and dangers indeed are present, this does not mean that social workers should avoid cyberpractice. There appears to be enough potential to make investigation worthwhile. You will want to consult with others who have provided online services - find an experienced colleague - and make sure that you have thought through what you will need to practice effectively and safely online. Share what you learn with your colleagues who will follow.