Emotional Stability, Safety, and Emergency Risk Management
It is important to assess the emotional and psychological stability of the client to ensure that virtual counseling services are appropriate. In situations in which involuntary commitment might become a necessity, technology-assisted therapy might not be the best choice. It might be important to assess for suicidal or homicidal ideation, hallucinations, or delusions prior to engaging in virtual services. This assessment for appropriateness of services should be ongoing and continue throughout treatment. For safety purposes, it is important to verify the client’s location at the beginning of each session and maintain a safety plan (AMFTRB, 2016). A safety plan should be proactive in considering the potential risks and potential needs of each individual client. It is recommended that an emergency contact (an adult older than age 18 who is able to respond) be identified who resides within 10 minutes of the client during scheduled sessions. Informed consent should provide permission for the counselor to speak with emergency contacts in case of an emergency. Local law enforcement, medical personnel/emergency medical services, and fire services in the client’s location should be identified as well. This safety plan should be kept current and up-to-date as the client moves or travels or as emergency contacts become unavailable. In addition, there should be a plan in place in case the technology fails. Counselors should be aware that state laws, liability insurance companies, supervision laws, and other governing and regulatory bodies do not view all technologies in the same manner. The counselor must be aware that if synchronous videoconferencing software fails, a phone call might address the client’s welfare, but it might not be bill-able or count toward counseling hours. Counselors and supervisors should identify the various technological methods that both serve clients’ needs and meet the expectations of insurance providers. Please see a sample Readiness for Online Counseling checklist in Appendix A.
Anonymity and Confidentiality
There are numerous benefits to engaging in distance counseling, including accessibility, anonymity, and comfort and convenience for the client (Harris & Birnbaum, 2015). However, the appropriate degree of anonymity is often uncertain and not always clearly defined. Counseling provided via teletherapy must be held to the same standard as face-to-face practice. ACA (2014) identified the need for counselors to provide adequate information about themselves and the counseling process, obtain informed consent, maintain records, and collaborate with clients around goals and treatment. AMFTRB (2016) established concrete guidelines and notes that “an appropriate therapeutic relationship has not been established when the identity of the therapist may be unknown to the client or the identity of the client(s) may be unknown to the therapist” (Guideline 3.B). This has very specific implications, especially for asynchronous counseling services. The benefit of anonymity and confidentiality primarily lies in a natural sense of what it entails (Harris & Birnbaum, 2015; Richards & Vigano, 2013). Some clients feel less fear of stigmatization seeking counseling services online than traveling to a counselor’s office (McAdams & Wyatt, 2010).
Limits and Risks of Confidentiality
Counselors must identify the limits of confidentiality when retaining electronic records or using technology in the counseling process. There are authorized and unauthorized risks involved in the use of technology. Counselors must inform clients of these risks. In addition, counselors should anticipate these potential risks and take appropriate precautions to mitigate them. Appropriate encryption should be used in an effort to protect confidential information. Client identification protocols should be in place to verify clients’ identity throughout the counseling process. Ongoing verification might include alpha or numeric code words, graphics, or other nondescript identifiers (ACA, 2014).
Security
Throughout this book, there are conversations around risk and recommendations to avoid intentionally or unintentionally breaching confidentiality; however, here are a few basic steps to follow to avoid breaches of confidentiality.
Remember the Two-Lock Rule
Remember that when physical client files are stored, they must be secured behind two locks (a file cabinet and a locked door or something similar). Consider where you leave your technology and who has access to it. Often, a phone or laptop is such an accoutrement to daily life that it can go unattended. Individuals allow children to play on work phones or watch videos and play games on their laptops. Be aware of the location of and contact that is allowed on work devices. It might be prudent to purchase separate devices for home use and work use to maintain healthy boundaries and security. Keeping digital devices secured physically and through encryption is as imperative as protecting a paper client file.
Use and Protect Security Settings
Counselors should remain aware of the security settings on their devices and understand how programs use them. Do not jailbreak or root devices in an effort to bypass security settings, and remain aware of a device’s capacity to use a kill switch or other mechanism in the event that it is lost or stolen (Wheeler & Bertram, 2015). Remain aware of loading applications that allow access to phones or computers, and use security settings. Remain aware of the way in which your phone or computer accesses the internet, and avoid public or unsecured Wi-Fi.
Liability Insurance and State Licensure Regulations
Each state has regulations governing various elements of distance counseling and technology integration that are constantly evolving. Many changes are made in response to questions or situations posed by practicing counselors or complaints from the public. It is essential to remain current on these ongoing changes by attending state licensure board meetings or visiting licensure board websites for updates and rule changes. In addition, it is important to explore your professional liability insurer’s risk management guidelines and policies to understand how they view technology-assisted services in contrast to face-to-face services. Additional insurance riders may be required to supplement the standard policy. The risk management team may also provide recommendations for safeguards. Wheeler and Bertram (2019) warned that eventually counselors may need to explore cyber-risk insurance as a part of their liability insurance coverage or as a stand-alone policy. Please explore Chapter 6 for more information on hardware and software safety.
Synchronous Videoconferencing
One of the major concerns with the integration of technology into the counseling process is the inability to read nonverbal cues and interpret nonverbal communication, as this provides critical information. Synchronous videoconferencing allows the counselor and client to see each other in real time and captures the facial and body signals communicated during the session. In addition, the synchronous connection has a significant impact on rapport and the therapeutic alliance. In some situations, licensing boards and insurance companies recognize synchronous videoconferencing similarly to face-to-face interactions, but they regard email and text services very differently.
Texting
The security of the texting platform is another aspect to consider, as many texting applications and services are not considered secure and others might be accessible from several access points. Text messaging in the therapeutic process is one of the more controversial modes of communication. Wade (2015) stated, “It may or may not be a good idea, and there are a number of considerations that can determine the answer” (p. 11). Counselors should identify whether clients are comfortable with the use of text, recognize and communicate
