Eye on Ethics

Tele-Social Work in a COVID-19 World: An Ethics Primer
By Frederic G. Reamer, PhD
April 2020

The coronavirus pandemic has transformed social work. Legions of practitioners who have customarily provided face-to-face services to clients have shifted suddenly to online and distance counseling. Of course, a relatively small percentage of social workers have been providing remote services for quite some time, as video, text-based, e-mail, and smartphone technology has matured. But, for most social workers, this rapid transition to online and distance service delivery because of COVID-19 has come with a steep learning curve.

In addition to mastering the logistics involved in adapting technology to serve clients remotely, social workers have had to learn quickly about an array of ethical and legal standards with which they must comply. In short, social workers must adhere to key NASW Code of Ethics standards, national practice standards, federal and state laws, and agency policies related to informed consent, confidentiality, practitioner competence, and licensure.

Informed Consent
Social workers respect clients’ right to consent to services. The advent of distance counseling and other remote social services delivered electronically has enhanced social workers’ ethical duty to ensure that clients fully understand the nature of these services and their potential benefits and risks. Obtaining clients’ truly informed consent can be especially difficult when social workers never meet clients in person nor have the opportunity to speak with clients directly about informed consent. Special challenges arise when minors contact social workers and request distance or remote services, particularly when social workers offer services funded by contracts or grants and do not require payment from minor clients’ parents or insurance companies; laws around the world vary considerably regarding minors’ right to obtain services from social workers without parental knowledge or consent.

When social workers provide services to clients remotely, the informed consent protocol should address the following:

• the nature of the services that the social worker will provide remotely, such as video counseling, text-based counseling, e-mail counseling, and use of smartphone applications;

• possible benefits of remote service delivery, which may include geographical and scheduling convenience;

• differences between services provided face to face and remotely;

• the skills and equipment (such as computer specifications and smartphone applications) the client will need to receive services remotely;

• the importance of privacy for both social worker and client. Social workers should describe steps clients can take to ensure privacy. Social workers should describe the steps they will take to ensure privacy (for example, use of encryption, firewalls, and data backup software);

• the possibility of technology failure and transmission interruption, along with instructions in the event these occur (for example, callback protocols);

• the possibility that stored data could be accessed by unauthorized people or companies, and the steps social workers will take to prevent this;

• an emergency response plan to address crises that may arise. Details may include names and telephone numbers of individuals the social worker can contact, telephone numbers the client can call, and circumstances under which the client should access care at the client’s local hospital emergency department;

• steps social workers will take if they believe that the client needs to access face-to-face services because of clinical needs. Social workers should include details about referral and termination-of-service protocols;

• guidelines for clients’ use of e-mail and text messaging to communicate with the social worker (i.e., whether electronic communications should be used only for administrative and scheduling purposes, as opposed to counseling issues); and

• an agreement that the client will not record any remote counseling sessions or other discussions, unless agreed upon in advance.

Confidentiality
The rapid emergence of digital technology and other electronic media used by social workers to deliver services has added a new layer of challenging privacy and confidentiality issues. Fortunately, sophisticated encryption technology can protect client confidentiality very effectively, although it is not foolproof. Social workers who offer video counseling services must recognize that they have much less control over confidentiality than when they provide traditional office-based services. For example, a client receiving video counseling services may invite a family member or acquaintance to sit in on a session—outside of camera range—without the social worker’s knowledge or consent.

Encryption of social work services provided online is more challenging with some forms of technology than others. These novel confidentiality issues are addressed directly in the current NASW Code of Ethics: “Social workers should take reasonable steps to protect the confidentiality of electronic communications, including information provided to clients or third parties. Social workers should use applicable safeguards (such as encryption, firewalls, and passwords) when using electronic communications such as e-mail, online posts, online chat sessions, mobile communication, and text messages” (standard 1.07[m]). Further, per the technology standards adopted jointly by NASW, Association of Social Work Boards, Council on Social Work Education, and Clinical Social Work Association, “When using technology to deliver services, social workers shall establish and maintain confidentiality policies and procedures consistent with relevant statutes, regulations, rules, and ethical standards” (standard 2.07).

To practice ethically, social workers who use digital and other technology to provide distance services must develop privacy and confidentiality protocols that draw on several key sources. Social workers must review and adhere to relevant statutes and regulations, including federal and state laws pertaining to the confidentiality of health and mental health records and exceptions to clients’ right to confidentiality to protect clients and third parties from harm.

Also, social workers must develop confidentiality agreements when conducting group treatment or facilitating support groups online. As with in-person group sessions, social workers should ensure that clients adhere to appropriate confidentiality guidelines and agree to respect other group members’ privacy.

Practitioner Competence
To practice ethically, social workers who use digital and other technology to provide distance services must seek training and continuing education focused explicitly on the use of distance counseling technology, including developing protocols for screening potential clients, obtaining clients’ informed consent, assessing clients’ clinical needs, maintaining confidentiality, implementing distance interventions and services, maintaining clear boundaries, managing documentation and client records, and terminating services. Such knowledge and skills include knowing how to communicate effectively while using the technology to provide social work services; handle emergency situations from a remote location; apply the laws of both the social worker’s and client’s location; be sensitive to the client’s culture, including the client’s cultural community and linguistic, social, and economic environment; attend to clients’ unique needs and challenges; ensure that the technology is in working order to provide effective services and avoid disruption; keep abreast of the changing landscape of technology; and adapt accordingly.

Key Resources
Social workers who provide online and distance services to clients should consult and comply with a number of guidelines pertaining to social workers’ use of technology to communicate with clients, deliver services to them, store and manage confidential information, and search online for information about clients without their knowledge or consent. These include the following:

• the updated NASW Code of Ethics, which includes many new and revised technology standards;

• the national technology practice standards adopted jointly by NASW, Association of Social Work Boards, Council on Social Work Education, and Clinical Social Work Association;

• federal laws, such as the Privacy Act; HIPAA; Health Information Technology for Economic and Clinical Health, or HITECH, Act; 42 CFR Part 2 (Confidentiality of Substance Use Disorders Patient Records); and FERPA, the Family Educational Rights and Privacy Act;

• state laws governing management of confidential health care information, informed consent, social work licensure required to provide services to clients remotely, treatment of minors, and documentation; and

• agency policies that address social workers’ use of technology to serve clients.

The coronavirus pandemic has changed all of our lives, both personally and professionally. Many clients are struggling with isolation, depression, and anxiety, among other behavioral health challenges, because of COVID-19. Social workers are in a position to provide much-needed assistance, albeit from a distance. This is the time to do so as ethically as possible, mindful of the venerable standards of our profession.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work at Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, health care, criminal justice, and professional ethics.