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Eye on Ethics

The Expanding Use of Computer-Based Services in Clinical Social Work
By Frederic G. Reamer, PhD
November 12, 2010

Twenty years ago I served as an expert witness in a licensing board case involving a clinical social worker whose former client, a woman with a trauma history, claimed that the social worker harmed her by using a nontraditional, unorthodox clinical intervention. The prosecuting attorney argued that the social worker should be sanctioned because she used a clinical approach that posed a risk to the woman; the intervention deliberately included ambiguous boundaries that involved extensive social worker-client contact outside the clinical office. The prosecutor supported her claim by demonstrating to the administrative law judge that the clinical intervention—which involved travel and meals with the client—was not taught in social work education programs, was not recognized or discussed in the professional literature, and did not comply with prevailing ethical standards in social work.

Now, two decades later, I find myself wrestling with similar issues involving a social worker's use of a very different nontraditional, unorthodox intervention. The current case involves an intervention that I could not possibly have imagined 20 years ago, primarily because the technology it uses had not yet been invented: social workers' provision of clinical services to clients who live hundreds of miles away, in another state, using cyberspace.

In so-called cybertherapy, a client uses a computer-designed avatar to represent himself or herself in a virtual world. The avatar is a visual image the client creates as a character or a persona that he or she presents to others on an Internet-based therapy site. Avatar-based cybertherapy enables clients to use chat room technology with relative anonymity to engage in a virtual approximation of traditional face-to-face therapy. Participating clients log on to a clinician's website and view a simulated therapy room and therapist. Clients can participate in one-on-one counseling or group counseling, where a group of clients log on simultaneously and dialogue with each other in real time by typing messages that appear on participants' computer screens.

Expanding the Frontiers of Clinical Interventions
Cybertherapy is just one example of a wide range of computer-based technologies that a relatively small but growing number of social workers are using to provide clinical services. In recent years clinical social workers have provided Internet-based counseling services to people they have not met in person; practitioners use live chat technology and e-mail (sometimes known as e-therapy or online counseling), moderated forums, and self-guided Web-based interventions with automated feedback.

Social workers who use this computer-based technology argue that it expands the range of ways in which practitioners can help people. For example, people who live in remote areas, long distances from clinical social workers' offices, can now access services. People with agoraphobia may be too anxious to travel to a clinician's office but may be willing to engage electronically with a social worker and others who struggle with anxiety (for instance, in a virtual chat room). Some clients may feel emotionally safer when they interact anonymously with a social worker or others electronically or may prefer the convenience, flexibility, and cost-effectiveness of electronically based clinical services.

Ethical Challenges
Not surprisingly, many social workers are concerned about a number of ethical risks associated with these novel, cutting-edge forms of clinical intervention. First and foremost, there is the potential loss of the human factor that is so vital to clinical encounters. Clinicians and clients who interact electronically lose the opportunity to connect in person and experience visual and vocal cues. This may lead to clinically relevant misunderstandings.

Computer-based clinical interventions may also pose privacy and confidentiality risks. A social worker who counsels a client in the office can control who has access to that conversation simply by closing the door. However, a social worker whose client is sitting at a computer hundreds of miles away may not be able to control who has access to the client's computer screen. There is always the possibility, however remote, that the privacy of electronic communications can be breached by hackers or others who access a client's or a social worker's computer account without authorization.

There is also some risk that clients who engage a social worker electronically are not who they say they are. Both the ambiguous identity and geographical distance may limit social workers' ability to intervene in the event that the client experiences a crisis that requires emergency services.

Computer-based clinical services may be particularly ill suited for treating clients with chronic, complex clinical issues. Social workers who use electronic interventions may not be able to meet the needs of people with, for example, persistent clinical depression, eating disorders, and substance abuse orders. Clients who are in distress and need a quick response from a social worker may be frustrated or do harm if a social worker does not respond to an electronic message immediately. Computer-based interventions are also risky when clients pose a danger to themselves or others, are cognitively impaired, or otherwise distort reality.

Social workers who provide clinical services electronically to clients who reside in other states may face an additional risk if a client alleges that the social worker violated licensing board standards. Licensing boards may expect that a social worker who provides clinical services that are received electronically in the client's state be licensed in that state, even if the social worker lives in another state hundreds of miles away. The result could be an allegation that the clinician practiced social work in the client's state without a license.

And, of course, there is always the possibility of technological failure that could compromise the quality of clinical care. An Internet server that fails or a computer that crashes may prevent a social worker from meeting clients' needs.

Managing Ethical Risk
The advent of electronically based clinical interventions comes with potential benefits and risks. Social workers who consider using emerging computer-based technology should be sure to comply with relevant standards in the National Association of Social Works Code of Ethics, as follow:

Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services (standard 1.03[e]).

Social workers should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques (standard 1.04[b]).

When generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps (including appropriate education, research, training, consultation, and supervision) to ensure the competence of their work and to protect clients from harm (standard 1.04[c]).

Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible (standard 1.07[m]).

Social workers should not automatically shy away from clinical innovations or shun novel approaches to clients' complex problems. Indeed, many contemporary, widely accepted clinical tools such as eye movement desensitization and reprocessing therapy, behavioral therapy, and play therapy were once considered unorthodox and nontraditional. Over time, social workers' constructively critical examination of emerging interventions will determine which are, and which are not, ethically acceptable. Conscientious social workers will explore and adopt innovative interventions only when they are consistent with the profession's ethical standards.

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