1. Presented by Michael D. Swafford, Psy.D., LPC at Oklahoma Mental Health Counselors Association Conference June 10, 2011

2. Technology-Assisted Supervision/Counseling According to a 2009 study, as estimated 210 Billion e-mails are sent each day. Gastor et al. (2003) reported 72% of physicians in large academic medical center used it to communicate with patients. Houston, Sands, Nash, and Ford (2003) found that electronic communications may improve physician-patient relationship by providing rapid, asynchronous interactions for responding to patient questions. Bradley et al. (2011)

3. Rochlen, Zack, and Speyer (2004) in a study of psychologists found that some clients involved in online therapy improved significantly. This was particularly those with panic disorders, eating disorders, head injuries, posttraumatic stress, and grief. Noted issues about permanent written record (email) misinterpreted, lag time, accidental interception by known third party, lack of nonverbal cues,

4. Study of Social Workers by Finn (2006) found 69% never used e-mail to interact with clients 87.7% reported they did not believe that e-mail was appropriate for providing continuing therapeutic services. Bradley, et al. (2011)

5. Trepal, Haberstroh, Duffey, and Evans (2007) study regarding the effectiveness of Internet counseling drew mostly favorable conclusions. Problems noted in the study: lapse of time between communication and response, issues of ethics and confidentiality, and lack of nonverbal communication.

6. On different note: A study by Hricik and Scott (2007) regarding attorneys and clients and the use of electronic communication…may lead to disqualification of the attorney and the law firm because someone not yet a client can send unsolicited confidential information to a lawyer. This implies an attorney/client relationship when none exists. It implies that the lawyer has manifested an intent to offer to form attorney-client relationship and to keep submitted information confidential. Study found that law firms and attorneys are now using disclaimers to negate any perceived intent.

7. Know the rules of your respective License(s) regarding the use of electronic technology/email. Know what the policy for your agency or organization is regarding electronic technology/email. Refer to the respective professional codes of ethics, ie ACA, AMHCA, NASW, APA. Last, but not least, check with your malpractice/liability insurance carrier regarding use of electronic technology/email.

8. According to Professional Counselor Licensing of the Oklahoma State Department of Health, there are no current rules in LPC or LMFT regarding the use of email, telephone, video media, facebook, twitter, etc. in the counseling environment. LMFT rules allow for some supervision to occur by way of technology assistance.

9. Section 1925.2 Definitions (LMFT) "Technology-assisted supervision" refers to supervision that occurs through video teleconferencing, over secure internet connections, wherein an Approved LMFT Supervisor and a Licensed Marital and Family Therapist Candidate are in separate physical locations. Technology-assisted supervision must be approved by the Department prior to the accrual of hours. Factors to be considered by the Department include: distance between approved supervisor and candidate; financial hardship on approved supervisor or candidate; physical hardship on approved supervisor or candidate; specialty credentials; and other pertinent factors.

10. A.12. Technology Applications A.12.a. Benefits and Limitations Counselors inform clients of the benefits and limitations of using information technology applications in the counseling process and in business/ billing procedures. Such technologies include but are not limited to computer hardware and software, telephones, the World Wide Web, the Internet, online assessment instruments and other communication devices. A.12.b. Technology-Assisted Services When providing technology-assisted distance counseling services, counselors determine that clients are intellectually, emotionally, and physically capable of using the application and that the application is appropriate for the needs of clients. A.12.c. Inappropriate Services When technology-assisted distance counseling services are deemed inappropriate by the counselor or client, counselors consider delivering services face to face. A.12.d. Access Counselors provide reasonable access to computer applications when providing technology-assisted distance counseling services. A.12.e. Laws and Statutes Counselors ensure that the use of technology does not violate the laws of any local, state, national, or international entity and observe all relevant statutes. A.12.f. Assistance Counselors seek business, legal, and technical assistance when using technology applications, particularly when the use of such applications crosses state or national boundaries.

11. A.12.g. Technology and Informed Consent As part of the process of establishing informed consent, counselors do the following: 1. Address issues related to the difficulty of maintaining the confidentiality of electronically transmitted communications. 2. Inform clients of all colleagues, supervisors, and employees, such as Informational Technology (IT) administrators, who might have authorized or unauthorized access to electronic transmissions. 3. Urge clients to be aware of all authorized or unauthorized users ACA Code of Ethics 7 including family members and fellow employees who have access to any technology clients may use in the counseling process. 4. Inform clients of pertinent legal rights and limitations governing the practice of a profession over state lines or international boundaries. 5. Use encrypted Web sites and e-mail communications to help ensure confidentiality when possible. 6. When the use of encryption is not possible, counselors notify clients of this fact and limit electronic transmissions to general communications that are not client specific. 7. Inform clients if and for how long archival storage of transaction records are maintained. 8. Discuss the possibility of technology failure and alternate methods of service delivery. 9. Inform clients of emergency procedures, such as calling 911 or a local crisis hotline, when the counselor is not available. 10. Discuss time zone differences, local customs, and cultural or language differences that might impact service delivery. 11. Inform clients when technologyassisted distance counseling services are not covered by insurance.

12. A.12.h. Sites on the World Wide Web Counselors maintaining sites on the World Wide Web (the Internet) do the following: 1. Regularly check that electronic links are working and professionally appropriate. 2. Establish ways clients can contact the counselor in case of technology failure. 3. Provide electronic links to relevant state licensure and professional certification boards to protect consumer rights and facilitate addressing ethical concerns. 4. Establish a method for verifying client identity. 5. Obtain the written consent of the legal guardian or other authorized legal representative prior to rendering services in the event the client is a minor child, an adult who is legally incompetent, or an adult incapable of giving informed consent. 6. Strive to provide a site that is accessible to persons with disabilities. 7. Strive to provide translation capabilities for clients who have a different primary language while also addressing the imperfect nature of such translations. 8. Assist clients in determining the validity and reliability of information found on the World Wide Web and other technology applications.

13. CASE Gwen is a mental health counselor who has been in private practice for 20 years. She states that she wants to be accessible to her clients, so to increase her accessibility Gwen give them her e-mail address. Recently, Gwen went on vacation, camping in the mountains for a week. Since she was not close to a town, she did not take her computer. When Gwen returned home, she began checking the e-mails that had accumulated. She found one to be of major concern: a client diagnosed with clinical depression wrote that the was very sad and troubled to the extent that he could not sleep, did not want to get up and get dressed, and avoided eating. At the end of the e-mail, the client said, “I really need to see you as I do not think I should wait for my next appointment.” The e-mail had been sent four days before. Gwen immediately called the client and was relieved to hear him answer the phone. The client told her that although he became depressed earlier in the week, he was feeling better. Gwen scheduled a counseling appointment to see the client that day. Bradley, et al. (2011)

14. QUESTIONS RAISED BY GWEN: What responsibilities are associated with e-mail communications with clients? What issues of confidentiality should I consider? Is e-mail communication between client and counselor considered counseling? What boundary issues in the counseling relationship must be addressed with respect to e-mails? What might happen if I had not returned home and checked my e-mail? What might have happened if my client had completed suicide? Could I have been held liable even though I was unaware that I had an e-mail from him? What ethical or legal liability do I have if I communicate with clients by e- mail? What is my responsibility for checking my e-mail? Do I need to check it hourly? Daily? Weekly?

15. REFERENCES 1. American Counseling Association (ACA). Code of Ethics (2005). 2. American Mental Health Counselors Association (AMHCA). Code of Ethics (2000). 3. Bennett, B. et al. Assessing and Managing Risk in Psychological Practice: An Individualized Approach (2006). The Trust. Rockville, MD. 4. Bradley, L., Hendricks, B., Lock, R., Whiting, P., Parr, G. (2011). E-Mail communication: Issues for mental health counselors. Journal of Mental Health Counseling. Vol.33. Number 1. pages 67-79. 5. Corey, G., Haynes, R., Moulton, R., Muratori, M. (2010). Clinical Supervision in the Helping Professions 2 nd Edition. American Counseling Association. 6. Jacobs, D., David, P., Meyer, D. (1995). The Supervisory Encounter. Yale University Press. 7. Oklahoma State Department of Health, Professional Counselor Licensing. Rules and Regulations (2011). 8. Wheeler, A., Bertram, B. (2008). The Counselor and the Law: A Guide to Legal and Ethical Practice. Fifth Edition (2008)

16. Michael D. Swafford, Psy.D., LPC 105 S. Bryant, Suite 302 Edmond, OK 73034 405.844.7793 DrMikeSwafford.com DrMikeSwafford@aol.com