Practice Notes is designed as an educational tool to help Ontario social workers, social service workers, employers and members of the public gain a better understanding of recurring issues dealt with by the Professional Practice Department and the Complaints Committee that may affect everyday practice. The Notes offer general guidance only and College members with specific practice inquiries should consult the College, since the relevant standards and appropriate course of action will vary depending on the situation.
Communication technology has become an integral part of everyday life. It follows that many social workers and social service workers use communication technologies regularly, as part of their practice. This might include using email, social media platforms or texting to share information, schedule appointments, maintain documentation and/or invoice clients – either in the context of a private practice or within an organization. While communication technology
may make some aspects of practice easier, it also requires members to remain vigilant in order to ensure that they maintain clear and appropriate professional boundaries and other ethical practices.
This article addresses a number of themes raised regularly by members in calls to the College’s Professional Practice Department, including: confidentiality, the need for members to be continually aware of the professional information posted about them online, various considerations with respect to client service agreements and policies, and remote practice. In this article, “communication technology” refers to texting, email, video chat platforms, social media platforms, websites, or other types of online communication. The discussion is limited to services provided by members in Ontario, to clients within Ontario. It is intended to assist members in understanding how the Standards of Practice apply to these aspects of their practice.
Confidentiality and Privacy
Previous Practice Notes have addressed a number of issues for members to consider when using social media[1] and communication technology[2]. As these technologies quickly evolve and embed themselves in our everyday lives, these topics are worthy of further exploration. Increasingly, members are communicating with their clients through email or text messaging, and many clients now expect to communicate with them via these media. The Standards of Practice, which set out the minimum standards for all members of the College, require members to “inform clients of foreseeable risks as well as rights, opportunities, and obligations associated with the provision of professional services.”[3] The Standards of Practice also require members to “comply with any applicable privacy and other legislation.”[4]
One risk associated with communication technology is the fact that it is not a secure form of communication.[5] Members cannot guarantee that client information will be kept confidential when they communicate with clients online or texting. Members must consider a number of issues with regard to communicating with clients online or texting (e.g. protection of client privacy through passwords, encryption or other means, risk of loss or theft of a mobile device).[6] Members are strongly advised to review and follow any recommendations/advisories from the Office of the Information and Privacy Commissioner (IPC) which may be applicable to their practices. In particular, the IPC has published a fact sheet titled “Communicating Personal Health Information by Email,”[7] which considers, among other things, email communication between health information custodians and their patients of personal health information.
The Standards of Practice also require College members to “inform clients early in their relationship of the limits of confidentiality of information.”[8] In view of this requirement, members may wish to consider developing a communication technology policy that outlines potential risks to clients as well as their professional obligations as regulated professionals.[9] Clients should be provided with this information in order to make informed decisions with respect to the benefits and limitations of the services being provided.
Developing a Social Media and Communication Technology Policy
The Standards of Practice require members to “establish and maintain clear and appropriate boundaries in professional relationships for the protection of clients.”[10] In terms of communication technology, this means that members should be transparent about the purposes for which they will communicate using communication technology. For example, members may wish to be explicit with their clients about whether they can share clinical reflections via text message or email, or instead reserve these platforms for administrative purposes, such as scheduling appointments. Members would also be well advised to reflect upon how often and when they will check emails and other correspondence from their clients, and when or under what circumstances they will respond. This information should be clearly communicated to clients at the beginning of the professional relationship as well as later, if necessary.
Consider the following scenario:
A client tells a member in an initial session that he has a blog where he shares reflections about his personal life. After the session, the member goes online to review the client’s blog. She informs the client that she has done so at their next session. The client feels that this is an invasion of his privacy, but does not feel comfortable communicating this fact in the session. After the session, the client writes an angry email to the member. The member does not respond to the client email, which upsets the client further. At the next session, the member discusses the email with the client, explaining that the email is part of the client’s clinical record. The client becomes even more upset, stating that he would not have written the email if it was going to become part of his “permanent record”. The client terminates the session at this point. Upon further consideration, the member decides that the therapeutic relationship cannot be repaired; in order to avoid a confrontation, she terminates the professional relationship with the client via email.
In this scenario, it may have been helpful for the member to consider the following prior to deciding to use communication technology in her work with her client:
- What is their policy on searching information about their client online?
- What information will be shared using electronic communication outside of clinical sessions?
- How often will they read messages sent to them by clients?
- Will they respond to messages sent via electronic communication?
- What will be documented or included in the client record?
- What other Standards of Practice are applicable to this situation?
In the example above, the client was unaware of the member’s practice of going online to find out information about her clients. Members should consider whether it is appropriate to search for information about their clients online, or in which circumstances this might be appropriate or necessary. The most cautious course of action for members may be to “[d]evelop and disclose to clients policies on the use of Internet-based search engines to gather information about clients.”[11] Members might also wish to consider how this activity will be reflected in the client record, particularly if relevant information about a client is collected from online sources.
With respect to documentation, the Standards of Practice state that members must “ensure that records are current, accurate, contain relevant information about clients,”[12] and that “records include any or all of the following: reports (handwritten, typed, or electronic); progress notes; checklists; correspondence; minutes; process logs; journals or appointment records; films and audio or video tapes.” [13] It follows that members should consider how they will document information about clients found online and through client correspondence. Members should always have clear conversations with clients regarding documentation practises, including recording information obtained in their use of communication technology.
The Standards of Practice require that “College members provide clients with accurate and complete information regarding the extent, nature, and limitations of any services available to them.”[14] It is apparent in this scenario that the member did not clearly communicate to the client her practices in terms of responding to clients using electronic communication. Some members may choose to use electronic communication only for administrative purposes; others may choose not to respond to members using these platforms. Regardless of their decision in this regard, it is advisable for members to consider how often they will view and respond to their professional emails, text messages and other forms of communication technology and ensure that they inform clients of these practices early in the therapeutic relationship.
Finally, the scenario above raises issues with respect to termination of the professional relationship. The Standards of Practice state that members “terminate professional services to clients when such services are no longer required or requested.”[15] They also describe the circumstances in which a member may terminate the client relationship. When doing so, the member must make “reasonable efforts to hold a termination session with the client.”[16] In the scenario above, it does not appear that the member made reasonable efforts to offer the client a termination session, nor did she “distinguish (her) … needs and interests from those of their clients to ensure that, within professional relationships, clients’ needs and interests remain paramount.”[17]
Developing Websites and Online Professional Profiles
Members may also use communication technology by having professional websites to advertise their services, share resources and connect with clients. Similarly, different social media platforms enable members to create professional profiles and network with other colleagues. Members may create these websites or profiles at one point in their career, and then leave these resources online unedited or unaltered as their career progresses. It is important for members to consider the fact that information that is posted online remains there indefinitely. The following scenario illustrates some of the risks associated with this practice:
A member established a private practice several years ago and created a professional website. Over time, the member received further training and shifted the focus of her practice, at which point she developed a new website. The member’s first website remained online, which the member realized when she began to receive calls from potential clients who were seeking the services she described on that website. The member was able to refer the clients to another clinician, but was concerned to find that the disappointed clients had left negative comments about her under the “comments” tab of her website. This member called the Professional Practice Department to determine what her professional obligations were with respect to her first website, and how she might best address the negative comments.
In this scenario, the member may wish to consider the following questions:
- Is information about her professional services that is posted online current and accurate?
- Is it appropriate to include a “comment” tab on a professional website?
The content on members’ professional websites and their professional profiles on social media platforms must adhere to the Standards of Practice, which require that their “education, training, and experience, as well as areas of competence, professional affiliations and services are described in an honest and accurate manner.”[18] This means that members should maintain the currency of information about their practice that is online. It is also important for members to “review professional information about themselves that appears on websites and in other publicly available resources to ensure accuracy.”[19]
In the course of her call to the Professional Practice Department, the member in this scenario was able to identify some of the issues to consider when posting professional content online. She was made aware that the Standards of Practice require members to “correct, whenever possible, false, misleading or inaccurate information and representations made by others concerning College members’ qualifications or services”[20] and the fact that this requirement also applies to information that is online. Additionally, the member reflected on how remarks left on a comments page could be a form of endorsement or testimonial, neither of which are permitted in the Standards of Practice.[21] The member recognized that she had overlooked her earlier website and the implications of it remaining online. As a result of her discussion with Professional Practice staff, she noted that she had not considered that a “comments” page may solicit testimonials. After the call, the member decided that she would take steps to correct inaccurate information that was posted about her services online, and take down her out-of-date website.
Remote/Online Counselling
Some members engage in sessions with their clients via email, Skype or other video chat platforms. Indeed this can be an effective way to communicate for clients who live in remote parts of the province, are very busy or have difficulty attending an in-person session for a variety of other reasons. As discussed previously, members must engage in transparent conversations about confidentiality early in the relationship with their clients, regardless of whether they are providing services online or in person.[22] There are additional factors to consider, however.
Consider the following:
A member called the Professional Practice Department because he had been approached by a client seeking remote social work services. The client said she hoped to use a social media platform’s video chat function to communicate with the member, and that she might like to have sessions over email as well. The member realized that he would have to “friend” the client in order to use the social media platform the client had referred to. The member realized that it was inappropriate to “friend” the client, and decided that he should consult with the College regarding other factors that he should consider before agreeing to provide remote services to this client.
In this scenario the member may wish to consider:
- Whether he had the required knowledge and skills to provide remote services.
- What appropriate boundaries might be in terms of requests from clients to “friend” them online, for the purpose of providing professional services.
- Whether an in-person initial assessment is appropriate or feasible.
- How a technological malfunction will be managed.
- Whether there needs to be a process to verify the identity of the client.
- Whether it is advisable to develop a crisis plan for a client in a remote location.
Competence is required if using communication technology in practice. Professional Practice staff discussed with the member that he was “responsible for being aware of the extent and parameters of [his] competence and [his] professional scope of practice and limit [his] practice accordingly.”[23] It was further discussed that the member could enhance his knowledge and skills “by seeking additional supervision, consultation and/or education.”[24] The member applied his professional judgment and determined that due to the training he has received, he was competent to practise using communication technology.
The member was clear about his decision not to “friend” his client on social media. He recognized that even if the purpose of the client’s request was to access professional services, accepting such a request could blur boundaries and imply a personal relationship. Professional Practice staff reminded the member that he was “responsible for ensuring that appropriate boundaries are maintained in all aspects of professional relationships.”[25] The member decided that he would explore other options for video chatting with his client, and would discuss with his client the limits of confidentiality when communicating in this way.[26]
Professional Practice staff also discussed with the member the feasibility of conducting an in-person consultation or assessment. The member wasn’t sure if this was going to be a viable option, given the client’s circumstances. Regardless of whether or not an in-person assessment were possible, the member should in the course of his initial assessment use his professional judgment to determine if remote social work services were appropriate for the client.[27] In the course of his call, the member also discussed how he might manage if there was a technological malfunction that either prevented or terminated a clinical session. The member was encouraged to make a proactive plan with the client to address how service would be provided in the event of technological failure.[28]
Professional Practice staff also discussed what might be reasonable steps to verify the identity of his clients.[29] It was suggested that this might be a useful practice either during a technological failure when the member wasn’t able to visually identify the client, or if switching from video chat to email correspondence with clients. This practice may serve to minimize the risk that someone might impersonate a client, gain access to confidential health information, or influence a member’s assessment or opinion of a client.[30]
Lastly, it was suggested that when providing remote services to a client, the development of a crisis plan is an important consideration. The member understood that it would be good practice to be prepared in case a client endorsed thoughts of harm or if another crisis situation emerged for which additional help was required. Such a plan would include an assessment of the extent to which the client had access to family, friends, and social supports as well as the provision of information about community resources and emergency services.[31]
The member decided that he would discuss with his client how to identify a crisis and, in such an event, who would be contacted. The member realized that he would need to ensure that he had gathered contact information for the person the client consented to have contacted in the event of an emergency and with respect to appropriate resources. It was noted that this would be another opportunity for the member to discuss with the client the limits of confidentiality, including a potential duty to warn or protect.[32] The member was advised to be clear about the fact that information obtained via email or video chat would be documented in the client’s record, and that this information was subject to the limits of confidentiality.
Conclusion
This article has addressed a number of issues to be considered by members in relation to their use of communication technology in the context of their practice. By ensuring that they are competent and informed, and clear and transparent with clients about the limits of confidentiality as well as their communication technology practices and policies, members can ensure that they are providing professional and ethical service in the age of technology.
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Checklist for Using Communication Technologies in Practice
- I have taken steps to ensure that I am current and knowledgeable with respect to communication technologies
and digital practice. - I have reviewed the Standards of Practice and considered how they apply to the use of communication
technologies in my practice. - I have reviewed any applicable privacy and other legislation, considered how they apply to the use of
communication technologies in my practice and obtained legal advice, as advisable. - I have explained to my clients the limits of confidentiality in using communication technologies.
- I have reflected upon and clearly articulated to my clients my policies and practices in relation to seeking
information about them online. - I have been transparent with my clients about what (if any) information will be communicated outside of clinical
sessions via communication technology. - I have clearly articulated to clients how often I check messages received via communication technology.
- I have made it explicit to clients whether or not I will respond to messages from them sent via communication
technologies, and indicated if I do reply, the timeframe within which I will respond. - I have explained what information, including information gained from communication technology, will be
documented in the client record. - I have reviewed online professional information about myself to ensure its accuracy, and I have made reasonable
efforts to correct any inaccurate information. - I have ensured that none of my online platforms solicit testimonials or endorsements.
- I have made clear my policy about accepting clients as “friends” on social media.
- Before providing clinical services via communication technology, I have determined whether or not an in-person
initial assessment is required and whether remote services are appropriate. - I have explored with my client how to manage service provision in the event of a technological malfunction.
- I have explored with my client a process to verify their identity if required.
- I have developed a crisis plan with clients to whom I am providing services via communication technology.
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[1] Betteridge, Lise, “Practice Notes: Social Media and Practice: Protecting Privacy and Professionalism in a Virtual World”, Perspective, Fall 2011. http://ocswssw.org/wp-content/uploads/2015/01/PN-Social-Media-and-Practice.pdf
[2] Betteridge, Lise, “Practice Notes: Communication Technology & Ethical Practice: Evolving Issues in a Changing Landscape”, Perspective, Fall 2012. http://ocswssw.org/wp-content/uploads/2015/01/PN-Communication-and-Technology.pdf
[3] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle III: Responsibility to Clients, interpretation 3.6.
[4] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle V: Confidentiality, interpretation 5.1.
[5] Reamer, Frederic G., “Eye on Ethics: Developing a Social Media Ethics Policy”, Social Work Today, July 1, 2011 retrieved July 27, 2017 from http://www.socialworktoday.com/news/eoe_070111.shtml
[6] Betteridge, Lise, “Practice Notes: Communication Technology & Ethical Practice: Evolving Issues in a Changing Landscape”, Perspective, Fall 2012. http://ocswssw.org/wp-content/uploads/2015/01/PN-Communication-and-Technology.pdf
[7] Fact Sheet: Communicating Personal Health Information by Email, Office of the Information and Privacy Commissioner (IPC), https://www.ipc.on.ca/wp-content/uploads/2016/09/Health-Fact-Sheet-Communicating-PHI-by-Email-FINAL.pdf
[8] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle V: Confidentiality, interpretation 5.4.
[9] Reamer, Frederic G., “Eye on Ethics: Developing a Social Media Ethics Policy”, Social Work Today, July 1, 2011 retrieved July 27, 2017 from http://www.socialworktoday.com/news/eoe_070111.shtml
[10] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle II: Competence and Integrity, interpretation 2.2.
[11] Association of Social Work Boards (ASWB) Draft Model Regulatory Standards for Technology and Social Work, Section II: Informed Consent, interpretation 2.05.
[12] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle IV: The Social Work and Social Service Work Record.
[13] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle IV: The Social Work and Social Service Work Record, footnote 1.
[14] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle III: Responsibility to Clients, interpretation 3.1.
[15] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle III: Responsibility to Clients, interpretation 3.9.
[16] Ibid.
[17] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle I: Relationship with Clients, interpretation 1.6.
[18] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle VII: Advertising, interpretation 7.3.
[19] ASWB Draft Model Regulatory Standards for Technology and Social Work, Section I: Practitioner Competence and Compliance with Ethical Standards, interpretation 1.10.
[20] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle VII: Advertising, interpretation 7.3.3.
[21] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle VII: Advertising, interpretation 7.1.4.
[22] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle VI: The Social Work and Social Service Work Record, interpretation 4.4.1.
[23] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle II: Competence and Integrity, interpretation 2.1.1.
[24] Ibid.
[25] The Code of Ethics and Standards of Practice Handbook, Second Edition, 2008, Principle II: Competence and Integrity, interpretation 2.2.
[26] “Q&A: I have been asked by my employer to provide service to a client in another province, using Skype. Can the College offer any guidance on this issue?”, Perspective, Fall 2014. https://ocswssw.org/wp-content/uploads/2015/01/QA-On-Skype.pdf
[27] ASWB Draft Model Regulatory Standards for Technology and Social Work, Section II: Informed Consent, interpretation 2.08.
[28] The College of Psychologists of Ontario, Standards of Professional Conduct, 2017, Standard 15: Use of Technology in the Provision of Psychological Services, interpretation 15.8.
[29] ASWB Draft Model Regulatory Standards for Technology and Social Work, Section II: Informed Consent, interpretation 2.04.
[30] The College of Psychologists of Ontario, Standards of Professional Conduct, 2017, Standard 15: Use of Technology in the Provision of Psychological Services, interpretation 15.7.
[31] ASWB Draft Model Regulatory Standards for Technology and Social Work, Section II: Informed Consent, interpretation 2.08.
[32] Betteridge, Lise, “Practice Notes: Meeting Professional Obligations and Protecting Clients’ Privacy: Disclosure of Information Without Consent”, Perspective, Spring 2013. https://ocswssw.org/wp-content/uploads/2014/11/PN-Meeting_Professional_Obligations.pdf