Distance Counseling and Supervision. Группа авторов
their identity, and to conduct an initial informed consent interview. When an in-person session is not possible, a synchronous videoconferencing session might be appropriate (AMFTRB, 2016). It is important for clients to understand the risks and limits to confidentiality prior to engaging in an initial session using technology. Clinicians should consider the following areas of appropriateness prior to engaging in virtual clinical services with clients.
Access to and Knowledge About Technology
Technology-assisted counseling sessions are most effectively conducted with clients who are very comfortable using similar technologies. It can be risky or stressful to use technology in the counseling session when the client has not used it in the past or when appropriate supports are not in place. In some cases, rural agencies have opted to send out technologists or case managers to assist clients in their homes during initial sessions when they are new to using virtual technology. Other providers have constructed telehealth rooms in their agencies that are monitored by administrative staff to support connections with counselors who are off-site. It is helpful to provide clients with a list of the required technologies prior to the first session. This list might include a computer with the capacity necessary to handle a teleconferencing program, a webcam with microphone, headphones with an integrated microphone, and an Ethernet-accessed internet connection. It is recommended that clients and counselors use Ethernet cables to connect to the internet, as wireless internet may not be secure and risk confidentiality breaches. It is also helpful when both clients and counselors use a virtual private network as a means to secure and protect confidentiality. HIPAA-compliant encrypted software should this time of crisis; however, it also recognized the need to continue to safeguard privacy:
If telehealth cannot be provided in a private setting, covered health care providers should continue to implement reasonable HIPAA safeguards to limit incidental uses or disclosures of protected health information (PHI). Such reasonable precautions could include using lowered voices, not using speakerphone, or recommending that the patient move to a reasonable distance from others when discussing PHI. (Office for Civil Rights, 2020, p. 3)
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