Public Places, New Technology Can Create Ethical Challenges

graphic of two people sitting in sofas

By Josette Keelor

Carolyn Schaefer Placko remembers feeling snubbed by a psychologist many years ago. "I remember how hurt I was when I was a client and my doctor wouldn't acknowledge me," said Placko, now a licensed clinical social worker in Park Ridge, Ill.

At the time of her treatment, Placko was living in Milwaukee and struggling with depression. She bumped into her psychologist at an art gallery. Though he did greet her, he then said he couldn't talk with her. "This was before I was taught about confidentiality," Placko recalled.

Her doctor explained his reasoning when they met again for their next appointment, telling Placko he had been concerned about betraying doctor-patient confidentiality in a place where others were within earshot. But Placko said the encounter still left her feeling cold. Since then, she's made a point of avoiding similar scenarios with her own clients whenever possible.

Though maintaining a client's privacy and anonymity is paramount in social work, she said encountering a client in a public setting isn't always avoidable and that social workers must be prepared for how they'll react.

"I think we do far more damage when we say 'I can't talk to you,'" she said.

Donald Doornbos, a daytime care manager for the State of New York Office of Mental Health, has also had to think on his feet when unexpectedly confronted with clients in public areas.

"I totally leave it up to them to acknowledge me," said Doornbos, an LCSW-R with a part-time private practice in Birmingham, N.Y. Though he might give clients a look of recognition, he said he won't gesture to them or approach them unless they initiate contact.

Placko follows the same rule of thumb, but said complications arise if she can't immediately recall how she knows the person."It's like, I know you, but I can't place you," she said. Once she does place them, it might be too late to avoid engaging the person. If that happens, she will usually apologize as discretely as she can.

Engaging a client cautiously is an "acknowledgment of that sacred space we have," she said.

Her clients need to feel comfortable with her, and that's a reality whether they meet in her office or elsewhere. So far, she said her clients usually have been gracious in how they respond to accidental meetings in public.

Working and living in a suburb of Chicago, Placko said her community of about 40,000 residents has a small-town feel that offers a greater likelihood of running into someone she knows, including clients.

Placko began her career 16 years ago in hospice doing a lot of home visits. She's run a private practice for the last 10 years and made it her primary focus about two years ago.

Privacy is a necessary part of the job, she said, but the reality is, "We have lives."

Ignoring someone is usually not an option, she said, recalling when a client of hers came up behind her in the grocery store checkout line.

"She clearly recognized me," Placko recalled. "How do I not acknowledge her?"

Doornbos and Placko said accidental meetings require some quick thinking, but both social workers also prepare their clients for such scenarios during initial therapy sessions. This practice lays out expectations for all parties, informing clients of the importance for privacy while also helping therapists better understand their clients' concerns about others in the community becoming aware of their treatment plans.

"Basically, I call my office the Chamber of Secrets," Placko said. Information discussed in sessions isn't leaving the office, she explained. A white noise machine even makes it so her office neighbors can't hear the details of conversations, or vice versa.

"I do my best to keep that enclosed space, and that's really great for a lot of clients," she said.

Dawn Hobdy, an LCSW and director of NASW's Office of Ethics and Professional Review, stressed the importance of that first meeting between client and counselor for establishing expectations.

Ideally, that's a conversation to have at the beginning, though she said social workers should also revisit this conversation as often as necessary.

"It's one of those things that social workers should have in their toolbelt," she said. "Especially if you live in a small community."


Walk and Talk Therapy


Though meeting clients in public settings has long been a challenge social workers face, the advent of new therapies or technology in recent years has increased their concerns for maintaining clients' privacy.

One such concern is for Walk and Talk Therapy, which has been in practice for years but offers a range of complications depending on where and how it's used.

Simply put, Walk and Talk Therapy, or WATT, takes a therapy session outdoors by offering clients a chance to get some exercise and commune with nature while talking through issues with their therapist. For certain clients, the act of moving while talking can be a welcome distraction from confusing or unpleasant thoughts while they work through difficult issues.

Doornbos has experienced success using WATT with some of his less verbal or anxious clients as "a release that calms and quiets their minds. It gives them an outlet that oftentimes can help them think more clearly, speak more clearly about their experiences."

Many of his clients have post-traumatic stress disorder and feel more at ease outdoors than in a cubical or on a couch, he explained, adding that WATT "increases their comfort level."

When it comes to stress, he said, "The body keeps a score. Often, trauma survivors are more acutely aware of their physical symptoms."

He also has found that sitting for long periods at a time can be like bottling up emotions for such clients; some of them have felt they can't express themselves as well during a therapy session if they're sitting down.

Placko has used WATT to help ease an agoraphobic client into the world slowly through controlled situations. She's also found it useful in helping grieving clients get through difficult times in their lives.

"I go over the risks so they can make an informed decision," she said. Many times, her clients don't take her up on the therapy, because they feel safer in the enclosed setting of her office, they would rather be free from distractions, or they aren't much for walking.

But Placko said WATT can offer all the same measures of safety that would be available in her office, such as confidentiality and easy access to medical aid.

It's important for her to have a "sort of bubble of safety" around her conversation with a client, "So I try to create that."

Lisa Wessan, a psychotherapist and life coach living in Westford, Mass., touts WATT for its psychological benefits to her clients.

She has found it can help the brain process trauma in similar ways to other physical methods, such as trauma-informed yoga, a type of yoga that focuses on helping people who have suffered through traumatic events or situations.

"It has to be a good fit for them," Wessan said of WATT.

She refers potential WATT participants to guidelines outlined at HikeSafe.com, so she and her clients can better ensure their safety while outside together. She also has them sign her indemnity agreement, review the legal and privacy issues, and agree to follow the guidelines of the website's Hiker Responsibility Code.

"There's a certain way to go hiking to keep it simple and safe," Wessan said.

In addition to advising hikers to prepare themselves ahead of time with knowledge and weather gear, like proper footwear, the site outlines other ways hikers should take responsibility for themselves: Leave your hiking plans with someone who knows where you are in the event you need help; stay together on the trail; turn back if conditions get bad; and be prepared in case of emergencies.

Wessan is co-chair of NASW's Northeast Private Practice Shared Interest Group and hosts "The Lisa Wessan Show" on cable TV to explore best practices in transformation and healing.

She teaches Dialectic Behavior Therapy (DBT) and facilitates several DBT groups in Westford. She also uses DBT in individual and family therapy. The NASW Private Practice SIG meets on the first Friday of each month in Westford.

At her website, lisawessan.com, she says her WATT therapy sessions consist of about 35-40 minutes of walking at a comfortable pace, followed by 10-15 minutes reserved at the end for sitting on "a lovely bench overlooking a beautiful lake." Clients may walk longer or shorter times, if they like.

At the end, she and her client review and summarize what was shared on the walk, and then contemplate the client's solution-focused next steps. Her site says the session is greatly strengthened by the beauty of the location and opportunity to be filled with nature's healing energy. "Something about moving É is a good release," Wessan said. "Plus, it's fun."

"Any movement that stimulates the bilateral brain, such as walking, swimming, some yoga positions, will help release stressful thoughts and allow the client to withstand the discomfort of sharing painful thoughts with more ease."

Despite their success so far, Placko, Doornbos and Wessan all recognize it's easier to use WATT in settings where clients are less likely to be seen or overheard by anyone they know, such as bigger towns or cities, or along wooded pathways where there are fewer ears to hear them.

"Being out among nature I think is really helpful for people," said Placko, who likes to bring her clients to area botanical gardens. "[And] it just looks like we're out exercising."

Wessan said she researched WATT for several years before taking on the practice in 2014, reading articles and books and searching out suitable locations around Massachusetts and in Nashua, N.H., where she could bring clients. The places she found are all accessible to clean bathrooms; have safe, private pathways for walking, are equipped with chairs or nearby benches, and are near a lake or river.

"The privacy issue is one obstacle," she said. But otherwise, "I think it's worth it. Obviously, it's not for everybody, but I think it's great."


Old Concerns, New Ways


Despite the potential benefits that WATT can bring to a social worker's practice, there are some concerns that go beyond who from the community might be listening.

Hobdy has concerns about the unpredictable nature of WATT or other therapeutic methods that remove a session from the safety of a controlled office setting.

She wonders if social workers will take adequate notes while walking outdoors with patients or devote enough attention to their clients' words or facial cues. She also fears for emergency situations that could render social workers alone on a deserted pathway with a client in need of medical care.

There's a "serious limit" to protecting a client's privacy and security while outside, she said, and these are some considerations she recommends before social workers decide to use a form of therapy they haven't tried.

Advances in technology are also a concern for Hobdy, who said she hears from about 50 social workers each week who call her office with questions of ethical challenges in their work.

Privacy comes up a bit in these conversations, she said. Though largely she's noticed that her callers are well-versed in how to maintain their clients' privacy, she has noticed an uptick in calls that surround the use of technology in traditional therapeutic methods.

"We are starting to see some of the old concerns presented in new ways," she said.

Technology provides a way to reach clients in ways that socials workers couldn't before - such as by phone, through texting or instant messenger, or by video chat. These methods all present challenges for social workers to ethically and competently perform their jobs.

In areas that aren't private - whether walking outside or chatting online - she said social workers are seriously limited in how they can protect a client's privacy.

In late 2017, the NASW Delegate Assembly approved 19 new standards and additions to the longstanding NASW Code of Ethics, a highly accepted standard for worldwide social work ethical practice. The recent additions address the way technological advances affect social workers.

The code is explained as a set of guidelines, not rules:

The Code offers a set of values, principles, and standards to guide decision-making and conduct when ethical issues arise.

"... the NASW Code of Ethics does not specify which values, principles, and standards are most important and ought to outweigh others in instances when they conflict. Reasonable differences of opinion can and do exist among social workers with respect to the ways in which values, ethical principles, and ethical standards should be rank ordered when they conflict."

Ethical decision-making requires "the informed judgment of the individual social worker," the Code states.

Recent additions to the Code include sections e and f under the Conflicts of Interest subheading:

(e) Social workers should avoid communication with clients using technology (such as social networking sites, online chat, email, text messages, telephone, and video) for personal or non-work-related purposes.

(f) Social workers should be aware that posting personal information on professional websites or other media might cause boundary confusion, inappropriate dual relationships, or harm to clients.

That's not to say social workers aren't using technology to great benefit.

Wessan has used technology for years. While working at New York City-based national telehealth provider AbilTo from about 2008 to 2010, she used video chat software to communicate with homebound clients.

She now uses Regroup Therapy for HIPAA-compliant, encrypted video therapy sessions, available at regrouptelehealth.com, to continue relationships with longtime clients who have moved away for school or work, but who want to maintain their relationship with her.

"I have many people who I see internationally now," she said. But that doesn't mean all forms of technology are equal, and she stressed the importance of using encrypted software to protect against hackers.

Wessan doesn't use Skype to interact with clients, since she said it can easily be hacked.

She said she's also wary of FaceTime, which made headlines in January when it was discovered that Apple software users could eavesdrop on each other's private conversations, even accessing video of unsuspecting Mac or iPhone users. Though Apple admitted the issue was caused by a software bug, this serves as yet another concern for social workers who might consider using any number of tech devices in their work.

It can be tempting to use the latest technology, Hobdy said. "[But] we have to do so responsibly, and there are limits."

"Some of them don't allow us to practice ethically," she said. "But when it works, it's great."