If someone wakes up at 2 a.m. and can’t sleep because they’re upset about something, help may not be too far away, says Frederic Reamer, an expert in social work ethics.
Technology has made this possible, he says.
“It’s pretty much a guarantee that someone can reach out, 24/7, 365 days a week, and there will be a social worker somewhere who can help,” says Reamer, a professor at the Rhode Island College School of Social Work who gave a presentation called “The Interface of Ethics and Technology” at NASW’s national conference in July. He also spoke on the same topic at the association’s 2012 hope conference.
Reamer says there is a long list of digital and online services social workers are using, like online social networking sites, Web-based avatars, smartphone apps and text messaging. At the top are video counseling and email counseling, which he says social workers may use synchronously and asynchronously.
“Synchronous means that the client and social worker will schedule an appointment to be online at the same time, chatting online or emailing back and forth,” he says. “Asynchronous means a client can send an email to a social worker about an issue that’s troubling him or her — even at 2 a.m. — and expect a response within 24 hours.”
With more and more social workers using technology to deliver services, it’s important for them to be aware of the advantages and challenges, Reamer says.
“Social workers really need to look at individual forms of technology, how it’s being used, and the potential benefits and risks associated with it,” he says.
NASW member Celia Woolverton says there are a lot of things to be mindful of when using a technology like video therapy/counseling, which involves a client and social worker meeting through an online video platform on their own computers. Both parties will be able to see and talk to each other in real time — no matter where they are located — for the duration of the session.
Woolverton says she used to have a private practice in Nashville, Tenn., but moved to New Hampshire. Before moving, she did what any good therapist would do and offered referral services for her Nashville clients. But that didn’t really work.
“Literally 98 percent of my clientele didn’t want to be referred and didn’t want to work with someone else,” she says. “So what I offered was to video conference with them three weeks out of the month, and one week a month see them in person in Nashville. I’ve been doing this for four and a half years.”
Woolverton is licensed as a clinical social worker in New Hampshire, Tennessee and Massachusetts and treats patients from all three states in person and through video therapy. But she says social workers have to be careful from a legal standpoint if they use or want to explore using an online video option, as “telehealth” laws vary from state to state.
“If I have a patient in California, I’d need to be licensed in California to do therapy,” she says. “You have to be very careful about things like that, and be responsible.”
Reamer says it’s important to note that social workers should use online video software that is compliant with the Health Insurance Portability and Accountability Act (HIPAA), and that maintains the patient’s privacy.
“Skype is deemed by many lawyers to not be HIPAA compliant,” Reamer says. “Social workers should be sure to use special online video software that is.”
NASW member Mike Langlois, who uses several online tools in his clinical social work practice in Cambridge, Mass., says an online video format may say it is HIPAA compliant, but it’s important to verify this. Check to see if the site has an online copy available of its business associate agreement with the government stating they are indeed HIPAA compliant and will share risk with providers for HIPAA compliance, he advises.
“If the business associate agreement isn’t available, they may not be HIPAA compliant — even if they say they are,” he says. “If it is not HIPAA compliant, there could be risk involved.”
Other challenges with video therapy include spotty Internet connection, lack of face-to-face and eye contact, and the possibility of missing nonverbal cues, Woolverton says.
“The lack of face-to-face and eye contact, which is obviously huge to the nonverbal cues we give off, may mean that I miss a client shaking their foot or pinching their fingers — things that would be meaningful for me to take note of,” she says.
This is why it’s important to schedule in-person appointments with clients in addition to video therapy, and to screen clients for profound mental health issues and suicidal tendencies before deciding if video therapy would be appropriate, she adds.
“I’m very grateful for my once-a-month visits face to face, and I make sure to see a person first before saying yes to video therapy,” Woolverton says. “It’s not the best option for everyone.”
Although video therapy may not work for some people, it can work very well for those who live in rural areas or those who struggle with things like work-related issues and need occasional counseling, says NASW member Tara Bulin, a licensed clinical social worker who offers online services through Ask The Internet Therapist.
“Video counseling bridges the gap for those who are not able to access mental health care because of distance, and allows them to speak to a social worker from the comfort of their home,” says Bulin, who lives on Long Island, N.Y.
Woolverton says this type of therapy also works well with the college-aged crowd, because they have high-functioning, busy lives.
“This group tends to be very comfortable with video therapy,” she says. “It can also be a good option for those with a disability who can’t leave their home, those who live in areas with bad weather, those with anxiety, and those who have agoraphobia and may fear leaving their house,” she says.
It’s important to keep checking on what’s current, since video therapy hasn’t been around that long, she adds.
“This way of seeing clients is still extremely new, every state is looking at it, and it changes frequently,” Woolverton says. “You can’t always go by what one source says, because next week it could be something different.”
Video games and apps
Langlois says Minecraft is one video game that’s great to play with clients.
It’s a game where players create artwork, structures and different “worlds” within a virtual space that mimics the appearance of an actual sandbox.
“Games like Minecraft can tell me a lot about the client,” Langlois says. “It’s an amazing sandbox environment that you can use in play therapy to do all kinds of therapeutic things. It’s an emulator of consciousness.”
He says online therapy platforms — such as the asynchronous and synchronous methods — make up about 20 percent of his clinical practice.
He works with a lot of children and adolescents and likes to use video games as a component of play therapy. It helps him relate to their experiences and it can be a healthy adaptive coping tool, Langlois says, adding that video games are like another form of social media, especially for his younger clients.
“I am a gamer-affirmative therapist, which means I won’t immediately ask a client how many hours of video games they play. And if they say three to five hours, (I won’t) make them feel like there is a problem with it or assume there is an addiction issue,” Langlois says. “Rather, I’ll ask them what games they are playing and what they have achieved in it.”
He says incorporating video games in play therapy can be more effective than using other perhaps outdated methods, like playing Uno. The mainstream media talk about video games causing violence and being dangerous, but Langlois says there should be more awareness about the positive benefits.
“I’m certainly not the first person to use video games in therapy, but I think there definitely needs to be more people out there that are helping clinicians understand the therapeutic components and benefits,” he says. “Some may be a little hostile to technology, or mistrustful, and as many of us get older we fear becoming irrelevant. They may not know anything about video games and, as a result, dismiss it.”
Langlois says in order to be sure the games are played in a HIPAA-compliant way, he does not play video games with clients outside of his office. He also makes sure to use encrypted email and chatting platforms for anything that deals with clinical content so he can protect patient privacy.
“I like to use GoToMeeting for video and online chat, as this is HIPAA compliant,” he says. “And online chat is especially helpful when working with clients who are hearing impaired.”
Langlois also uses some apps, such as Pinterest, to help clients learn how to self-soothe in a pinch. He recommends using larger-market apps that have capital backing, as these have the potential to be around longer and to be successful.
“I recommend for a client who wants to develop a better ability to self-soothe under distress to select images that are cooling and calm for them — like polar bears and glaciers — and set up a Pinterest app that they can refer to whenever they need it,” Langlois says.
With social media and technology developing so rapidly, patients will expect a lot more of social workers, he says, adding that the notion of privacy doesn’t quite exist in the same way it once did.
“To paraphrase Ray Clifford, an educator, I do not believe social workers will ever be replaced by technology, but social workers who don’t use technology will be replaced by social workers who do,” Langlois said. “We should get past whatever the fear is of not knowing something and become more comfortable with exploring.”
Listen to Frederic Reamer talk more about emerging ethical and regulatory standards as they relate to social workers embracing technology.
Task force addresses use of technology in social work practice
In 2012, the Association of Social Work Boards put together a task force to address the use of technology and social work practice.
The issue had been on ASWB’s radar for some time, says ASWB CEO and NASW member Mary Jo Monahan.
“We have been developing relationships with social work regulators across the world to put together the International Technology Task Force,” Monahan says. “There are 13 members on it and we have representatives from ASWB, NASW, CSWE, and the Canadian Association of Social Workers, which is NASW’s counterpart in Canada.”
The task force has met periodically over the last year and a half. Monahan says ASWB will work closely with NASW and CSWE to update the 2005 Technology Practice Standards jointly developed by ASWB and NASW. The document — called the Model Regulatory Standards for Technology in Social Work Practice — will be distributed to social work regulatory boards for use in their regulatory work.
Dawn Hobdy, director of ethics and professional review at NASW; and Mirean Coleman, NASW senior practice associate, are members of the task force and will represent NASW in the development of the revised technology standards.
Frederic Reamer, who is chairman of the task force, says the standards address six key areas of concern that involve social work and technology:
- Informed consent
- Privacy and confidentiality
- Boundary-related issues
- Social worker competence
- Records and documentation
- Collegial relationships
“(The standards) will look at challenges, such as boundary issues involving Facebook, encryption, accessing records and appropriate online behavioral conduct,” Reamer says.
The regulatory standards are scheduled to be adopted by the ASWB board of directors this month and ready for publication in early March.
The standards could be applied to the social work profession nationwide, as well as internationally in Ireland, New Zealand and Wales, Monahan says.
Download the Model Regulatory Standards for Technology in Social Work Practice (PDF) through the ASWB website.