Technology in counselling

Volume 35INumber 3IJuly 2OI3iPage$ 211-227

Text Messaging and Private Practice:Ethical Challenges and Guidelines forDeveloping Personal Best Practices

Michael E. Sude

The impact of technology on mental health practice is currently a concern in the counselingliterature, and several articles have discussed using different types of technology in practice.In particular, many private practitioners use a cell phone for business. However, no article hasdiscussed ethical concerns and best practices for the use of short message service (SMS), betterknown as text messaging (TM). Ethical issues that arise with TM relate to confidentiality,documentation, counselor competence, appropriateness of use, and misinterpretation. Thereare also such boundary issues to consider as multiple relationships, counselor availability, andbilling. This article addresses ethical concerns for mental health counselors who use TM inprivate practice. It reviews the literature and discusses benefits, ethical concerns, and guide-lines for office policies and personal best practices.

Teehnology is evolving rapidly (Haberstroh, Parr, Bradley, Morgan-Fleming, & Gee, 2008) and ean help elinicians free up time and spaee(MeMinn, Orton, & Woods, 2008). In partieular eounselors are using cellphones to eonduet business (Baker & Bufka, 2011; McMinn et al., 2008)because they provide options for communicating with clients at the clini-cian's convenience (McMinn et al., 2008).

Cell phones can be used to connect with clients for administrative taskslike scheduling, cancelling, and rescheduling; to send appointment remind-ers; and to communicate brief thoughts or questions between face-to-faee(FTF) meetings. Smartphones may have the ability to connect to the Internetand interact with others in a variety of ways, but almost all cell phones at leasthave a text message option.

Individuals are increasingly communicating via short message service(SMS), better known as texting or text messaging (TM; Boschen & Casey,2008; Militello, Kelly, & Melnyk, 2012). TM is now used clinically to providesupport or interventions for certain conditions and populations (Merz, 2010).Text messages can include pictures, videos, and text up to 160 characters

Michael . Sude is affiliated with La Salle University and maintains a private practice in the suburbsof Philadelphia. Correspondence about this article can be directed to Dr. Michael . Sude. La SalleUniversity, Psychology Department, 1900 West OIney Avenue, Philadelphia, PA, 19141. Email: [email protected].

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(Coss & Ferns, 2010; Merz, 2010; Militello et al., 2012). Although TM usu-ally occurs between cell phones, messages can also be sent ftom email andweb sites (Merz, 2010). For counselors in private practice, TM is a low-costand convenient tool.

All forms of technology have ethical implications that raise concernsfor counselors (Baker & Bufka, 2011; Baltimore, 2000; McMinn et al., 2008;Van Allen & Roberts, 2011; Zur, 2010). As a result, every conversation aboutusing technology in practice must discuss ethics and ethical decision-making(McMinn et al., 2008). Centore and Milacci (2008), who studied distancecounseling, reported that counselors experienced decreased ability to fulfilltheir ethical duties for all types of distance counseling, which underscoresthe need for training on the ethical issues in using technology in practice.Studies addressing best practices for specific types of technology (Baker &Bufka, 2011), including TM, are lacking.

This article explores TM benefits and ethical concerns for counselorsin private practice and offers guidelines for personal best practices. It reviewsthe literature on use of technology in private practice and of TM for clinicalinterventions. Spcifie clinical benefits and ethical concerns are outlined.Although they are likely to use TM to communicate with clients, becauseprivate practitioners are not likely to have received technology training,they have the greatest need to manage ethical risks carefully. As Bradley,Hendricks, Lock, Whiting, and Parr (2011) said about e-mail, my purpose isnot to decide for counselors whether or not they should use TM in privatepractice but rather to raise awareness of ethical concerns to help them makemore informed decisions.

RESEARCH ON USE OF TECHNOLOGY IN PRACTICE

Private PracticeMcMinn, Buchanan, Ellens, and Ryan (1999) conducted one ofthe

earliest studies on use of technology in private mental health practice (N =429). Behaviors cited most often as unethical were compromising client con-fidentiality by allowing others to access client information and conductingany clinical services online or through email.

In another early study, Negretti and Wieling (2001) explored issues formarriage and family therapists (N = 42) in terms of boundaries, being avail-able to clients out of session, and engaging in ethical practice. Only 50% ofthe clinicians then surveyed used email and only 36% cell phones, comparedto 40% who used pagers. None ofthe respondents who gave out their emailaddresses reported charging for email interactions, and only 13% who used itwarned clients about confidentiality' and privacy risks.

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Text Messaging and Private Practice

Recently, McMinn, Bearse, Heyne, Smithberger, and Erb (2011) exam-ined the responses of private psychologists (N = 296) to questions about theethical implications of technology use, including email, cell phones, andTM. Respondents most often reported using cell phones to provide clinicalservices and store client contact information, and scheduling appointmentsthrough email. The biggest ethical concerns were providing clinical servicesvia TM and email.

Perceptions of Technology UseCentore and Milacci (2008) surveyed clinicians about how they used

different fypes of distance counseling. Online, real time text-chat wasreported by 5.6% of participants and 28.1% reported using email; of all fypesattitudes toward text-chat were most negative, among them perceptions ofdecreased abilify for counselors to build rapport with clients and decreasedabilify to assess and treat clinical issues and deal with crises.

Two studies (Haberstroh, Duffy, Evans, Cee, & Trepal, 2007; Leibert,Archer, Munson, & York, 2006) investigated client perceptions of technol-ogy-mediated counseling. Leibert et al. (2006) found that email and instantmessaging (IM) were the most common fypes of communication reported,and both studies reported convenience and privacy/comfort as benefits.Participants in both reported that the lack of audio/visual cues impactedinteractions, but anonymify provided safefy for self-disclosure (Haberstroh etal., 2007; Leibert et al., 2006).

TEXT MESSAGING AND OTHER TEXT-BASED COMMUNIGATION

Two reviews of TM in clinical practice (Militello et al., 2012; Wei,Hollin, & Kachnowski, 2011) concluded that it may be a helpful adjunct toFTE services; however, the limitations of the few studies make it impossibleto draw clear conclusions about its clinical effectiveness. Recent studieswere related to crisis intervention (Coss & Ferns, 2010) and eating disorders(Bauer, Okon, Meermann, & Kordy, 2012; Shapiro etal., 2010). TM may alsohelp prevent relapse after termination (Aguilera & Munoz, 2011; Shapiro &Bauer, 2010; Shapiro et al., 2010); initiate search for mental health services(Coss & Ferns, 2010; Joyee & Weibelzahl, 2011); and help individuals pursueoutpatient services after inpatient treatment (Bauer et al., 2012).

Furber et al. (2011) studied TM between youth in treatment and thera-pists and discovered that most of the interaction dealt with coordinating FTFmeetings. In a small pilot study, patients in a psychotherapy group reportedthat TM helped with attendance (Aguilera & Munoz, 2011). In a muchlarger pilot study in the United Kingdom (UK), sending clients text messagesseveral days before scheduled appointments improved attendance 25-28%. If

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the rates for the clinics studied were extended to the entire UK, the annualnational savings would be close to US$250 million (Sims et al., 2012).

No other published research into individual counselors sending andreceiving text messages with clients could be found. In other words, all thestudies listed involve programmable software that manages sending text mes-sages to certain populations or clientele at certain days and times. Gounselorsin private practice will likely not have the training or the software for that;they will probably be sharing TM through their cell phones. More research istherefore needed on the benefits and risks of TM interactions for counselorsin private practice.

Advantages of Text-Based InteractionsElectronic text-based interactions include TM, IM, and email, which

all have benefits for both clients and counselors. One advantage is flexi-bility (Shapiro et al., 2010); text-based communication may be used bothsynchronously (immediate response) and asynchronously (lag time betweenresponses; Suler, 2000). Also, the stigma of speaking with a counselor is less-ened because ofthe anonymity of text-only interactions (Gentore & Milacci,2008; Suler, 2000), which may lead clients both to be more candid (Suler,2000) and to experience increased ownership of the counseling process(Gentore & Milacci, 2008). The pace and process of writing in asynchronousinteractions can, like journaling, help clients process and express thoughtsand feelings (Gentore & Milacci, 2008; Haberstroh et al., 2007; Suler,2000). Some clients may express themselves better in writing (Suler, 2000),and text-based counseling helps clients feel less pressure about disclosing(Haberstroh et al., 2007; Suler, 2000).

Beyond the clinical benefits, cell phones are so common that theyattract little attention from others, so individuals can use them with little fearof social stigma (Boschen, 2009; Gentore & Milacci, 2008). TM, in particu-lar, is widely available (Militello et al., 2012) because it costs little (Aguilera& Muoz, 2011; Boschen, 2009; Boschen & Gasey, 2008; Shapiro et al.,2010) and does not require a smartphone (Aguilera & Muoz, 2011). TM isalso convenient (Goss & Ferns, 2010; Shapiro et al., 2010); is accessible atany time (Boschen, 2009; Gentore & Milacci, 2008; Militello et al., 2012;Shapiro et al., 2010); and offers privacy and anonymity (Goss & Ferns, 2010).Individuals who are highly sensitive to others' perceptions or reactions mayprefer a method of communicating that feels safer (Gentore & Milacci, 2008;Haberstroh et al., 2008; Leibert et al., 2006).

For counselors, text-based interactions are easily documented (Suler,2000). Haberstroh et al. (2008) reported among the clinical advantages theability to review the transcript ofthe interactions during the session to clarify

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previous wording, and the slower pace allowing more time to reflect on theclinician's own responses.

TM also offers the ability to have regular contact between sessions(Aguilera & Muoz, 2011) and to remind clients of skills learned ETE tohelp prevent relapse between meetings (Boschen, 2009). Eor administrativetasks like scheduling, cancelling, or rescheduling appointments and sendingbilling or appointment reminders, TM can save private counselors timebeeause it can be read and responded to asynchronously (Boschen, 2009;Sims e t a l , 2012).

Eor some elients TM can also serve as a transitional object or a tangibleway to remain connected to the counselor (Neimark, 2009). TM may helpelients through the times between therapy sessions, much like ealling aeounselor's voice mail and leaving messages that do not need to be returned(Gutheil & Simon, 2005). Texts from counselors to clients also serve astransitional objects, similar to the letter-writing common in narrative therapy(Winek, 2010).

In family counseling, TM can help family members who struggle tointeract with eaeh other in real time. Asynchronous TM allows them to taketime to make meaning of messages received and to formulate responses thatcan be edited before being sent. The counselor can be eopied on messagesbetween family members so that there is no eonfusion about the words eom-munieated, and so that there is a monitor of the communication. Koocher(2009) described using email with separated or divorced parents to commu-nicate about visitation schedules and other parenting issues.

TM has also been cited as a particularly helpful adjunct for Gognitive-Behavioral Therapy (GBT; Boschen, 2009; Boschen & Gasey, 2008; Shapiro& Bauer, 2010). It can be used for self-monitoring (Boschen & Gasey, 2008;Shapiro & Bauer, 2010) and to report on or complete homework (Boschen,2009; Boschen & Gasey, 2008; Shapiro & Bauer, 2010). TM lessens thepossible shame of carrying around paper and pen and allows clients tosend counselors information and reeeive feedback more quickly (Shapiroet al., 2010). TM time and date stamping helps keep the information beingexchanged more accurate than is possible with journals (Shapiro & Bauer,2010). Messages can be sent at set times and can be helpful when ETE orphone contact is not possible or appropriate. Asked by TM for information,counselors can respond immediately, respond later, and store communica-tions electronically (Boschen & Gasey, 2008). Einally, as distance counsel-ing, TM is an option for clients who live in rural areas or cannot leave homebecause of disability or illness (Gentore & Milacci, 2008).

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Limitations of Text-Based InteractionsOne limitation is the lack of a sense of therapeutic presence (McAdams

& Wyatt, 2010; Suler, 2000)clients may have difficulty feeling connectedto counselors because there are no audio or visual cues (Centore & Milaeci,2008; Haberstroh et al., 2007; Haberstroh et al., 2008; Siiler, 2000). Theymay also feel less understood, less cared for, and less safe (Centore & Milaeci,2008). Text-based interactions may also lack spontaneity (Suler, 2000), andthe slower pace eould limit disclosure (Haberstroh et al., 2007).

Another limitation can be the technology itself (Haberstroh et al.,2007; Haberstroh et al., 2008). TM technology can fail, so that messages arenever sent or received (Shapiro & Bauer, 2010). Also, some clients may notknow how to use cell phones or be able to read messages because of limitedeyesight, and some may be unable to afford TM (Aguilera & Muoz, 2011;Shapiro & Bauer, 2010).

The main limitations of TM interactions are the ethical concerns theyraise and the lack of regulations and ethical guidelines for best practices.Wliat follows addresses the guidelines that do exist and then explores specificissues that are important for counselors to consider if they choose to use TMin private practice. The last section suggests best practices for each of theethical concerns raised.

Ethical and Regulatory GuidelinesTechnology evolves so quickly that state regulatory boards and profes-

sional organizations may never be able to provide guidance for using specifictypes in practice (McAdams & Wyatt, 2010; McMinn etal., 2008; Nicholson,2011; Van Allen & Roberts, 2011). However, some state boards and pro-fessional organizations do provide general guidance for doing so (Baker &Bufka, 2011; McAdams & Wyatt, 2010).

Bradley etal. (2011) noted that the American Mental Health CounselorsAssociation (AMHCA) Code of Ethics (2010) is current on providing guid-ance for the use of technology. The seetion dedicated to technology-assistedcounseling provides guidelines for preserving confidentiality when transmit-ting and storing information electronically. The AMHCA has also publisheda white paper (2012) as a companion to the Code of Ethics (2010) that makesrecommendations for technology-assisted counseling. The white paperrecommends, for instance, that counselors be "technologically savvy in themodality of communication being used," plan for crises and use with at-riskclients, and encrypt all text-based communication.

The American Counseling Association (ACA) Code of Ethics (2005)also has guidelines for counselors using technology in practice. It addressesconfidentiality, encryption, counselor competence, appropriateness for treat-

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ment, emergency protocols, expectations of responses, and billing policies(Bradley et al., 2011; Trepal, Heberstroh, Duffey, & Evans, 2007).

Furthermore, as of mid- to late-2008, 14 state boards had issued reg-ulations for technology-assisted counseling, and 20 more were drafting ordiscussing such regulations (McAdams & Wyatt, 2010). Ten states have pro-hibited technology use, and many boards have supported it conditioned onspecial circumstances (McAdams & Wyatt, 2010).

ETHICAL CONCERNS FOR PRIVATE COUNSELORS

Although counselors can currently use several types of technologyin practice, many have little understanding of the associated ethical risks(McAdams & Wyatt, 2010). For eounselors using TM as an adjunct to FTFservices, ethical concerns include confldentialify, documentation, counselorcompetence, appropriateness of use, and misinterpretation. Boundary issuesto consider include multiple relationships, counselor availability, and billing.

ConfidentialityThe primary ethieal concern for counselors who use TM is informa-

tion security (Bosehen & Casey, 2008; Merz, 2010) because ofthe risk ofviolating client eonfidentialify (Bradley et al., 2011; Furber et al , 2011; Zur,2010). Among TM identifleation problems are not knowing whether a elientis alone when receiving a text, whether the client is actually the one texting,and whether someone else has access to the client phone and saved conver-sations (Suler, 2000). Like email (Barnett & Scheetz, 2003), text messagesare more like postcards than private letters and, like voice mail, clients mayassume that only counselors can access them (McMinn et al., 1999). Alsolike email (Cutheil & Simon, 2005; Van Allen & Roberts, 2011), they canaccidently be sent to the wrong person.

Portable electronics and the information stored on them can be easilylost or stolen (Van Allen & Roberts, 2011; Zur & Barnett, 2008), and even thedigital contact list on a counselor's cell phone can compromise eonfidential-ify. Finally, keeping information confidential is not completely in the controlofthe phone owner (Van Allen & Roberts, 2011). For example, counselorsneed to consider the risk to confldentialify if TM is intercepted by hackers(Merz, 2010).

DocumentationBesides protecting the information exchanged, counselors need to

know how to securely document and store text messages. McMinn et al.(2008) questioned what constitutes secure password protection or encryptionfor electronic records storage and transfer, and what can be done to ensure

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that confidential information cannot be retrieved when electronic devicesare disposed of. As clinical contacts (Zur, 2010), like e-mail (Bradley &Hendricks, 2009; Gutheil & Simon, 2005; Zur, 2008, 2010), text messagescan be subpoenaed as part ofa client's file. Providers also must be preparedfor technology "death" and have secure backup services and a protocol fordisposing of dead technology (McMinn et al., 1999).

The counselor must give precedence to the client's rights to privacy andconfidentiality over any personal convenience (Nicholson, 2011), and how todo this for TM is not clear. For example, email should be printed and placedwith notes, but it is more like a transcript than a session summary (Gutheil& Simon, 2005). TM is a transcript of interaction as well, but may have lessinformation because of the character limits.

Counselor Competence, Appropriateness, and MisinterpretationBeyond confidentiality, there are ethical concerns related to counselor

competence, the appropriateness of using TM, and misinterpretation ofinteractions. Gounselors are rarely prepared or trained to use technologyproperly within professional relationships (Neimark, 2009; Van Allen &Roberts, 2011). For instance, as Haberstroh et al. (2008) noted for onlinecounseling, TM leaves open the possibility of interacting with several clientsat the same time, which can lead to distractions and mistakes.

Once counselors are trained to use TM, they will need to decidewhat types of interactions to use it for. TM can be a quick way to contactcounselors in crisis situations, any day or time, but Haberstroh et al. (2008)reported on situations when text-based interactions may not be appropriate,and self-harm was one. There are also practical barriers to the use of TM inemergencies. Gounselors may not receive messages immediately or be able toreach clients in crisis (Shapiro & Bauer, 2010), and neither party may knowwhether messages were received. In short, counselors must determine whenand how it is appropriate to use TM with clients.

There is also a higher chance of misinterpretation, misunderstandings,and confusion in text-based communication, especially with culture-specificlanguage and a lack of audio or visual cues (Baltimore, 2000; Barnett &Scheetz, 2003; Koocher, 2009). Glient difficulties with expressing themselvesin writing (Suler, 2000) may be magnified in TM because it is so hard toexplain something lengthy or complex in a limited space (Shapiro & Bauer,2010). Moreover, the lack of audio or visual cues may limit ability to makemeaning of interactions, so counselors must be able to tolerate ambiguity(Trepal et al., 2007) and check out assumptions.

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Boundary ConcernsOne possibility for misinterpretation is the counseling relationship

being interpreted differently. Counselors must be careful to avoid treatingelectronic communication with clients as off the record or casual. The possi-bility that casual or informal interactions might lead to boundary confusionfor clients has been explored for email (Bradley et al., 2011; Cutheil &Simon, 2005), and the risk is higher with TM because it is less common inprofessional relationships. Counselors may also reeeive inappropriate mes-sages from clients by mistake, or because TM is disinhibiting (Suler, 2000).

Furthermore, interactions through TM can be time-consuming, andthere is less time for actual exchange than in the same amount of FTF time(Trepal et al , 2007). This is a consideration for billing: Should TM be billedper text? per minute? or how? (Zur, 2008).

Cutheil and Simon (2005) raised concerns about billing for email inter-actions with clients. If email contact is not billed, clients could interpret it associal interaction. Failure to bill for clinical emails could also lead to issuesof countertransferenee if counselors come to feel resentful. Furthermore,counselors who fail to bill for email contact could be unknowingly collud-ing with clients to extend sessions. For example, many emails, ranging fromlong stories to seemingly easy questions expressed in one sentence, can takea great deal of time to read and respond to (Cutheil & Simon, 2005; Zur,2008). This can fit for TM as well, because one limitation of asynchronouscommunication is boundary confusion around appointments (Suler, 2000).Time spent communicating with clients through asynchronous communica-tion must be established by counselors (Bradley & Hendricks, 2009; Bradleyet al , 2011; Negretti & Wieling, 2001; Shapiro & Bauer, 2010; Zur, 2008) inorder to model self-care and boundaries. Counselors will need to determinepersonal best practices based on how they feel about being available outsideof session.

CUIDELINES FOR PERSONAL BEST PRACTICES

Van Allen and Roberts (2011) stated that newer generations of mentalhealth professionals, who have grown up with modern technology, oftenare naive about its privacy, security, and professional implications. In otherwords, familiarity with technology does not mean that counselors know howto avoid professional problems. Clinicians tend to use new forms of tech-nology in practice before fully understanding the risks. They do not need tobecome experts but should understand the technology they are using, weighrisks as well as benefits, and make decisions in terms of upholding ethicalcodes and regulationsthe ethical responsibility always lies with the pro-fessional (McAdams & Wyatt, 2010; Nicholson, 2011; Van Allen & Roberts,

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2011). The following section addresses specific issues already raised, but firstaddressed are general recommendations for private counselors who use TM.

The basic decision private counselors must make is whether or not touse separate cell phones for their business and personal hves. For counsel-ors in full-time private practice, a separate business phone may make sensebecause of the volume of contacts. Part-time counselors may choose to usetheir personal cell phone to conduct business, designate their voice mails"confidential," and provide emergency contacts for clients in crisis. However,it is recommended that counselors not use personal cell phones for clinicalpractice in order to protect the data exchanged, the therapist's privacy, andclinical boundaries (Shapiro & Bauer, 2010).

After securing a separate business cell phone, counselors should findout what technology-assisted services are covered by their hability insurancebefore using the phone as an adjunct to FTF practice (Baker & Bufka, 2011;Bradley & Hendrieks, 2009; Bradley et al., 2011). This is vital. Counselorsworking in agencies often have guidelines for how they can and cannot inter-act with clients, but private counselors decide for themselves.

If covered by liability insurance, the third step is for counselors to writeup consent policies addressing technology-assisted services (Baker & Bufka,2011; Barnett & Scheetz, 2003; Bradley & Hendrieks, 2009; Bradley et al.,2011; Merz, 2010; Negretti & Wieling, 2001; Trepal etal., 2007; Van Allen& Roberts, 2011; Zur, 2008, 2010; Zur & Barnett, 2008). Signed clientinformed consent is one ofthe clearest ways to manage risk and limit liabil-ity, and it allows clients to make informed choices about clinical services.The policies should be reviewed in a conversation at the start of servicesand periodically thereafter (Barnett & Scheetz, 2003; Bradley & Hendrieks,2009; Bradley et al., 2011; Merz, 2010; Trepal et al., 2007; Zur, 2008; Zur &Barnett, 2008). Each counselor must decide what the policies should cover.

Most state boards agree that the policies should inform clients of whatcan be expected in terms of technology-assisted services (McAdams & Wyatt,2010). Policies should address confidentiality (Baltimore, 2000; Barnett &Scheetz, 2003; McAdams & Wyatt, 2010; Trepal et al., 2007; Zur, 2008,2010); security measures to protect electronic information (Zur, 2010; Zur &Barnett, 2008); how to handle emergencies (Bradley et al., 2011; McAdams& Wyatt, 2010; Zur, 2008); what is appropriate to send to a counselorelectronically (Baltimore, 2000; Bradley & Hendrieks, 2009; Zur, 2008);appropriate times and ways to contact the therapist out of session (Negretti &Wieling, 2001); the times and frequencies when the therapist will communi-cate out of session (Bradley & Hendrieks, 2009; Bradley et al., 2011; Negretti& Wieling, 2001; Zur, 2008); and fees or billing policies for non-FTF contact(Bradley et al., 2011; Negretti & Wieling, 2001; Zur, 2008). The following

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subsections explore guidelines for drafting personal best practices for thesespecific ethical issues.

ConfidentialityAs with email (Bradley et al , 2011), counselors must inform clients that

third parties may be able to access electronic interactions. Private counselorscan do several things to help protect the information transmitted and storedon cell phones. Zur and Barnett (2008) provided practical recommendationsfor protecting portable electronic devices, sueh as removing unnecessary fileswhen traveling, never leaving deviees unattended, and never letting anyoneborrow them.

The SIM card in cell phones stores text messages, so password securityfor cell phones is also recommended. Furthermore, eounselors should sendand read text messages in private; eell phones should have spyware andantivirus software to help ensure privaey (Merz, 2010); and settings shouldbe adjusted so that messages do not appear when the phone is locked. Onsome cell phones counselors and elients can also set an option to send"read receipts" that will help both parties know whether text messages werereceived.

The use of a secure server and software that manages the texting is rec-ommended (Shapiro & Bauer, 2010), and any digitally stored informationon portable devices should be without identifiable confidential information(Nieholson, 2011). Although it would be more convenient for counselors tostore contacts by full names, it is recommended that they use only initials.Furthermore, passwords for files are insufficient; counselors should learnto code or enerypt confidential data stored on portable electronic devices(Boschen & Casey, 2008; Nicholson, 2011) and transmitted electronically(Trepal et al , 2007).

Counselors can encrypt messages using technology from cellular servieeproviders or using third parties (Merz, 2010). For smartphone owners, appsoffer options. Both sender and receiver may need the apps to decrypt mes-sages, or only messages already sent or reeeived (stored) may be enerypted,leaving them unprotected during transmission.

Confirming identity in each contact is also important (Baltimore, 2000;Barnett & Scheetz, 2003). There is no clear way to do this securely, but oneoption is for clients to use a code word to identify themselves. Another is forclients to begin eaeh TM interaction by answering a question agreed uponat the start of services. As a general rule, a eounselor communicating withclients through TM should pay close attention to the client's language tosee if it is aligned with previous TM interactions. Counselors should also bevigilant to double-check who the message is being sent to in order to avoidaccidentally breaking confidentiality (Van Allen & Roberts, 2011).

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DocumentationCounselors also need to decide how to store and document text mes-

sages after transmission. Text messages, like voice messages and emails, areclinical contacts (Zur, 2010). In order to limit the information stored onhighly portable cell phones, counselors may wish to transfer stored informa-tion. Archiving text messages involves either forwarding them to email to besaved or printed, taking screen shots of them with a smartphone and thensending them to email, or using third-party services to archive them (Zur,2010).

There must also be a plan for disposal of cell phones used for therapy thatis communicated to clients (Bosehen, 2009). When disposing of cell phones,counselors should wipe the data from the devices by resetting or reformattingthem (Barnett & Scheetz, 2003; Merz, 2010). Cell phone manufacturers canexplain how counselors can erase or reformat their cell phones.

Counselor Competence, Appropriateness, and MisinterpretationCounselors must consider their comfort level, competence with tech-

nology, and knowledge of TM before using it in practice (Bradley et al.,2011; Merz, 2010). They will need to determine how TM will be used witheach client (administrative tasks, support, intervention, etc.), and regularlyevaluate its helpfulness (Merz, 2010). They should be trained before usingany type of TM software, take time to learn to use the programs properly, andbe able to troubleshoot problems (Baker & Bufka, 2011; Bradley et al., 2011;Merz, 2010; Shapiro & Bauer, 2010). Counselors interacting with clientsthrough TM from home should have a designated space, sueh as a homeoffice, to limit distractions and keep interactions professional (Haberstroh etal., 2008).

For some clients, TM may not be appropriate or helpful (Shapiro &Bauer, 2010). Counselors must assess whether each client can use the tech-nology effectively (Bradley et al., 2011). Just as counselors must be familiarwith the technology used in practice (Negretti & Wieling, 2001), so must cli-ents. This would include how often elients use TM in daily life, how familiarthey are with common TM emoticons and acronyms, whether or not theycan afford the service, and whether they have reading or eyesight limitations.

If counselors determine that a client is competent with TM, they canhave a conversation to decide if the client would consider TM as an adjunctto FTF treatment (Bosehen, 2009). In these conversations counselors needto address handling clinical emergencies, such as self-harm, and discussemergencies, including having another way to contact the client, and anothercontact person for the client in case of emergency (Shapiro & Bauer, 2010).

Counselors should also be aware of different ways messages might beinterpreted, and discuss with clients at the start of services a protocol for

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handling misinterpretation (Shapiro & Bauer, 2010). They need to attend toboth TM content and process, be sensitive to cultural issues and stereofypes(Trepal et al , 2007), and be able to process TM interactions in FTF sessions(Neimark, 2009).

To help limit misinterpretation, both parties may add visual cuesthrough in-text graphics, spacing, punctuation, and use of caps (Suler, 2000).Counselors also need to become familiar with common acronyms used intext-based communication, such as, "LOL (laugh out loud), ROTFL (rollingon the floor laughing), AFK (away from keyboard)," and the use of emoti-cons or characters to convey emotions (i.e., :-( - sad or annoyed; :) - happy;"(::( )::) = a band-aid used to represent help)" (Trepal et al , 2007, p. 272).Counselors can also write out their own reactions and nonverbal responses(i.e., s m i l i n g , l a u g h i n g , etc.; Haberstroh et al , 2008; Trepal eta l , 2007).

Boundary ConcernsWhen using TM in practice, particular attention should be paid to its

tone and the professional language. This is difficult because the TM inter-action is designed to be concise. Counselors should reread text messagesbefore they hit "send," asking themselves whether they would say it the sameway in an FTF session. If not, language or tone must be changed (Cutheil& Simon, 2005).

Counselors who receive text messages from clients that they interpretas out of character or unprofessional should address their concerns withclients in therapeutic, nonconfrontational ways (Cutheil & Simon, 2005).Neimark (2009) depicted a scenario in which a client texts a clinician to saythat the previous session was "useless," and the clinician is unsure whether orhow to respond. Counselors should discuss with clients what information isappropriate to exchange through TM (Shapiro & Bauer, 2010). A counselorwho believes that a message received was inappropriate can respond thera-peutically by describing her or his own experience of the message, askingabout the client's intentions, not pathologizing the interaction, and givingprecedence to the client's needs.

To avoid feeling on call, counselors should also decide how much timethey will be available through TM and communicate the decision to clients(Koocher, 2009; Shapiro & Bauer, 2010). As with any other technologicaladjunct, there must be clear agreement on TM boundaries and billing poli-cies (Boschen, 2009; Shapiro & Bauer, 2010). One option is for clients to beable to send messages any time, and for counselors to respond at predeter-mined times (Shapiro & Bauer, 2010). Similarly, Bradley et al. (2011) sug-gested setting a time of day to check and return emails and setting boundaries

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around when they are not checked or returned, such as nights and weekends.Presented in this way, it is made clear that TM is asynchronous only.

Gounselors must also decide how to bill for TM because in private prac-tice time is money. Haberstroh et al. (2008) reported that the slower pace oftext-based sessions meant that less material was covered than in FTF settings,even though counselors may spend a great deal of time responding to shortTM messages or questions.

It is recommended that private counselors who agree to TM interactionsbeyond administrative tasks make clear the fee for reading and sending eachmessage. For some TM plans, customers are charged per message or givena limited number of monthly messages. Gharging per message read andreceived is in line with many cell phone contracts, and is a more concreteway for counselors to set boundaries than recording time spent reading, for-mulating, and responding to text messages. The private counselor thus hasthe option to set boundaries around the time and energy spent on these tasks,knowing it will be compensated.

TrainingIt appears that no study has yet looked at ways graduate training programs

address or fail to address the ethical risks of using TM in practice. However,several articles have called for graduate ethics courses to address issues ofprofessionalism when posting on and searching the Internet (Lehavot, 2009;Myers, Endres, Ruddy, & Zelikovsky, 2012; Van Allen & Roberts, 2011).The consensus is that because they are the best way to address ethical usesof technology, vignettes summarizing risks and benefits of TM use should beincorporated into graduate ethics courses. Finally, the benefits and risks ofusing many forms of technology should be addressed as needed in clinicalsupervision and through professional development activities (Lehavot, 2009;Lehavot, Barnett, & Powers, 2010; Myers et al., 2012) for both graduate stu-dents and working professionals.

CONCLUSION

Technology-based counseling services will continue to grow (Gentore& Milacci, 2008; Haberstroh et al., 2007; McAdams & Wyatt, 2010). Ratherthan closing off to new technology, it may be more effective for mentalhealth counselors to learn about the benefits, risks, and ethical issues relatedto using it in practice (Barnett & Scheetz, 2003). TM is possibly the mostinexpensive and widely available technology that can impact mental healthtreatment (Aguilera & Muoz, 2011). It is expected to become more popularbecause of its advantages as a tool for contact between sessions, so counselorsmay need to embrace it to some degree (Merz, 2010). Distance counseling,

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including TM, is also likely to continue to grow because it lowers overheadeosts and also offers counseling options for clients who cannot access ETEservices because of where they live or their health problems (Gentore &Milacci, 2008). Glinicians need to inform colleagues through professionalpublieations of the benefits and challenges of using technology so that bestpractices can be formulated (MeAdams & Wyatt, 2010). Eor private mentalhealth counselors using TM, this is a beginning.

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