Controversy on record keeping

Volume 35INumber 3IJuly 2OI3iPage$ 211-227

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

Michael E. Sude

The impact of technology on mental health practice is currently a concern in the counseling literature, 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 has discussed ethical concerns and best practices for the use of short message service (SMS), better known as text messaging (TM). Ethical issues that arise with TM relate to confidentiality, documentation, counselor competence, appropriateness of use, and misinterpretation. There are also such boundary issues to consider as multiple relationships, counselor availability, and billing. This article addresses ethical concerns for mental health counselors who use TM in private 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 cell phones 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 tasks like 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 Internet and interact with others in a variety of ways, but almost all cell phones at least have 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 provide support 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 suburbs of Philadelphia. Correspondence about this article can be directed to Dr. Michael £. Sude. La Salle University, Psychology Department, 1900 West OIney Avenue, Philadelphia, PA, 19141. Email: sudem@ lasalle.edu.

Journal of Mental Health Counseling 2 | |

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

All forms of technology have ethical implications that raise concerns for counselors (Baker & Bufka, 2011; Baltimore, 2000; McMinn et al., 2008; Van Allen & Roberts, 2011; Zur, 2010). As a result, every conversation about using technology in practice must discuss ethics and ethical decision-making (McMinn et al., 2008). Centore and Milacci (2008), who studied distance counseling, reported that counselors experienced decreased ability to fulfill their ethical duties for all types of distance counseling, which underscores the 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 counselors in private practice and offers guidelines for personal best practices. It reviews the literature on use of technology in private practice and of TM for clinical interventions. Spécifie clinical benefits and ethical concerns are outlined. Although they are likely to use TM to communicate with clients, because private 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 is not to decide for counselors whether or not they should use TM in private practice but rather to raise awareness of ethical concerns to help them make more informed decisions.

RESEARCH ON USE OF TECHNOLOGY IN PRACTICE

Private Practice McMinn, 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 conducting any clinical services online or through email.

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

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

Perceptions of Technology Use

Centore and Milacci (2008) surveyed clinicians about how they used different fypes of distance counseling. Online, real time text-chat was reported by 5.6% of participants and 28.1% reported using email; of all fypes attitudes toward text-chat were most negative, among them perceptions of decreased abilify for counselors to build rapport with clients and decreased abilify 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 instant messaging (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 impacted interactions, but anonymify provided safefy for self-disclosure (Haberstroh et al., 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 to FTE services; however, the limitations of the few studies make it impossible to draw clear conclusions about its clinical effectiveness. Recent studies were related to crisis intervention (Coss & Ferns, 2010) and eating disorders (Bauer, Okon, Meermann, & Kordy, 2012; Shapiro etal., 2010). TM may also help 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 pursue outpatient 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 FTF meetings. In a small pilot study, patients in a psychotherapy group reported that TM helped with attendance (Aguilera & Munoz, 2011). In a much larger pilot study in the United Kingdom (UK), sending clients text messages several 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 annual national savings would be close to US$250 million (Sims et al., 2012).

No other published research into individual counselors sending and receiving text messages with clients could be found. In other words, all the studies listed involve programmable software that manages sending text mes- sages to certain populations or clientele at certain days and times. Gounselors in 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 is therefore needed on the benefits and risks of TM interactions for counselors in private practice.

Advantages of Text-Based Interactions Electronic 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 both synchronously (immediate response) and asynchronously (lag time between responses; 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 asynchronous interactions can, like journaling, help clients process and express thoughts and 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 they attract little attention from others, so individuals can use them with little fear of social stigma (Boschen, 2009; Gentore & Milacci, 2008). TM, in particu- lar, is widely available (Militello et al., 2012) because it costs little (Aguilera & Muñoz, 2011; Boschen, 2009; Boschen & Gasey, 2008; Shapiro et al., 2010) and does not require a smartphone (Aguilera & Muñoz, 2011). TM is also convenient (Goss & Ferns, 2010; Shapiro et al., 2010); is accessible at any 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 may prefer 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 the ability 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 the clinician's own responses.

TM also offers the ability to have regular contact between sessions (Aguilera & Muñoz, 2011) and to remind clients of skills learned ETE to help prevent relapse between meetings (Boschen, 2009). Eor administrative tasks like scheduling, cancelling, or rescheduling appointments and sending billing or appointment reminders, TM can save private counselors time beeause 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 tangible way to remain connected to the counselor (Neimark, 2009). TM may help elients through the times between therapy sessions, much like ealling a eounselor's voice mail and leaving messages that do not need to be returned (Gutheil & Simon, 2005). Texts from counselors to clients also serve as transitional objects, similar to the letter-writing common in narrative therapy (Winek, 2010).

In family counseling, TM can help family members who struggle to interact with eaeh other in real time. Asynchronous TM allows them to take time to make meaning of messages received and to formulate responses that can be edited before being sent. The counselor can be eopied on messages between 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 the possible shame of carrying around paper and pen and allows clients to send counselors information and reeeive feedback more quickly (Shapiro et al., 2010). TM time and date stamping helps keep the information being exchanged more accurate than is possible with journals (Shapiro & Bauer, 2010). Messages can be sent at set times and can be helpful when ETE or phone 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 home because of disability or illness (Gentore & Milacci, 2008).

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

& Wyatt, 2010; Suler, 2000)—clients may have difficulty feeling connected to counselors because there are no audio or visual cues (Centore & Milaeci, 2008; Haberstroh et al., 2007; Haberstroh et al., 2008; Siiler, 2000). They may also feel less understood, less cared for, and less safe (Centore & Milaeci, 2008). Text-based interactions may also lack spontaneity (Suler, 2000), and the 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 are never sent or received (Shapiro & Bauer, 2010). Also, some clients may not know how to use cell phones or be able to read messages because of limited eyesight, and some may be unable to afford TM (Aguilera & Muñoz, 2011; Shapiro & Bauer, 2010).

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

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

sional organizations may never be able to provide guidance for using specific types 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 Counselors Association (AMHCA) Code of Ethics (2010) is current on providing guid- ance for the use of technology. The seetion dedicated to technology-assisted counseling provides guidelines for preserving confidentiality when transmit- ting and storing information electronically. The AMHCA has also published a white paper (2012) as a companion to the Code of Ethics (2010) that makes recommendations for technology-assisted counseling. The white paper recommends, for instance, that counselors be "technologically savvy in the modality of communication being used," plan for crises and use with at-risk clients, 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 addresses confidentiality, 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 or discussing such regulations (McAdams & Wyatt, 2010). Ten states have pro- hibited technology use, and many boards have supported it conditioned on special circumstances (McAdams & Wyatt, 2010).

ETHICAL CONCERNS FOR PRIVATE COUNSELORS

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

Confidentiality The primary ethieal concern for counselors who use TM is informa-

tion security (Bosehen & Casey, 2008; Merz, 2010) because ofthe risk of violating client eonfidentialify (Bradley et al., 2011; Furber et a l , 2011; Zur, 2010). Among TM identifleation problems are not knowing whether a elient is 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 messages are more like postcards than private letters and, like voice mail, clients may assume that only counselors can access them (McMinn et al., 1999). Also like email (Cutheil & Simon, 2005; Van Allen & Roberts, 2011), they can accidently be sent to the wrong person.

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

Documentation Besides 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 encryption for electronic records storage and transfer, and what can be done to ensure

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

The counselor must give precedence to the client's rights to privacy and confidentiality over any personal convenience (Nicholson, 2011), and how to do this for TM is not clear. For example, email should be printed and placed with 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 less information because of the character limits.

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

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

Once counselors are trained to use TM, they will need to decide what types of interactions to use it for. TM can be a quick way to contact counselors 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 in emergencies. Gounselors may not receive messages immediately or be able to reach clients in crisis (Shapiro & Bauer, 2010), and neither party may know whether messages were received. In short, counselors must determine when and 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-specific language and a lack of audio or visual cues (Baltimore, 2000; Barnett & Scheetz, 2003; Koocher, 2009). Glient difficulties with expressing themselves in writing (Suler, 2000) may be magnified in TM because it is so hard to explain something lengthy or complex in a limited space (Shapiro & Bauer, 2010). Moreover, the lack of audio or visual cues may limit ability to make meaning of interactions, so counselors must be able to tolerate ambiguity (Trepal et al., 2007) and check out assumptions.

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Boundary Concerns

One possibility for misinterpretation is the counseling relationship being interpreted differently. Counselors must be careful to avoid treating electronic communication with clients as off the record or casual. The possi- bility that casual or informal interactions might lead to boundary confusion for 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 in professional 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, and there is less time for actual exchange than in the same amount of FTF time (Trepal et a l , 2007). This is a consideration for billing: Should TM be billed per 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 as social interaction. Failure to bill for clinical emails could also lead to issues of 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 from long stories to seemingly easy questions expressed in one sentence, can take a 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 asynchronous communication is boundary confusion around appointments (Suler, 2000). Time spent communicating with clients through asynchronous communica- tion must be established by counselors (Bradley & Hendricks, 2009; Bradley et a l , 2011; Negretti & Wieling, 2001; Shapiro & Bauer, 2010; Zur, 2008) in order to model self-care and boundaries. Counselors will need to determine personal best practices based on how they feel about being available outside of session.

CUIDELINES FOR PERSONAL BEST PRACTICES

Van Allen and Roberts (2011) stated that newer generations of mental health professionals, who have grown up with modern technology, often are naive about its privacy, security, and professional implications. In other words, familiarity with technology does not mean that counselors know how to avoid professional problems. Clinicians tend to use new forms of tech- nology in practice before fully understanding the risks. They do not need to become experts but should understand the technology they are using, weigh risks as well as benefits, and make decisions in terms of upholding ethical codes and regulations—the 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 first addressed are general recommendations for private counselors who use TM.

The basic decision private counselors must make is whether or not to use separate cell phones for their business and personal hves. For counsel- ors in full-time private practice, a separate business phone may make sense because of the volume of contacts. Part-time counselors may choose to use their 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 clinical practice in order to protect the data exchanged, the therapist's privacy, and clinical boundaries (Shapiro & Bauer, 2010).

After securing a separate business cell phone, counselors should find out what technology-assisted services are covered by their hability insurance before using the phone as an adjunct to FTF practice (Baker & Bufka, 2011; Bradley & Hendrieks, 2009; Bradley et al., 2011). This is vital. Counselors working 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 write up 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 client informed 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 services and 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 what can 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 counselor electronically (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 these specific ethical issues.

Confidentiality As with email (Bradley et a l , 2011), counselors must inform clients that

third parties may be able to access electronic interactions. Private counselors can do several things to help protect the information transmitted and stored on cell phones. Zur and Barnett (2008) provided practical recommendations for protecting portable electronic devices, sueh as removing unnecessary files when traveling, never leaving deviees unattended, and never letting anyone borrow them.

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

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

Counselors can encrypt messages using technology from cellular serviee providers or using third parties (Merz, 2010). For smartphone owners, apps offer 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 one option is for clients to use a code word to identify themselves. Another is for clients to begin eaeh TM interaction by answering a question agreed upon at the start of services. As a general rule, a eounselor communicating with clients through TM should pay close attention to the client's language to see if it is aligned with previous TM interactions. Counselors should also be vigilant to double-check who the message is being sent to in order to avoid accidentally breaking confidentiality (Van Allen & Roberts, 2011).

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Documentation Counselors also need to decide how to store and document text mes-

sages after transmission. Text messages, like voice messages and emails, are clinical contacts (Zur, 2010). In order to limit the information stored on highly portable cell phones, counselors may wish to transfer stored informa- tion. Archiving text messages involves either forwarding them to email to be saved or printed, taking screen shots of them with a smartphone and then sending 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 that is communicated to clients (Bosehen, 2009). When disposing of cell phones, counselors should wipe the data from the devices by resetting or reformatting them (Barnett & Scheetz, 2003; Merz, 2010). Cell phone manufacturers can explain how counselors can erase or reformat their cell phones.

Counselor Competence, Appropriateness, and Misinterpretation Counselors 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 with each client (administrative tasks, support, intervention, etc.), and regularly evaluate its helpfulness (Merz, 2010). They should be trained before using any type of TM software, take time to learn to use the programs properly, and be able to troubleshoot problems (Baker & Bufka, 2011; Bradley et al., 2011; Merz, 2010; Shapiro & Bauer, 2010). Counselors interacting with clients through TM from home should have a designated space, sueh as a home office, to limit distractions and keep interactions professional (Haberstroh et al., 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 familiar with the technology used in practice (Negretti & Wieling, 2001), so must cli- ents. This would include how often elients use TM in daily life, how familiar they are with common TM emoticons and acronyms, whether or not they can afford the service, and whether they have reading or eyesight limitations.

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

Counselors should also be aware of different ways messages might be interpreted, 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 to both TM content and process, be sensitive to cultural issues and stereofypes (Trepal et a l , 2007), and be able to process TM interactions in FTF sessions (Neimark, 2009).

To help limit misinterpretation, both parties may add visual cues through in-text graphics, spacing, punctuation, and use of caps (Suler, 2000). Counselors also need to become familiar with common acronyms used in text-based communication, such as, "LOL (laugh out loud), ROTFL (rolling on 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 a l , 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 a l , 2008; Trepal et a l , 2007).

Boundary Concerns When 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 messages before they hit "send," asking themselves whether they would say it the same way in an FTF session. If not, language or tone must be changed (Cutheil & Simon, 2005).

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

To avoid feeling on call, counselors should also decide how much time they will be available through TM and communicate the decision to clients (Koocher, 2009; Shapiro & Bauer, 2010). As with any other technological adjunct, there must be clear agreement on TM boundaries and billing poli- cies (Boschen, 2009; Shapiro & Bauer, 2010). One option is for clients to be able 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 of text-based sessions meant that less material was covered than in FTF settings, even though counselors may spend a great deal of time responding to short TM messages or questions.

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

Training It 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 of professionalism 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 uses of technology, vignettes summarizing risks and benefits of TM use should be incorporated into graduate ethics courses. Finally, the benefits and risks of using many forms of technology should be addressed as needed in clinical supervision 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). Rather than closing off to new technology, it may be more effective for mental health counselors to learn about the benefits, risks, and ethical issues related to using it in practice (Barnett & Scheetz, 2003). TM is possibly the most inexpensive and widely available technology that can impact mental health treatment (Aguilera & Muñoz, 2011). It is expected to become more popular because of its advantages as a tool for contact between sessions, so counselors may 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 overhead eosts and also offers counseling options for clients who cannot access ETE services because of where they live or their health problems (Gentore & Milacci, 2008). Glinicians need to inform colleagues through professional publieations of the benefits and challenges of using technology so that best practices can be formulated (MeAdams & Wyatt, 2010). Eor private mental health counselors using TM, this is a beginning.

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