Volume 35 i number 3ijuly 2oi3ipage$ 211-227text messaging a

1. 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

2. (MeMinn, Orton, & Woods, 2008). In partieular eounselors ar e
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,

3. Philadelphia, PA, 19141. Email: [email protected]
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

4. 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

5. 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.
212
Text Messaging and Private Practice
Recently, McMinn, Bearse, Heyne, Smithber ger, 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

6. 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

7. 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 Kingdo m (UK), sending clients
text messages
several days before scheduled appointments improved
attendance 25-28%. If
213
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).

8. 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

9. 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,

10. 2000). Haberstroh et al. (2008) reported among the clinical
advantages the
ability to review the transcript ofthe interactions during the
session to clarify
214
Text Messaging and Private Practice
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

11. 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

12. (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).
215
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).

13. 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

14. 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-
216
Text Messaging and Private Practice

15. 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

16. 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

17. 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
217
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

18. 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

19. 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.
218
Text Messaging and Private Practice
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-

20. 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;

21. 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,
219
2011). The following section addresses specific issues already
raised, but first

22. 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

23. (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);

24. 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
220
Text Messaging and Private Practice
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.

25. 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

26. cellular serviee
providers or using third parties (Merz, 2010). …
Can we ask clients for testimonials?
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Dilemmas
This month's dilemma Sherifa completed her counselling
qualifications three years ago. However, she has been
unable to find paid employment as a counsellor. Although she
has continued to work in a voluntary capacity in order
to maintain her practice, she has become increasingly frustrated
and has decided to set herself up in private practice.
As a first step, she enrolled on and completed a business start-
up course, where she was advised to set up a website
and to include testimonials from her current clients at her
placement. However Sherifa has just seen a conversation
on a social networking site where some members have
suggested that this is not wise. What are the ethical issues
involved and what should Sherifa do? Opinions expressed in
these responses are those of the writers alone and not
necessarily those of the column editor or of BACP.

27. Andrea Sheehy
Marriage and couple counsellor, website design and
development
I can understand why Sherifa's business start-up course has
recommended that she use client testimonials. They can
be powerfully persuasive in a marketing package that includes a
professional-looking website, high quality
photographs and verifiable details.
However, the essence of this dilemma is to be found in the
conflict of interest between the benefits for the therapist
of obtaining a testimonial and ensuring the integrity of the
relationship for the client.
The BACP Ethical Framework suggests that a resolution of this
conflict should be biased heavily in the best
interests of the client. Therefore Sherifa should discuss the
soliciting of testimonials with her placement manager
and supervisor before proceeding. For example, I can see a
conflict of interest if testimonials from placement clients
are used to promote Sherifa's private practice.
In addition, supposing Sherifa were to solicit her clients for
testimonials. I wonder how many would feel free to
express reservations or refuse. Sherifa would need to satisfy
herself (and her placement manager) that she was
ensuring the integrity of the relationship, and this may be

28. difficult to do. Wouldn't it be anti-therapeutic for a client
who is being treated with dignity and respect possibly for the
first time in their life to be asked this? Aren't they
going to feel obliged to help the person who has helped them?
Arguably the soliciting of a testimonial creates a dual
relationship. The Ethical Framework says: 'The existence of a
dual relationship with a client is seldom neutral and can have a
powerful… impact… For these reasons practitioners
are required to… avoid entering into relationships that are
likely to be detrimental…'
A problem with testimonials is that they can imply that a benefit
that one client has experienced from therapy will be
universally available to all potential clients. This is not the
nature of such a diverse practice as therapy and such
testimonials could be interpreted as a misrepresentation of the
work of the therapeutic community. While it is true
that some therapists produce consistently better outcomes for
their clients than others, arguably what these therapists
are good at is motivating the client to engage in the work that
they themselves need to do for therapy to be effective.
Testimonials can be anti-therapeutic because they collude with
the client who seeks to project the responsibility for
effecting change onto the therapist. It could also be argued that
the client who writes a glowing testimonial is
discounting the work that they have put in and their courage in

29. facing their demons.
Monitoring our services through feedback is vital and positive
feedback is always gratifying but there are many
sound ethical reasons not to make them public. Satisfied clients
often do become our best sources of future referrals
and there are plenty of ways that Sherifa's clients can make
their voices heard effectively without involving her
directly.
Rob Hammond
Personal consultant, integrative coach-therapist
Sherifa should first consider the ethical guidelines of her
professional body. There maybe nothing specific about
testimonials in the guidelines but they will make clear that the
individual practitioner is accountable for her actions
and needs to be able to justify them if she is challenged.
Ultimately those of us in private practice are running a business
and 'social proof in the form of client testimonials is
a powerful advertising tool. But before requesting client
testimonials Sherifa must consider the ability of each client
to be objective about her request. Therapy should work towards
a client being self-directing in their life. However,
given the in-built power imbalance within the therapeutic
relationship, extreme care must be taken that a client

30. https://app-na-readspeaker-com.lopes.idm.oclc.org/cgi-
bin/rsent?customerid=5845&lang=en_us&readid=rs_full_text_c
ontainer_title&url=https%3A%2F%2Fweb-a-ebscohost-
com.lopes.idm.oclc.org%2Fehost%2Fdetail%2Fdetail%3Fvid%3
D1%26sid%3De57d6487-5074-45e1-8541-
7c75a9077b5c%2540sessionmgr4008%26bdata%3DJnNpdGU9Z
Whvc3QtbGl2ZSZzY29wZT1zaXRl&speedValue=medium&dow
nload=true&audiofilename=Canweaskclientsfor-20141101
doesn't feel under an obligation to provide a testimonial.
Equally, Sherifa needs to be sure that her client isn't
investing her with undue responsibility for their wellbeing,
thereby negating their own part in their progress.
On the other hand, to deny a client the opportunity to publicly
state their successful outcome from therapy, in the
interest of future clients, would seem unfair.
Sadly there is still a certain amount of social stigma around
receiving therapy. Client testimonials help to reduce the
stigma of therapy and reinforce the notion that it is natural and
acceptable. If a potential client is feeling nervous
about starting therapy, or is unsure of what to expect, feedback
from previous clients can be a useful way to make
them feel more at ease.
There are numerous ways for Sherifa to gather testimonials. She
could give clients a satisfaction questionnaire, with
a box to tick to give permission to use their comments and a
stamped, addressed envelope for them to post it back to

31. her when they are ready. She could send clients a follow-up
email once therapy has ended asking if they would
consider supplying a testimonial.
Sherifa should always explain how their feedback will be used
(eg on her website), whether it will be anonymised,
how long will it be on view etc, and obtain the client's
permission for this.
If the option of testimonials is openly discussed and the client
is fully able to be objective about the request and to
make an informed decision, then I don't see that there is any
problem.
Helen Cooke
Volunteer MBACP (Accred) counsellor
The pages of Therapy Today are heavy with references to the
lack of paid work in our profession and Sherifa's
dilemma reflects this difficult issue. Her situation has left me
wondering what drives her counselling career and
about the nature of her professional relationships.
For example, what do we understand by having 'completed' our
qualifications? Counselling training is not a finite
process and is often described as a journey, but Sherifa tal ks of
'maintaining' her practice rather than developing it
(and herself). Perhaps her motives are purely strategic, so

32. frustration at being unable to take the next step to
employment is completely understandable. Will she devote
energy to processing these feelings before she risks
carrying them forward into the work with her private practice
clients?
Sherifa's entrepreneurial flair is to be encouraged. However, she
has chosen what sounds like a generic business
course where the unique aspects of our profession are unlikely
to be catered for. The BACP Ethical Framework
encourages us to be open to and conscientious in considering
feedback from colleagues, and we can benefit
enormously from their guidance and advice. Have Shefira's
peers fallen by the wayside in her quest for progression?
Similarly, the question of whether or not to publish client
testimonials on her website has arisen vicariously, through
coming across online postings between other people. Her
dilemma centres on client confidentiality, which is a
hugely significant and precious element, yet she seems so
isolated professionally.
Her intention to acquire testimonials from placement clients
sounds very worrying. Trustworthiness, the BACP
Ethical Framework tells us, requires us to 'restrict any
disclosure of confidential information about clients to
furthering the purposes for which it was originally disclosed', so
client feedback provided to the agency cannot be

33. 'lifted' for secondary uses. There are also Data Protection Act
implications. For Sherifa to seek feedback separately
and overtly for her own promotional purposes, even with the
knowledge and blessing of the agency, leaves me
struggling to imagine how this could be safely managed.
Crucially, what are the implications for the therapeutic
relationship of this potential 'gift' from the client, or for clients
who refuse the request?
Sherifa needs to discuss all her plans with her placement
supervisor without delay to ensure there are no current or
potential boundary breaches. Here they might explore ways to
help her connect and flourish, including exploration
of the wealth of resources that BACP membership confers (eg
relevant CPD workshops, the BACP Private Practice
division, regional networking days, local network groups,
perhaps even setting one up in her area).
Sherifa might also take time to reflect on the personal moral
qualities of humility and integrity while assessing her
priorities as a practitioner. She may decide to slow down her
business-minded drive for the time being if it risks
overtaking the application of good ethical practice. Glowing
testimonials are of no value if the method of acquisition
sends her crashing headlong into the sanctions pages of Therapy
Today.

34. December's dilemma Ken and Rob both work for a telephone
counselling organisation and chat via Skype once or
twice a month, often about clients.
One day Rob confides that he is not qualified; he completed a
four-year psychotherapy training but did not take the
final examinations. His CV states that he is a trained
psychotherapist and he was not asked to produce documents
before being appointed. Ken is rather shocked but decides to do
nothing as Rob has not actually lied about his lack
of qualifications.
However, Rob is now under investigation as a former client has
complained that he was not qualified or competent
to deal with her needs and terminated therapy with him
abruptly. Rob has asked Ken to write a letter of support, in
particular saying that he is familiar with his work and that he is
competent to deal with complex issues.
What are Ken's options and what should he do? Email your
responses (500 words maximum) to Heather Dale at
[email protected] by 26 November 2014. Readers are welcome
to send in suggestions for dilemmas to be
considered for publication, but these will not be answered
personally.
Copyright of Therapy Today is the property of British

35. Association for Counselling & Psychotherapy and its content
may not be copied or emailed to multiple sites or posted to a
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permission. However, users may print, download, or email
articles for individual use.
Rubic_Print_FormatCourse CodeClass CodeAssignment
TitleTotal PointsPSY-510PSY-510-O500Case Study: Ethical
Consultation100.0CriteriaPercentageUnsatisfactory (0.00%)Less
than Satisfactory (74.00%)Satisfactory (79.00%)Good
(87.00%)Excellent (100.00%)CommentsPoints
EarnedContent70.0%Describe the ethical issues involved in the
situation.25.0%Essay omits or incompletely describes ethical
issues involved in the situation.Essay inadequately describes
ethical issues involved in the situation, but description is weak
and missing evidence to support claims.Essay adequately
describes ethical issues involved in the situation, but
description is limited and lacks some evidence to support
claims.Essay clearly describes ethical issues involved in the
situation, and description is strong with sound analysis and
some evidence to support claims.Essay expertly describes
ethical issues involved in the situation, and description is
comprehensive and insightful with relevant evidence to support
claims.Discuss the steps needed upon discovery of potential
ethical concerns.25.0%Essay omits or incompletely discusses
the steps needed upon discovery of potential ethical
concerns.Essay inadequately discusses the steps needed upon
discovery of potential ethical concerns. Discussion is weak and
missing evidence to support claims.Essay adequately discusses
the steps needed upon discovery of potential ethical concerns,
but discussion is limited and lacks some evidence to support

36. claims.Essay clearly discusses the steps needed upon discovery
of potential ethical concerns., and description is strong with
sound analysis and some evidence to support claims.Essay
expertly discusses the steps needed upon discovery of potential
ethical concerns, and description is comprehensive and
insightful with relevant evidence to support claims.Explain
some recommendations you would make to the supervisor and
the group practice to align their advertising with ethical
standards.20.0%Essay omits or incompletely explains some
recommendation.Essay inadequately explains some
recommendations is vague and inconsistent. Explanation is
weak and missing evidence to support claims.Essay adequately
explains some recommendation, but explanation is limited and
lacks some evidence to support claims.Essay clearly explains
some recommendation, and description is strong with sound
analysis and some evidence to support claims.Essay expertly
explains some recommendation, and description is
comprehensive and insightful with relevant evidence to support
claims.Organization and Effectiveness20.0%Thesis
Development and Purpose7.0%Paper lacks any discernible
overall purpose or organizing claim.Thesis is insufficiently
developed or vague. Purpose is not clear.Thesis is apparent and
appropriate to purpose.Thesis is clear and forecasts the
development of the paper. Thesis is descriptive and reflective of
the arguments and appropriate to the purpose.Thesis is
comprehensive and contains the essence of the paper. Thesis
statement makes the purpose of the paper clear.Argument Logic
and Construction8.0%Statement of purpose is not justified by
the conclusion. The conclusion does not support the claim
made. Argument is incoherent and uses noncredible
sources.Sufficient justification of claims is lacking. Argument
lacks consistent unity. There are obvious flaws in the logic.
Some sources have questionable credibility.Argument is
orderly, but may have a few inconsistencies. The argument
presents minimal justification of claims. Argument logically,
but not thoroughly, supports the purpose. Sources used are

37. credible. Introduction and conclusion bracket the
thesis.Argument shows logical progressions. Techniques of
argumentation are evident. There is a smooth progression of
claims from introduction to conclusion. Most sources are
authoritative.Clear and convincing argument that presents a
persuasive claim in a distinctive and compelling manner. All
sources are authoritative.Mechanics of Writing (includes
spelling, punctuation, grammar, language use)5.0%Surface
errors are pervasive enough that they impede communication of
meaning. Inappropriate word choice or sentence construction is
used.Frequent and repetitive mechanical errors distract the
reader. Inconsistencies in language choice (register) or word
choice are present. Sentence structure is correct but not
varied.Some mechanical errors or typos are present, but they are
not overly distracting to the reader. Correct and varied sentence
structure and audience-appropriate language are employed.Prose
is largely free of mechanical errors, although a few may be
present. The writer uses a variety of effective sentence
structures and figures of speech.Writer is clearly in command of
standard, written, academic English.Format10.0%Paper Format
(use of appropriate style for the major and
assignment)5.0%Template is not used appropriately or
documentation format is rarely followed correctly.Appropriate
template is used, but some elements are missing or mistaken. A
lack of control with formatting is apparent.Appropriate template
is used. Formatting is correct, although some minor errors may
be present.Appropriate template is fully used. There are
virtually no errors in formatting style.All format elements are
correct.Documentation of Sources (citations, footnotes,
references, bibliography, etc., as appropriate to assignment and
style)5.0%Sources are not documented.Documentation of
sources is inconsistent or incorrect, as appropriate to
assignment and style, with numerous formatting errors.Sources
are documented, as appropriate to assignment and style,
although some formatting errors may be present.Sources are
documented, as appropriate to assignment and style, and format

38. is mostly correct.Sources are completely and correctly
documented, as appropriate to assignment and style, and format
is free of error.Total Weightage100%