Advances Vol. 3, No. 2 Online Social Work Practice: Issues and Guidelines for the Profession Goutham M. Menon Julie Miller-Cribbs Abstract: There has been growth in the utilization of information and communica- tion (ICT) tools in the field of social work in recent years.While most of the work has revolved around community practice, some social workers have moved into the realm of online, web-based therapeutic practice. This paper discusses important issues emerging from this new form of social work practice and concludes with sug- gested guidelines for the use of ICTs in social work practice. Keywords: Web-based counseling, online therapy, technology-enhanced practice The profession of social work has witnessed a growth in the creative use of technology in various areas of professional work for many decades (Finn & Lavitt, 1994; Finn, 1995; Shyne, 1954). Ranging from telephone support groups (Kennard & Shilman, 1979; Meier, Galinsky & Rounds, 1995; Roffman, Beadnell, Ryan & Downey, 1995; Rounds, Galinsky & Stevens, 1991; Wiener, Spencer, Davidson& Fair, 1993) to themore recent exploration of computer-based applications in human services (Finn, 1995; Finn & Lavitt, 1994; Smyth & Harris, 1993;Weinberg, Uken, Schmale & Adamek, 1995; Stofle, 1997), professional prac- tice with individuals, families, and groups has seen the influence of emerging information and communication technologies (ICT). ICTs have also influenced the field of community practice in positive ways (Downing, Fasano, Friedland, McCullough,Mizrahi & Shapiro, 1991;McNutt, 2000), especially in the area of elec- tronic advocacy (Bennett & Fielding, 1999; Boland, 1998; Buck, 1996; Fitzgerald & McNutt, 1999; McNutt & Boland, 1988; 1999; Menon, 2002; 2000c). While most of the utilization of technology falls into the area of helping groups and communities, social work is beginning to see a growing interest in the provi- sion of online counseling and therapeutic services for individuals (Cutter, 1996; Grohol, 1997; Levenson, 1997; Sampson, Kolodinsky & Greeno, 1997). Some of these professionals offer such services alone or as part of a group of practitioners1. As students and practitioners becomemore familiar with technology-based appli- 104 Goutham M. Menon, Ph.D. is Assistant Professor & Director, Center for Technology in Social Work Education and Practice, College of Social Work, University of South Carolina, Columbia, SC 29208. Julie Miller-Cribbs, Ph.D. is Assistant Professor, College of SocialWork, University of South Carolina, Columbia, SC 29208. Copyright© 2002 Advances in SocialWorkVol. 3 No. 2 (Fall 2002) 104-116. Indiana University School of SocialWork. cations (either on their own or through education), it is probable that the use of ICT for counseling will becomemore prevalent. Professional organizations in fields similar to social work have begun to address the issue of online counseling. For example, the American Psychological Association (APA) and the medical field, particularly psychiatry, has begun to address ethical issues associated with the delivery of services online (see APA, 1997; American Medical Informatics Association, 1998). The National Board of Certified Counselors (NBCC) purports to “…create standard definitions of tech- nology-assisted distance counseling that can be easily updated in response to evo- lutions in technology and practice” (NBCC, 2001) and the American Counseling Association (ACA) approved ethical standards for Internet and on-line counseling in 1999 (ACA, 1999). Internet Healthcare Coalition (IHC), an organization that attempts to set high standards for the distribution of health information via the Internet, has developed a set of ethical guidelines relevant to our profession (IHC, 2000). Finally, the International Society forMentalHealthOnline (ISMHO)has also developed guidelines for the practice of online counseling, though these are not specific to social work (ISMHO, 2000). Despite this continued and expanded use of ICT in the field of social work, the profession currently has no established guidelines for the practice of social work online. Many individuals and organizations have begun to address issues related to the online practice of social work, citing possible advantages and disadvantages of such practice and occasionally providing some general guidelines for online practice (Coleman, 2000; Levenson, 1997; Stofle, 1997). Stofle (2001), a social work- er, has written a book about choosing an online therapist; yet, this book is geared towards potential consumers, not practitioners. Finally, it was noted by Powell (1998) that while the NASW Insurance Trust mentions that social workers who practice online are covered for malpractice, they express concern about the issue of online practice. Some social work organizations, such as the Clinical Social Work Federation (CSWF), have also argued strongly against the use of online counseling: “So much human suffering has been caused by disconnection—discon- nection between individuals, between thought and feeling, between body and mind—and e-therapy offers yet another form. Clients seek our serv- ices in order to improve the quality of their lives, the quality of their rela- tionships. Alienation from others and the self will not be healed through a virtual connection in cyberspace, a ‘connection’ that is fraught with risks and hazards for both clients and clinicians.” (CSWF, 2001) Despite CSWF’s position, social workers currently provide online services and are likely to continue doing so. It is the contention of the authors of this paper that simple warnings about the dangers of online therapy or broad ethical discussions of this new modality of practice are not enough to protect our clients and practi- tioners, alike.There is clearly a need for the profession to step up and lead a debate culminating in specific guidelines for practice that helps to regulate the profession in virtual therapeutic and supportive environments. 105Menon, Miller-Cribbs/ONLINE SOCIALWORK PRACTICE 106 ADVANCES IN SOCIALWORK The current practice of online counseling has heightened the need for the social work profession to seriously examine this avenue of service delivery. To expand this endeavor, this paper explores and highlights the important issues related to this area of social work practice. It will conclude by providing suggested guidelines for the practice of online social work. DEFINING ONLINE THERAPY Computer-mediated communication (CMC) is frequently thought of in terms of technology only, thus, many often assume that CMC is simply about receiving and exchanging information (December, 1997). However, it has been argued that CMC is “a process of human communication via computers, involving people, sit- uated in particular contexts, engaging in processes to shapemedia for a variety of purposes” (December, 1997).2 We know that social work communication in face- to-face settings involves the use of communication to bring about change. Online therapy is just one form of CMC, one that obviously involves more than simple information exchange. Bloom (1998) defines webcounseling™ as “the practice of professional counsel- ing that occurs when client and counselor are in separate or remote locations and utilize electronic means to communicate with each other” (p. 21). Obviously, this definition is fairly basic, including only the “context” of practice in the definition. Perhaps a definition adopted by King and Moreggi (1998) would be more inclu- sive and holistic. They define “behavioral tele-health” as “… all forms of synchro- nous and asynchronous Internet mental health efforts, where the stated goal is the establishment of some form of therapeutic contact” (p. 93). CMC can also be referred to as the creation and dissemination of meaning; through various mech- anisms (e-mail, chat, web sites), the perception ofmeaning, and the participation in “forums for communication that begin to exhibit characteristics of communi- ty—including a shared sense of purpose, norms for behavior, and traditions” (December, 1997). Distinguishing between the simple provision of information versus the com- munication and perception of meaning is particularly salient for social work. There are a wide range of services being provided online, ranging from the provi- sion of information to the actual provision of social work services. Often, the terms used to describe these services are used interchangeably and, thus, pro- voke a misunderstanding as to the nature of services provided. For example, sometimes, online counseling services are simply informational services. At such websites the client has an opportunity to request information or ask a question related to a specific problem area. This is analogous to the many “help” columns seen in popular newspapers and magazines. Sometimes, the individual pays for the e-mail response that he or she receives for the question posed. Another type of service is what is commonly known as “online therapy.” The goal of online therapy is to provide a long-term therapeutic relationship. Such a service involves individual-therapist communication using electronic mail, chat rooms, instant messaging, and other tools over a protracted period of time. Such services aim to build rapport and provide for an ongoing therapeutic relationship. This paper largely focuses on the second kind of service, online therapy. For pur- 107 poses of this paper, we will define on-line therapy as the provision of therapeutic services utilizing Internet applications, both text-based and audio/video, which enable clients to receive services without real face-to-face contacts with the provider (Menon &Miller-Cribbs, 2001). There are major issues related to providing online therapy that must be addressed by the field of social work (Menon, 1998a/b; 2000a/b; 2001; Menon & Miller-Cribbs, 2001). The following is a discussion of important issues related to providing online therapy by social workers: the issue of face-to-face contacts, anonymity, technical aspects of the provision of the service, legal issues, licensing and cross border practice, and evaluation of online therapy. Face-to-Face: Is It Better? Is It Necessary? The inability of a social worker to assess non-verbal cues online is an area that concerns many in the profession (Coleman, 2000). Thus, social workers are pressed to think about why face-to-face contact is preferable and highlight ways in which therapy can be conducted without non-verbal cues. Can warmth, car- ing, and compassion be conveyed via text? How should social workers account for the absence of non-verbal communication? Therapy essentially involves an ongoing therapeutic relationship between two people who meet face-to-face. The therapist establishes trust and rapport with clients through this relationship. Often, non-verbal communication is as impor- tant as verbal communication. Online, it may be more difficult to establish trust and rapport since face-to-face contact is unavailable and the subsequent utiliza- tion of non-verbal cues becomes impossible. However, others have argued that face-to-face communication is not necessar- ily themost ideal type of therapy for all clients and their problems.Walther (1996) argues that when a therapist has freedom from the social responsibilities of “look- ing interested,” then, he or she is able to take the time to thoughtfully respond in terms of selecting the right words and message. Furthermore, the time delay betweenmessages forces individuals to think about what they send prior to com- municating their feelings. There are also some possibilities for mimicking non-verbal cues using the key- board. For example, Internet-based communication is filled with the usage of acronyms and emoticons (emotional icons, such as :) happy face ;( crying sadly, etc.).3 One possibility is to develop a set of standardized emoticons and acronyms to capture the feelings of the client at any given point in time. These could be tai- lored into the software utilized for online practice. Alternatively, an online thera- pist could provide clients with a sheet of “emoticons,” so that the client could incorporate these during sessions with the therapist. Some of the issues listed above may be addressed once social workers have faster access to the Internet through broadband Internet-video technology. Broadband, either through DSL connections or by cable TV providers, may allow practitioners to have computer-based video conferencing options. This will enable social work practitioners to have adequate visual access to clients. However, until then, one must expect poor quality video/audio streams when Menon, Miller-Cribbs/ONLINE SOCIALWORK PRACTICE 108 ADVANCES IN SOCIALWORK using telephone lines. Currently, the majority of the population who have Internet access utilize modems to dial-up in speeds ranging from 28.8K to 56K using regular analog phone lines. In some sectors of the country, we are also see- ing an increase in DSL linkups. DSL, which stands for Digital Subscriber Line, provides high-speed Internet Access using regular telephone lines. It has the abil- ity to move data over the phone lines at speeds up to 6Mb/s (six million bits per second) or 140 times quicker than the fastest analog modems available today (56,000 bits per second). In addition to its high speed, DSL hasmany benefits over analog connections. Unlike dial-up connections that require analog modems to “dial-in” to the Internet Service Provider every time the user wants to retrieve e- mail or obtain access to the Internet, DSL connections are always on. That means no more logging on and off, no more busy signals, and no more waiting for the connection to happen. Another benefit is the ability to use the telephone while accessing the Internet and not having to choose between the two. The Cloak of Anonymity—A Good or Bad Thing? There is a growing body of literature that attempts to disentangle the concerns around intimacy and nonverbal communication (Burgoon, Buller & Woodall, 1989; Cherny, 1995; Guerrero, DeVito & Hecht, 1999; Patterson, 1983; 1990). Furthermore, there are greater philosophical conversations conducted regarding the meaning of intimacy and self-disclosure (Walther, 1996). In fact, Lerner’s (1990) definition of intimacy reveals little about the necessity for face-to-face contact in establishing intimacy as she notes: For starters, intimacymeans that we can be whowe are in a relationship, and allow the other person to do the same. “Being who we are” requires that we can talk openly about things that are important to us, that we take a clear position on where we stand on important emotional issues, and that we clarify the limits of what is acceptable and tolerable to us in a relationship. “Allowing the other person to do the same”means that we can stay emotionally connected to that other party who thinks, feels, and believes differently, without needing to change, convince, or fix the other. An intimate relationship is one in which neither party silences, sacrifices, or betrays the self and each party expresses strength and vul- nerability, weakness and competence in a balanced way.” (p. 3) Others have argued that the lack of face-to-face contact can be a positive fea- ture when working with certain clients. In some cases, the anonymity that face- less interaction provides could have certain advantages, such as higher levels of self-disclosure, more intimacy, heightened self-expression, and stigma manage- ment (Cohen & Kerr, 1998). People who are reluctant to seek out counseling in a traditional setting may be more willing to seek out an online counselor. Thus, online counseling may be a viable method of service delivery for certain client groups and problems. The telephone, for example, has been a long estab- lished and accepted mode for delivering crisis intervention services. As Cohen & Kerr (1998) note, “While clients with strong needs for emotional supportmay find the reduced cues environment a poor substitute for face-to-face interaction, computer-mediated counseling may be a viable option for more independent 109Menon, Miller-Cribbs/ONLINE SOCIALWORK PRACTICE people dealing with specific problems or those interested in personal growth” (p. 24). Stofle (2001) addresses the issue of the appropriateness of online counseling in his conceptualization of “Levels of Care and Online Therapy” continuum. He refers to varying levels of intensity of treatment that need to match the intensity of the client’s problem. He places online therapy on the lower intensity side of the level of care continuum and, so, it is best used for issues/problems that are low intensity, as well. Such a conceptualization is helpful in determining the uses and possibilities of online therapy by social workers. The profession of social work should carefully consider what kinds of problems and issues are best suited for online delivery and establish guidelines for the delivery of such services. The provision of anonymity is both a strength and weakness of online social work practice. Often, particularly in small communities, people know where the therapists live or practice, so by simply parking a car in a certain place, an indi- vidual risks being “found out.” These risks are not as apparent with online coun- seling. This could be especially beneficial for those individuals who seek help but are too embarrassed to go to a social worker’s office. Online practice also has the potential to limit or eliminate biases that can cor- rupt treatment and slow the rapport-building process. In this way, the Internet can be seen as a social leveler (Levenson, 1997). Age, gender, ethnicity, race, national origin, and other demographic features that provoke bias are absent.The client is a “faceless” individual and, thus, therapist and client bias are held in check. Some authors have stated that the “faceless” nature of counseling might, in fact, improve the chances of certain reluctant individuals seeking treatment (Cohen & Kerr, 1998). Under the cloak of supposed anonymity, certain people might actively take part in therapy sessions. It might allow some to bemore open about the problems they face and not be embarrassed to talk about them. Technical Aspects: Hardware, Software, and Skills for SocialWorkers and Clients The utilization of technology for counseling has its inherent technological prob- lems. Typically, web-based therapies are conducted through the client-side com- puter, the therapist-side computer, and the servers that connect the two. Furthermore, depending on the nature of the counseling session, somewhere between two and six software programs are used (see Table 1). Adding hardware and software into the practice repertoire creates some noteworthy salient issues. Social workers who practice online are ultimately responsible for protecting data (Levenson, 1997) as well as ensuring that they have the technical skills that are requisite for practicing online (Stofle, 1997). Keeping Data Secure The most important is data security. The “real world” is replete with reports of data and identity theft either through the improper, unauthorized access to a person’s personal computer or through the malicious hacking of server or net- work traffic. In a review of websites conducted by the authors, it was dishearten- ing to note that many of the mental health professionals who conduct web- based therapy often utilize unsecured servers and almost never use encryption software. 110 ADVANCES IN SOCIALWORK With the growth of software that “snoops,” it is also becoming much easier for anyone withmalicious intent to load certain software into an unsuspecting client or therapist’s computer (see Walker, 8/21/2000). The software, thus, is pro- grammed to “capture” activities on a regular basis. Such an individual is then able to read confidential material and access client files and records. Protecting health information is a critical social work issue, even beyond the online arena. There are numerous cases regarding the violation of health care information security4 that are critical for social workers to be aware of while embarking in virtual practice. For the most part, social workers are unaware of who ultimately has access to their data, particularly electronic data such as e-mail. Text Residue A gravematter in the area of web-based counseling is the issue of reporting and taking down case-related notes. In an online, text-based environment, entire transcripts are recorded which include files that are seemingly “deleted” by the user. In fact, text residue is left behind even if records are deleted from the thera- pist or client computer. This residue can be resuscitated through the use of widely available data scavenging software. Current convention on recording case notes emphasizes that the social worker record only what is truly important in the case. In a web-based environment, this is not possible. As previously mentioned, pro- tective measures such as encryption can be taken, but it is impossible to remove all the residual effects of communication (unless the hard drive is reformatted). This has legal implications for social workers, as these text-based communica- tions, including electronic mail and other forms of data stored on the computers and servers, could be subpoenaed in court cases. As such, case notes would include the content of entire sessions and the social worker has less control over how the notes are to be interpreted. For example, if a social worker were conducting a group session using an online chat session, each group member would have a transcript of the group session that could be printed, copied, and distributed to other individuals. Of course, this risk also exists in “live” group sessions, but individual group members do not have access to a printed record. However, the danger of the “printed” record should not be ignored. Clients in violent relationships who receive counseling Client/Therapist Side Server Side •Modem Dial-up (AOL, MSN, etc.) • Encryption software • Browser (MS Internet Explorer/ • HTML server software Netscape) • FTP server software • Instant Messenger clients (MSN, Yahoo, • Java Applets ICQ, etc.) • Credit card processing • Video Link (MSN, NetMeeting) • Firewall • Java programs for applets • Real Media (for videos/audios)l •MSWord/WordPerfect for documents Table 1: Software That May Be Utilized During Sessions For detailed information on any of the terms used here, search http://www.google.com. 111 online might become more vulnerable if their text residue, e-mail, or chat infor- mation is intercepted. Of course, there are risks associated with any kind of therapy (on-line or off- line) as a result of negligence on the part of the social worker or malicious intent by an individual. However, most can be eliminated by proper use of secured sites and/or encryption software. Encryption5 allows the sender and the receiver to scramble and unscramble messages sent through the network. This prevents the data from falling into the wrong hands. Currently, no one is required to utilize such software when they practice online, but such a requirement may be a useful guideline. Licensing and Cross Border Practice:Who Is Responsible ForWhom? The “global” nature of online therapy makes the issue of licensing quite compli- cated. Obviously, ensuring accountability in social work practice is an important aspect of social work. Almost all states have some form of exam and/or the mandatory upgrading of skills through the accumulation of continuing education units. In an online environment, verification of such qualifications becomes more difficult. However, requirements for social work licenses vary from state to state. The licensing boards in each state are free to set their own standards and require practitioners to abide by them. Furthermore, most licenses have limited portability. State differences in licensing and portability issues make agreement on national standards for online counseling difficult. Social workers providing services to individuals in countries other than the U.S. is also an issue that needs to be addressed. Stofle (1997) remarks that online therapists should practice only in states where they are licensed and that a “national certification for online ther- apists” should be instituted. He further argues that only “experienced therapists” should practice online counseling. Currently, several online sites provide a service that provides a “credentials check” of therapists. Consumers can go to such sites and retrieve information regarding the education, degree(s), and licensees of registered online therapists. It may be feasible to require that social workers register with such services and for the profession to develop some kind of national certification program for those interested in online therapy. To date, no national or state social work organiza- tions have attempted such a service. Evaluating Online SocialWork Practice The efficacy of online therapy has not been well studied. Most of the evidence, thus far, has been anecdotal with a few exceptions (Barak, 1999; Barak &Wander- Schwartz, 2002; King &Moreggi, 1998;Murphy &Mitchell, 1998). There is an obvi- ous need to conduct empirical studies in order for the social work profession to proceed in this area of practice. The same standards utilized to evaluate face-to- face therapy should be applied to online therapy. There aremany approaches one could try in order to understand the nature of semantic conversations. Apart from using standardized measures that are typically used in real-life settings, tran- scripts of online sessions could give way to the potential for rich qualitative and content analysis. It would also be interesting to see what types of theoretical frameworks work best in an online setting. Menon, Miller-Cribbs/ONLINE SOCIALWORK PRACTICE 112 ADVANCES IN SOCIALWORK CONCLUSIONS There is enormous potential for the delivery of online social work practice. ICT can provide services to hard-to-reach clients, as it is geographically accessible and can reach clients in remote areas. Online counseling can be conducted from home, thus, bringing services to homebound individuals or those with limited mobility. ICT can be convenient, perhaps helping busy individuals carve time from their lives to talk to a social worker. From a physical standpoint, online serv- ices are a safe way to deliver services. Some people may enjoy the anonymity it provides either because of the issue they would like to discuss or because the community in which they live is small, which compromises their privacy. It may be the best, most cost-effective way to deliver services such as follow-up, refer- rals, support for relapse prevention, group services, informational services, and case management. Not much is known regarding the effectiveness of online therapy. In addition, there are a host of possible legal and ethical issues thatmust be considered. Social work must begin to seriously consider the impact of online therapy on the pro- fession. As previously noted, many social workers are already using these new forms of electronic service delivery without having a set of specific social work guidelines in place. Professional organizations in other fields have begun to take online counseling seriously, to the point of amending the language in their Code of Ethics to reflect on-line therapies. Social workmust also develop guidelines for the online practice of social work. It is suggested that social work consider the following as suggestions for incor- porating standards for online therapy into the social work profession: 1. Revise the Code of Ethics to reflect technological innovations, includ- ing such issues as: a. Confidentiality of clients. b. Providing services via secured and non-secured websites. c. Transferring information electronically. d. Securing client records. e. Identifying best use or a mandatory list of software, particularly encryption. f. Identifying the scope and boundaries of online practice. g. Establishing guidelines regarding the types of clients and issues for which online therapy is appropriate. h. Establishing availability of therapists. i. Providing limits of confidentiality (as in face-to-face therapy) but also including a discussion of the pros/cons and limits of online counseling. j. Addressing issues related to professional identification online, perhaps by mandating participation in “credentials check” services or establishing a “National SocialWork Credential Check.” k. Addressing issues related to developing social work websites that advertise therapy services. 113 2. NASW tasks a. Reflect issues ofweb-based counseling in theNASWpractice standards. b. Create a task force to examine the practice of and effectiveness of online therapies. c. Offer specific technology-based CEUs to online therapists. d. Limit cross-state/national borders counseling until liability guide lines are laid out. 3. Other tasks a. Mandate an intense empirical evaluation of any type of web-based therapy. b. Generate a list of accredited social work programs and licensed social workers available to potential clients on the web, with a link placed at the bottom of online social workers’ web pages. c. Establish constant credibility/content checks of websites by NASW, CSWE, and other professional bodies. The SocialWork profession must keep pace with the new and emergent tools of practice. Traditional counseling will not “disappear” as these new approaches are adopted; however, poor practice of social work may occur if clear guidelines are not created for those social workers practicing online. Like it or not, social work practice will occur online, and it is up to the profession to ensure that such prac- tice is conducted thoughtfully and ethically. 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Some Sites of Interest • www.metanoia.org • http://www.ismho.org/ • http://www.rider.edu/users/suler/psycyber/psycyber.html • http://netpsychology.com/ • http://members.aol.com/stofle/onlinepsych.htm Author’s Note: Address correspondence to: GouthamM. Menon, Ph.D., Center for Technology in SocialWork Education and Practice, College of Social Work, University of South Carolina, Columbia, SC 29208, USA. E-mail: goutham.menon@sc.edu. ADVANCES IN SOCIALWORK