It wasn’t talk therapy that Michelle Wade’s client needed most during crisis. It was text therapy.

The safety plan for Wade’s adolescent client dictated that she call Wade, a private practitioner in La Plata, Md., whenever she felt like cutting herself. But instead of calling, the client kept texting Wade. When Wade responded by calling the client back to try to de-escalate the situation, the girl would hang up on Wade, insisting she didn’t want to talk. The client would then explain the whole situation via text. “I clearly had an ethical obligation to communicate with her, [but] I needed to do it in a way that she was going to be receptive to,” says Wade, a member of the American Counseling Association who also works in a group counseling practice and is working toward her doctorate. “We had a discussion about the lack of confidentiality regarding [texting] and my uneasiness about it, but the fact of the matter was, I had to do what was in the best interest of my client. And in that situation, it was to text and calm her down that way.”

“I had to meet my client where she was at in that moment,” Wade continues. “She could not and would not communicate via voice, but she was willing to follow through with the safety plan and communicate her feelings with me [via text]. If I had fought that simply because it was ‘new and technical,’ the rapport and trust that she had with me would have been negatively impacted, if not destroyed. She was unwilling to listen to me via voice, so really I was only allowed to be helpful and effective through her chosen medium of communication.”

Generally, Wade tries to limit texting with clients to simply verifying or rescheduling appointments. But she acknowledges that she uses the technology when necessary, even giving each of her clients an individual code to send her so she can verify their identities. As for other technologies, Wade uses her iPad to play games with younger clients because she has found the approach keeps them entertained, engaged and talkative. She thinks Facebook can be a great avenue for counselors to advertise their services and says the social media site also holds potential as a tool to help clients talk in session about how others may perceive them. Wade has also heard of using Twitter to perform feelings checks with group members. While counselors must always keep in mind issues of confidentiality, Wade says the possible uses of technology and social media in counseling are limited only by the professional’s level of creativity.

Wade isn’t alone among counselors in trying to utilize emerging technologies in an effort to more effectively serve and reach clients. With the technological landscape continuously expanding and with social media, smart phones and iPads quickly becoming a part of everyday life, a growing number of counselors are looking to incorporate new technologies into their work. These technologies aren’t yet free of potential drawbacks or ethical considerations, but many counselors contend that if used properly, they could open up a whole new horizon for the profession.

Being social

Social media’s popularity has grown exponentially in recent years, with almost every business imaginable beckoning the public to follow it on Twitter or “like” it on Facebook. Counselors should make sure they’re not left out of the trend, says Marty Jencius, an associate professor of counseling at Kent State University and column editor for “The Digital Psyway” in Counseling Today. According to Jencius, people spend 22 percent of their online time using social media. “That’s where your clients are going right now,” he says. “That’s where they are, and that’s where you need to reach them.”

Nathan Gehlert, a counselor who works at the Imago Center in Washington, D.C., agrees. Two-thirds of the global Internet population already visits social networks, Gehlert says, and time spent on social networks is growing at three times the overall rate of time spent on the Internet. “If you want to connect with those people and have their business, you really need to be there,” says Gehlert, who offers social media consultations to mental health professionals.

Jencius points to a wide variety of social media, including social networks such as Facebook; wikis and blogs; microblogging sites such as Twitter; podcasts; video sharing sites; and virtual worlds such as Second Life. The term social media generally implies that information is sent out to a group of people, and those people then have the ability to respond to that information in some way, making it more interactive than past technologies have been, explains Jencius, a member of ACA.

Social media offers counselors a valid advertising and networking platform, Jencius says, providing a venue where they can introduce themselves and the counseling profession to potential clients, while also supplementing their work with existing clients. Gehlert, also a member of ACA, echoes that point. “It’s a great way for counselors to put themselves out there and build a tribe of followers,” he says.

Social media can help counselors connect with members of the community who aren’t already clients, Gehlert says. By getting conversations started on social media venues about particular topics in counseling, counselors can effectively position themselves as “gurus” on those topics, Gehlert says. By doing this, he adds, followers on social media are more likely to think of these counselors when they need help or when they want to refer someone else for help.

Counselors shouldn’t overlook their current clients when using social media either, Gehlert says. For example, counselors might post articles relevant to their clients’ issues on a professional Facebook page, allowing current clients access to additional helpful information outside of session. Counselors can write these posts themselves or link to other articles and websites it would benefit clients to read. Counselors could also post book reviews, top 10 lists related to certain topics, links to community resources and links to videos.

Social media can also be put to good use as part of counselors’ advocacy efforts, Gehlert says. For example, counselors can post to their legislators’ Facebook pages before an important vote comes up, explaining why the topic is significant to counselors and why the legislator should vote yes or no. One of the advantages of advocating in this manner is that the message doesn’t just go to someone’s inbox, Gehlert says. “It’s very public that way by posting to Facebook.”

In addition, because an estimated 25 percent of people search for health information online, Gehlert believes counselors have a responsibility to share reliable information, address misleading information and help the public attain an accurate understanding of mental health issues.

Social media is also an effective networking tool that allows counselors to connect with other professionals in their communities, Gehlert says. This can be helpful both in making referrals and in allowing counselors to advertise their own expertise and services to other colleagues, he says.

Wade says social media can prove useful in session as well, including using virtual worlds with clients to offer therapeutic healing. “Autistic clients can learn social skills in a nonthreatening way [in virtual worlds] by having to interact in normal, everyday situations,” she says. “PTSD [post-traumatic stress disorder] clients can reenact their trauma through programs like Second Life or other virtual worlds so that they can create a new narrative.”

To get their feet wet with social media, Gehlert recommends that counselors seek out workshops or find someone in their area who offers consultations. Then, start small. Facebook is an easy place to start, he says, because most people are already familiar with it. Counselors can establish a professional Facebook page for their practice. But because the page automatically will be linked to any personal Facebook page that the counselor might have, Gehlert warns that counselors should maintain the highest level of security on their personal pages.

Bridging the distance

Telephones have allowed counselors to reach clients at a distance for years, but today there are a host of additional options for distance counseling. DeeAnna Merz Nagel, a private practitioner in Atlantic Highlands, N.J., and cofounder of the Online Therapy Institute, says online therapy is defined as therapy delivered via technology, including by phone, e-mail, discussion forums, chats, instant message, videoconferencing and virtual worlds. Nagel, who is managing coeditor of TILT Magazine — Therapeutic Innovations in Light of Technology, points out that online counseling is not a modality but rather a method of delivery. Within that delivery, she says, a counselor can utilize various modalities.

Nagel sees the benefits of online counseling as wide ranging. One of the primary advantages is that it allows practitioners to reach a larger client base, including clients who live in rural environments, those who have disabilities, those who are afraid of potentially bumping into other community members at a counselor’s office and those with social phobias who might not leave home. On the negative side, Nagel says counselors should be aware of online therapy’s “disinhibition effect,” which can cause clients to disclose too much personal information too quickly and then leave a session feeling very vulnerable.

Counselors interested in offering online counseling should know up front that it is unlikely to make up 100 percent of their business, Nagel says. “A lot of therapists think they can hang their virtual shingle and the clients will come in droves, and that is not the case,” says Nagel, a member of ACA’s task force on cyberspace and technology. She recommends counselors begin online work as an adjunct to their brick-and-mortar practices, offering online services to existing clients.

E-mail therapy can be challenging, Nagel says, because it requires counselors to have excellent command of the language, both to minimize the number of possible misunderstandings and to clarify those that inevitably arise. E-mail therapy probably has the steepest learning curve, she says, with online chats being a little more similar to face-to-face communication and video conferencing even more so. But the online therapy that Nagel thinks offers both the most potential and the most risk is avatar therapy using virtual worlds.

Some counselors are beginning to conduct therapy in Second Life, an online virtual world. Nagel doesn’t recommend this because Second Life is not secure and encrypted, but she says other platforms are being created that will be more geared toward health care delivery. Nagel uses Second Life as a tool in session with clients only if they want to show her the worlds they’ve created, which she equates to bringing a journal entry to session.

Supervision is another element of counseling that can be aided by technology and conducted from a distance. However, Nagel, who conducted online supervision for about six years while living in Georgia, says using online clinical supervision for the purpose of obtaining licensure can be tricky. She recommends checking with state boards ahead of time to ensure the hours will count. Go to the board and explain very specifically how the online supervision will occur, she says, and then ask the board to approve or disapprove it. Nagel says the Online Therapy Institute offers two courses on the topic for counselors interested in starting online supervision.

On the positive side, Wade says, technology offers opportunities for live supervision without the supervisor needing to be in the next room. “I see technology as a way to bring back live supervision versus having to watch tapes or have a play-by-play of the session,” Wade says. “With web-conferencing programs like WebEx, in theory, a supervisee could have a session with a client and be observed by his or her entire practicum/internship class regardless of the classmates’ locations. … The students could log in to the WebEx location and be able to view the webcam of the session.”

Wade adds that the ability of video-conferencing programs to offer live, face-to-face supervision through webcams negates one of the criticisms of technology-based supervision: the loss of nonverbal communication. She also points to sites such as voicethread.com, where videos can be uploaded to a secure server. “Say a supervision assignment is to videotape a mock therapy session. One can post the video into the voicethread.com class account, and the supervisor and peers can comment either by text, webcam or audio,” Wade says.

Three years ago, Jencius developed the Counselor Education in Second Life training center, a virtual world that offers training workshops throughout the year and which features areas that simulate client environments. Wade has found past role-play training in the virtual play therapy room particularly helpful. For instance, she says, the virtual setting can help a supervisee practice a counseling session with a child. “I, as the supervisor, could change my avatar [a virtual representation of an individual] to look more like what a 5-year-old would look like and interact with my supervisee in the same manner I might role-play within a classroom setting, but my supervisee is now getting a visual cue to his or her brain that it is an actual 5-year-old in front of him or her rather than a graduate student. It can help trick the brain in some form or fashion into interacting in a more authentic way with the type of client who is being visually represented.”

Integrating technology into supervision requires careful thought and preparation, Wade says. “I think the thing to keep in mind as a supervisor is whether or not technology is useful and how to use it in the best possible way to train, not just to use technology because you can.” The major challenges with distance supervision include ensuring security and confidentiality, she says, as well as acquiring the necessary knowledge to use the technology effectively and preparing a backup plan in case the technology fails — for example, in a power outage.

With supervision that happens over e-mail, instant message or even text message, it can be easy to read into something or misinterpret what is being said, Wade warns. “The important thing to remember is that one does need to be cognizant that tone is missing,” she says. “So, when the supervisor or supervisee has questions about the true intent of the e-mail, there needs to be a level of trust and respect on both [sides] to ask what the true intent was. Admit that you may have misread the e-mail and just wanted to clarify.”

The pros (and cons) of being plugged in

One positive effect of technology’s integration into counseling is that it has reduced the stigma for some clients. “Think about what we as counselors ask our clients to do — trust a complete stranger with their darkest secrets that sometimes they don’t even express to themselves,” Wade says. “There is an almost implied safety within the anonymity of technology and not having to be face-to-face with someone who is that perceptive of one’s inner turmoil.”

Another benefit is that counselors can post resources and information online that might encourage the public to feel more normal about seeking help, Jencius says. For example, if a counselor posts information about phobias and an agoraphobic person comes across the information, that person might feel less stigmatized about working with a counselor on that issue.

Confronting stigma is one of the most important reasons for counselors to maintain a strong presence online, Gehlert says. “If you think about the online world as a marketplace, there’s a big conversation going on in that marketplace. The more mental health counselors who are engaged in that conversation, putting out more and more informative information, normalizing issues that people are struggling with, the more stigma can be reduced.” If someone comes across a counselor talking about the issues that person happens to be struggling with, it might provide that individual a sense of normalcy and an impetus to get help, he says.

Promoting yourself online or offering online counseling also tends to break down some of the barriers that typically prevent potential clients from showing up at the office door, Jencius says, whether because they feel stigma about a particular problem or simply because they don’t necessarily take notice of a counselor’s office in casually passing by. In addition, Jencius says, opening communication with a counselor online can feel less threatening to some clients who wouldn’t reach out otherwise. “Sending an e-mail or a Facebook message might be easier than starting with a 15-minute introduction or dropping by the counselor’s office,” he says.

Online counseling also allows for more flexibility, both for the counselor and the client. The same holds true for online supervision. “I live in the [Washington] D.C. metro area,” Wade says. “For me to drive in for supervision at school, it was a minimum of 45 minutes with little traffic. With heavy traffic, an hour and a half. So, for an hour of supervision, I’ve had to allot two and a half to three hours of my day, whereas during Skype supervision, I just had to allot the scheduled hour. Also, there are a number of clients out there who may hesitate to do therapy because they travel a lot. Technology gives those clients the ability to access services in nontraditional ways and in ways that work for their schedule.”

The advent of social media allows counselors to become their own advertising specialists instead of hiring one, Gehlert says. “It means that anyone can engage in advertising or reaching out to the community. It used to be that you had to have some knowledge about marketing or you’d get an expert to help you, and they would put things in the newspaper or other older forms of marketing. But now everyone can do it with relative ease and without experience.”

At the agency where Gehlert works, counselors use another facet of technology in their work: storing electronic medical records with the free iPad app called drchrono. The program allows them to complete a variety of tasks, including billing, scheduling appointments and taking notes, using a tablet instead of waiting to boot up their computers. “It really does streamline the process,” Gehlert says.

With all the positives that technology offers also come a few negatives, and counselors generally agree that boundary issues belong at the top of that list. “This has become a 24/7 sort of society, and with that comes the blurred lines of boundaries,” Wade says. “Clients do not understand why it’s not necessarily appropriate to ‘friend’ their counselors, for example. Also, if [a counselor is] going to do texting, being aware that you would not answer your office phone at 10 p.m., so what makes you reply to a [client’s] text that late? The communication ability is so easy and fast, it is very easy to set unknown expectations. Also, I think there is a lack of understanding of the hidden messages we might send when using the technology. For example, I am a night owl. I have to be very aware at times to not write professional e-mails at 2 a.m., even if that is my best functioning moment, because what does that say about me?”

This is why some counselors take issue with new technologies, Jencius says — because they’re worried clients will expect them to be available at all times and expect responses to anything clients post via social media. But Jencius says counselors can establish their own individual boundaries about what is right for them in professional practice.

He does, however, caution counselors to pay close attention to privacy settings and to “do a good job of editing themselves before they push the post button.” If photos of a counselor doing shots at a friend’s party surface on Facebook, it’s entirely possible that could affect the counselor’s employment status and reputation down the line, Jencius says.

Dabbling in technology can be positive or negative, says Gehlert, who adds that the outcome is the counselor’s choice. “If you have a positive digital footprint, I think it’s really going to be helpful to a counselor when it comes to clients deciding to work with you or your colleagues … that you’re someone they can respect and trust. The larger presence you have, the better — it gives you greater credibility. The flip side of that, though, is that if your footprint is negative or questionable, there’s a real possibility that that can harm you.”

Two other challenges Jencius mentions related to online counseling: the concern over whether the client really is who he says he is and the task of setting up an emergency plan. But both of those hurdles also exist in face-to-face counseling, he points out. “We don’t always know what we’re getting when a client walks in, and we don’t always know they’re being truthful,” Jencius says. “And we always have to figure out what to do in emergencies. It’s just a little different doing it from a distance.”

Gehlert also cautions that self-care can be negatively affected if counselors who rely on technology aren’t careful. With social media, iPads, smart phones and other tech tools, it’s incredibly easy to get sucked into being connected to your work at all times, he says. “I think that’s really dangerous because we need to have that experience of going home at the end of the day and turning that off, [then] having our personal lives and engaging in things that are healthy.”

An ethical gray area

When the ACA Code of Ethics was last revised in 2005, social media wasn’t the popular and powerful societal force it is today. In part to address social media’s ethical implications as they relate to counseling, ACA announced earlier this year that it is undertaking a major revision of its ethics code. The goal is to release the revision in its final form in spring of 2014.

Until then, counselors who are embracing the use of technology in their practices must use their best judgment. “I think the things to constantly ask … [are] ‘Am I doing this as ethically as possible?’ and ‘What is the worst-case scenario?’” says Wade, appointed as a student member to the ACA Ethics Revision Task Force. “Encryption and secure servers and virus protection are essential, but so is technological competency. And technological competency is not simply understanding how the technology works, but also how to present oneself through the technology.”

Regarding social media, Wade says counselors must take time to understand privacy settings and to stay on top of if and when those settings change. “Informed consent needs to be inclusive of all the threats to confidentiality and how the counselor is trying to protect all of the client’s information,” she says. “Also, I strongly suggest that if you are going to have a presence in social media, have a social media policy regarding whether you are going to friend or follow a client and vice versa. The client deserves to know from the start where you stand on that, so when you do refuse that friend request, the client does not take that as a personal offense but rather just as part of the counselor’s policy.”

Let clients know your policies and boundaries concerning how you’ll connect with clients online, Gehlert says, and stress that the reason for those boundaries is to protect their confidentiality. Counselors using electronic medical records should let clients know their information is being stored that way in the informed consent and explain the level of security protecting those records, he adds.

Gehlert also advises that counselors should never search on Google or social media sites for information about their clients. A counselor’s natural tendency is to be as helpful as possible, so looking for information to better understand clients might seem like a good idea. But it’s not, Gehlert insists. “It’s up to the client to decide what to bring in [to counseling],” he says.

Nagel says the Online Therapy Institute offers a number of ethical frameworks for the use of technology and social media in the mental health fields. She recommends counselors desiring to integrate technology into their work seek training on a variety of topics, possibly including crisis intervention, handling yourself online in a professional manner, transferring your face-to-face skills online and understanding cyberculture. In addition to trainings offered through the Online Therapy Institute, Nagel points to opportunities at the ACA Annual Conference & Exposition as well as the Distance Credentialed Counselor training offered by the Center for Credentialing and Education.

The No. 1 question Nagel gets regarding distance counseling is whether practicing across state lines is ethical. “What I recommend is that in order to practice solid risk management, they stay within their state lines,” Nagel says. “But if they choose to practice outside their state lines, they need to check with their state board, they need to check with the client’s state board, they need to check with their malpractice insurance and, overall, they need to have legal consult in terms of setting up their online practice.”

Nagel agrees that a counselor’s informed consent policy needs to cover as much information as possible, including social media presence, online record storage and security. Nagel’s own informed consent says she will only communicate via encrypted channels, which means she doesn’t talk to clients calling from cell phones. Counselors who choose to communicate with clients on cell phones need to inform clients about the security risks, Nagel says.

Life online

Technological advances aren’t only affecting counselors’ practices, of course. They’re also affecting counselors’ clients, whether they walk through the virtual door or the real one. “I see technology as a way to enhance clients’ lives, but also in some way as increasing isolation,” Wade says. “It is incredibly easy to get lost in a game like Angry Birds and waste numerous hours not engaged in social activity.”

Technology has also raised unrealistic expectations among some people regarding how quickly they should be responded to by friends, family members and acquaintances, Wade says. “Because it is so easy to quickly respond, when one doesn’t, the other person can feel a sense of abandonment or feel as if he or she is being ignored, when [it’s probably because] the battery is dead or something not related to the response.”

Maintaining relationships online can also come with complications, Gehlert says. “I’ll hear clients say they were offended by something someone said online, or they’ll say, ‘This happened. Should I defriend this person?’ There is sort of a lack of established etiquette in our culture about what’s the right and wrong thing to do. It can be confusing to people.”

On the side of enhancing lives, Wade says the amount of information available and the ease with which it can be obtained is phenomenal. “I remember having to use my World Book Encyclopedia in elementary school for projects, and now information is a Google search away. Also, people are not limited to their own geographical locations anymore. For example, that small town gay male does not have to feel alone in the world because he can connect with an LGBTQ (lesbian, gay, bisexual, transgender, queer/questioning) community online.”

There is also a wealth of information available online that empowers people to take charge of their own self-care, Nagel says, ranging from a plethora of self-help websites, blogs and articles to encrypted journaling websites to self-paced programs for insomnia and depression. “In many ways, there is more available to the average person to assist with a mental health issue than ever before,” she says. “The more counselors know about that, the better help we’ll be to our clients.”

Understanding the web culture of clients is a counselor’s responsibility, Nagel emphasizes. “The relationships that occur in virtual worlds are real relationships,” she says. “The relationships between people on Facebook who don’t know each other or on Twitter are real. If we can’t wrap our minds around how those are real, then we’ll have a hard time establishing a genuine relationship with the client or understanding them. It doesn’t mean they’re good or bad relationships, but they’re real.”

Although conceding it’s possible for someone to become immersed in a virtual world or another technology that is ultimately bad for them, Nagel says counselors should avoid jumping to the worst conclusions. The advent of television and telephones worried many people at the time, says Nagel, adding that with every new technological breakthrough, society first tends to swing to an extreme before eventually finding a balance.

Nagel recommends that counselors screen for the possibility that technology is having a negative impact on their clients, but she says counselors should also be aware of the wide variety of potential benefits. In particular, counselors need to remain open to clients’ web cultures, Nagel says. “It’s not that we’re less social people now; we’re socializing in different ways. While I might choose not to socialize online, just as we learn in a multicultural class, it would be really inappropriate for me to judge a person’s culture without understanding them.”

 

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Letters to the editor: ct@counseling.org

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Self-teaching for students

Kelly Erney, one of Beto Davison Aviles’ former counseling students at Bradley University, first introduced him to video self-modeling when she showed her peers in Davison Aviles’ internship class some videos of her preschool students using video self-modeling to learn. Davison Aviles, an associate professor of education and coordinator of Bradley’s professional school counseling program, was hooked, and the pair ended up presenting on the topic at the American Counseling Association Annual Conference & Exposition in New Orleans earlier this year.

“School counselors can use video self-modeling to help students learn pro-social behaviors and develop academic success skills, like following directions and improving time on task,” says Davison Aviles, a member of the American Counseling Association and the American School Counselor Association, a division of ACA.

The idea was developed by Jessica Roberts, author of Success Stories: Using Video Stories to Connect, Communicate and Create True Success With Your Students, for use with kids who are developmentally delayed, Davison Aviles says. A school counselor can “direct” a short video clip, walking the student through an appropriate social interaction or task while taping it. Then, when the student needs help accomplishing that task the next time around, the student can watch himself or herself complete the task in the video, whether on a laptop, a smart board or somewhere else in the classroom.

“School counselors seeking to improve pro-academic behaviors such as following directions and increasing time on task can use video self-modeling,” Davison Aviles says. “Video self-modeling can also be used to teach social skills, the ability to play with others and the ability to initiate and engage in conversations.” In ways not yet fully understood, video stories seem to help students who have not responded to traditional face-to-face or group interventions, Davison Aviles says.

Taking the approach one step further, Davison Aviles suggests a school counselor could post a video story on a social networking site so parents could access the video to help their child after school hours. Another opportunity tied to social media is to have parents use video-conferencing programs to connect to their child’s schoolroom during the day, Davison Aviles says. The parents can then see the child accomplish certain tasks and provide real-time reinforcement, he says.

— Lynne Shallcross