Basic Ethics for Clinical Practice

WELCOME! Please have a seat…preferably near someone you DON’T work with! “It’s not the car you SEE that runs you over…”

Basic Ethics for Clinical Practice • Emergency exits are where you see them • Restrooms in the waiting area, • Please mute your cell phone, and only take emergency calls • Lunch will be on your own from 12:45 – 2pm If you would like to join in the OPTIONAL interactive portion of the training, please follow directions on the next slide Optional audience interactive participation

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TO USE THE INTERACTIVE FEEDBACK FEATURE: (1) On your tablet or smart phone, please log onto the Conference WiFi : (2) Then log onto www.menti.com (3) enter the code displayed Here’s the road map for this morning…

08:30 – 08:45 Introduction & ground rules 08:45 – 09:30 Principles of biomedical ethics Boundary issues in the helping relationship 0930 – 10:30 Client “Bill of Rights”

10:30 – 10:45 BREAK 10:45 - 12:00 Discussion of YOUR ethical questions Dual Relationahips Ethical Multi-Cultural Practice 12:00 – 12:45 Ethics Codes including ND “Century Code” 12:45 – 2:00 LUNCH [on your own] What are your learning goals for today?

[We’ll check back at the end of the Training…] What are YOUR ethical concerns?

Please take some time between now and the 10:30 break to write down any ethical questions or concerns. We’ll have an opportunity to discuss them – anonymously – after the break.

“A code of ethics cannot guarantee ethical behavior. Moreover, a code of ethics cannot resolve all ethical issues or disputes, or capture the richness and complexity involved in striving to make responsible choices within a moral community. Rather a code of ethics sets forth values, ethical principles and ethical standards to which professionals aspire and by which their actions can be judged.” NASW Code of Ethics 1999 The essence of Ethics…

Client or Clinician or Consumer Counselor

Ethical & Legal Obligations Best Practice 6 Basic Principles of Biomedical Ethics

• Autonomy • Let them “be themselves” • Beneficence • For their “own good” • Justice • Fair, equal and “right” • Competence • Know what you’re doing • Discretion • Protect client’s privacy • “Non- • “First of all…do no harm” maleficence” Autonomy

Is the counselor giving the Client the freedom to make choices about their directions & goals in Treatment? Beneficence

Is the counselor providing hope, encouragement & support for the Client’s decisions? Justice • Are all ethical codes, laws and universal values being followed by the Counselor? • Is the Counselor providing fairness to all who are involved with this Client’s treatment? Competence

• Is the Counselor acting within the limitations of their education and training? • Are they within their scope of practice? • Do they know when to seek Clinical Supervision or refer? Discretion

Is the Counselor not only following the “letter of the law”, but proactively protecting the client’s privacy and dignity? “Non-maleficence”

“Primum, non nocere” Hippocrates. Is the counselor working with the Client in a way that will “first of all - do no harm”? ETHICS and the LAW Relative “Stringency” of Codes of Professional Ethics

N ACA / NASW A AHIMA A ASAM AMA APA D ANA APPO A C

MOST LEAST STRINGENT STRINGENT

19 The Client’s BILL OF RIGHTS

Is the Counselor giving each Client: the right FREEDOMS…

…to make decisions, choose options and evaluate consequences, while offering the the right SUPPORT…

…within appropriate boundaries? Is the Counselor taking the right ACTIONS…

…to protect the Client’s rights and welfare, and doing so for the right REASONS…

…with appropriate consideration and fairness to all? Boundary Issues in the Helping Relationship

Adapted from Cynthia Geppert MD, PhD, MPH Chief Psychiatric Ethics Consultant New Mexico VA Hospital “Ethical geography”… where are YOUR boundaries? • Have you ever hugged a client? What type of hug was it? • Have you ever given or accepted a gift from a client? • Have you ever seen a client when you were tired or distressed? (Come now, be honest.) • Have you ever given a client a peck on the cheek? (In some cultures, that’s the equivalent of a handshake.) • Have you ever given an indigent client bus fare home, perhaps out of the company kitty or perhaps out of your wallet? • Have you ever gone to the funeral of a client’s loved one? Of the client themselves? How did you handle the interactions or questions such as, “Oh, how did you know my son?” • Have you ever felt sexual attraction to a client? (If you have any blood in you, you likely have.) http://www.counselormagazine.com/2012/Jul_Aug/Ethics_In_Counseling/#sthash. bXJVlRth.dpuf David J Powell - 2012 What is the basis of “professionalism”? a) Making lots of money b) Placing the interest of clients above all other considerations c) Being respected d) Being in an unequal power relationship with our clients What is a “boundary”? • Ethical principles, laws and professional values that define the professional-patient relationship • Boundaries are “limits” that indicate behavior that is not acceptable • They are also guidelines and directives that recommend what behavior is appropriate Boundaries & Professionalism

• The core ethic of professionalism is to “place the interests of the patient above all other priorities.” • The public trusts health care professional to serve patients and society with integrity and expertise • Without this higher standard of conduct, health care would become like any other “job” What is the main purpose of boundaries? a) To keep you from getting into trouble with your boss b) To avoid breaking laws c) To prevent clients from suing you d) To enable vulnerable clients to trust clinicians without fear of being exploited e) All of the above Boundary Violations • Compromise professional judgment, objectivity and behavior • Place either self or another interest above that of the patient • Compromise the trust between the patient, professional and community (Usually obvious to the Counselor, Patient and/or community) Boundary Crossings… …have the potential to, but do not necessarily go beyond, the limits of acceptable professional conduct Boundary “adaptations”… …are inevitable overlapping or dual relationships which preserve the patient/provider relationship, but might be considered crossings or even violations in other settings. (This is why God invented Clinical Supervisors!) What boundary concerns don’t mean…

• …that we can’t having our own personal, family, religious or social values – this is part of being human • …that we don’t deserve to be paid for our work, be respected, or have certain privileges by virtue of our training • …that certain behaviors – like accepting gifts or socializing – are always wrong in themselves. Some violations are obvious: • Romantic or sexual relationships with current clients • exploitative business deals with current or past clients • Breaches of confidentiality (not covered by Tarasoff or current law) What are some others? Others are less clear-cut, especially in rural areas: • Social relationships with current clients • Favoritism • Accepting gifts • Business dealings • Hiring clients to work for you • Treating friends or family What are some other examples? Boundary dilemmas unique to rural practice • Cultural dimensions of behavioral health care • “Generalist” care and “scope of practice” issues • Limited resources for consultation on clinical and ethical issues • Overlapping relationships in villages After Roberts LW: Frontier Ethics – mental health care needs and ethical dilemmas in rural communities. Psychiatric Services 50: 497-503 (1999) Boundary dilemmas unique to rural practice (con’t) • Increased stresses on rural Providers • Role conflicts inherent in village life (eg. “I’m your cousin…” and “…but today, I’m your counselor.”) • Altered therapeutic relationships between patients, caregivers & families

After Roberts LW: Frontier Ethics – mental health care needs and ethical dilemmas in rural communities. Psychiatric Services 50: 497-503 (1999) Which of the following might NOT be considered a boundary violation? a) Accepting home-made cookies from a client b) Hiring a client who is a carpenter to work on your house c) Going out to lunch with a former client d) Giving some patients their preferred appointment times The problem is…

…many boundaries aren’t black-and-white, but drawn in shades of grey. Are any of the following a type of boundary crossing, but not yet a violation?

a) Calling a client by their first name without being invited a) Sleeping with a discharged client of another counselor b) Accepting stock tips from a current client c) Telling a client about the times you relapsed before getting sober d) “Friending” a former Client on Facebook Possible consequences of getting it wrong:

• Rupture of the therapeutic relationship • Loss of patient and public trust • Reprimand or censure by employer • License suspended or revoked • Lawsuits for malpractice or battery • Criminal charges for sexual misconduct One of the “biggies” in our field… Appropriate uses of Touch

• For the safety of the client (eg. Therapeutic hold) • Culturally appropriate greeting • For a therapeutic intervention… • …ALWAYS with the client’s permission! Do NOT use touch if… • …it mainly meets the Counselor’s needs • …it brings up difficult transference or counter-transference issues • …Client has a history of unresolved boundary violations • …either the Client or Counselor sense discomfort • …it could be misunderstood or misinterpreted by others (especially in public) Prohibited Relationships “To feel attraction to a Client is not unethical; to acknowledge and address the attraction is an important ethical responsibility.” Kenneth Pope There is a predictable pattern to exploitive relationships…

• Counselor’s neutrality gradually decreases • Sessions become less clinical - more social • Client is “special” • Counselor self -disclosure increases • Counselor touches Client, leading to “innocent” embraces There is a predictable pattern to exploitive relationships…

• Client needs “extra” sessions • Counselor begins to manipulate transference • Sessions are longer – end of day or Friday • Counselor stops billing for sessions • “Having lunch” or dinner after session leads to dating Membership expulsions for ethical violations from major counseling, psychology, and social work organizations in the United States: a 10-year analysis • The most common reason for expulsion was for violations under the category of dual relationships, particularly those of a sexual nature. • Data indicated that the rates of expulsions stayed steady or declined, were dispro- portional across organizations, and that organizational sanctioning may be even more rigid than that of state boards. Phelan , JE Psychol Rep. 2007 Aug;101(1):145-52. Malpractice is limited, generally, to six types of situations: 1) The procedure demonstrated by the practitioner was not within the realm of accepted professional practice; 2) the practitioner used a technique without proper training; 3) the therapist did not use a procedure which would have been more helpful; 4) the therapist failed to warn and protect others from a violent crime; 5) informed consent to treatment was not obtained or documented; 6) the practitioner did not explain the possible consequences of the treatment (Anderson, 1996) The following four elements of malpractice must be present for a successful malpractice claim: • Duty – a professional relationship existed between therapist and client. • Breach of duty - therapist acted in a negligent or improper manner, or deviated from the “standard of care” by not providing services considered “standard practice in the community.” • Injury - client suffered harm or injury and must show proof of actual injury. • Causation - a legally demonstrated causal relationship between practitioner’s negligence or breach of duty and the claimed injury or damage of the client. Whaddayathinq? Down in SMOKE… The NAADAC Code of Ethics offers advice – but NOT explicit guidance There are 5 sections of the Code which might apply to medical marijuana: • Trustworthiness • Compliance with the law • Rights and duties • Preventing harm • Duty of Care Ethical dilemmas related to medical cannabis • LEGALITY – • Efforts to “NORML-ize” decriminal-ized cannabis use vs “legalized” • Emerging literature • Still illegal at Federal supporting use for level (Schedule 1) – “terminal & debilitating funding? conditions” • Legal risks to Agency and/or Counselor • Patients with chronic • Philosophical conflicts pain, cancer, HIV etc. with abstinence-based • Societal shift in percep- programs tions of medical MJ and • Possible effects on CBD’s other clients What Are YOUR Personal Ethics Around:

• Harm reduction? Is “abstinence” a goal, or a given? • How about for poly-drug abusers? • How to engage folks with co-occurring disorders…which comes first? • How about methadone? Suboxone? • Needle exchanges? Injection sites? Naloxone inhalers for family members? • “Licit” drugs like Kratom? Peyote? • What about “vaping” for tobacco? Please take a moment to collect the papers with your ethics questions and dilemmas for discussion.

10:30 – 10:45 Discussion of ETHICAL DILEMMAS and Case Vignettes Discussion of ETHICAL DILEMMAS and Case Vignettes #1 Here’s an easy one: You are a Counselor for Catholic Social Services, and the only clinician in a remote village. A 15 year-old girl comes to you for counseling because she was sexually assaulted at a party, never told anyone, and now is pregnant. She wants advice on terminating her pregnancy – an abortion. What are the ethical considerations, and how do you respond? #2 The “Two-Hatter” dilemma As a member of a 12-Step fellowship, you are at a meeting. A former client from your Program, who had a different counselor, discloses that she has relapsed, is drinking every weekend, and having unprotected sex. Because you have seen her file, you know that she is HIV-positive. Do you have an ethical responsibility? If so, what? #3 A theoretical example:

You are a counselor in an Agency. You have a female client, and her partner is also a client with a different counselor. She comes to session extremely upset, saying that her partner is drunk and using crystal meth. He is threatening to kill her and the kids if anybody finds out. Is there an ethical dilemma? If so, what do you do? #5 An actual case study from a counselor (in another State) Is it ethical for a Counselor to enforce a court order for a immigrant client to pay $150 for a psycho-educational group when that person (1) cannot see or read well, and (2) the Counselor is unable to interpret all this into their native language? Is there an ethical dilemma? If so, how can it be resolved? #6 No problem here… A female client comes to you and discloses, in confidence, that she was solicited sexually by another counselor in your Agency. She begs you not to say anything, because she’s afraid she’ll get kicked out of treatment and lose her children. Are there any ethical compli- cations? If so, what? How do you respond? #7 Confidentiality vs. Ethics

Mr. E is a twenty-five-year-old man with symptoms of fever and fatigue. He sees his doctor and asks for an HIV test, which is positive. The doctor gives him the news in a gentle, supportive manner and recommends treatment and counseling. Mr. E says he has only one sexual partner and is adamant that the partner not be told of Mr. E’s HIV status. The doctor tries to convince Mr. E to do so but to no avail. Should the doctor inform the partner? The answer may be: “It depends.” It depends on state and local laws, the patient’s right to confidentiality and the well-being of society. (David J Powell – 2012) #8 Duty to report?

Ray is a recovering alcoholism counselor. He has a brief (two-day) lapse following the death of his wife. He immediately goes to AA, meets with his sponsor, and sees a grief counselor. He is not drinking now. Your agency’s policy requires two years of continuous sobriety. No one knows of Ray’s lapse. He fears he may lose his job if he discloses the lapse. He comes to you as a coworker and friend seeking your advice. What do you do? What do you say to Ray? If Ray does not want to report his lapse to management, would you? How about ACCBO? #9 Rules are for everybody

Mary is a heroin addict in withdrawal from an over- dose. She comes into the emergency room for help. She’s smoking a cigarette. The ER nurse tells Mary she is not permitted to smoke in the ER as it is a fire hazard with oxygen around. Mary refuses to stop smoking. The nurse tells her she must leave the ER then. Mary leaves, and an hour later she is brought into the hospital in an ambulance, dead on arrival. Did the nurse do anything “wrong?” Legally, likely not. Ethically, the questions are: “Did she do all she could do to help Mary?” “Were there alternative directives she could have offered?” Morally, when she goes home tonight, how will she feel about what she did today? (David J Powell – 2012) #10 Honoring Cultural and Professional Values Ms. J is a Clinician working with Tribal members in a Native community. They so appreciate her care for them that they invite her to participate in a Ceremony usually reserved for tribal members, and will make her an extended member of the community. She feels uneasy about accepting the invitation, but realizes she will offend the community if she refuses. What should she do? #11 All in the family • The only Clinician in a rural area is approached by his sister for emergency help with her daughter (his niece) who was just arrested because of a serious alcohol problem and depression. • Then their mother calls the Counselor and says that her granddaughter is suicidal, but afraid to tell her mother. • How can the Clinician negotiate the difficult family dynamics? • The Counselor is faced with multiple risks, both personal and professional. He must put the patient above all other priorities. • He should provide only emergency care until the patient can be stabilized and transferred to another provider or facility. • The Clinician must tell family only what is necessary to protect the patient, even if it causes bad feelings within the family. #12 “Two-hatting” never gets easier…

As a Counselor who is also a member of a 12- Step fellowship, you are at a meeting. A former client from your Program, who had a different counselor, discloses that he has relapsed, and is drinking until he blacks out. He is upset because his girlfriend told him that he “touched” her 10 year-old daughter sexually, and hit her 8 year-old son when he tried to stop the abuse. Do you have an ethical responsibility? If so, what? Dual Relationships? Casual Prohibited Encounters Relationships

• Normal social • Are PLANNED contacts • Accidental meeting • Are ONGOING • Infrequent • Contacts protect the • Are MUTUAL integrity of the Counseling relationship • Are EXPLOITIVE Some Problem Areas for Dual Relationships

• Self-disclosure • Gifts • Social media – eg. Facebook • 12 Step & Peer Support Meetings • Relationships after Termination • Boundary violations • Business relationships Self-Disclosure – “Whose needs are being met?”

• Benefit is to the Client • Consistent with Treatment Plan • Due consideration of impact on Client • Not a current or unresolved issue for Counselor • Potential consequences for both are considered • What is the frequency? “If you’re not sure – DON’T!” With apologies to Johnny Cochran:

If you must “suppose” …

don’t disclose! There are three issues we must face when considering making a decision about how to act: what is legal, what is ethical and what is moral. • The legal standard is typically the minimum acceptable level to meet the requirements of the law. • The ethical standard, on the other hand, is the opposite: what is the most I should do for this individual? • The moral issue is, when I put my head on the pillow tonight, how will I feel about what I am about to do? http://www.counselormagazine.com/2012/Jul_Aug/Ethics_In_Counseli ng/#sthash.ofgAauaz.dpuf David J Powell Some guidelines for Business Transactions with current or former Clients: • Is the exchange open and public? • Is the transaction of equal value to both parties? • Is there a “paper trail”? [Eg. an estimate before and receipt after?] • Was there a fair market process? • If it were published in the paper, would either of you be embarrassed? Guidelines for Gifts from Clients

• Is it a gift of “time, or treasure?” • Is there significant value? • Is there a hidden agenda? • Are there transference issues? • Would rejecting the gift do more harm than accepting it? • Could the gift be misinterpreted by others? Some guidelines for ethical decision-making

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7 Steps in Ethical Decisions

• Gather all the facts • Brainstorm possible • Identify all stake- resolutions with all holders and their stakeholders interests • Conduct a “fairness • Consult your Ethics test” Code and Agency • Develop & Policies implement action • Identify “worst-case steps to resolve the scenarios” dilemma and after Joseph Paliwoda, MBA prevent recurrence Paragon Consulting © 2005 First of all, ask yourself…

…does it meet the “Mom test?” The “fairness test” questions:

• Does it meet the “Mission test?” • Does it meet the “pride test?” • Does it meet the “explanation test?” • How about the “front page of the newspaper test” ?!? Again with apologies to Johnny Cochran: If you might rue it… … you best not do it! Some Principles for Ethical Multi-Cultural Practice from NAADAC Ethics: the Client-Counselor Relationship

• Recognition… • Knowledge… • Awareness… • Respect… Some Principles for Ethical Multi-Cultural Practice

Recognition of individual and cultural differences between myself and my client. Some Principles for Ethical Multi-Cultural Practice

Knowledge of the Cultural values as well as the mental health and substance abuse needs of clients living in a pluralistic society. Some Principles for Ethical Multi-Cultural Practice

Awareness of personal, societal and institutional biases about different cultures. Some Principles for Ethical Multi-Cultural Practice

Respect for Traditions, pathways and ways of knowing different from my own. Working in a Culturally Diverse World • “An addiction professional understands the significance of the role that ethnicity and culture plays in an individual’s perceptions and how he or she lives in the world.” • “…many individuals have disabilities which may or may not be obvious…and unless described might not appear to inhibit expected social, work and health care interactions… • “…Persons having such limitations might be younger than age 65...” • “Part of the intake and assessment must include a question about any additional factor which must be considered when working with the client.” • NAADAC Code of Ethics (revised) 2011 A Few Examples of Ethical Multi-Cultural Practice

• Conducting treatment in a language understood by the client [translate or refer] • Educating clients about Western treatment processes and expectation, while also • Learning all we can about our clients’ Culture and Wisdom Traditions • Only using assessment instruments normed for populations representing the client’s culture The “Seven Deadly Sins” A of Cross-Cultural Treatment

affiliation. S Cultural identity. S that all Natives are alike. U that you “know what they need”. M that you are aware of all your prejudices. I that you are welcome because you “want to help.” N that you are understood because there are no G questions.

Cultural Treatment Values E xplanation of patient’s view of problem T reatment(s) already tried. (results?) H ealers other cultural resources involved? N egotiate a mutually agreeable plan I ntervention(s) endorsed by both parties C ollaboration with family, community & Traditional Healers Levin, Like & Gottlieb 2000 Discipline-Specific Ethics Codes

• North Dakota – “Century Code” • NAADAC and NDBACE – Substance Abuse • NBCC – Professional Counselors • NASW – Social Work • LMFT – Marriage & Family Therapists And last, but not least… The Bible: Your own Agency’s CODE OF PROFESSIONAL CONDUCT PROFESSIONAL CODE OF ETHICS

Here are links to the code of ethics for some of the most common mental health professions:

• American Art Therapy Association (AATA) Code of Ethics • American Association of Marriage and Family Therapy (AAMFT) Code of Ethics • American Counseling Association (ACA) Code of Ethics • American Psychiatric Association (APA) Code of Ethics • American Psychological Association (APA) Code of Ethics • National Association of Social Workers (NASW) Code of Ethics • United States Association for Body Psychotherapy (USABP) Code of Ethics • https://www.naadac.org/code-of-ethics NAADAC - the Association for Addiction Professionals North Dakota “Century Code” https://www.legis.nd.gov/cencode/t43.html

North Dakota Century Code is a commemoration of the 100th anniversary of the establishment of Dakota Territory in 1861. ETHICS Codes - ND “Century Code”

• Addiction Counselors http://www.ndbace.org/images/forms/NAADACethics.pdf • Marriage & Family https://www.legis.nd.gov/information/rules/docs/pdf/2010/ndmftl b012910changes.pdf • Professional Counselors http://www.ndbce.org/ethics.shtml

• Psychologists https://www.apadivisions.org/division- 31/publications/records/north-dakota-record-keeping-laws.pdf

• Social Work Code of Ethics: North Dakota Administrative Code Chapter 75.5-02-06.1

NOTE: There is NO mention of “social media” or “internet” or “distance counseling” in the Standard! Please take a moment to collect the papers with your ethics questions and dilemmas for discussion.

AND NOW THE PART YOU’VE ALL BEEN WAITING FOR… Please be back in your seats at 2:00 Here’s the road map for this afternoon…

2:00 – 3:00 The “Brave New World” – social media Guidelines for ethical decision-making NOTE: There is no scheduled afternoon break – please do what you need to in order to feel comfortable 3:00 – 3:45 Guidelines for a Social Media Policy 3:45 – 4:00 Review of individual learning goals, feedback and wrap-up Is this the face of counseling in the digital age?

“To Friend or Not to Friend?” Social Media and Ethical Dilemmas for BH Clinicians

Session Description: • Social media like Facebook, Instagram, and Twitter didn't yet exist, when many of us were in graduate school, and their impact on our communication with each other - and with our clients - could hardly be anticipated.

• In this session we will explore this emerging challenge by discussing the Behavioral Health Ethical codes that apply to "virtual interactions", and share our challenges and solutions with each other. Session ObjectivesSession Objectives

Upon completion of this session attendees will be able to:

① Recite the ethical guidelines for Behavioral Health Clinicians that apply to social media. ② Identify at least 3 possible ethical dilemmas inherent in social media. ③ Express their own challenges and solutions with other colleagues on psychologist’s & clinician’s ethical codes. “Things your Grad School Professor never told you…” Social Media ▪ Facebook - Linkedin ▪ Twitter - Instagram ▪ The “blogosphere” ▪ Google searches ▪ GPS-enabled phones ▪ Do you have a website?

Polling question # 1

Andhttps://www.tiktok.com/en/

• TikTok—or Douyin as it is known in China, where it originated—is a mobile-only social network that allows users to create 15-second videos, most often set to the tune of pop songs, and offers a wide variety of built-in editing tools and visual effects. • It is currently one of the fastest-growing social media platforms, with 500 million–plus monthly active users across 150 countries, currently outranking both Snapchat and Facebook on Apple’s app store. • TikTok feels like the definitive mark in a forthcoming tide shift. Millennials are aging out and Gen Z is taking over as the dominant online culture. To quote an anonymous 15-year-old user: “Boomer is a state of mind, not an age. We all become boomers eventually.” • (owned by the Chinese government – no problems there….)

“Social Media” is a broad term… [Following slides adapted from “Best Practices for an online world” Lannin & Scott 2014]

• Networking sites: FaceBook, LinkedIn • Publishing media: Wordpress, Blogger, Wikipedia • Content sharing: YouTube, Flickr, Digg, TicTok • Discussion sites: Yahoo Messenger, Googletalk • “Micro-blogging”: Twitter, Tumblr, Posterous • Livestreaming: Friendfeed, Lifestream • Livecasting: eg. LiveStream • Virtual worlds: Second Life and There • (Never heard of ‘em? Your clients have…) Take Facebook for example:

• Most-used site by Americans 18 or older • 901 million monthly active users worldwide • More than 527 million users log on to Facebook on any given day • 81% of Psychology graduate students maintain an on-line profile •33% of those are on Facebook

Levahot, Barnett & Powers (2010) – how much has changed since then?? Our expanding digital world is shrinking!

• Social networking sites may be ushering in a “small world” online environment analogous to rural and frontier settings • Clinicians in remote areas have had to deal with more visibility and transparency than their urban counter- parts for years • Eg. Just as clients in a small village know where the Counselor lives, some networking sites tag photos with GPS coordinates. • This requires heightened awareness of online ethical dilemmas around boundary violations, self-disclosure and unavoidable multiple relationships. From: Ethics and Social Media – Kumar Jain PT, DPT If Facebook was a country…

From: Ethics and Social Media – Kumar Jain PT, DPT The Cambridge Analytica scandal changed the world – but it didn't change Facebook

“While it appears that Facebook is suddenly ‘woke’ to privacy issues, it’s safe to assume it’s business as usual there” Ashkan Soltani, formerly of the FTC Facebook–Cambridge Analytica data scandal results in $5 million fine (NY Times - July 24th 2019) • The Facebook–Cambridge Analytica data scandal involves the collection of personally identifiable information of up to 87 million Facebook users that Cambridge Analytica began collecting in 2014. The data was used to influence voter opinion on behalf of politicians who hire them. Following the breach, Facebook apologized and experienced public outcry and lowered stock prices, calling the way that Cambridge Analytica collected the data "inappropriate." facebook Gains the world's biggest repository of online photos

• Instagram – Perhaps Facebook's most famous purchase, Instagram was acquired for $1 billion, Facebook's largest acquisition at the time. Instagram's competing photo sharing social network still operates under its own brand and its own stand alone app, although many features including photo sharing have been integrated with Facebook itself. Facebook also acquired the smaller photo sharing service Lightbox.com which specialized in mobile, HTML5 and Android photo sharing. • Face.com – This Israeli company allowed integration of facial recognition for Facebook's photos. Uploaded photos could now be tagged using automatically generated suggestions for who that person might be. The deal was valued at $100 million. 4 Social Media HIPAA Violations That Are Shockingly Common

According to Healthcare Compliance Pros, there are four major breaches of HIPAA compliance on social media.

• Posting information about patients to unauthorized users (even if their name is left out) • Sharing photos of patients, medical documents, or other personal information without written consent • Accidentally sharing any of the above while sharing a picture of something else (e.g. visible documents in a picture of employees) • Assuming posts are deleted or private when they’re not

The easiest solution? Keep strict policies in place for how employees can use social media. From: Ethics and Social Media – Kumar Jain PT, DPT From: Ethics and Social Media – Kumar Jain PT, DPT A Therapist’s Guide to Ethical Social Media Use March 4, 2019 • By Crystal Raypole SETTING BOUNDARIES IN A DIGITAL WORLD As you begin to market your private therapy practice (or clinic), you’ll likely turn to all available channels in order to achieve the greatest visibility. Today, most of these marketing opportunities are found online on social media platforms such as Facebook and Twitter. It’s very common to have a Facebook account. More than 2 billion people worldwide, and 68% of Americans, use Facebook each month. Twitter has more than 300 million monthly users, and many professionals also use Twitter to market their practice. If you do use these or other social media channels, it’s generally recommended to make a business or professional page and clearly indicate it as such. Then use privacy tools to make your personal Facebook profile (the one you share with friends and family) as private as you can make it. This may not prevent your clients from seeking you out online, but it can limit the information they’re able to access. You can use privacy tools to set everything you post to “Friends Only,” or you can tailor your settings to each new post. WHEN A PERSON IN THERAPY SENDS A FRIEND REQUEST At some point, a person you’re working may send you a friend request through Facebook. There’s no ethics code that explicitly forbids accepting such a request, but guidelines from the American Psychological Association and experts in mental health ethics recommend against having clients as Facebook friends. People often use social media accounts to share very revealing information about themselves. Having a client as a Facebook friend will give you the opportunity to see details about their life they may not share with you in therapy, which they may not have considered when sending you the friend request. They might also see details about your life you wouldn’t share within the therapeutic relationship. Having access to this level of detailed personal information can significantly affect the bond you have with your client—on both sides. This is also important if you’re considering looking up your client online. This may be necessary if you have a real concern for someone’s safety, but in most other cases it’s not advised or appropriate. MARKETING YOUR PRACTICE ON SOCIAL MEDIA When setting up your business Facebook page or Twitter profile, think of it as a business card or ad you’ve taken out. In other words, you’re introducing yourself to potential clients with your social media page. Consider the following tips on social media business etiquette for therapists as you begin to market your practice online: Remember your likes and comments are often public. Not everyone uses privacy settings. If you like a public post or leave a comment, anyone can see this activity. The best practice here may be only liking or commenting on other professional posts that directly relate to therapy services or mental health treatment. Caution is still recommended. Even if you aren’t divulging any client information, consider whether there’s any possibility your words could help someone identify a person in therapy. If there’s any chance of this, reconsider your comment. In short, use care when liking posts, even those from other private practices or therapists, and consider how your likes and comments might reflect on you and your practice. MARKETING YOUR PRACTICE ON SOCIAL MEDIA

Interact with other therapists carefully. Building a social network of other mental health care providers can be a great way to use social media professionally, but it’s essential to cultivate awareness of potential ethical concerns. If another therapist shares client information that could violate confidentiality, for example, avoid replying publicly. You might consider, however, reaching out to that therapist through private message to express your concerns.

Avoid interacting with posts that could be unprofessional. If another therapist or private practice page shares information you feel is more personal than professional, ignoring the post is probably the best course of action. As stated above, a better option might be sending a private message to that professional letting them know why their post could seem inappropriate—if you feel comfortable doing so. MARKETING YOUR PRACTICE ON SOCIAL MEDIA Consider preventing incoming messages. On Facebook, you can set your business page settings to allow incoming messages, but you can also prevent this. Because Facebook correspondence isn’t private, you may want to prevent potential clients from sending you Facebook messages that might contain sensitive information about their mental health. Instead, post your contact information clearly on the business page. Include your phone number and email address, if you accept email correspondence, and encourage clients to reach out to you with these methods.

CONCLUSION Navigating the internet and learning how to make the best choices for your private practice is challenging for many, but it doesn’t need to be difficult. If you hesitate to use social media for your therapy business, consider taking a continuing education course on the subject. These can help you learn to use social media tools like Twitter and Facebook ethically and effectively. Back to the Future?

“Fast and Furious - communication at the speed of thought”… with focus on speed, rather than thought

Social Media as an “echo chamber” – the tyranny of swipes and likes creates “filter bubbles”

Tips for HIPAA Compliant Social Media

• Create a Social Media Working Group to discuss any potential concerns about implementing a social media strategy. The group should include representatives from various parts of the organization. • Ensure a thorough understanding of the HIPAA patient privacy regulations and how they pertain to your healthcare organization’s social media accounts. • Create an employee use policy for social media and clearly communicate it to all staff. • Educate and train staff on the use of social media – plus how not to use it – with real life examples. • Create a realistic content strategy that specifies both the frequency and types of social media posts to reduce the likelihood of breaches. • Develop a process with the Legal and Compliance departments to approve content prior to being posted. • Monitor social media communications with technology controls that flag any words or phrases that may indicate HIPAA non-compliance, so that they can be reviewed before posting. • Capture and save records that preserve the format of social communications, including edits and deletions. • Archive electronic records so that they can be found, in accordance with federal and state recordkeeping rules. • Develop metrics to measure the effectiveness of social media programs. Establish Guidelines for Social Media Use by Healthcare Employees The social media policy of your facility should establish guidelines for the use of social media, both personal and professional. As employees who work for an organization that is identified as a covered entity, they must follow HIPAA Privacy Rules and ensure the privacy and security of protected health information at all times.

• Do • Be professional, especially if you have identified yourself as an employee • Include a statement stating your views are your own and not your employers • Remove tags on pictures that a patient posts to keep the picture off of your page or profile • Don’t • Participate in any online communication with patients of the medical office • Post pictures of patients under any circumstance even if it is unidentifiable • Discuss any details of your job or activities that occurred during the work day

Ethics Alive! The 2017 NASW Code of Ethics: What's New? by Allan Barsky – Chair of the NASW Code Review Task Force

A new standard, 1.03(i), guides social workers to obtain client consent before conducting an electronic search on clients. This fits with other informed consent procedures, ensuring clients are informed about the worker’s plans for gathering information, assessing, and intervening with a client. An exception is provided for compelling professional reasons, such as the need to prevent serious, foreseeable, and imminent harm (e.g., a client who is suicidal or homicidal). A new standard, 1.06(e), discourages social workers from communicating with clients using technology for personal or non-work- related purposes. Given the rapid growth in online social networking and other forms of social media, it is important for social workers to be aware of the importance of maintaining appropriate client-worker boundaries (including with respect to digital communications) Ethics Alive! The 2017 NASW Code of Ethics: What's New?

A new standard, 1.06(g), suggests that social workers should be aware that clients may discover personal information about them based on their personal affiliations and use of social media. The Task Force determined that prohibiting social networking could be a violation of a social worker’s freedom of association and freedom of speech. As with Standard 1.06(f), this standard focuses on the social worker’s being aware of potential pitfalls, so the social worker will use professional judgment when making decisions about online social networking and posting information using digital technology.

A new standard, 1.06(h), suggests that social workers should avoid accepting requests from or engaging in personal relationships with clients on social networks or other electronic media. The purpose of this section is to prevent boundary confusion, inappropriate dual relationships, and harm to clients. The Task Force felt that this provision was in keeping with other sections of the Code that encourage social workers to avoid personal relationships with clients. Ethics Alive! The 2017 NASW Code of Ethics: What's New?

One of the most outdated standards in the 2008 Code was 1.07(m), which referred to facsimile machines, answering machines, and telephones as examples of technology. This standard instructed social workers to avoid disclosing confidential information when using such technology. This standard was first adopted in 1996, long before social workers were using online videoconferencing, smart phones, text messaging, social robots, remote electronic storage of client records, online social networking, and other forms of technology. Today, transmitting identifying information through technology is not only pervasive, but required for many purposes (e.g., submitting client information to insurance companies for reimbursement for services). The new version of 1.07(m) permits transmission of identifying information, but advises social workers to take reasonable steps to protect the confidentiality of electronic communications, including information provided to clients or third parties. To protect client confidentiality, social workers should use applicable safeguards, such as encryption, firewalls, and passwords. As technology changes, social workers need to keep up to date on which methods are most appropriate ways to protect client confidentiality. Ethics Alive! The 2017 NASW Code of Ethics: What's New?

A new standard, 1.07(p), advises social workers to develop and inform clients about their policies on the use of electronic technology to gather information about clients. This section is intended to make social workers aware of client privacy issues, particularly when considering whether to gather client information electronically. A new standard, 1.07(q), builds on 1.07(p) by discouraging social workers from searching or gathering client information electronically unless there are compelling professional reasons, and, when appropriate, with the client’s informed consent. For instance, a social worker may need to gather information electronically to protect the life or safety of the client or another person. Whenever possible, the client’s consent should be requested in advance of search for client information. A new standard, 1.07(r), states that social workers should avoid posting any identifying or confidential information about clients on professional websites or other forms of social media. Although clients may consent to having identifying information posted on a social worker’s social media, social workers should ensure that such consent is fully informed. Consider, for instance, a client who offers to post a positive comment on a social worker’s website attesting to the great addictions counseling she received. The client may not realize how future employers or others may have access to this information, or how it may be safer to post a comment without identifying information. 2016 NAADAC/NCC AP Code of Ethics

VI-13 Addiction Professionals shall appreciate the necessity of maintaining a professional relationship with their clients/supervisees. Providers shall discuss, establish and maintain professional therapeutic boundaries with clients/supervisees regarding the appropriate use and application of technology, and the limitations of its use within the counseling/supervisory relationship. VI-19 Addiction Professionals shall not accept clients’ “friend” requests on social networking sites or email (from Facebook, My Space, etc.), and shall immediately delete all personal and email accounts to which they have granted client access and create new accounts. When Providers choose to maintain a professional and personal presence for social media use, separate professional and personal web pages and profiles are created that clearly distinguish between the professional and personal virtual presence. VI-20 Addiction Professionals shall clearly explain to their clients/supervisees, as part of informed consent, the benefits, inherent risks including lack of confidentiality, and necessary boundaries surrounding the use of social media. Providers shall clearly explain their policies and procedures specific to the use of social media in a clinical relationship. Providers shall respect the client’s/supervisee’s rights to privacy on social media and shall not investigate the client/supervisee without prior consent. Web 2.0 Ethical Implications for Therapists Vignettes for discussion:

Jane is your client. Both of you live and work in the same community. Jane is the director of a local charity. She sends you an invitation to be one of her contacts on LinkedIn.

Marcie is a former client. She was a teenager when you treated her. Several years later she has friended you on Facebook with a private message thanking you for being such a positive influence in her life.

John is a current client who has begun following you on twitter. He has sent you a direct message and has also sent you an @reply to one of your tweets. He recently posted a tweet stating what a great therapist you are with a link to your website.

Mary has been your client for over a year. She has a history of childhood abuse and you have encouraged her to write in a journal. You receive an email from her asking to change times for her next appointment. She closed her email with “By the way, the journal writing has been so helpful, I have decided to start a blog. Here’s the link! www.maryrevealsinherblog.com. You open the link to discover that her first blog entry contains emotionally charged and highly graphic information about past childhood sexual abuse she has not previously revealed in therapy. Web 2.0 Ethical Implications for Therapists Vignettes for discussion:

Kim was your client for over a year. You have not heard from her in at least that long. She was often hostile during sessions and would call between sessions feigning crisis and then apologise for her behavior during the previous session. The reason for termination was due to her move out of the area. Today you do an internet search for your name and you see that Kim has created a website, www.bewareofbadtherapy.com. Your name is on the website’s blacklist with links to excerpts of verbatim chat transcripts from sessions you held with Kim online.

You login to your email first thing in the morning. You have received an email from email address [email protected]. The email states, ” I am so desperate. I lost my job yesterday and I have not told my wife. I don’t know what to do- I owe huge $$ to this loan shark – I gambled my way into a mess. I just don’t know- I mean I think my family would be better off if I just kill myself. Can you help?” Facebook Safety: Tips for Counselors

• Think twice (or even three times) before engaging in Facebook friendships with current or former patients/clients. • This also applies to engaging in Facebook friendships with family members or friends of clients (former or current). • Adjust Facebook privacy settings to allow only “friends” to view your profile, status, photos, posts, etc. Even choosing the option “friends of friends” can leave counselors susceptible to ethical violations. Do consider making your profile unsearchable as a privacy setting. • Do not accept friendship requests from persons unknown to you, even if you share mutual friends. • Do not post your e-mail address, phone number, date of birth or physical address on your Facebook page. • Do have honest communication with new patients/clients about not engaging in online relationships with them via Facebook as part of an overall review of the therapeutic contract. • Use great care in selecting photos of yourself for display on Facebook. Remember that photos of yourself from past years can cast suspicion on your otherwise stellar reputation. • Use discretion when joining certain groups, fan clubs or specialty pages. This can open up your personal information to others who have also joined these pages. • Avoid discussing confidential, work related matters on your Facebook page with friends, even in general terms. Having worked in bush Alaska, SNS’s are a lot like a HUGE small village: • You never know who’s looking or when • You might bump into a client by surprise • Unavoidable overlapping personal and professional relationships • There is always the inevitable gossip • There are many risk factors for unintentional self- disclosure • All can damage the therapeutic relationship • If something goes sideways, you can’t “un-ring the bell” – it’s OUT there!

To “friend” or not to “friend”:

• Is entering into a relationship in addition to the professional one necessary, or should it be avoided? • Can the dual relationship be potentially harmful to the client? • If harm seems unlikely or avoidable, would the additional relationship prove beneficial? • Is there a risk that the dual relationship could disrupt the therapeutic relationship? • CAN I EVALUATE THIS MATTER OBJECTIVELY? (emphasis added) [Youngren & Gottlieb 2004] What about “googling” your clients? • Why do I want to conduct this search? • Would my search advance or compromise the treatment? • Should I obtain informed consent from the patient? • Should I share the results of the search with the patient? [Why or why not?] • Should I document the results of the search in the medical record? • How do I monitor my motivations and the ongoing risk/benefit profile of searching? [Clinton, Silverman & Brendel 2010]

NASW promotes the use of Social Media…

www.twitter.com/nasw Linkedin www.socialworkblog.org www.facebook.com/socialworkers www.youtube.com/socialworkers

http://www.socialworkers.org/socialmedia/default.asp 7/13/2015 National Association of Social Workers, 750 First Street, NE • Suite 800, Washington, DC 20002 NASW Member Services 800-742-4089 Mon-Fri 9:00 a.m. - 9:00 p.m. ET or [email protected] ©2015 National Association of Social Workers. All Rights Reserved. … and yet had no specific official Ethics Codes until 2017!

Good Intentions

Good Therapy Some thoughts on Social Media

G Bowden McElroy, Med Licensed Professional Counselor [email protected] More guidelines for ethical decision-making

anaq Don’t be alone with it! Consider asking:

• your Clinical Supervisor • an Elder • a trusted colleague Or, if necessary • legal counsel, Human Resources, Privacy Officer, etc. 8 Tips for Counselors from NASW:

• Don’t “friend” clients • Don’t blog, post, or make negative comments about work matters or colleagues • Manage your privacy and location settings on social media accounts • Implement a social media and technology policy • Make clients aware of how their use of social media may compromise their confidentiality • Do NOT Google Clients • Become fully competent in the use of technology before implementing it into your practice • Implement security and privacy measures for electronic communications and records A “Twitter version” Social Media Ethics Policy:

•Don’t Lie, Don’t Pry •Don’t Cheat, Can’t Delete •Don’t Steal, Don’t Reveal

Farris Timimi M.D . Medical Director Mayo Clinic Center for Social Media.

BFFacebook ▪ Rick has successfully discharged a female client, who is moving to a remote community with no counselors available. He agrees with her re-quest to “friend” him just to offer some support and friendly advice. He is careful not to breach her confidentiality, or provide “professional” counseling on her Facebook page. He does, however, offer occasional support and encouragement. Whaddayathink? BFFacebook (con’t.) ▪ Rick goes on an extended family vacation to rural Alaska, where there is no reliable internet access. He doesn’t check his Facebook page or posts. When Rick returns home, he learns that his former Client had completed suicide while he was gone.

The Lawyers for the Client’s family are suing Rick for “clinical abandonment”. His former Client became fixated on their Facebook “relationship”, and became convinced that it had become “romantic”. There were 240 Facebook posts awaiting Rick on his return. When he didn’t “respond”, she committed suicide. Maintaining the Counselor–Client Relationship: Ethical Decision-Making in Online Counseling and Social Networking

Keith M. Brown, Emily K. Byrnes, and Kelly G. Fleenor

• Facebook has since changed its security options from 2010. It is now possible to manually activate a secure encryption from the user's account settings. This will activate the encryption for whenever the account is used, regardless of location. It is, however, only active on the account that has activated this feature. Other users may not be utilizing this feature and it is not possible to ascertain whether they are, in fact, using a secure login. Since a secure connection cannot be guaranteed, this form of Internet counseling remains an unsecured medium for counseling. Any counselor who engages in Internet counseling must be proficient in the use of computer programs and its services. What are some of YOUR concerns and experiences? Developing a Social Media Ethics Policy

Ideally, a comprehensive social media ethics policy should address the most common forms of electronic communication used by both clients and Counselors: • social networking sites, • search engines, • e-mail and text messages, • location-based services, and • consumer review sites. (For a useful model, visit the website www.drkkolmes.com) WHY have a Social Media Ethics Policy? • social networking • Confidentiality and sites, boundary issues • search engines, • Client privacy • e-mail and text • Confidentiality (and messages, perhaps boundaries) • location-based • GPS-enabled phones services, and and photos • consumer review • Have you ever been sites. “YELPed”?

Developing a Social Media Ethics Policy by Frederic G. Reamer, PhD

• A carefully constructed social media policy that counselors share with their clients can prevent confusion and minimize the likelihood of ethics- related problems concerning boundaries, dual relationships, informed consent, confidentiality, privacy, and documentation. • Ideally, a comprehensive social media ethics policy should address the most common forms of electronic communication used by clients and clinicians: social networking sites, search engines, e-mail and text messages, location-based services, and consumer review sites Developing a Social Media Ethics Policy (con’t)

• Social networking sites: I have consulted on several cases where counselors learned painful lessons after the fact about boundary, dual relationship, confidentiality, privacy, informed consent, and documentation problems that can arise if they interact with clients on such networking sites.

• Although some Behavioral Health Clinicians—a distinct minority, it appears—seem comfortable with these electronic relationships with clients, most agree that a social media policy should inform clients that their counselor does not interact with clients as electronic friends or contacts on social networking sites. Developing a Social Media Ethics Policy (con’t)

• Search engines: For example, the National Association of Social Workers Code of Ethics states, “Social workers should respect clients’ right to privacy” (standard 1.07[a]). When the current code of ethics was ratified in 1996, the committee that drafted it never imagined that this standard could possibly be applied to social workers’ use of electronic search engines, which did not yet exist. • Today, however, BH clinicians must decide whether it is ethical to conduct electronic searches about their clients. To respect clients’ privacy, an ethics-based social media policy should explain to clients that their counselro will not conduct electronic searches about them unless there is, for example, a genuine emergency where information obtained electronically might protect the client from harm. Developing a Social Media Ethics Policy (con’t)

• E-mail and text messaging: BH Clinicians who correspond with clients via e-mail or text messages about sensitive, clinically relevant information may expose a client to confidentiality and privacy breaches. E-mail correspondence and text messages are not 100% secure. Further, informal e-mail and text message exchanges, especially during what are customarily nonworking hours, may confuse clients about the boundaries in their relationship with social workers. • A social media policy should explain to clients that counselors limit such electronic messages to appointment scheduling and other routine correspondence. Clients should understand that e- mail and text message communications may not be secure and that any electronic messages may become part of the clinical record. Developing a Social Media Ethics Policy (con’t) • Location-based services: Many clients use location-based services such as Foursquare, Loopt, and Gowalla to enable friends and acquaintances to follow their itinerary via their mobile telephones. • A social media policy should inform clients that their use of location-based services, especially if their mobile telephones are GPS enabled, may inform friends and acquaintances that they are visiting a therapist, thus jeopardizing their privacy. Developing a Social Media Ethics Policy (con’t)

• Consumer review sites: Some clients choose to post publicly available comments on Web- based business review sites such as Healthgrades, Yahoo!, and Yelp about the clinical social workers from whom they receive therapeutic services. • Remember that responding to comments in any way violates HIPAA and 42CFR§2 • A social media policy should alert clients that posting comments on these websites with identifying information would compromise their privacy and confidentiality. Developing a Social Media Ethics Policy (con’t)

• Most contemporary counselors completed their formal education and entered the profession before currently available social media were invented. Until relatively recently, electronic communication with clients meant telephone calls using landline equipment. Today, however, the social media revolution that has permeated clients’ and practitioners’ lives has introduced a wide range of clinical and, especially, ethical challenges. • To ensure compliance with prevailing ethical standards related to boundaries, dual relationships, confidentiality, privacy, informed consent, and documentation, prudent counselors should develop comprehensive social media policies and review them with clients. • Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics. [email protected] [email protected] KeyKey Learnings Learnings,, Process Process Improvements Improvements andand TakeTake--Aways:Aways

① While social media have impacted every area of modern culture – and behavioral health practice – the Code of Ethics for Social Work, SUD Counselors and Clinicians have been slow to address the risks specifically and in detail ② This leaves the Social Worker/Counselor with the responsibility to research the implications on their own ③ The NASW publication on Standards for Technology and Social Work Practice offers many useful guidelines ④ There are numerous articles in the professional literature for Social Work and counseling that address these issues ⑤ Ultimately, the greatest safety may lie in collaborative consultation with peers and supervisors. Final discussion, feedback and wrap-up

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