“Bob” and I had some trouble keeping our sessions to an hour. His desire to unpack some historically traumatic events, combined with his clinically significant anxiety and ADD left a pretty tight squeeze. What’s more, Bob agreed that his cannabis use immediately before sessions didn’t give him a full-range of emotional expression, but he was even more scattered without it. So, I was really proud of him in a recent session. He hadn’t smoked ahead of time, and still put in a solid hour of difficult anxiety work using CBT techniques with me. He even went away promising to complete both his clinical and non-clinical homework, the latter piece of which involved discussing the idea of 2-hour sessions with his parents who were paying for therapy. I was proud of Bob’s strides, and felt he would benefit from more encouragement. So, a few hours after our session, I sent him a text message (GASP!). Here’s how it went. Me: Hey…great job today! I kno this stuff is tuf. I apprec ur desire to wk thru things and to come 2 session w/o using. Bob: Thnx Bob: Monday is good for 2 hours. Me: Sweet! CU Then. Bob: K! Granted, this wasn’t a particularly long exchange, but it was meaningful! On my end, it was sufficient to display empathy and support. On Bob’s end, it gave him an opportunity to reaffirm his commitment to therapy by confirming our appointment, and by reporting that he had already completed his homework! Ethical Considerations. While effective, was the communication with Bob ethical? Yes, it was! The practice is consistent with all applicable sections of the ACA ethics codes. Here are a few reasons why: 1. Section A.5.c & A.5.d: Non-professional interactions are to be avoided except when beneficial to the client. Yet, there is no reason to consider this form of interaction “non-professional” simply because of the medium employed to communicate. To do so effectively displays a bias against the medium itself, rather than a founded ethical complaint. If it is just too much for you to consider “I kno this stuff is tuf” a professional communication, the extra display of support to clients it represents would meet the criterion outlined for exceptions here anyhow. In accordance with A.5.d., my rationale for this sort of interaction is detailed in my notes, and I’m square. 2. Section A.10b: Text-messaging engages in a service for which I do not directly bill. But, I don’t want to spend gobs and gobs of time doing it for no money. So, I include a catchall note in my informed consent documentation indicating that though fees are charged “per session”, there is a range of peripheral services that fee also includes, such as between-session communications. Listing these kinds of services out is a great way to highlight pieces of care clients typically underappreciate, and can even be used as a rationale for an increased per session fee. 3. Section A.12.a & A.12.g (and other applicable confidentiality codes) As part of our informed consent, clients are advised as to the limitations of confidentiality in technology. At The Change Group, one piece of that disclosure reads as follows: “Clients should know that electronic communications, both telephone and Internet (including email), are generally not secure methods of communication, and there is risk that one’s confidentiality could be compromised with their use. Counselors at The Change Group, LLC, as a means of general practice, do communicate with clients using these mediums because of their potential benefit in maintaining rapport and establishing an efficient back and forth line of communication at minimal inconvenience to all parties. If you would prefer to not be contacted by telephone or email, please inform your counselor and we will honor this request. Please also note that we may collect various other kinds of information including pre and post assessments, feedback, payment, etc. using secure (encrypted) forms on our website. We may also engage in various forms of electronic counseling which have varying levels of security, including text, message, and video chat, text messaging, and phone conversations. The Change Group, LLC makes every effort to provide each of these services and all others in the most secure fashion possible, and according to generally accepted industry standards.” Also, we take care to: • Store our client’s names in our cell phones in a non-identifying manner, and delete them after termination. • Password protect our contact lists and phone access in general • Delete transcripts after recording them appropriately in notes Brass Tacks. According to a recent Nielsen study of more than 60,000 mobile subscribers, the average teenager aged 13-17 sends a staggering 3,339 texts per month. 18-24 year-olds average nearly 1700. 25-64 year-olds range from around 1000 to several hundred per month. The world has changed, and the world of our clients within it. It seems naïvely optimistic to expect 1 hour a week to compete with this without some reinforcement. So, if texting done well is ethical, a potentially a helpful addition to the therapeutic process, and part of an inevitable tide of change in the lives of our clients, why aren’t more therapists doing it??? Perhaps we hesitate to join the tide because we’re fundamentally no different than those we help – we resist change. Rationalizations a’plenty do not alter this reality. I wonder whether our model has become so regulated, so wrought with fears about covering one’s proverbial behind, so entrenched in the status quo, that we’ve practically rendered ourselves incapable of trying anything new. I wonder whether we’re so frightened of being sued or that confidential information will be compromised, that we have become limited in our ability to engage clients meaningfully in any way that doesn’t fit neatly into our dated paradigm. And what’s worse? We call it professionalism. In fact, it runs the risk of being quite the opposite. Like most good things, this can be taken too far. I’m not going to respond to text messages sent at 2am, or to interrupt my night out with my wife because clients want to vent. Just because I provide my cell phone number and email address doesn’t mean I’m on-call. I’m not talking about enmeshment, codependency, or indulging a need to be needed. But there is a reasonable degree to which we must learn to pursue our clients again, rather than expecting them to pursue us. We must again become passionate about communicating empathy in culturally relevant ways, and more frequently and more creatively than in-session. So, here’s the bottom line. In the 1980’s, people were fascinated with an anvil-like machine that sent a piece of paper over a phone line from Tinseltown to Timbuktu in about 2 hours. Now, in a half a dozen different ways, I can communicatively ping-pong with the other side of the globe as many times as I want before I sit down to my morning bowl of frosted mini-wheats. The only limitation is my own willingness. The same is true for my approach with clients. As a therapist, I am voice that seeks to stand out among the myriad others in my clients’ lives, encouraging them toward healthy and productive living. The competition is deafening sometimes, so I endeavor to possess creative and skillful methodology, and a constant, insatiable desire to grow and adapt in both my style and means of communication. As technology increases my clients’ ability to communicate in fresh and exciting ways with their milieu, I must continually seek to become a meaningful part of that dynamic as well. Rather than leading us away from professionalism, less formal interventions like text messaging move us toward our clients. But, if there is any sense in which the plaques on the wall and the letters behind our name have erected walls rather than built bridges, we may have to come out from behind them a bit. But there’s good news. In so doing, we sense afresh our deepest calling, and reaffirm the sincerity of our commitment to those for whom we care. It doesn’t get much better than that!
Ryan Thomas Neace is a counselor, professor, and entrepreneur. He is the co-founder and managing director of The Change Group. More at http://changegroupcounseling.com